THE

OSCE
MEDICAL REFERENCE
POCKET GUIDE

2024 EDITION

TM
EXAMINATION TABS
History Taking.................................... 1-2
Cardiology......................................... 3-5
Respiratory........................................ 6-8
Gastroenterology............................... 9-11
Thyroid.............................................. 12-13
Diabetic Foot...................................... 14-15
MSK: Shoulder................................... 16-17
MSK: Spine........................................ 18-19
MSK: Knee......................................... 20-21
Neurology: Upper Limb....................... 22-23
Neurology: Lower Limb....................... 24-25
Neurology: Cranial Nerves.................. 26-27
Mental State Exam (MSE)..................... 28
Lymph Nodes / Glascow Coma............. 29
Snellen Chart...................................... 30

INITIAL STEPS
MUST complete before
commencing any exam

1. HAND HYGIENE

2. INTRO & INSTRUCTION

3. CONSENT

4. GENERAL OBSERVATIONS
Respiratory status
Body habitus
Vital charts
Environmental cues
 Hx
1 INTRODUCTION
i) Introduce yourself iii) Explain purpose
ii) Identify patient iv) Gain consent

2 PRESENTING COMPLAINT (PC)

i) Identify main concern (signs, symptoms, etc.)

3 HISTORY OF PC 1.
S ite Where exactly is the pain?
O nset What were they doing when the pain started?
C haracter What does the pain feel like?
R adiates Does the pain go anywhere else?
A ssociations e.g. nausea/vomiting
T ime How long have they had the pain?
E xacerbating Anything make pain better/worse?
S everity Obtain an initial pain score

4 PAST MEDICAL HISTORY

i) Surgical History iii) Allergies
ii) Existing conditions iv) Medications (dosage + freq)

5 FAMILY HISTORY
i) Known genetic conditions
ii) Common conditions in the family (i.e. diabetes)
iii) Ask about health of parents, siblings, etc.

6 SOCIAL HISTORY
i) Smoking & Alcohol iv) School/work/hobbies
ii) Illicit drug use v) Living arrangements
iii) Diet & Activity vi) Ask about driving

7 SYSTEMS REVIEW
i) Ask questions covering other systems

8 SUMMARY
i) Summarize & repeat complete history
ii) Clarify if you missed any details
iii) Ask patient for any final questions & thank them
Hx MALE SEXUAL HISTORY
i) Testicular swelling/pain iv) Urethral discharge
ii) Itching/sore genital skin v) Dysuria
iii) Skin lesions vi) Systemic symptoms

FEMALE SEXUAL HISTORY

i) Abdominal/pelvic pain v) Systemic symptoms
ii) Vaginal bleeding/discharge vi) Menstrual history
iii) Dyspareunia vii) OB history
iv) Vulva changes/itches viii) GYN history

BOTH
i) Last sexual contact iii) Focused PMHx
ii) HIV risk assessment iv) Travel history

SYSTEM REVIEW QUESTIONS

Chest pain Syncope
SoB Leg pain or swelling
Palpitations

Cough (blood)
Unusual phlegm production
Wheeze

Loss of consciousness Weakness/

Headaches numbness
Change in vision Dizziness

Nausea/vomiting Heartburn
Difficulty swallowing Change in
Abdominal pain bowel habits

Muscle/joint/bone
Pain/swelling/stiffness
Unusually dry mouth/eyes

Fever Skin changes (rash)

Excess sweating Fatigue
Weight loss/gain
 1 SPECIFIC OBSERVATIONS
i) Cyanosis iv) Shortness of breath
ii) Pallor v) Edema

CVS
iii) Malar flush vi) Specific cues (ECG, Meds, IV)

2 HANDS *IE = Infective Endocarditis*

i) Clubbing vi) Signs of IE
ii) Palmar crease pallor Janeway lesions
iii) Tar stains Osler nodes (“O”uch)
iv) Xanthomata Splinter hemorrhages
v) Capillary refill time (< 2 secs)

3 PULSE & BP
i) Radial Pulse (rate, rhythm, strength) iii) Take BP
ii) Radial-Radial delay & Radial-Femoral delay

4 NECK
i) Carotid (palpate & auscultate) ONE AT A TIME
ii) JVP (45º, head left, sternal angle, < 4cm)

5 FACE
i) Eyes (conjunctival pallor, xanthalasma)
ii) Mouth (central cyanosis, high-arched palate,
angular stomatitis, dental/gum hygiene)

