Station Title & Timing

  • Title: Focused Hand Examination and Neurological Assessment
  • Duration: 10 Minutes (2 minutes reading time, 8 minutes performance)
  • Focus: Focused Physical Examination, Clinical Reasoning, and Communication.

Learning Objective(s)

  • Perform a systematic “Look, Feel, Move” examination of the hand and wrist.
  • Differentiate between musculoskeletal and neurological pathology (Median nerve focus).
  • Communicate findings professionally using a “Running Commentary” (25% to patient, 75% to examiner).

Patient Profile

  • Name: Mrs. Elena Rossi
  • Age: 48 years old
  • Ethnicity: Caucasian (Italian-Australian)
  • Occupation: Data Entry Clerk / Stenographer
  • Social History: Lives with her husband; enjoys knitting. Non-smoker.

Presenting Complaint

Mrs. Rossi presents with a six-month history of “pins and needles” and a feeling of “clumsiness” in her right hand, which has become significantly worse over the last three weeks, especially at night.

Contextual Information

  • HPC: Numbness affects the thumb, index, and middle fingers. She often has to “shake her hand” in the morning to get the feeling back. She recently dropped a boiling pot of water because her grip felt “empty.”
  • PMHx: Hypothyroidism (stabilized on Levothyroxine); BMI 31 (Obese).
  • Medications: Levothyroxine 100mcg daily; occasional Ibuprofen for hand pain.
  • Allergies: Nil.

Exam Instructions

Candidate Instructions

Mrs. Elena Rossi presents with right-hand symptoms.

  1. Perform a focused physical examination of the patient’s right hand and wrist.
  2. Incorporate a neurological assessment relevant to her symptoms.
  3. Provide a running commentary to the examiner during the process.
  4. Briefly discuss your provisional diagnosis with the examiner.

Standardised Patient (SP) Instructions

  • Setting: You are sitting on a chair next to a clinical table with a pillow on it.
  • Affect: You are anxious about “losing the use of your hand” as your job depends on typing.
  • Physical Signs: When the candidate asks to see your hand, place it on the pillow.
    • If they test sensation, report “dulled feeling” on the pads of the thumb and index finger.
    • If they perform the “Pen Test” (Abduction), act as if your thumb is slightly weak compared to the other side.
    • Tinel’s Sign: If they tap your wrist, say: “Oh! That sends an electric shock into my middle finger.”
    • Phalen’s Test: If they hold your wrists in flexion for 30 seconds, say: “The tingling is starting to come back now.”

Examiner Checklist Items

  • Washes hands and introduces self (WIPE).
  • Positions the patient correctly using the pillow.
  • Performs Inspection (Looks for Thenar wasting, scars, protective posture).
  • Performs Palpation (T-C-P-T): Temperature, Capillary Refill, Radial Pulse, Tenderness.
  • Tests Active Movements (Fist, Extension, Abduction).
  • Conducts Neurological Motor Tests (M-U-R): Specifically the Pen Test (Median) and Froment’s (Ulnar).
  • Performs Special Tests: Phalen’s and Tinel’s.
  • Maintains professional communication/Running Commentary.

Key Clinical Findings

  • Inspection: Mild wasting of the thenar eminence (base of the thumb). No redness or Bouchard’s/Heberden’s nodes.
  • Palpation: Normal temperature; Capillary refill < 2 seconds; Pulse 72 bpm regular. No tenderness over the Scaphoid/Snuffbox.
  • Neurological: Reduced sensation over the Median nerve distribution. Positive Pen Test (weakness in Abduction). Negative Froment’s sign.
  • Special Tests: Positive Tinel’s and Phalen’s signs.

Communication Triggers (Murtagh’s Approach)

  • Open-ended: “Mrs. Rossi, can you show me exactly where the numbness feels the worst?”
  • Empathy: “I understand this is worrying, especially given how much you rely on your hands for work.”
  • Lay Language: Instead of “Thenar atrophy,” say “Some slight thinning of the muscle at the base of your thumb.”

Assessment & Marking Guide

CriteriaSatisfactoryUnsatisfactory
Systematic ApproachFollowed L-F-M structure logically.Haphazard exam; skipped steps.
Technical SkillCorrectly performed Phalen’s and Pen Test.Poor technique; caused patient pain.
Clinical ReasoningIdentified Median nerve involvement.Failed to differentiate from Ulnar/Radial.
CommunicationUsed the pillow/paper; clear commentary.Silent exam; ignored patient comfort.

Global Rating:

  • Pass: Demonstrated a safe, structured exam with a clear focus on Carpal Tunnel differentials.
  • Fail: Missed the neurological component or failed to inspect the palmar aspect of the hand.

Sample Answers / Model Performance

Candidate’s Running Commentary:

“I am inspecting the hands on the pillow. I note some mild wasting of the thenar eminence on the right side, suggesting chronic median nerve compression. There are no surgical scars or signs of inflammatory arthritis. Moving to ‘Feel,’ the temperature is equal bilaterally, and capillary refill is brisk. I am palpating the wrist and snuffbox; Mrs. Rossi, is there any pain here? (Patient: No). Now for ‘Move,’ I’ll ask the patient to make a fist and tuck her thumb in. Now, I will perform the ‘Pen Test’ for the Median nerve—Mrs. Rossi, please lift your thumb up to touch my pen. This shows slight weakness. Finally, I’ll perform Phalen’s test to provoke the symptoms.”

Provisional Diagnosis:

“Based on the thenar wasting, sensory loss in the first three and a half digits, and positive provocative tests, the most likely diagnosis is Carpal Tunnel Syndrome, likely exacerbated by her occupation and underlying hypothyroidism.”