Advice from Dr H on clinical examination…
Today I did one scenario as candidate. It was short neuro clinical station.
Task was: Motor examination
Universal cue given were shown in video: waddling gait, positive gower sign obviously clear.
Diagnosis was very clear Proximal myopathy and most likely DMD.
Went through steps and sequence like introduction, request permission, asked for pain and building rapport.
First look for Dysmorphic features, support, wheel chair, orthotic support. Wt & ht, well or ill.
After that confusion started – shall i have to request gait by asking heel walk and toe walk although waddling gait clearly given in clue?
However i asked for heel and toe walk. Gower sign was shown in clue. Then did tone, power and reflex verbalisation.
Dependent clue: was given tone reduced, power grade 3 in hips both side and 4 in both knee and ankle.
Reflexes preserved in knee while absent in ankle and babinski.
Did back examination and upper limb only tone then times finished 6 minutes.
I couldn’t finish Upper limb power and reflex examination.
Presented the case as 8 year old child looks smaller for age would like to plot in appropriate chart.
There is waddling gait, decreased tone in lower limb, calf pseudohypertrophy and reduced reflexes
Consistent with LMN lesion mostly DMD, D/ D offered SMA type 3 but need to check tongue fasiculation.
Spina bifida but no back scar and no wasting on both legs so unlikely.
Then Discussed investigation like Gene study, Creatinine kinase, muscle biopsy.
Need to do Respiratory, and CVS Examination as it affects (cardiomyopathy, and chest infections).And supportive management MDT which include physio, genetic and parental education.
Problem which i noticed is how to skip or cut short phrases which needs to be asked in question or what part we can minimise of examination technique when we verbalise so that it can be finished in 5 minutes as here i could have skipped heel and toe walking as clear waddling gait.
I was practicing with a candidate and noticed above mentioned hurdles so sharing with u.
Thanks for wonderful session today
COMMENT: WHAT WAS THE TASK? CANNOT BE JUST MOTOR EXAMINATION.
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