6 CHEST
i) Inspect (wall deformities, scars, pulsations)
ii) Palpation (apex, heaves, thrills)
iii) Auscultate (APTM #2245)
iv) Maneuvers + listen to M with bell
Left lateral decubitus mitral regurgitation
Lean forward + breathe out friction rubs

7 BACK
i) Inspect & Palpate (sacral edema)
ii) Auscultate lung fields

8 LEGS
i) Inspect (trophic changes, varicose veins, swelling)
ii) Palpate (pedal edema, temperature, pulses)
 AUSCULTATION
A2 = Aortic 2nd ICS
P2 = Pulmonic 2nd ICS
CVS

T4 = Tricuspid 4th ICS

M5 = Mitral 5th ICS
Pulmonic
Aortic
Pulmonic stenosis
Aortic stenosis systolic ejection
crescendo-decrescendo
Tricuspid
systolic
Systolic
Tricuspid regurg.
Erb’s Point VSD
Diastolic
Systolic Tricuspid stenosis
HOCM ASD
Left
Diastolic Mitral
sternal Systolic
Aortic regurg.
border Mitral regurg.
decrescendo/blowing
Pulmonic regurg. Right Mid holosystolic
sternal clav. Diastolic
border line Mitral stenosis
opening snap

RULES FOR MANEUVERS

Inspiration rIght-sided murmurs Except
HOCM &
Expiration lEft-sided murmurs MVP

INC Preload/Afterload ALL murmur intensity

Squatting Leg Raise Hand Grip Valsalva

INC Preload INC Preload INC Afterload DEC Preload

Scan to
Blood Pressure listen!
Urine Dipstick
12-lead ECG
Troponins (MI)
 JUGULAR VENOUS PRESSURE (JVP)
i) Patient at 45º, turn head to left
ii) Look for JVP (between medial
end of clavicle under the medial
sternoclemastoid)
iii) Measure vertical distance
between the sternal angle & top
pulsation point
iv) Normal < 4cm

BLOOD PRESSURE
1 2 3

Twist air release Wrap cuff above elbow Place stethoscope

valve all the way to with arrows pointing head on brachial
right to close it off to brachial artery artery & find pulse

4 5 6

0
Inflate cuff to ~160
Slowly release the 1st “thud” = Systolic P
(until pulse is no
valve & listen closely Sound absent = Distolic P
longer present)

SYMPTOMS POTENTIAL Dx
Cold + white + painful limbs Acute limb ischemia

C/P + neck, jaw or L-arm pain Acute coronary

syndrome

Impending sense of doom Cerebral hypoxia

Unilateral leg swelling DVT (risk of PE)

Sudden onset throbbing C/P Thoracic AA

radiating to scapula

Syncope/Presyncope on exertion Aortic Stenosis

 1 SPECIFIC OBSERVATIONS
i) Cyanosis iv) Shortness of breath
ii) Pallor v) Cough, wheeze, or stridor
iii) Edema vi) Surroundings (O2 , sputum, cigs)

2 HANDS
i) Clubbing (schamroth window test)
ii) Skin changes (bruising, thinning, tar stains)
iii) Capillary refill time (< 2 secs)
iv) Tremor (fine & flapping/asterixis)
Hold for at
3 PULSE least 30s!

i) Radial Pulse (rate, rhythm, strength)

ii) Respiratory rate

4 NECK
i) JVP (45º, head left, sternal angle, < 4cm)
ii) Trachea (position, cricosternal distance)
Normal =
5 FACE 3-4 fingers

i) Eyes (conjunctival pallor, xanthalasma, Horner's)

ii) Mouth (central cyanosis, oral candidiasis)

6 ANTERIOR CHEST
i) Inspect (wall deformities, scars, pulsations)
ii) Palpation (apex, chest expansion, RV heave)
iii) Percuss (supra/infra clavicular, chest wall, axilla)
iv) Vocal Resonance (say "99")
v) Auscultate (deep breaths in + out through mouth)

