Step-by-Step OSCE Guide

The HINTS exam is a 3-part bedside test to help differentiate central from peripheral vertigo in patients with acute vestibular syndrome (AVS). It includes:
– Head-Impulse test
– Nystagmus assessment
– Test of Skew

GETTING STARTED

1. Perform hand hygiene and don PPE if needed.
2. Introduce yourself: “Hi, I’m Jamie, one of the advanced clinical practitioners.”
3. Confirm the patient’s full name and date of birth.
4. Briefly explain the exam: “I’m going to perform a quick series of tests to assess your balance system. It may feel a little strange but it’s completely safe.”
5. Gain verbal consent and offer a chaperone.
6. Ask if the patient has any neck pain, stiffness, or recent trauma.
7. Sit the patient upright in a chair or on an examination couch.

HEAD-IMPULSE TEST (VESTIBULO-OCULAR REFLEX)

8. Instruct the patient to fix their eyes on your nose.
9. Gently turn their head 15–20° side to side, checking for neck stiffness.
10. Then, with their gaze fixed on your nose, quickly turn their head ~15° to one side and then back to the centre.
11. Repeat both sides. Look for a corrective saccade — this suggests a peripheral cause (e.g. vestibular neuritis). A normal response (no saccade) is concerning for a central cause (e.g. stroke).

NYSTAGMUS

12. Ask the patient to look straight ahead — observe for spontaneous nystagmus.
13. Then ask them to look far left and far right — without fixating on a finger or object.
14. Direction-fixed horizontal nystagmus is typically peripheral.
15. Direction-changing, vertical or torsional nystagmus is suggestive of a central lesion.

TEST OF SKEW

16. Ask the patient to look directly at your nose.
17. Cover one of their eyes, then rapidly switch to cover the other.
18. Observe the newly uncovered eye for vertical correction or misalignment.
19. A vertical shift = positive test = central pathology.

CLOSING THE EXAM

20. Let the patient know the exam is complete and thank them.
21. Offer assistance if they feel dizzy.
22. Dispose of PPE and perform hand hygiene.
23. Summarise your findings clearly.
24. Suggest next steps – e.g. urgent CT/MRI, stroke team referral, or ENT input.

A HINTS exam is most accurate in patients with continuous dizziness, nystagmus, and no other focal neurological signs. It can be more sensitive than early CT in stroke, but it’s clinician dependent. Use it in the right clinical context.