Duration: 10 minutes (2 mins reading, 8 mins performance)
Focus: Physical Examination & Clinical Reasoning (Neurological)
Learning Objectives
- Perform a structured lower limb neurological examination using the I T P R S C framework.
- Demonstrate accurate myotome testing (L2–S1) and reflex technique.
- Communicate findings to the patient using lay language and Murtagh’s patient-centered approach.
Patient Profile
- Name: Mr. Robert Miller
- Age: 58 years old
- Occupation: Retired Carpenter
- Social History: Lives with his wife; non-smoker; drinks 1–2 glasses of wine on weekends.
Presenting Complaint
Mr. Miller presents with a 3-month history of progressive “heaviness” in his right leg and occasional tripping while walking.
Contextual Information
- HPC: Gradual onset. No sudden trauma. No back pain or urinary incontinence. He feels he has to lift his right foot higher than his left to avoid catching his toe on the carpet.
- PMHx: Type 2 Diabetes (well-controlled on Metformin), Hypertension.
- Medications: Metformin 500mg BD, Ramipril 5mg OD.
- Allergies: Nil.
Exam Instructions
Candidate Instructions
“Mr. Miller has presented complaining of right leg weakness. You have 8 minutes to:
- Perform a focused neurological examination of the lower limbs.
- Explain your findings and your suspected diagnosis to the patient.
Note: You are expected to provide a ‘running commentary’ of your examination to the examiner while maintaining rapport with the patient.“
Standardised Patient (SP) Instructions
- Affect: Cooperative but slightly anxious about “getting old.”
- Physical Findings (Simulated): * Tone: Normal.
- Power: When the candidate tests Right Foot Dorsiflexion (L5), offer only Grade 3 resistance (can move against gravity but not against the examiner’s hand). All other myotomes are Grade 5.
- Sensation: If tested with a “sharp/soft” touch, report reduced sensation in the web space between the big toe and second toe on the right foot.
- Reflexes: All appear normal (2+).
- Response to Questions: If asked about pain, say “No pain, just feels clumsy.”
Examiner Checklist Items
- Properly introduces self and gains consent.
- Follows I T P R S C sequence (Inspection, Tone, Power, Reflexes, Sensation, Coordination).
- Correctly identifies L5 weakness (Dorsiflexion).
- Maintains patient dignity (appropriate draping).
- Uses Australian reference standards (Talley/Murtagh) for technique (e.g., “log roll” for tone).
Key Clinical Findings
- Vitals: BP 135/85, HR 72 (Stable).
- Inspection: Mild wasting of the right tibialis anterior; no fasciculations.
- Power: Isolated weakness in right L5 (Dorsiflexion and Hallux Extension).
- Gait: Evidence of a mild “high steppage” gait on the right.
- Sensation: Sensory deficit in the L5 dermatome distribution.
Communication Triggers (Murtagh’s Approach)
- Open-ended start: “Mr. Miller, I understand you’ve been having some trouble with your leg. Can you tell me more about how that’s affecting your daily walk?”
- Normalizing: “I’m going to perform some movements that might feel a bit repetitive, but they help me understand exactly which nerves are working.”
- The “Tell-Back”: “Just to make sure we’re on the same page, you’ve noticed your foot catching on the ground, but you haven’t had any back pain or accidents, is that right?”
Assessment & Marking Guide
| Domain | Key Performance Indicators |
| Physical Exam | Systematic (I-T-P-R-S-C). Correct L2-S1 sequence (Swing Phase logic). |
| Technique | Correct use of reflex hammer; “Log roll” for hip tone; proper sensory comparison. |
| Clinical Reasoning | Correctly identifies L5 nerve root involvement. Mentions differential (e.g., Common Peroneal Nerve vs. L5 Radiculopathy). |
| Communication | Avoids jargon. Empathetic tone. Summarizes findings clearly to the patient. |
Sample Model Performance
Examination Commentary (The “Running Commentary”)
“I am starting with Inspection, looking for wasting or fasciculations. Now assessing Tone via the ‘log roll’ and ‘knee lift’ tests. Moving to Power—I’m testing L2 (hip flexion), L3 (knee extension), L4 (inversion), L5 (dorsiflexion), and S1 (plantarflexion). I note weakness in L5 on the right. I will now check Reflexes (Knee S1,2; Ankle L3,4) and Sensation following the dermatomes. Finally, Coordination via heel-to-shin.”
Explanation to Patient
“Mr. Miller, based on the exam, the weakness you’re feeling in your foot is linked to a specific nerve root in your lower back, which we call the L5 level. It’s causing your foot to drop slightly, which is why you’re tripping. I’d like to organize an imaging scan of your back and perhaps a nerve conduction study to see exactly where the nerve is being pinched.”