7 BACK *pt cross arms + lean forward*

i) Inspect (wall deformities, scars, recessions)

ii) Percuss (anterior/middle/lower lobes)
iii) Vocal Resonance (say "99")
iv) Auscultate (deep breaths in & out through mouth)

8 LEGS
i) Inspect (signs of DVT, erythema nodosum)
ii) Palpate (pedal edema, temperature, pulses)
 ANT LUNG FIELDS POST

RES
Wheeze Stridor
“Whistle” “Squeaky Do(o)r”
High pitched “musical flute” High pitch inspiratory squeak
Asthma & COPD Upper airway obstruct,
croup

Crackles Rhonchi
“Crackle-Pop” “Rumble”
Fluid crackly/bubbly sound Low pitched rattle or rumble
Pulmonary edema, CHF Bronchitis, COPD, Pneumonia

Friction Rub Scan to

listen
“Cat Scratch”
High pitched scratchy sound
Pleurisy, pericarditis

CHEST EXPANSION

i) Position your hands beneath the nipples

ii) Wrap fingers around the chest & bring thumbs together at midline
iii) During patient's deep breath, observe:
symmetrical upward/outward movement during inspiration
downward/inward movement during expiration
 TRACHEAL PALPATION

Cricosternal Distance Trachea Position

RES

RES
Normal = 3-4 fingers
i) Dip finger into thorax beside trachea
A = cricoid cartilage ii) Apply side pressure to locate border
B= suprasternal notch iii) Compare space on both sides

Interpretation:
SCHAMROTH'S Midline = normal position
Clubbing = NO window
Away = tension pneumothorax,
large pleural effusion
lobar collapse,
Towards =
pneumonectomy

PERCUSSION
keep middle finger flat!

Resonant = normal tissue

Chest X-Ray fluid (i.e. pneumonia,

Dull =
atelctasis, edema)
ABG
Sputum Sample Stony Dull = pleural effusion
Spirometry
Hyperresonant = pneumothorax,
COPD

SYMPTOMS POTENTIAL Dx
Hemoptysis TB, Lung cancer, PE

Weight loss Lung cancer, COPD (end stage),

Cor pulmonale

Sudden onset C/P Spontaneous pneumothorax, PE

Sudden onset dyspnea Spontaneous pneumothorax, PE

Sudden onset stridor Anaphylaxis, foreign object,

acute epiglotitis
 1 SPECIFIC OBSERVATIONS
i) Confusion iv) Abdominal distention & ascites
ii) Pallor v) Hyperpigmentation
iii) Jaundice vi) Specific cues (stoma & drains)

2 HANDS
i) Clubbing
ii) Palms (pallor, erythema, Dupuytren's contracture)
iii) Nails (koilonychia, leukonychia)
iv) Tremor (flapping tremor/asterixis)

3 PULSE

GIT
i) Radial Pulse (rate, rhythm, strength)
ii) Respiratory rate

4 ARMS & AXILLA

i) Bruising, spider nevi, stretch marks)
ii) Axilla (acanthosis nigricans, hair loss)

5 FACE
i) Eyes (conjunctival pallor, jaundice, Kayser-Fleischer)
ii) Mouth (stomatitis, glossitis, candidiasis, ulcers)

6 NECK & CHEST

i) Neck (lymphadenopathy & left supraclavicular node)
ii) Chest (spider nevi, gynecomastia, hair loss)

7 ABDOMEN
i) Inspect (scars, distention, striae, Cullen's/Grey Turn)
ii) Palpation (9 quadrants: superficial deep)
iii) Liver: Palpate & Percuss (RIF Rt. costal margin)
iv) Spleen: Palpate & Percuss (RIF Lft. costal margin)
v) Ballot kidneys (push fingers together on breath in)
vi) Palpate aorta (width < 3cm)
vii) Shifting dullness (percuss Umbilicus Lft. flank)
viii) Auscultate (bowel sounds, aortic & renal bruits)

8 LEGS
i) Palpate (pitting edema)
 9 QUADRANTS
Right Left
Hypochondriac Epigastric Hypochondriac
Hepatitis Gastritis Pancreatitis
Cholecystitis GERD
Splenic Infarct /
Cholengitis Pancreatitis
Gallstones Peptic Ulcer Rupture

