Station Title & Timing

  • Title: The Unsteady Gait (Lower Limb Neurological Examination)
  • Duration: 10 Minutes Total
    • Reading Time: 2 minutes
    • Performance Time: 8 minutes

Learning Objective(s)

  • Primary: Perform a focused lower limb neurological examination with an emphasis on sensory modalities.
  • Secondary: Demonstrate clinical reasoning by distinguishing sensory ataxia from cerebellar ataxia using the Romberg test.
  • Tertiary: Communicate a diagnosis of Alcohol-Induced Sensory Neuropathy using patient-centered language.

Patient Profile

  • Name: Mr. James Bennett
  • Age: 50 years old
  • Gender: Male
  • Occupation: Warehouse Supervisor
  • Social History: Lives alone; reports drinking 8–10 beers daily for the last 15 years. Non-smoker.

Presenting Complaint

Mr. Bennett presents with a 4-month history of “unsteadiness on his feet” and a feeling of “walking on cotton wool.” He has had two near-falls in the bathroom at night.

Contextual Information

  • HPC: Gradual onset, symmetrical. Worse in the dark or when closing eyes to wash face. No focal weakness.
  • PMHx: Hypertension (controlled).
  • Medications: Amlodipine 5mg daily.
  • Investigations Provided in Stem: FBE, B12/Folate, HbA1c, LFTs, and Thyroid Function Tests are all within normal limits.
  • Allergies: Nil known.

Exam Instructions

Candidate Instructions

  1. Briefly assess the patient’s gait.
  2. Perform a focused neurological examination of the lower limbs.
  3. Discuss your findings and most likely diagnosis with the patient.
  4. Answer any questions the examiner may have regarding differentials.

Standardised Patient (SP) Instructions

  • Demeanour: Cooperative but slightly anxious about “losing balance.”
  • Gait: When asked to walk, take small, hesitant steps. You feel like you don’t know exactly where your feet are.
  • Romberg Test: Stand with feet together. You are steady with eyes open. As soon as you close your eyes, you begin to sway significantly and lose balance (the examiner should catch you).
  • Sensory Exam:
    • Light Touch/Pinprick: You cannot feel the cotton wool or pin clearly until the mid-shin level (Glove and Stocking distribution).
    • Vibration: You cannot feel the tuning fork at the big toe or ankle; you only feel it at the knee.
    • Proprioception: With your eyes closed, you cannot tell if the doctor is moving your big toe “up” or “down.”

Examiner Checklist Items

  • Performs Gait and Romberg test safely.
  • Systematically tests Light Touch, Pinprick, Vibration (128Hz), and Proprioception.
  • Identifies the “Glove and Stocking” sensory loss pattern.
  • Explains the diagnosis of Alcohol-Induced Sensory Neuropathy clearly.

Key Clinical Findings

  • Vital Signs: Stable (BP 130/85, HR 72).
  • Gait: Sensory ataxic (hesitant, non-broad-based). Positive Romberg’s Sign.
  • Sensory: Symmetrical distal loss of all modalities (L4-S1 distribution).
  • Motor: Power 5/5 globally.
  • Reflexes: Ankle jerks are absent/diminished; Knee jerks are present.
  • Cerebellar: No nystagmus, no dysmetria (finger-to-nose normal), no dysdiadochokinesia.

Communication Triggers (Murtagh’s Approach)

  • Open-ended Opening: “Mr. Bennett, I understand you’ve been feeling unsteady. Can you describe that sensation for me?”
  • Signposting: “I’m going to test the sensation in your legs now to see exactly which nerves are affected.”
  • Lay Language: Avoid “Proprioception” or “Distal Polyneuropathy.” Use “Position sense” and “Nerve damage caused by alcohol.”
  • Empathetic Closing: “I know this is concerning. The good news is we have ruled out diabetes and vitamin deficiencies, but we need to talk about how alcohol is affecting your nerves.”

Assessment & Marking Guide

Assessment DomainKey Performance Indicators
Physical ExamCorrect use of 128Hz tuning fork; demonstrates Romberg test safely; maps sensory level accurately.
Clinical ReasoningCorrectly identifies that a positive Romberg sign points to sensory loss, not a brain (cerebellar) issue.
CommunicationExplains the link between 8-10 beers/day and nerve damage without being judgmental.
ManagementMentions alcohol cessation, safety at home (lighting/rails), and podiatry referral.

Sample Answers / Model Performance

Candidate: “Mr. Bennett, based on my examination, you were able to balance with your eyes open, but you lost balance the moment you closed them. This, along with the loss of feeling in your feet, tells me that the nerves carrying ‘position signals’ from your legs to your brain are damaged. This is called Sensory Neuropathy.”

Patient: “What caused it? Is it a stroke?”

Candidate: “No, it’s not a stroke. Your blood tests ruled out diabetes and vitamin shortages. The most likely cause here is the long-term effect of alcohol on your nerves. Alcohol acts as a toxin to these nerve fibers over time. We need to work on a plan to reduce your intake to prevent this from getting worse, and I’d like to refer you to a podiatrist to ensure your feet stay healthy since you can’t feel them as well now.”