Clinical Skill Assessment Task

Plastic Surgery – Neurological System

Content: Neurological System Examination / Peripheral Neuropathy

Skill: Physical Examination

Candidate’s task list

Your tasks are to:

 Perform a focused neurological system physical examination on the patient

 Discuss your expected findings as you proceed with the examination
 Discuss your clinical impression with the examiner

Candidate’s brief scenario

You are an Intern attached to the Department of Plastic Surgery. Your Registrar asks
you to examine Marsha Ferguson, a 35-year-old female typist, who presented to the
Hand Clinic with altered sensation in her right hand.

Examiner’s instructions

This CSAT station tests the candidate’s ability to perform a focused neurological
system examination. Essential skills and knowledge tested include:

1. Professional approach to patient

2. Physical examination
Marking Sheet

1. Approach / Attitude to patient

Did the candidate demonstrate an appropriate professional approach towards the

patient?

Surpasses Achieves Standard not

Standard Standard Achieved
Appropriate beginning (CE)
 Knocks before entering
 Introduces self by name
0.5 0.25 0
 Identifies role / position
 Correctly uses patient’s name and
makes eye contact with patient
Explains examination and obtains
0.5 0.25 0
verbal consent (CE)

TOTAL MARKS /1

2. Content / Knowledge

Did the candidate adequately perform a neurological examination?

Surpasses Achieves Standard not

Standard Standard Achieved
Washes hands using alcohol hand wash
0.25 0.25 0
provided
Checks that patient is comfortable and
0.25 0.25 0
ensures patient is correctly positioned
Ensures that both upper limbs are fully
0.5 0.25 0
exposed
Examiner to ask:
Which peripheral nerves provide
the main sensory supply from the hand?
0.5 0.25 0
Expected candidate response:
Radial, ulnar and median nerves
(CE).
Examiner to say:
Using the patient’s hand, please
indicate the areas which provide
sensory supply to each of these nerves.
Indicates the following areas: 1 0.5 0
 Median nerve: radial 3½ digits (CE)
 Ulnar nerve: ulnar 1½ digits
 Radial nerve: anatomical snuff box
Examiner to say: 1 0.5 0
Please proceed to examine the
patient’s sensorium in the hands.
Examines the 3 areas correctly:
 Median nerve: distal palmar aspect
of index finger / thumb (CE)
 Ulnar nerve: distal palmar aspect of
little finger
 Radial nerve: anatomical snuff box
 Compares both hands
 Reports median nerve
mononeuropathy / carpal tunnel
syndrome (CE)
Examiner to say:
Please proceed to examine the
patient’s hands based on your clinical - - -
impression, vocalising your expected
findings.
Inspects and palpates the patients hands
 Wasting of thenar muscles
 Thenar eminence atrophy 1 0.5 0
 Fasciculations
 Compares both hands
Assesses motor function
 Thumb opposition
 Thumb abduction 1 0.5 0
 Tests against resistance
 Compares both hands
Assesses practical function
 Various (e.g. undoing button, 0.5 0.25 0
writing, opening screw-cap bottle)
Elicits Tinel’s sign
 Unless otherwise reported,
1 0.5 0
examiner to ask for expected results
of a positive sign
Peforms Phalen’s test
 Unless otherwise reported,
1 0.5 0
examiner to ask for expected results
of a positive test

TOTAL MARKS /8

3. Communication Skills

Did the candidate appropriately communicate with the patient during the
examination?

Surpasses Achieves Standard not

Standard Standard Achieved
Performs examination in a professional 0.5 0.25 0
manner
Concludes examination properly (CE)
 Asks patient to cover or covers
patient, maintaining comfort and
0.5 0.25 0
dignity
 Thanks patient at the completion of
the examination

TOTAL MARKS /1

4. Clinical Reasoning

Was the candidate able to provide appropriate answers to the examiners questions?

Surpasses Achieves Standard not

Standard Standard Achieved
Examiner to ask:
What are some of the causes of
carpal tunnel syndrome?
 Repetitive wrist flexion (work
related) (CE)
 Obesity 2 1 0
 Pregnancy
 Hypothyroidism
 Oedema
 Trauma (e.g. fractures)
 Rheumatoid arthritis
Examiner to ask:
What are some management options
for carpal tunnel syndrome?
 Rest
 Physiotherapy
2 1 0
 Immobilisation (wrist splints)
 Oral corticosteroids
 Corticosteroid injections
 Release surgery (CE)
 Possibly NSAIDs / diuretics
Examiner to say:
Phalen’s sign is reported to have a
sensitivity of 51% and a specificity of
76%. Please explain these statistics.
Expected candidate response: 1 0.5 0
The test correctly picks up 51% of
all patients with carpal tunnel syndrome
and correctly identifies 76% of those
without carpal tunnel syndrome.

TOTAL MARKS /5
CSAT Station: Neurological Examination
Student Name Total marks Marks Remarks for performance beyond the scope of
possible obtained pre-defined, pre-marked criteria
Briefing document for role player

This station tests the candidate’s ability to perform a focused neurological system
examination.

Key attributes

You are Marsha Ferguson, a 35-year-old female typist, who presented to the Hand
Clinic with altered sensation in your right hand.

Prompts

If asked what change in sensation you feel, reply:

Just a numb, slightly painful, tingling feeling.

If asked to localise the change in sensation, reply:

I’m not sure.

When the candidate proceeds to examine your hands for sensation, report numbness
in these areas (applies only to your right hand):