Right Lumbar Umbilical Left Lumbar

Kidney stones Apendicitis (early) Kidney stones

GIT

Pyelonephritis Gastroenteritis Pyelonephritis

Colitis Ruptured AAA Colitis

SBO

Right Iliac Hypogastric Left Iliac

Ovarian Torsion Cystitis Ovarian Torsion

Crohn’s Disease PID Ulcerative Col.
Apendicitis
Ectopic Pregnancy Diverticulitis
Testicular Torsion
McBurney’s 2/3s from umbilicus to right ASIS
Point 8

Rt Costal Margin, Mid-Clavicular line

Murphy’s Sign Pain on deep breath in

Pain in right iliac region upon

Rovsing’s Sign palpation of left side

Left supraclavicular node (enlarged)

Virchow's Node
Associated with gastric cancer

SPIDER NEVUS KAYSER-FLEISCHER KOILONYCHIA

Estrogen Metabolites Copper Deposition Iron Deficiency

 INCISIONS/SCARS PALPATION

Mercedes Benz LIVER

Kocher’s Upper Rt. 5-10th rib

Midline
SPLEEN
Right
Lft. 9-11th rib
Paramedian
Lower
Midline

Appendicectomy Left Inguinal

KIDNEYS
Hernia exam
DRE
External
genetalia

SHIFTING DULLNESS

1. Percuss umbilical 2. Continuing percussing 3. Roll patient to side,

region to right flank wait 30s & repeat

SYMPTOMS POTENTIAL Dx
Shock, guarding, rebound
Peritonitis
tenderess
Severe intermittement RUQ
Biliary Colic
pain (worse with fatty food)
Severe epigastric pain Pancreatits
radiating to back
Loin to groin pain Renal colic
(cannot lie still)
Distended tender abdomen Bowel obstruction
(tinkling bowel sounds)
Pain out of proprtion to exam Acute mesenteric
ischemia
 1 SPECIFIC OBSERVATIONS
i) Weight loss or gain iv) Hoarse voice
ii) Behavior v) Pretibial myxoedema
iii) Clothing

2 HANDS
i) Thyroid acropachy (similar to clubbing)
ii) Onycholysis (nail bed detachment)
iii) Palmar erythema
iv) Radial pulse (rate, rhythm, amplitude)
v) Access for peripheral tremor
vi) Access for Pemberton’s sign (arms above head)

3 FACE
i) Dry skin (hypothyroidism)
ii) Excessive sweating (hyperthyroidism)
iii) Eyebrow loss (outer ⅓ = hypothyroidism)

4 EYES
i) Lid retraction iii) Movement (“H”)
ii) Exophthalmos (bulging eyes) iv) Lid lag

5 THYROID
i) General inspection (midline, masses, scars)
ii) Swallow assessment
iii) Tongue protrusion
iv) Palpation (size, symmetry, consistency, mass)
v) Auscultation (bell →
bruit)
vi) Percuss sternum (retrosternal dullness)

6 LYMPH NODES
i) Cervical lymphadenopathy
Submental Superficial cervical
Submandibular Deep cervical
Pre-auricular Posterior cervical
Post-auricular Supraclavicular

7 REFLEXES & MYOPATHY

i) Biceps & knee jerk ii) Proximal myopathy
 HYPOTHYROID HYPERTHYROID
T3 & T4 Dry Hair Hair loss T3 & T4
TSH TSH
Bulging eyes
Puffy face
(exopthalmos)
Goiter Goiter
Cold intolerance Heat intolerance

Slow heartbeat Rapid heartbeat

(bradycardic) (tachycardic)

Weight gain Weight loss

Constipation Diarrhea

Thyroid

THY
acrophacy
Dry skin
Oncholysis
Palmar
erythema

1 Stand behind patient PALPATION

(with chin tilted down)

