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STATION NUMBER: 5 NEUROLOGY HISTORY TAKING AND CLINICAL EXAMINATION CANDIDATE INSTRUCTIONS You are a third year medical student in the General Neurology Clinic. The consultant has asked you to see the next patient, who has been admitted with limb weakness. • History Taking (14 marks): take a history of the presenting complaint from the patient. • Clinical Examination (14 marks): Please perform a neurological examination of the patient’s upper limbs. • Core Consultation Skills (8 marks): marks awarded for appropriate and effective patient interactionSTATION NUMBER: 5 NEUROLOGY HISTORY TAKING AND CLINICAL EXAMINATION EXAMINER INSTRUCTIONS PAGE 1 Station timings: all stations are fourteen minutes in duration (one minute to read the task, ten minutes for undertaking the task, plus an additional three minutes to allow for feedback). You must not move candidates on to additional tasks during the station; they are responsible for managing their own time. A whistle will be sounded during the station as follows: - At the start: candidates have 60 seconds to read the candidate instructions outside the room - At one minute: candidates must enter the room and can commence their station tasks - At nine minutes: candidates have two minutes remaining to complete their tasks. - At eleven minutes: candidates must end their tasks immediately. You have 3 minutes to provide feedback on their performance and suggest areas of improvement if possible (help em’ out!) - At fourteen minutes: candidates must leave the room and move onto their next station. This is the same whistle as whistle 1, and candidates will have 60 seconds to read the candidate instructions outside the room If a candidate finishes the station early, they must remain in the station until the whistle is sounded at fourteen minutes. Feedback: you must not provide feedback to candidates at any time. If a candidate clearly misunderstands the instructions, simply ask them to “please re-read the instructions”. While examining candidates, only give a mark if the task is completed accurately by shading the appropriate circle. If the task is not attempted, incomplete or inadequately performed do not award the mark. Please fill in the mark sheet contemporaneously as the candidate is performing the task. Grade the candidate as fail, borderline, pass, or good pass. STATION NUMBER: 5 NEUROLOGY HISTORY TAKING AND CLINICAL EXAMINATION ACTOR INSTRUCTIONS Name: Mrs Elizabeth Smith/ Mr Fitzwilliam Smith Age: 45 History Taking: History of presenting complaint: You present with right sided weakness of the upper and lower limbs (RUL+RLL). History of presenting complaint: ● You had initially reported to the GP with similar symptoms of a 1 month history 2 months ago (total 3 months now). He had referred you on to this neurology clinic to be seen by a specialist. ● Symptoms include a weakness in the whole RUL and RLL that started out as clumsiness when holding heavy objects. Now, you cannot even lift a glass of water without difficulty. ● Symptoms started spontaneously, are progressive and slowly worsening. Nothing has made the weakness better or worse. This is the first time you’ve experienced this. ● There is no other weakness, pain, paraesthesia, anaesthesia or restricted ROM of note. ● Associated symptoms include generalised tiredness, malaise and fatigue nowadays due to the increased work to achieve the same function or daily activities. ● No other significant symptoms and systems review is otherwise meant to be normal with no red flag or B symptoms. ○ No weight loss, night sweats or fevers ○ No joint pain or stiffness ○ No difference in daytime vs nighttime muscle strength and no facial asymmetry ○ No issues PU or PR, no constipation, no diarrhoea, nausea or vomiting ○ No breathing difficulties or prior infections ○ No excessive bleeding (bleeds) or clot formation (DVT) ○ etc. STATION NUMBER: 5 NEUROLOGY HISTORY TAKING AND CLINICAL EXAMINATION Past medical history: Generally well, but you recall an episode of eye pain and blurry vision (one episode only). The pain: ● Was in your right eye ● Started spontaneously and lasted about a month in duration ● Progressively got worse before getting better ● Was worse on movement and better with eye closing and reduced movement ● Did not spread to anywhere else ● Was not associated with any headaches, nausea or vomiting ● Was associated with blurry vision ○ Visual acuity/eyesight was affected, vision was dull, colours looked less saturated or paler Drug history: Vitamin D supplements. No Known Drug Allergies. Family history: Dad had Asthma, Mum had T2DM. You are an only child if asked about siblings. Social history: You worked as an engineer and live in a flat on the 2nd floor with your husband/wife and one daughter. You don’t smoke or drink alcohol and do not use recreational drugs. You are generally an active person. Understandably, getting in and out of home, physical activity and your work have all been affected by this weakness. Diet is vegetarian and balanced if asked (but lacking in fish, liver, eggs, red meat or vitamin d-fortified foods) ICE: You think it might be a slow stroke. Very concerned about future implications of condition and ability to earn a living. Your expectation is that the doctors help you figure out what’s going on. Answer questions directly. Answer all other questions in the negative. Do not volunteer additional information to non-direct questions.STATION NUMBER: 5 NEUROLOGY HISTORY TAKING AND CLINICAL EXAMINATION Clinical Examination: Please be prepared to have your upper limbs examined by the students. Exposure should ideally be up to the shoulders. They have been briefed that you are attending the neurology clinic with limb weakness. Please co-operate with the students, without giving any hints or assistance to them. If you have any questions or concerns, please do let the examiner or OSCE team know before the start of the stations. Thank you for allowing the students to examine you! STATION NUMBER: 5 NEUROLOGY HISTORY TAKING AND CLINICAL EXAMINATION Task Done/Correct Introduces self, identifies patient, explains purpose of interview and obtains O consent Don/Doffs PPE OR “washes hands” O History Taking (enquires about): Establishes reason patient has OP Clinic O1 Asks about weakness (any 1 Sx per category) ● Site, onset, character, radiation, timing O1 ● Alleviating or exacerbating factors, severity, impact on ADLs O1 Asks about associated symptoms (any 1 Sx per category) O1 ● Headaches/Nausea/Vomiting ● Paraesthesia/Anaesthesia O1 Asks about red flag signs for weakness (any 1 Sx per category) O1 ● Stroke - Facial Asymmetry, Sudden and Acute Onset ● Malignancy - Fever, Weight Loss, Night Sweats O1 Asks about past neurology (optic neuritis) (adequately explores each Sx) O1 ● History of eye pain (SOCRATES) ● History of blurry vision (visual acuity/colour vision) O1 O1 Past medical history Drug history and allergies O1 O1 Family history Social history (must ask about both smoking and alcohol for mark) O1 O1 ICEClinical Examination: Inspection: Scars, Muscle Wasting, Involuntary Movements, Fasciculations, Tremors O1 Inspection: Pronator drift O1 Tone: Assesses tone and compares both sides O1 Power: Assesses shoulder abduction and adduction O1 Power: Assesses elbow flexion and extension O1 O1 Power: Assesses wrist flexion and extension Power: Assesses finger flexion and extension O1 O1 Power: Assesses thumb abduction Reflexes: Assess biceps reflex, triceps reflex, supinator reflex O1 Sensation: Assess light touch sensation of upper limb dermatomes O1 O1 Sensation: Assess pin-prick sensation of upper limb dermatomes Sensation: Assess vibration sense and proprioception of upper limb dermatomes O1 O1 Co-ordination: Performs finger-to-nose test Co-ordination: Performs dysdiadokinesia O1 Core Consultation Skills: Examiner’s Rating: Well below expected standard O1 Borderline O1 Satisfactory O1 O1 Good O1 Excellent Patient’s Rating: Below expectations/student was not proficient O1 O1 Satisfactory consultation/adequate performance O1 Highly satisfactory consultation/highly proficient Overall Assessment of Performance: Fail O Borderline O Pass O Good Pass O