Station Title: Neurological Examination – Chronic Unsteadiness

Duration: 10 Minutes (2 minutes reading time, 8 minutes performance)

Focus: Physical Examination, Clinical Reasoning, and Patient Safety.

Learning Objectives

  • Demonstrate a structured and safe neurological examination of the lower limbs and gait.
  • Differentiate between cerebellar ataxia and sensory ataxia using the Romberg test.
  • Identify signs of chronic alcohol-related neurological damage.
  • Maintain patient safety and professional communication throughout the assessment.

Patient Profile

  • Name: Mr. Robert Miller
  • Age: 54 years old
  • Ethnicity: Caucasian
  • Occupation: Retired construction worker
  • Social History: Lives alone; reports drinking 8–10 beers daily for the past 20 years.

Presenting Complaint

Mr. Miller presents with a 6-month history of becoming increasingly “clumsy” on his feet. He feels like he is walking “like a drunk person” even when he hasn’t had a drink that morning.

Contextual Information

  • HPC: Gradual onset, progressive. No sudden weakness, no recent falls (but many “near misses”). No vertigo or hearing loss.
  • PMH: Hypertension, Type 2 Diabetes (diet-controlled).
  • Medications: Perindopril 5mg daily.
  • Allergies: Nil.

Candidate Instructions

Setting: General Practice / Outpatient Clinic

Task: 1. Perform a focused physical examination to determine the cause of the patient’s unsteady gait.

2. Formulate a differential diagnosis and brief management explanation for the patient.

3. You must prioritize patient safety during the examination.

Standardised Patient (SP) Instructions

  • Demeanour: Cooperative but slightly embarrassed about his “clumsiness.”
  • Gait: When asked to walk, use a broad-based gait (feet wide apart).
  • Tandem Walk: Stumble significantly when asked to walk heel-to-toe.
  • Romberg Test: You are unstable as soon as you stand with feet together, even with eyes open. You must sway/stumble immediately. (The candidate should catch/support you).
  • Coordination: * Finger-to-Nose: Slight tremor as your finger nears your nose.
    • Heel-to-Shin: Your heel wobbles and slips off your shin several times.
  • Speech: Slightly slurred/staccato when saying “West Register Street.”

Key Clinical Findings

  • Vitals: BP 145/90, HR 82 (regular), Afebrile.
  • Gait: Broad-based, ataxic. Positive tandem gait impairment.
  • Romberg: Positive (Eyes open = Cerebellar).
  • Cerebellar Signs (DANTES):
    • D: Dysdiadochokinesia present in upper limbs.
    • A: Truncal ataxia (difficulty sitting up without arms).
    • N: Nystagmus (horizontal/vertical).
    • T: Intention tremor.
    • E: Staccato speech.
    • S: Pendular knee reflexes.
  • Pertinent Negatives: No loss of vibration or proprioception (rules out simple sensory neuropathy).

Communication Triggers (Murtagh’s Approach)

  • Open-Ended: “Mr. Miller, tell me more about how this balance trouble is affecting your daily life?”
  • Safety Check: “I’m going to stand right beside you while you walk to make sure you don’t lose your balance.”
  • Signposting: “Now I’m going to test your coordination by asking you to tap your feet.”
  • Lay Language: Avoid “Ataxia.” Use “Incoordination” or “Issues with the brain’s balance center.”

Assessment & Marking Guide

CriteriaCritical ActionsScore (1-5)
Patient SafetyStands close to SP during gait/Romberg; prevents falls.
Gait AssessmentAssesses normal gait, tandem gait, and heel/toe walking.
The Pivot (Romberg)Correctly performs Romberg; identifies fall with eyes open.
Cerebellar ExamTests finger-nose, heel-shin, and dysdiadochokinesia.
EfficiencyMoves logically from Standing → Sitting → Lying.
Clinical ReasoningCorrectly identifies Alcoholic Cerebellar Degeneration.
CommunicationUses clear, non-judgmental language regarding alcohol use.

Sample Model Performance

The “Pivot” (Romberg Test):

  • Candidate: “Mr. Miller, please stand with your feet together and keep your eyes open. I am right here to catch you.”
  • SP: (Sways immediately).
  • Candidate: “Since you are unsteady with your eyes open, this suggests the issue is in the cerebellum—the balance center of the brain—rather than just a loss of feeling in your feet.”

Differential Diagnosis Explanation:

  • “Based on our exam, the main concern is Alcohol-Induced Cerebellar Degeneration. This happens when long-term alcohol use affects the back of the brain. However, I also want to rule out other causes like Vitamin B12 deficiency or issues with your inner ear. We will need some blood tests and potentially a scan of your brain.”