Place 3 fingers of each

2 hand along midline of neck
AA

3 Locate upper edge of thyroid

cart. (Adam’s Apple: AA) CC

4 Move fingers down to reach

cricoid cartilage (CC) Lobe Lobe

Palpate isthmus (midline) &

5 Isthmus
each lobe (laterally)

6 Ask patient to swallow, then

to protrude their tongue

SYMPTOMS POTENTIAL Dx
Soft & Diffusely Enlarged Grave’s Disease

Firm, diffusely enlarged, Hashimoto’s Thyroiditis

slighly tender

Firm, singular nodules Malignancy

Multinodular goitre Iodine Deficiency

 1 INSPECTION
i) Peripheral cyanosis & pallor
ii) Ulcers (diabetic, venous, arterial)
iii) Gangrene, scars, hair loss
iv) Foot deformities (i.e. Charcot)
v) Footwear (soles, size, materials)

2 PALPATION
i) Temperature
ii) Pulses (posterior tibial & dorsalis pedis)

3 SENSATION
i) Monofilament (pressure points - see next page)
ii) Vibration (128Hz tuning fork)
iii) Proprioception (access joint position)
DIA

4 GAIT
i) Pattern & abnormalities
ii) Speed, stance, Optic Disc

steps, turning Optic Cup

Macula
5 REFLEXES
i) Ankle-jerk (S1)
Retinal vein Fovea

6 FURTHER TESTS Retinal art.

i) Fundoscopy
ii) HbA1c/Glucose

Fasting Plasma Oral Glucose

HbA1c
Glucose Tolerence Test
(%)
(mg/dL) (mg/dL)

Diabetes ≥ 6.5 ≥ 126 ≥ 200

Pre-
5.7 - 6.4 100 - 125 140 - 199
Diabetes

Normal ~ 5.7 ≤ 99 ≤ 139

 MONOFILAMENT TESTING
1) Provide sensation to
patient’s sternum
2) Ask patient to close eyes
3) Apply monofilament to
4) Press aginst skin until
monofilament bends slighly
5) Ask paitent to report when
they feel the monofilament

PERIPHERAL PULSES
Extensor
hallucis longus
Medial
malleolus

Dorsalis
pedis artery

Posterior
tibial artery
DORSALIS PEDIS POSTERIOR TIBIAL

DIA
Lateral to extensor Posterior to medial
hallucis longus malleolus

KNEE (L3-4) REFLEXES ANKLE (S1-2)

L3-4 =
“Kick the
Door!
S1-2=
“Buckle my
Shoe!”

FOOT ULCERS
DIABETIC ARTERIAL VENOUS

Irregular, Red Irregular punched Thick cylinidrical,

Granulation out & Cold Pink base & Warm
Sensory deficit Weak pulse & pain Exudate & pain
 1 SPECIFIC OBSERVATIONS
i) Scars iv) Swelling
ii) Muscle wasting v) Symmetry of shoulder girdle
iii) Bruising vi) Abnormal bony prominence

2 LOOK
i) Anterior inspection (symmetry, swelling, wasting)
ii) Lateral inspection (deltoid wasting, scars)
iii) Posterior inspection (trapezius, scapula, scoliosis)

3 FEEL
i) Temperature
ii) Palpate
Swelling, bony abnormalities, tenderness

4 MOVE
i) Active movement (patient performs independently)
Shoulder flexion & extension
SHLD

Shoulder ABduction & ADduction

External & Internal rotation
Scapular movement
ii) Passive movement (controlled by examiner)
Instruct same movements as above
Look for restricted ROM, crepitus, pain

5 SPECIAL TESTS
Push-Off Wall Test Winged Scapula

Empty Can Test Supraspinatus

Supraspinatus
Painful Arc Assessment Impingement
Infraspinatus & Teres
External Rotation Power Minor
Internal Rotation
(Gerber’s Lift-Off Test) Subscapularis

Neer’s Test & Impingement Syndrome

Hawkins Kennedy Test

Speed’s Test Biceps Tendonitis

 2 5 3
PALPATION 4

1. Sternoclavicular joint 7
2. Clavicle 6
3. AC joint Supraspinatus
4. Acromion 8 Infraspinatus
Teres minor
5. Coracoid process (ant)
6. Head of humerus
7. Greater tubercle
8. Spine of scapula
9. Inf. border scapula
9

PASSIVE/ACTIVE MOVEMENT
Internal
rotation

ABduction

External
rotation
ADduction Extension Flexion

PUSH-OFF NEER’S TEST GERBER’S

SHLD

EMPTY-CAN SPEED’S PAINFUL ARC

Pa
in l
es
s

Painful
arc

s
le s
in
Pa
 1 SPECIFIC OBSERVATIONS
i) Scars iv) Swelling
ii) Muscle wasting v) Symmetry shoulders/hips/knees
iii) Bruising vi) Abnormal bony prominence

