Duration: 10 Minutes (2 minutes reading time, 8 minutes encounter)
Learning Objective
- Primary: Demonstrate a systematic, chronological lower limb neurological examination.
- Secondary: Demonstrate the ability to filter clinical distractors (statin-induced myopathy vs. neuropathy) and maintain professional narration.
Patient Profile
- Name: Mr. David Miller
- Age: 62 years old
- Ethnicity: Caucasian
- Occupation: Retired Accountant
- Social History: Lives with his wife; non-smoker; drinks 1–2 glasses of wine on weekends.
Presenting Complaint
Mr. Miller presents with a 3-week history of “clumsiness” in his legs and occasional difficulty getting out of deep chairs. He is also concerned about recent erectile dysfunction and wonders if it’s related to his cholesterol medication.
Contextual Information
- History of Presenting Complaint (HPC): Gradual onset. No back pain, no urinary or fecal incontinence. No “pins and needles.”
- Past Medical History: Hypercholesterolemia (5 years), Hypertension (10 years).
- Medications: Atorvastatin 40mg daily, Amlodipine 5mg daily.
- Allergies: No known drug allergies.
Exam Instructions
Candidate Instructions
- Perform a focused Lower Limb Neurological Examination.
- Provide a running commentary to the examiner, including relevant nerve roots for power and reflexes.
- Explain your findings to the patient using lay language.
- Note: You do not need to take a full history; focus on the examination as requested.
Standardized Patient (SP) Instructions
- Demeanor: You are slightly anxious. You are worried that your “statins” are causing muscle damage or that your erectile dysfunction is a sign of a serious nerve problem.
- Gait: If asked to walk, walk slowly and slightly wide-based.
- Examination: * Tone: Normal.
- Power: 4/5 in hip flexion and knee extension; 5/5 everywhere else.
- Reflexes: 1+ (diminished) at the knees; 2+ (normal) at the ankles.
- Sensation: Normal to light touch across all dermatomes.
- Coordination: Slightly unsteady on the heel-to-shin test.
- Scripted Question: “Doctor, I read that my cholesterol tablets cause muscle problems. Is that what’s happening to my nerves?”
Examiner Checklist Items
- [ ] Washes hands and introduces self (WIPPE).
- [ ] Assesses Gait at the start of the exam.
- [ ] Inspects for wasting/fasciculations.
- [ ] Performs the I-T-P-R-S-C sequence in order.
- [ ] Identifies correct nerve roots for Knee (L3, L4) and Ankle (S1, S2) reflexes.
- [ ] Uses only one sensory modality (e.g., cotton wool) across L1–S1.
- [ ] Correctly demonstrates the Heel-to-Shin test before asking the patient to perform it.
Key Clinical Findings
- Vital Signs: Stable (BP 135/85, Pulse 72).
- Gait: Mildly ataxic (unsteady).
- Motor: Proximal weakness (L2/L3) 4/5; distal power 5/5. No wasting.
- Reflexes: Symmetrically diminished knee jerks (L3/L4).
- Sensation: Intact L1 through S1.
- Coordination: Impaired heel-to-shin bilaterally.
Communication Triggers (Murtagh’s Approach)
- Open-Ended Start: “Before we begin the physical exam, can you tell me in your own words how this weakness is affecting your daily life?”
- Signposting: “I am now going to test your reflexes by tapping on your tendons with this hammer.”
- Addressing the “Trap”: “Mr. Miller, while statins can cause muscle aches (myopathy), the findings today suggest we need to look closer at the coordination signals from your nerves.”
- Empathy: “I understand the erectile dysfunction is concerning; we will address that once we’ve finished checking your leg nerves.”
Assessment & Marking Guide
| Domain | Minimal Competence (C) | Superior Performance (A) |
| Systematic Approach | Follows most of the I-T-P-R-S-C sequence. | Flawless I-T-P-R-S-C sequence with no backtracking. |
| Technical Skill | Tests power and reflexes adequately. | Narrates specific nerve roots (L3/L4, S1/S2) clearly to the examiner. |
| Sensory Exam | Tests multiple levels. | Stays focused on one modality; moves logically L1 -> S1. |
| Patient Safety | Ensures patient is comfortable. | Explains every step; ensures patient doesn’t fall during gait/coordination. |
Sample Answers / Model Performance
Suggested Running Commentary:
“I am observing the patient’s gait… I note a slight unsteadiness. Now, I am inspecting the muscle bulk for wasting or fasciculations. Assessing tone at the hip, knee, and ankle… Tone is normal. Testing power: Hip flexion L2/L3 is 4/5. Knee extension L3/L4 is 4/5. Testing Knee Reflexes, representing L3 and L4 nerve roots… they appear symmetrically diminished.”
Addressing the Patient (Closing):
“Mr. Miller, thank you for your patience. Based on my exam, your sensation is perfectly fine, but there is some mild weakness in your thighs and some issues with coordination. While your cholesterol medication can cause muscle aches, it wouldn’t usually cause this specific pattern of coordination trouble. I’d like to organize some further imaging of your back and perhaps some nerve conduction studies to get to the bottom of this.”
Would you like me to generate a marking rubric specifically for the “Standardized Patient” to use during the feedback session?