Station Title & Timing

  • Title: Focused Neurological Examination – Lower Limb Sensory Loss
  • Duration: 10 minutes total (2 minutes reading time, 8 minutes performance)
    • Note: Candidates are expected to complete the physical examination and explanation within the 8-minute window.

Learning Objectives

  • Perform a systematic and efficient sensory/neurological examination of the lower limbs.
  • Demonstrate proficiency in using the 10g monofilament and 128Hz tuning fork.
  • Communicate clinical findings and a working diagnosis to a patient using lay language.
  • Identify potential differential diagnoses for peripheral neuropathy.

Patient Profile

  • Name: Mr. Arthur Miller
  • Age: 55 years old
  • Ethnicity: Caucasian
  • Occupation: Retired Accountant
  • Social History: Lives with his wife. Non-smoker, occasional glass of wine.

Presenting Complaint

Mr. Miller presents to the GP clinic complaining of “pins and needles” and a “numb, fuzzy feeling” in both of his feet that has been progressively worsening over the last three months.

Contextual Information

  • History of Presenting Complaint (HPC): The sensation is bilateral and symmetrical. It feels like he is “walking on cotton wool.” No motor weakness reported. No back pain or urinary symptoms.
  • Past Medical History (PMH): Type 2 Diabetes Mellitus (diagnosed 12 years ago), Hypertension.
  • Medications: Metformin 1000mg BD, Ramipril 5mg OD.
  • Allergies: Nil.
  • Recent Labs: Last HbA1c was 8.4% (elevated).

Exam Instructions

Candidate Instructions

Arthur Miller has presented with sensory symptoms in his feet.

  1. Conduct a focused physical examination of the lower limbs relevant to his complaint.
  2. Provide a “Running Commentary” to the examiner during your examination.
  3. Explain your findings and a likely diagnosis to the patient.
  4. Briefly outline the next steps in management.

Note: You do NOT need to assess gait or perform a Romberg’s test.

Standardised Patient (SP) Instructions

  • Demeanour: Concerned but cooperative.
  • Key Instruction: If the candidate asks you to walk or stand for a balance test (Gait/Romberg), walk extremely slowly and deliberately. Your goal is to be a “time-sink” if they choose the wrong clinical path.
  • Sensory Testing: * Report reduced sensation from the toes up to the mid-calf (stocking distribution) for light touch and pinprick.
    • You cannot feel the 10g monofilament on the soles of your feet.
    • You can only feel the tuning fork vibration when it reaches your knees, not on your toes or ankles.
  • Opening Statement: “Doctor, my feet have been feeling very strange lately, like they’re falling asleep and won’t wake up.”

Examiner Checklist Items

  • Was the examination sequence logical (Inspection $\rightarrow$ Sensation $\rightarrow$ Reflexes)?
  • Did the candidate inspect between the toes and check for Charcot joints?
  • Did the candidate correctly use the 128 Hz tuning fork and 10g monofilament?
  • Did the candidate vocalize the dermatomes ($L1$–$S1$) during the exam?
  • Did the candidate avoid the “Gait Trap”?

Key Clinical Findings

  • Inspection: Dry skin, loss of hair on lower legs. No active ulcers, but a small bunion on the right hallux.
  • Sensation: Bilateral “glove and stocking” sensory loss to light touch and pinprick up to the mid-shin.
  • Vibration/Proprioception: Loss of vibration sense at the hallux and malleolus. Proprioception (joint position) is intact at the hallux but slow.
  • Monofilament: 0/4 points felt on the plantar surface of both feet.
  • Reflexes: Ankle jerks (S1, S2) are absent bilaterally. Knee jerks (L3, L4) are present but sluggish.

Communication Triggers (Murtagh’s Approach)

  • Open-ended: “Can you tell me more about how this feeling in your feet is affecting your daily life?”
  • Summarising: “So, you’ve noticed this numbness in both feet for three months, and it’s worse at night, is that correct?”
  • Lay Language: Avoid “distal symmetrical polyneuropathy.” Use “damage to the small nerves caused by sugar levels.”

Assessment & Marking Guide

CategoryKey Performance Indicators
Physical ExamSystematic inspection (toes/soles); Correct dermatomal testing; Correct tool technique.
EfficiencyAvoided gait/Romberg; Vocalized findings clearly (“Running Commentary”).
Clinical ReasoningIdentified “Stocking” distribution; Mentioned HbA1c correlation.
CommunicationEmpathic delivery of diagnosis; Used the D-I-V-I-N-E mnemonic for differentials if asked.

Sample Answers / Model Performance

Suggested History/Intro Questions

  • “Mr. Miller, besides the pins and needles, have you noticed any sores on your feet that are slow to heal?”
  • “Have you had any trouble with your balance or tripped lately?”

Explaining the Diagnosis

“Arthur, based on the tests today, it appears you have developed what we call diabetic neuropathy. Essentially, over time, high blood sugar levels can damage the tiny blood vessels that feed your nerves, particularly the long ones going to your feet. This is why you feel that ‘stocking’ sensation of numbness. It’s important because it means you might not feel a cut or an injury, which could lead to an infection.”

The DIVINE Differential (for the Examiner)

If the examiner asks for other causes, the candidate should state:

  • Diabetes
  • Infection (or B12 deficiency)
  • Vasculitis
  • Idiopathic
  • Neoplasia
  • Endocrine (Hypothyroidism)