Gen Med Examination 1

Station 1

I just don’t feel steady any more

Start the Timer and Begin

Intro

Introduces self with name and job

Adheres to appropriate infection control measures

Gain consent for examination

Asks patient if they are any pain prior to beginning examination.

End of Bed Inspection

Adequately exposes the patient - all 4 limbs and face should be clearly visible, ideally to removes shirt

Assesses patient from the end of the bed - patient looks well, stooped posture

Identifies findings around the examination space - nil

Inspection

Please show the candidate the following video as they inspect the torso.

Inspects muscles for fasciculation, tremor, dyskinesia, & wasting - comments on tremor in the right forearm/wrist/hand

Tests gait - shuffling gait (please act; have particular difficulty when starting your gait, with tiny steps about 2 inches long, before elongating into a more normal stride. Take 8+ small shuffling steps whilst trying to turn around. No arm swinging. Remember your stooped posture). See an example..

Tests heel to toe gait - unbalanced (keep stepping off to one side)

Performs Romberg’s test - negative (you are stable when standing still)

Tone

Full marks

Candidate checks for both velocity dependent (spasticity) and velocity independent (rigidity) tone changes

Shoulder - hypertonia (rigid) on the right side only (act by giving constant resistance against movement)

Biceps/triceps - hypertonia (rigid) on the right side only

Wrist pronation/supination - hypertonia (rigidity with cogwheeling) on the right side only

Leg roll / leg drop - normal

Checks for pronator drift - normal

Power

Tests power in the upper limbs at least 6/7 - power is rated out of 5;

Tests power in the lower limbs at least 6/7 - power is rated out of 5;

Reflexes

Elicits all 3 upper limb reflexes;

Elicits all 3 lower limb reflexes;

Coordination

Please show the candidate the following video when they test for Dysdiadochokinesia.

Dysdiadochokinesia - slow initiation of movement present with bradykinesia

Finger-nose test - nil (no past pointing but there is still the tremor observed earlier - it is not worse on movement)

Heel-shin test - nil

Special Tests

Please show the candidate the following video when they perform the finger tap test. Note the movements getting smaller and smaller as the movement is repeated - this is the same phenomenon that leads to micrographia (handwriting which gets steadily smaller) in Parkinsonism.

Finger tap - bradykinesia with slowly reducing magnitude of movement

To Complete the Exam

Thanks patient and asks them to redress

Examiner Instruction

At this point please direct the candidate to move on to diagnosis.

Diagnosis

Main differential - Parkinsonism (accept parkinsons) (please inform the candidate of the correct diagnosis once they have given their differentials, regardless of whether their answer was correct or not).

Clinical reasoning mark - uses at least 4/7 to clinically justify Parkinsonism;

No sensory upset makes other diagnoses less likely e.g. stroke
Tremor - which is a 1-4hz as in Parkinsonism, and no worse on movement (which would suggest essential tremor instead)
Rigidity (not spasticity) - one of the cardinal signs of Parkinsonism
Bradykinesia - one of the cardinal signs of Parkinsonism
Postural instability
Shuffling gait - difficultly initiating movements due to basal ganglia insufficiency
Unilateral onset of symptoms - typical of idiopathic Parkinson's disease

Summary

Timothy went on to be diagnosed with Parkinson’s Disease. A common presentation of Parkinson’s disease is repeated falls due to postural instability. The unilateral onset, initially worse in the upper limbs, is typical of idiopathic Parkinson’s disease. It’s worth knowing about other forms of Parkinsonism such as vascular parkinson’s (normally with lower limb onset), drug induced parkinson’s (from dopamine blocking medications e.g. risperidone, haloperidol, olanzapine, prochlorperazine), and parkinson’s plus disorders.

Timothy was started on Levodopa after being formally diagnosed in a neurology clinic. His symptoms improved greatly and he returned to your GP surgery for an unrelated problem some weeks later and thanked you for making an early diagnosis. His symptoms are now well controlled with medication.

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Station Written by: Dr Benjamin Armstrong

Peer Reviewed by: Dr Rishil Patel

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Gen Med Examination 1

Station 1

Candidate Instructions

Setting:

Name: Timothy Watson

Tasks:

Simulated Patient Instructions

Briefing

Opening Statement

Appearance and Behaviour