Station Title & Timing
- Title: The Unsteady Patient (Neurological Examination Station)
- Total Duration: 10 minutes (2 minutes reading time + 8 minutes performance time)
Learning Objectives
- Primary: Perform a focused neurological examination to differentiate between cerebellar ataxia and sensory neuropathy.
- Secondary: Demonstrate patient safety (fall prevention), effective clinical reasoning using the “Romberg Pivot,” and professional communication of findings.
Patient Profile
- Name: Mr. David Miller
- Age: 54 years old
- Ethnicity: Caucasian
- Occupation: Unemployed (formerly a construction worker)
- Social History: Chronic alcohol use (approximately 6–8 standard drinks daily for 15 years). Lives alone.
Presenting Complaint
“Doctor, I’ve been feeling very wobbly on my feet lately. It feels like I’m walking on a boat, and I’m worried I might have a fall.”
Contextual Information
- History of Presenting Complaint: Gradual onset of unsteadiness over the last 4 months. No recent head trauma. No sudden weakness or facial drooping.
- Past Medical History: Hypertension, Type 2 Diabetes (poorly controlled).
- Medications: Metformin 1000mg BD, Ramipril 10mg OD.
- Allergies: Nil known.
Exam Instructions
Candidate Instructions
Mr. David Miller has presented to the clinic complaining of an unsteady gait. He has a known history of chronic alcohol use and diabetes.
- Introduce yourself and obtain consent.
- Conduct a focused physical examination to determine the cause of his unsteadiness.
- Ensure patient safety at all times.
- Briefly summarize your findings and differential diagnosis to the examiner.
Standardised Patient (SP) Instructions
- Demeanour: You are anxious about falling. You are cooperative but physically unsteady.
- The Gait: When asked to walk, adopt a broad-based gait (feet wide apart). Stagger slightly.
- The Romberg Test: * Scenario A (Cerebellar): If the candidate asks you to stand with feet together, you begin to sway even with your eyes open.
- Scenario B (Sensory): If the candidate asks you to stand with feet together, you are steady with eyes open, but as soon as you close your eyes, you lose balance and need to be caught.
- (Note: For this exam, the examiner will prompt you on which scenario to act out—usually Scenario A: Cerebellar Degeneration).
- Physical Signs: If tested for “finger-to-nose,” your hand should shake as it nears your nose (Intention tremor).
Examiner Checklist Items
- [ ] Performs a safe gait assessment (stands close to patient).
- [ ] Correctly performs and interprets the Romberg Test.
- [ ] Selects the correct pathway (Cerebellar vs. Sensory) based on Romberg.
- [ ] Checks for Nystagmus and Dysdiadochokinesia (if cerebellar).
- [ ] Checks for Peripheral Sensation and Proprioception (if sensory).
- [ ] Maintains professional “running commentary.”
Key Clinical Findings
- Vitals: BP 145/90, HR 88 (regular), Temp 36.6°C.
- General Appearance: Mild hand tremor, spider naevi on chest, smell of alcohol.
- Focused Exam (Cerebellar Focus):
- Gait: Broad-based, ataxic.
- Romberg: Positive (Unsteady with eyes open).
- Eyes: Horizontal nystagmus present.
- Upper Limbs: Intention tremor and dysdiadochokinesia present.
- Lower Limbs: Heel-to-shin ataxia; pendular knee jerks.
Communication Triggers (Murtagh’s Approach)
- Open-ended start: “Mr. Miller, I understand you’ve been feeling unsteady. Can you tell me more about how this affects your daily life?”
- Safety First: “Before we start the walking test, I’ll be right here beside you to make sure you’re steady. I won’t let you fall.”
- Signposting: “I’ve checked your balance while standing; now I’d like to check the coordination in your arms and legs.”
- Summarizing: “So, you’ve noticed this wobbliness for four months, it’s worse when you’re tired, and you’ve had a few near-misses. Is that correct?”
Assessment & Marking Guide
| Skill Area | Superior (Pass) | Satisfactory (Borderline) | Unsatisfactory (Fail) |
| Safety | Constant physical proximity; clear verbal warnings. | Stands nearby but hands not ready to catch. | Allows patient to walk/stand unsupported. |
| Clinical Logic | Uses Romberg to pivot; performs targeted DANISH/VTP exam. | Performs a mix of tests without clear direction. | Performs a generic, incomplete neuro exam. |
| Technique | Correct finger-to-nose (full extension) and heel-to-shin. | Shoddy technique; misses one or two maneuvers. | Incorrectly performs core maneuvers. |
| Diagnosis | Correctly identifies Alcoholic Cerebellar Degeneration. | Identifies “balance issue” but lacks specificity. | Unable to interpret Romberg or gait. |
Sample Answers / Model Performance
Suggested History/Intro Questions
- “When you feel unsteady, does it feel like the room is spinning (vertigo) or just that your legs won’t go where you want them to?”
- “Have you noticed any changes in your speech or any double vision?”
- “Do you find the walking gets much worse when it’s dark, like walking to the bathroom at night?” (Screens for sensory ataxia).
Model Explanation of Findings (to Examiner)
“On examination, Mr. Miller demonstrates a broad-based ataxic gait. His Romberg test was positive even with eyes open, which, along with his intention tremor, dysdiadochokinesia, and nystagmus, is highly suggestive of Cerebellar Degeneration, likely secondary to chronic alcohol use. I would also like to rule out Vitamin B12 deficiency and consider an MRI of the brain to exclude structural lesions.”