2 LOOK
i) Anterior inspection (symmetry, posture, wasting)
ii) Lateral inspection (lordosis & kyphosis)
iii) Posterior inspection (alignment, wasting, hair)

3 GAIT
i) Access full gait cycle
Symmetry & Turning
Signs of discomfort

4 FEEL
i) Temperature
ii) Palpate
Cervical spinal processes
Thoracic/Lumbar spinal processes
Paraspinal muscles (tenderness, spasms)
SPNE

5 MOVE
i) Active movement (patient performs independently)
Cervical Spine (flexion, extension, rotation)
Thoracic Spine (rotation)
Lumbar Spine (flexion, extension, lat flexion)
ii) Passive movement (controlled by examiner)
Instruct same movements as above
Look for restricted ROM, crepitus, pain

6 SPECIAL TESTS
Schober’s Test Restricted spinal flexion

Straight Leg Raise Sciatic nerve irritation

Femoral Nerve Stretch Test Femoral nerve irritation

Pelvic Distraction Test Sacroiliac joint irritation

 STRAIGHT LEG
C2 90º 75º
C7 60º
T1 45º
T7 30º

Inf.
Scapula 15º
0º

T12
PELVIC DISTRACTION

L4

PSIS

Coccyx FABER’S

Neurovascular
exam
Examine joints
above & below
Imaging

SCHOBER'S
FEMORAL
SPNE

STRETCH

SYMPTOMS
Age 20-50 Hx of osteoporosis

Trauma significant Hx of malignancy

for age
Night pain/constant IV drug use
pain (non-mechanical)
Chronic steroid use / Red+hot+swollen joint
immunocompromised with limited ROM
 PALPATION
Apophysitis
Joint lines
Patellar tendon

Peripatellar pain

Medial knee
Lateral knee

Quadriceps tendon

Posterior knee

ANT. DRAWER TEST LACHMAN’S

POST. DRAWER SIGN POST. SAG SIGN

KNEE

MCMURRAY TEST COLLATERAL TESTS

(INT + EXT rotation) Valgus Varus

 1 SPECIFIC OBSERVATIONS
i) Scars iv) Swelling
ii) Muscle wasting v) Symmetry shoulders/hips/knees
iii) Bruising vi) Abnormal bony prominence

2 LOOK
i) Anterior inspection (varus/valgus, patellar position)
ii) Lateral inspection (extension/flexion abnormalities)
iii) Posterior inspection (popliteal swellings)

3 GAIT
i) Access full gait cycle
Symmetry & Turning
Signs of discomfort

4 FEEL
i) Temperature
ii) Palpate
Quadricpes bulk
Extended Knee (patella, medial/lateral joint lines)
Flexed Knee (tibial tub, head of fib, popliteal fossa)
iii) Joint effusion (patellar tap & sweep test)

5 MOVE
i) Active movement (patient performs independently)
Knee Flexion & Extension
ii) Passive movement (controlled by examiner)
Instruct same movements as above
Look for restricted ROM, crepitus, pain

6 SPECIAL TESTS
Posterior Sag Sign PCL injury
KNEE

Anterior/Posterior ACL/PCL injury

Draw Tests
Lachman's test ACL injury

Medial & Lateral

Collateral Ligament Tests collateral ligaments
Medial & Lateral
McMurray's Test meniscus
 1 SPECIFIC OBSERVATIONS
i) Scars iv) Fasciculations
ii) Muscle wasting v) Chorea & Clonus
iii) Tremor vi) Pronator Drift

2 TONE
i) Support patient's limb & ask them to relax
ii) Move each muscle group with varying velocity
iii) Access for spasticity, rigidity, hypotonia

3 POWER
i) Shoulder ABduction (C5) & ADduction (C6/7)
ii) Elbow Flexion (C5/6) & Extension (C7)
iii) Wrist Extension (C6) & Flexion (C6/7)
iv) Finger Extension (C7) & ABduction (T1)
v) Thumb Abduction (T1)

