Free medical quiz

Upper Limb Neurological OSCE Examination Quiz

Focused SBA-style practice, followed by the answer and explanation for every question.

Free now: 7 questions
Full bank: 47 questions
Answers: Explained

Free question

Try one with the answer

A question from this quiz. Answer it to see the explanation students get.

A right-handed woman has progressive clumsiness of the hands. On examining the upper limbs you find wasting and fasciculations in the small hand muscles, reduced tone, weak finger abduction and thumb opposition, and reduced biceps and triceps reflexes. Sensation and coordination are normal. After thanking the patient and washing your hands, which is the single best way to finish and present the examination?

Present a lower motor neurone pattern, then examine gait, lower limbs and cranial nerves, and suggest blood tests, nerve conduction studies/EMG and imaging. Present an ulnar nerve palsy, arrange nerve conduction studies, and finish by checking for Froment's sign, because the wasting is in the hands. Present a cervical radiculopathy, arrange MRI of the cervical spine, and finish by performing Spurling's test, because the lesion is likely to be a single nerve root. Present an upper motor neurone pattern and arrange MRI of the brain and spinal cord, because wasting and fasciculations are upper motor neurone signs. Present a myopathy, arrange creatine kinase and a muscle biopsy, and finish by examining the cranial nerves and gait.

A Present a lower motor neurone pattern, then examine gait, lower limbs and cranial nerves, and suggest blood tests, nerve conduction studies/EMG and imaging. ✓
B Present an ulnar nerve palsy, arrange nerve conduction studies, and finish by checking for Froment's sign, because the wasting is in the hands.
C Present a cervical radiculopathy, arrange MRI of the cervical spine, and finish by performing Spurling's test, because the lesion is likely to be a single nerve root.
D Present an upper motor neurone pattern and arrange MRI of the brain and spinal cord, because wasting and fasciculations are upper motor neurone signs.
E Present a myopathy, arrange creatine kinase and a muscle biopsy, and finish by examining the cranial nerves and gait.

The answer is A: Present a lower motor neurone pattern, then examine gait, lower limbs and cranial nerves, and suggest blood tests, nerve conduction studies/EMG and imaging.

Explanation

Why A is correct

See Completing the Examination. Option A is correct. The findings are the classic lower motor neurone (LMN) picture. The lower motor neurone is the nerve cell that runs from the spinal cord out to the muscle, so when it is damaged the muscle loses its supply, becomes thin and weak, and its reflexes fade. Because progressive weakness with wasting and fasciculations warrants assessment, the examination should not stop at the arms. After thanking the patient and washing your hands, you summarise the pattern and then suggest examining gait, the lower limbs and the cranial nerves, and arranging blood tests, nerve conduction studies with electromyography (tests of the nerves and of the electrical activity of the muscle) and imaging guided by the likely level of the lesion. The lower motor neurone signs in this patient are:

Wasting of the small muscles of the hand
Fasciculations, fine twitches visible under the skin from spontaneous firing of motor units (a motor unit is one nerve cell and the muscle fibres it controls)
Reduced tone and reduced reflexes, with weakness in the affected muscles

Pattern: wasting, fasciculations, reduced tone and reduced reflexes make a lower motor neurone picture.
Next steps: summarise, then examine gait, the lower limbs and the cranial nerves.
Tests: blood tests, nerve conduction studies with electromyography and imaging.

Why the other options are incorrect

B. Present an ulnar nerve palsy, arrange nerve conduction studies, and finish by checking for Froment's sign, because the wasting is in the hands.: The ulnar nerve does not supply thumb opposition, biceps or triceps, so an ulnar nerve palsy cannot account for the full lower motor neurone picture seen here. Froment sign tests ulnar adduction of the thumb, not the pattern described.
C. Present a cervical radiculopathy, arrange MRI of the cervical spine, and finish by performing Spurling's test, because the lesion is likely to be a single nerve root.: A single cervical root lesion follows one myotome, whereas this patient has weakness across the hand and reduced biceps and triceps reflexes, suggesting a more diffuse lower motor neurone process. Spurling's test is not the appropriate finishing step without first completing the wider neurological examination.
D. Present an upper motor neurone pattern and arrange MRI of the brain and spinal cord, because wasting and fasciculations are upper motor neurone signs.: Wasting and fasciculations are lower motor neurone signs, not upper motor neurone signs, and the reduced tone and reflexes also fit a lower motor neurone pattern. MRI of the brain and spinal cord would not assess the peripheral nerves.
E. Present a myopathy, arrange creatine kinase and a muscle biopsy, and finish by examining the cranial nerves and gait.: Myopathy typically causes proximal weakness and preserves reflexes until late, and it does not cause fasciculations; this patient has distal wasting and reduced reflexes. Creatine kinase and muscle biopsy are not the best next tests for this pattern.

Hard

With Premium, questions you miss become Revision Coach flashcards, scheduled for review.

Question preview

What you will practise

More questions from this set. Start the quiz to answer them and see each explanation.

1
On the finger-to-nose test, which finding most directly suggests a cerebellar lesion?
2
Before an upper limb neurological examination, a 32-year-old woman holds both hands outstretched. When she closes her eyes, her fingers develop slow, writhing movements that are less obvious when her eyes are open. Which interpretation best explains this finding?

Need wider coverage?

Explore every OSCE topic set, or build a tailored mixed session.

Browse subject quizzes