AMC Clinical Exam Station: The Shaking Hand (Movement Disorder)

Station Title & Timing

  • Title: Focused Neurological Examination: Tremor and Movement
  • Duration: 10 minutes (2 minutes reading time + 8 minutes performance)

Learning Objective(s)

  • Examination Skills: Systematically differentiate between resting, postural, and kinetic tremors using specialized maneuvers.
  • Clinical Reasoning: Correctly identify extrapyramidal signs (rigidity, bradykinesia) to distinguish Parkinson’s Disease from Essential Tremor.
  • Communication: Explain the diagnosis and examination findings to the patient with empathy and clarity.

Patient Profile

  • Name: Mr. Arthur Bennett
  • Age: 65 years old
  • Occupation: Retired Accountant
  • Social History: Enthusiastic gardener; enjoys woodworking but has recently found it difficult to hold a chisel.

Presenting Complaint

Mr. Bennett presents with a “bothersome shake” in his right hand. He notices it most when he is sitting watching television, though his wife mentions his handwriting has become very small and difficult to read.

Contextual Information

  • HPC: Tremor started 6 months ago, gradually worsening. It is mostly on the right side.
  • PMH: Hypertension (controlled). No history of head injury or stroke.
  • Medications: Perindopril.
  • Family History: Negative for tremors or Parkinson’s Disease.
  • Allergies: NKDA.

Exam Instructions

Candidate Instructions

You are a GP seeing Mr. Bennett.

  1. Perform a focused upper limb neurological examination to characterize his tremor.
  2. Formulate a differential diagnosis based on your findings.
  3. Explain the likely diagnosis to Mr. Bennett and discuss the next steps.
  4. Note: You must verbalize your examination steps and maneuvers to the examiner.

Standardised Patient (SP) Instructions

  • Affect: Calm but slightly frustrated by his loss of fine motor skills.
  • The Tremor:
    • At Rest: When your hands are in your lap, demonstrate a rhythmic “pill-rolling” motion in the right hand ($3–5$ Hz).
    • On Action: When you reach for the “Finger-to-Nose” test, the tremor disappears or significantly diminishes.
  • Distraction: If the doctor asks you to count backward or name months, make the resting tremor in your right hand more pronounced.
  • Tone: If the doctor moves your wrist, offer a “clicking” resistance (Cogwheel rigidity).
  • Face: Maintain a slightly fixed, “mask-like” expression with infrequent blinking.

Examiner Checklist Items

  • Observes for “Mask-like facies” and resting tremor during the initial introduction.
  • Specific Maneuver: Uses a distraction technique (e.g., counting backward) to uncover the resting tremor.
  • Tremor Differentiation: Assesses for postural tremor (arms outstretched) and kinetic tremor (finger-to-nose).
  • Tone: Formally checks for “Cogwheel Rigidity” at the wrists.
  • Coordination: Tests for Bradykinesia (rapid finger tapping) and Dysdiadochokinesia.
  • Functional Test: Asks the patient to draw a spiral or write a sentence (identifies micrographia).
  • Communication: Explains findings without causing unnecessary alarm while being honest about Parkinsonian suspicions.

Key Clinical Findings

SystemFindings
InspectionRight-sided “pill-rolling” tremor at rest; reduced blinking; small-step gait (if observed).
TremorPresent at rest; disappears with action; absent intention tremor.
ToneAsymmetrical Cogwheel Rigidity (Right > Left).
CoordinationBradykinesia (progressive slowing/reduction in amplitude of finger tapping).
WritingMicrographia: Small, cramped handwriting that drifts upward.

Communication Triggers (Murtagh-Aligned)

  • Open-ended questions: “Arthur, can you tell me in which situations you notice the shaking is at its worst?”
  • Summarising back: “So the shaking happens mostly when you are relaxed, it’s mostly on your right side, and you’ve noticed your handwriting is getting smaller. Is that right?”
  • Handling emotions: “I understand it’s frustrating to give up woodworking. Our goal today is to find out why this is happening so we can help you get back to your hobbies.”
  • Lay language: Instead of “Extrapyramidal signs,” say “the systems that control the smoothness of your movements.”

Assessment & Marking Guide

DomainKey Item for Global Rating
DistractionCritical: Did the candidate use a mental task to bring out the resting tremor?
Tone CheckCritical: Did the candidate specifically check for rigidity/stiffness in the wrists?
DifferentiationCorrectly identified the tremor as “Resting” rather than “Essential” or “Cerebellar.”
BradykinesiaEvaluated for slowness of movement (e.g., finger tapping).
ExplanationLinked the triad of Tremor, Rigidity, and Bradykinesia to Parkinson’s Disease.

Sample Answers / Model Performance

Suggested History Questions:

  1. “Does the shaking improve when you pick up a glass of water or use a tool?” (Differentiates rest vs. action).
  2. “Have you noticed any change in your voice, your balance, or your sense of smell?” (Screens for Parkinsonian features).
  3. “Has anyone in your family had similar shaking issues?” (Probes for Essential Tremor).

Suggested Examination Commentary:

“I am inspecting Arthur’s face for reduced expression and his hands for a resting tremor. Arthur, could you please count backward from 20 for me? [Observes increased tremor]. I am now checking for a postural tremor—please hold your arms out like this. Now, please touch your nose and then my finger. I am now checking the tone in your wrists—I note some ‘cogwheel’ resistance on the right. Finally, Arthur, please tap your index finger and thumb together as fast and as wide as you can.”

How to explain the diagnosis:

“Arthur, based on my examination, you have what we call a resting tremor. This, combined with the stiffness I felt in your wrist and the slight slowness in your finger movements, suggests a condition called Parkinson’s Disease. It’s a condition where the brain’s ‘message system’ for movement becomes less efficient. While this is a significant diagnosis, there are many effective treatments available to help manage these symptoms and keep you active in your garden.”

Statistics and Prevalence

Parkinson’s Disease (PD) is the second most common neurodegenerative disorder globally.

  • Prevalence: Approximately 1% of the population over the age of 60 is affected.
  • Clinical Triad: The diagnosis is clinical, requiring 2 out of the 3 cardinal signs: Resting Tremor, Rigidity, and Bradykinesia.
  • Resting Tremor: Present in about 70-80% of PD patients at some point in their illness.