Duration: 10 Minutes (2 minutes reading time, 8 minutes assessment)
Focus: Physical Examination Skills, Clinical Reasoning, and Communication.
Learning Objectives
- Perform a systematic upper limb neurological examination using the ITPRSC framework.
- Differentiate between Upper Motor Neuron (UMN) and Lower Motor Neuron (LMN) signs.
- Provide a clear running commentary to the examiner.
- Formulate a differential diagnosis based on exam findings.
Patient Profile
- Name: Mrs. Elena Rossi
- Age: 62 years old
- Gender: Female
- Ethnicity: Italian-Australian
- Occupation: Retired Librarian
- Social History: Lives with her husband; non-smoker; occasional glass of wine.
Presenting Complaint
Mrs. Rossi presents to the clinic complaining of a “clumsy” right hand and a feeling of weakness that started suddenly two hours ago and lasted for approximately 25 minutes before resolving. She is now feeling “mostly back to normal” but is concerned.
Contextual Information
- HPC: Sudden onset weakness in the right hand while gardening. No headache, no visual changes, no speech difficulty. Symptoms lasted 25 minutes.
- PMHx: Hypertension (controlled), Type 2 Diabetes (diet-controlled).
- Medications: Amlodipine 5mg daily. No known allergies.
Exam Instructions
Candidate Instructions
Mrs. Rossi is here following an episode of right-hand weakness that has since resolved.
- Perform a focused neurological examination of the upper limbs.
- Provide a running commentary of your findings to the examiner.
- Briefly discuss your provisional diagnosis and immediate management with the patient.
Standardised Patient (SP) Instructions
- Demeanour: You are anxious but cooperative. You want to know if you’ve had a “mini-stroke.”
- Physical Findings: During the exam, you should act normally. All power, tone, and reflexes should appear normal now (as the TIA has resolved).
- Opening Statement: “Doctor, my hand just went dead for a while this morning. It’s better now, but I’m worried.”
Examiner Checklist Items
- Performs WIPE (Wash hands, Introduce, Permission, Exposure).
- Uses the ITPRSC mnemonic correctly.
- Verbalizes the search for wasting and fasciculations.
- Correctly identifies myotomes (C5–T1) during power testing.
- Assesses reflexes (Biceps/Triceps) and coordination (Finger-to-nose).
- Maintains patient rapport and explains steps in lay terms.
Key Clinical Findings (Current Status)
- Vitals: BP 155/90, HR 82 (regular), Temp 36.5°C.
- Inspection: No wasting, no fasciculations, no tremors.
- Tone: Normal throughout.
- Power: 5/5 in all groups (C5–T1).
- Reflexes: 2+ (Normal) biceps and triceps bilaterally.
- Sensation: Intact to light touch in all dermatomes.
- Coordination: Normal finger-to-nose; no dysdiadochokinesia.
Communication Triggers (Murtagh Approach)
- Open-Ended Start: “Can you tell me more about what happened when your hand went weak?”
- Empathetic Bridging: “I understand this is a frightening experience. I’m going to check your nerves to see how things are working now.”
- Signposting: “First, I’ll look at the muscles, then check your strength, and then your reflexes.”
- Lay Language: Instead of “Dysdiadochokinesia,” use “rapid hand-clapping movements.”
Assessment & Marking Guide
| Criteria | Fail | Pass | Excellent |
| Systematic Approach | Missed multiple steps of ITPRSC. | Followed ITPRSC with minor prompts. | Fluid, logical sequence without prompting. |
| Running Commentary | Silent during the exam. | Mentioned most findings. | Detailed commentary (e.g., “Testing C7 extension”). |
| Localization | Could not distinguish UMN vs LMN. | Identified importance of wasting/fasciculations. | Expertly explained the absence of LMN signs. |
| Diagnosis | Missed the TIA diagnosis. | Identified TIA as a possibility. | Correctly identified TIA and the need for stroke prevention. |
Sample Answers / Model Performance
The Running Commentary:
“I am inspecting the small muscles of the hand and the forearms for any wasting or fasciculations, which would suggest a Lower Motor Neuron lesion. I see none. Now, I am assessing tone at the wrist and elbow… Tone is normal. I will now test power: push up against me (C5/C6)… push down (C7)… squeeze my fingers (C8/T1). Power is 5/5.”
The Diagnosis & Plan:
“Mrs. Rossi, your physical exam today is normal, which is actually expected given that your symptoms went away. However, based on the fact that your weakness lasted 25 minutes and came on suddenly, I am concerned you had a Transient Ischaemic Attack (TIA), or what some call a ‘mini-stroke.’ Because you have high blood pressure and diabetes, we need to act quickly to prevent a full stroke. I would like to refer you for an urgent brain scan and an ultrasound of the arteries in your neck.”