4 REFLEXES
i) Test Reflexes
Biceps (C5/6)
Brachioradialis (C5/6)
Triceps (C7)
ii) See next page for grading chart

5 SENSATION
i) Dermatomes (C3 -T1)
Light touch (dorsal columns & spinothalamic tract)
Pin-prick sensation (spinothalamic tract)
ii) Vibration
Patient eyes closed & ask if they feel tuning fork on
fingers 128-Hz
NEUR

iii) Proprioception
Hold distal phalanx by its sides & move thumb
"upwards" & "downwards" with eyes closed

6 COORDINATION
i) Finger-to-Nose Test (dysmetria, intention tremor)
ii) Dysdiadochokinesia (alternating movements)
 ANT POST

REFLEXES

Biceps Triceps Brachioradialis

POWER GRADING REFLEX GRADING

0 No contraction 0 Absent

1 Flicker of contraction
1+ Hypoactive

2 Active movement, no
gravity
2+ “Normal”
Active movement against
3 gravity
Hyperactive WITHOUT
3+ clonus
Active movement against
4
NEUR

gravity and resistance

4+ Hyperactive WITH clonus

5 Normal power
 1 SPECIFIC OBSERVATIONS
i) Scars iv) Fasciculations
ii) Muscle wasting v) Chorea & Clonus
iii) Tremor vi) Access Gait + Romberg's Test

2 TONE
i) Support patient's limb & ask them to relax
ii) Move each muscle group with varying velocity
iii) Access for spasticity, rigidity, hypotonia
iv) Ankle clonus (rapidly dorsiflex foot)

3 POWER
i) Hip Flexion (L1/2) & Extension (L5/S1/S2)
ii) Knee Flexion (S1) & Extension (L3/4)
iii) Ankle Dorsiflexion (L4/5) & Plantarflexion (S1/2)
iv) Big Toe Extension (L5)

4 REFLEXES
i) Test Reflexes
Knee (L3/4)
Ankle (S1)
Plantar/Babinski (L5/S1)
ii) See grading on previous page

5 SENSATION
i) Dermatomes (L1 -S1)
Light touch (dorsal columns & spinothalamic tract)
Pin-prick sensation (spinothalamic tract)
ii) Vibration
Patient eyes closed & ask if they feel tuning fork
on toes 128-Hz
iii) Proprioception
Hold distal phalanx by its sides & move big toe
"upwards" & "downwards" with eyes closed

6 COORDINATION
NEUR

i) Toe-to-Finger Test (dysmetria, intention tremor)

ii) Heel-to-Shin Test (lower limb ataxia = cerebellar)
 BABINSKI

Neg

Pos

ROMBERG’S
1.
Eyes
closed
2.
ANT POST Maintain
erect
posture
3.
Assess
for 60s

DYSDIADOCHOKINESIA
Full Neuro
Examination
Neuroimaging
(i.e. MRI spine
or head)

SYMPTOMS POTENTIAL Dx
Fever, neck stiffness, altered Meningitis
mental status
Morning headaches, fatigue, Brain tumor
cognitive dysfunction, N&V
Unilateral pulsating pain, Migraine Headache
photophobia, N&V
Sudden onset "worst Subarachnoid
headache ever" hemmorage

Ascending paralysis Gullian-Barre

Syndrome
Contralateral motor & sensory
deficets Stroke (UMN lesion)

Resting tremor, rigidity, Parkinson’s Disease

akinesia, shuffling gait
 SPECIFIC OBSERVATIONS
i) Speech abnormailites iii) Eyelid abnormalities
ii) Facial symmetry iv) Pupillary abnormalities

I. OLFACTORY i) Ask for recent changes in smell

II. OPTIC
i) Pupils (size, shape, symmetry)
ii) Visual Acuity (Snellen chart on back of guide)
iii) Pupillary reflex (direct & consensual, swinging light
reflex, accommodation)
iv) Visual fields (cover eye & swap hands)
v) Fundoscopy (if warranted)

III. OCULOMOTOR/IV. TROCHLEAR/VI. ABDUCENS

i) Eyelids (i.e. ptosis) & palsies
ii) Eye movements (make "H" with pin)
iii) Strabismus (light reflex & cover test)

