Duration: 10 Minutes (2 minutes reading time, 8 minutes performance)
Focus: Physical Examination, Clinical Reasoning, and Patient Counselling.
Learning Objectives
- Perform a focused neurological examination of the upper limb (C8/T1 focus).
- Synthesize neurological findings with systemic signs (Horner’s syndrome, respiratory signs).
- Communicate a complex diagnosis (Pancoast Tumor) using patient-centered language.
Patient Profile
- Name: Mr. Robert Miller, 45 years old.
- Occupation: Long-haul truck driver (heavy smoker).
- Ethnicity: Caucasian.
- Social History: 30 pack-year smoking history; currently lives with his wife.
Presenting Complaint
Robert presents for a follow-up after a biopsy of a lump in his right neck. He is also complaining of increasing weakness and “clumsiness” in his right hand, along with a drooping eyelid.
Contextual Information
- HPC: Right-sided neck lump noted 4 weeks ago. Biopsy results (provided to candidate) show Squamous Cell Carcinoma (SCC). Over the last 2 weeks, he has developed a dull ache in his right shoulder radiating down the inner aspect of his arm, and difficulty gripping his steering wheel.
- PMH: Hypertension, Chronic Bronchitis.
- Meds: Amlodipine, Salbutamol PRN.
- Allergies: Nil.
Exam Instructions
Candidate Instructions
Robert has been diagnosed with Metastatic Squamous Cell Carcinoma via a neck node biopsy. He is here today because he is concerned about new weakness in his right hand.
Your Tasks:
- Conduct a focused neurological examination of the right upper limb.
- Conduct a “relevant” further examination to identify the primary source and associated signs. (You may ask the examiner for findings).
- Explain your clinical suspicion and the likely diagnosis to Robert.
Standardised Patient (SP) Instructions
- Demeanor: You are anxious. You want to know why your hand is weak and if it’s related to the “cancer lump” in your neck.
- Symptoms: Your right hand feels “thin” and weak. You have a constant dull ache in your right armpit and the inside of your arm.
- Physical Signs: You will have a prosthetic drooping eyelid (Right side). If the candidate tests your grip, offer very little resistance on the right.
Examiner Instructions & Findings
- Upper Limb Exam: If asked, show wasting of the interossei and thenar/hypothenar eminence.
- Sensory: Numbness along the medial forearm/pinky finger (C8-T1).
- Horner’s: Right-sided Ptosis and Miosis are present.
- Respiratory: If the candidate percusses the chest, report “Stony dullness at the right base” and “Absent breath sounds at the right base.”
- Oral/Skin: No lesions in the mouth or on the skin.
Key Clinical Findings
| System | Finding |
| Vitals | Stable, though slightly tachycardic (anxiety). |
| Inspection | Right-sided Ptosis; wasting of intrinsic hand muscles (guttering). |
| Neurological | Weakness in finger abduction (T1) and finger flexion (C8). |
| Respiratory | Signs of Pleural Effusion on the right. |
| Diagnosis | Pancoast Tumor (Superior Sulcus Tumor) involving the Brachial Plexus and Sympathetic Chain. |
Communication Triggers (Murtagh Approach)
- Open-Ended Start: “Robert, I understand you’ve been noticing some changes in your hand. Can you tell me more about how that’s affecting you?”
- Signposting: “To understand what’s happening, I’d like to examine your hand, and then look at your eyes and chest.”
- The “ICE” Factor: Explore his Ideas, Concerns, and Expectations regarding the neck lump biopsy.
- Avoiding Jargon: Use “nerve bundle” instead of “brachial plexus” and “lung tip” instead of “apex.”
Assessment & Marking Guide
| Performance Item | Satisfactory |
| Neurological Exam: Systematically checked C8/T1 power and sensation. | ☐ |
| Horner’s Identification: Specifically looked for ptosis, miosis, and anhidrosis. | ☐ |
| Systemic Search: Checked oral cavity and skin for SCC primary sources. | ☐ |
| Respiratory Link: Asked for/performed chest percussion to find the effusion. | ☐ |
| Clinical Synthesis: Correctly identified the Pancoast/Superior Sulcus syndrome. | ☐ |
| Communication: Explained the “pressure” of the tumor on the nerves clearly. | ☐ |
Sample Answers / Model Performance
Suggested History/Assessment Questions
- “Robert, have you noticed any changes in your sweating on that side of your face?”
- “I’ve noticed your eyelid is drooping slightly; how long has that been happening?”
- “I’d like to check the roof of your mouth and your skin to see if we can find where this started.”
The Explanation (Model Response)
“Robert, based on the weakness in your hand and the changes I see in your eye, it appears that the lump in your neck is related to a growth at the very top of your right lung. We call this a Pancoast tumor. This growth is sitting right where the nerves for your arm and your eye travel. Because the tumor is pressing on those nerves, it’s causing the weakness and the drooping eyelid you’re experiencing. It also explains the fluid we found at the bottom of your lung. Our next step is an urgent CT scan of your chest and a referral to a chest specialist and an oncologist.”