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

Focus: Physical Examination, Clinical Reasoning, and Communication Skills.

Learning Objectives

  • Demonstrate a systematic upper limb neurological examination focused on tremors.
  • Correctly perform and interpret “special tests” for Parkinson’s Disease (Glabella tap, Piano test, Micrographia).
  • Differentiate Parkinson’s Disease from Benign Essential Tremor and Medication-Induced Extrapyramidal Side Effects (EPSE).
  • Communicate clinical findings to the patient using patient-centered language.

Patient Profile

  • Name: Mr. Arthur Miller
  • Age: 68 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 six-month history of a progressive tremor in his right hand which is now beginning to affect his left hand. He is frustrated because it interferes with his hobby of woodworking.

Contextual Information

  • History of Presenting Complaint (HPC): Tremor is most noticeable when he is sitting watching TV. It seems to improve when he reaches for a glass or a tool.
  • Past Medical History (PMH): Hypertension (well-controlled), Mild Anxiety.
  • Medications: Amlodipine 5mg daily. No history of antipsychotic use (e.g., Risperidone).
  • Allergies: Nil.
  • Family History: Father had a “shaky hand” in his 80s, but it was never formally diagnosed.

Exam Instructions

Candidate Instructions

Mr. Miller has come to the clinic complaining of a hand tremor. The GP has already taken a brief history.

Your Tasks:

  1. Perform a focused upper limb neurological examination to differentiate the cause of the tremor.
  2. Perform relevant “Special Tests” for Parkinson’s Disease.
  3. Briefly explain your preliminary findings to the patient.

Note: You are NOT required to examine the lower limbs or cranial nerves unless time permits after the primary tasks. Do NOT start with gait.

Standardized Patient (SP) Instructions

  • Demeanor: Slightly anxious but cooperative.
  • The Tremor: When your hands are in your lap, exhibit a rhythmic “pill-rolling” tremor (rest tremor) in the right hand. When the candidate asks you to reach for their finger, the tremor should mostly disappear (improvement with intention).
  • The Face: Maintain a “masked” expression (hypomimia)—try not to smile or change facial expressions much.
  • The Writing: If asked to write, produce very small, cramped letters that get smaller toward the end of the sentence (Micrographia).
  • The Tap: If they tap your forehead (Glabella tap), do not stop blinking even after 5–10 taps.

Examiner Checklist Items

  • Performs WIPE (Wash, Introduce, Position, Expose).
  • Assesses tremor at rest, posture (arms out), and action (finger-to-nose).
  • Assesses tone (specifically checking for cogwheel rigidity at the wrist).
  • Performs “Piano Test” (finger tapping) to assess for Bradykinesia.
  • Performs Glabella Tap correctly.
  • Assesses for Micrographia.
  • Maintains patient rapport and uses lay language.

Key Clinical Findings (For Examiner)

  • Resting Tremor: Present (Pill-rolling).
  • Postural/Action Tremor: Absent or minimal.
  • Tone: Cogwheel rigidity present in the right wrist/elbow.
  • Bradykinesia: Positive (Slow, decreasing amplitude in “Piano Test”).
  • Glabella Tap: Positive (Persistent blinking).
  • Micrographia: Present.
  • Gait (If performed): Shuffling, stooped, reduced arm swing.

Communication Triggers (Murtagh Approach)

  • Open-ended start: “Mr. Miller, I understand you’ve been having some trouble with a tremor. Can you show me how it usually behaves?”
  • Summarizing: “So, it bothers you most at rest and gets a bit better when you move. Is that correct?”
  • Lay Language: Instead of “Bradykinesia,” use “slowness of movement.” Instead of “Hypomimia,” use “reduced facial expression.”

Assessment & Marking Guide

DomainMinimal Competence (Pass)Superior Performance
Physical ExamChecks rest tremor and tone.Systematic WIPE; checks rest, postural, and kinetic tremors; performs all special tests.
Clinical LogicRecognizes it is likely Parkinson’s.Explicitly rules out Essential Tremor (no improvement with alcohol, rest vs. action) and EPSE (no Risperidone).
CommunicationExplains the next steps clearly.Empathetic; addresses the patient’s woodworking frustration; avoids jargon.

Sample Answers / Model Performance

History/Intro Question:

“Mr. Miller, I’ve noticed the shaking in your hand while we’ve been talking. Does that shake ever happen when you are trying to use a screwdriver or pick up a cup, or is it mainly when your hand is relaxed?”

Explaining the Diagnosis:

“Mr. Miller, based on the stiffness I felt in your wrist and the slowness in your finger movements, it appears you have signs of what we call Parkinson’s Disease. It’s a condition where the brain struggles to coordinate smooth movements. Because there isn’t a specific blood test for this, my clinical exam today is the most important way we make this diagnosis. I’d like to refer you to a neurologist to discuss a long-term management plan.”