OSCE Clinical Examinations & Management
Station Navigator
1. OSCE Station: Examination for Wilson's Disease
Scenario:
A 22-year-old woman presents for an urgent psychiatric review. She has a two-month history of irritability, emotional lability, and behavioral changes. Her family reports she has become disinhibited and impulsive, with poor judgment leading to financial difficulties. You note a subtle tremor in her hands and a slight slurring of her speech. USG shows liver cirrhosis. Do the relevant examination of this patient.
Sequence:
Start by verbalizing to the examiner that you are conducting a general observation. Assess whether the patient appears drowsy or alert. Next, proceed to examine the hands. Ask the patient to outstretch their hands and observe for wing-beating tremors or flapping tremors.
Then, inspect for signs of cirrhosis in the upper limbs, including nails, leukonychia, palmar erythema, Dupuytren contractures, and any indications of jaundice, scratch marks, or bruising on the skin. Proceed to check reflexes and tone.
Moving to the face, observe for masked facies and assess the patient's orientation. Look for Kayser-Fleischer rings, jaundice, and signs of anemia. Perform the finger-to-nose test and assess for dysdiadochokinesia.
Continue the examination by focusing on the gastrointestinal tract (GIT). Check for spider nevi, ascites, and hepatosplenomegaly. Proceed to examine the lower limbs for edema, bruising, tone, reflexes, and gait abnormalities.
STEP: CNS -> STEP: LIVER -> STEP: EYES
General Examination
- General appearance: Look for signs of chronic illness.
- Observation: The candidate should assess the patient's overall appearance. Points to note include:
- Nutritional status: Does the patient appear well-nourished, cachectic (extremely thin), or overweight?
- Signs of jaundice: Yellowing of the skin or eyes, indicating potential liver problems.
- Skin changes: Spider naevi (small dilated blood vessels), bruising, or signs of scratching (due to potential liver dysfunction).
- Overall alertness: Is the patient drowsy, confused, or fully alert?
Neurological status
- GAIT: Ask the patient to walk a short distance. Observe for:
- Ataxia (unsteadiness or lack of coordination).
- Shuffling steps or difficulty with balance.
- Wide-based gait.
- TREMORS: Look for tremors at rest, as well as "wing-beating" tremors when the patient extends their arms and wrists, characteristic of Wilson's disease. Observe for tremors in the hands, head, or voice.
- INVOLUNTARY MOVEMENTS: Note any unusual or uncontrollable movements, such as:
- Chorea (jerky, dance-like movements).
- Dystonia (sustained muscle contractions causing twisting or abnormal postures).
- Assess coordination (finger-nose, heel-shin):
- Finger-nose test: Ask the patient to touch their nose, then your finger, and back to their nose with their eyes closed. Observe for accuracy and smoothness of movement.
- Heel-shin test: Ask the patient to lie down and place the heel of one foot on the opposite knee, then slide it down the shin. Look for accuracy and ability to maintain a smooth line of movement.
- Assess muscle tone and reflexes:
- Muscle tone: Passively move the patient's limbs to assess for:
- Hypotonia (decreased muscle tone)
- Hypertonia (increased muscle tone) – rigidity, spasticity
- Reflexes: Check major reflexes (knee jerk, ankle jerk, biceps, triceps) and note if they are diminished, brisk, or exaggerated.
- Muscle tone: Passively move the patient's limbs to assess for:
- Check for dystonia (masked facies):
- Observation: Look for a reduced range of facial expressions, a fixed smile, or a staring appearance.
Targeted Physical Examination: EYES
Kayser-Fleischer (KF) Rings: These are pathognomonic for Wilson's disease (meaning they are unique to this disease and highly specific). Here's how to assess for them:
- Ideal Equipment: Slit-lamp examination (performed by an ophthalmologist) for the most accurate visualization.
- OSCE Adaptation: If a slit lamp isn't available, use a penlight or otoscope for general illumination and look closely at the edge of the cornea (where the colored iris meets the white sclera). You may be able to see the KF ring with this method, or consider using a magnifying glass.
- Appearance: KF rings appear as golden-brown or greenish-brown deposits of copper in the cornea. They usually start at the superior edge and form a complete circle.
HAND: Tremors
The presence of tremors is a major neurological finding in Wilson's Disease. Observe closely, and note:
- Resting tremor: Present when the hands are completely relaxed.
- Action tremor: Occurs with purposeful movement.
- "Wing-beating" Tremor: A classic finding in Wilson's disease where the tremor gets bigger when the patient holds their arms outstretched with their wrists extended.
ABDOMEN
- Look (Inspection):
- Jaundice: Yellowing of the skin and eyes due to liver dysfunction.
- Spider Naevi: Small, dilated red blood vessels radiating from a central point - a sign of chronic liver disease.
- Abdominal distension: Swelling of the abdomen could indicate ascites (fluid buildup due to liver disease) or hepatosplenomegaly.
- Palpate (Feel):
- Hepatosplenomegaly: Gently palpate to assess the size of the liver and spleen. Enlargement of either or both is common in Wilson's disease.
- Tenderness: Assess for any right upper quadrant tenderness, which could suggest liver inflammation.
- Percuss (Tap):
- Ascites: Percuss for signs of shifting dullness, which suggests the presence of fluid within the abdomen.
Note regarding Wilson disease chart:
- Epidemiology: Age of symptom onset: < 35 years.
- Pathophysiology: Autosomal recessive mutation in ATP7B gene -> defective copper transport -> copper accumulation in multiple organs (e.g. liver, CNS, cornea).
- Diagnostics: Slit lamp examination, Serum ceruloplasmin, free serum copper, 24-h urine copper excretion.
- Treatment: Low-copper diet, Chelating agents: penicillamine, trientine, zinc salts.