V. TRIGEMINAL
i) Facial Sensation (V1 forehead, V2 cheek, V3 jaw)
ii) Muscles of mastication (V3)
iii) Reflexes (jaw jerk & corneal)

VII. FACIAL
i) Ask if any changes in taste
ii) Muscles of facial expression

VIII. VESTIBULOCOCHLEAR
i) Gross hearing (whisper a number) 512-Hz fork
ii) Rinne's (mastoid process --- ext. acoustic meatus)
iii) Weber's (midline forehead --- ask for lateralization)

IX. GLOSSOPHARYNGEAL / X. VAGUS

i) Soft Palate & Uvula (say "ahh")
ii Ask patient to cough & perform swallow assessment

XI. ACCESSORY
i) Test trapezius (shrug) & sternoclemastoid (turn head)

XII. HYPOGLOSSSAL
i) Tongue (fasciculations, wasting, deviation)
 DERMATOMES EYE PALSY
OCULOMOTOR (III)
Down & Out
V1

C2

V2
TROCHLEAR (IV)
V3 C3 Head tilt to AWAY from lesion

WEBER’S TEST
Normal Midline
ABDUCENS (VI)
Conductive louder in
affected ear Cannot ABduct

Sensorineural
louder in
normal ear

1. Mastoid
1. RINNE'S TEST
process Normal Air > Bone
R
Conductive Bone > Air

2.Ext. Acoustic Meatus Sensorineural Air > Bone

ARGYLL ROBERTSON PUPIL

(late-stage syphilis, diabetes, multiple sclerosis)
NEUR

DO constrict when focused

Do NOT constrict to light
on near object
 MENTAL STATE EXAMINATION
1 OPENING THE CONSULTATION
i) Wash your hands and iv) Explain that you’d like to
don PPE if appropriate have a chat to see how
ii) Introduce yourself with they’re feeling
name and role v) Gain consent to proceed
iii) Confirm the patient’s with a mental state
name and date of birth examination

2 APPEARANCE i) Observe the patient’s appearance

3 BEHAVIOR
i) Note how the patient engages and if there seems to be
rapport
ii) Observe the patient’s level of eye contact
iii) Observe the patient’s facial expressions
iv) Observe the patient’s body language
v) Identify any evidence of abnormal psychomotor activity
vi) Note any abnormal movements or postures

4 SPEECH
i) Note the rate and quantity of the patient’s speech
ii) Note the tone and volume of the patient’s speech
iii) Note the fluency and rhythm of the patient’s speech

5 MOOD AND AFFECT

i) Explore the patient’s current mood by asking appropriate
questions
ii) Observe the patients affect

6 THOUGHT
i) Note the speed, flow, and coherence of the patient’s
thoughts
ii) Explore the content of the patient’s thoughts for
abnormalities
Ask about thought possession to screen for abnormalities
i) Explore the patient’s current
7 PERCEPTION perception
MSE

i) Formally assess the patient’s

8 COGNITION cognition (ex. AMTS, MMSE, ACE-III)
 LYMPH NODES OF HEAD & NECK

Posterior Preauricular
auricular
Occipital
Parotid

Superficial
cervical
Tonsillar
Deep
cervical

Posterior
Submental
cervical

Supraclavicular
Submandibular

GLASCOW COMA (/15)

Behavior Response
Eye Opening Response
4. Spontaneously
3. To speech
4 2. To pain
1. No response

Verbal Response 5. Oriented to time, person,

and place
4. Confused
5 3. Inappropriate words
2. Incomprehensible sounds
1. No response

Motor Response 6. Obeys command

5. Moves to localized pain
4. Flex to withdraw from pain
6 3. Abnormal flexion
2. Abnormal extension
1. No response
 20/200

20/100

20/80

20/50

20/40

20/25

20/20

Hold chart 6ft away from

d
patient's direct line of sight
Published: January 2024
Printed in the USA
Title: The OSCE Medical Reference Pocket Guide 2024 edition
Author: Jacob Portnoff, HBSc, MD Candidate 2025 (@MedSchoolBro)
Contact Info: [email protected]
MedSchoolBro assumes no liability or responsibility for any errors or omissions in the content
of this guide.This guide is intended for educational purposes only. Not medical advice.

TM