History Taking · Intermediate · Neurology

Tremor and Stiffness in a 72-Year-Old Man

Practise this PLAB 2 history taking station on Parkinson's Disease. 8-minute voice AI simulation with feedback on all 3 marking domains.

Clinical scenario

You are an FY2 doctor in a GP surgery. Mr Robert Williams, a 72-year-old man, has come to see you with a tremor in his right hand and increasing stiffness that has been developing over the past eighteen months. He appears slightly anxious about what this might be. Please take a focused history, perform relevant examination, discuss your clinical impression, and outline the next steps for diagnosis and specialist referral.

Background notes: PMH: Hypertension, Hypercholesterolaemia, Mild osteoarthritis knees, Appendectomy (age 35)

What this station tests

  • Identifying the Parkinson's clinical tetrad: resting tremor (stops with action), rigidity (lead-pipe throughout range), bradykinesia (micrographia, slow movements), and gait changes (reduced arm swing, shuffling)
  • Distinguishing Parkinson's rest tremor from essential tremor (bilateral, postural, improved by alcohol) and cerebellar intention tremor (worse on reaching)
  • Screening for non-motor features: anosmia, constipation, REM sleep behaviour disorder, depression, and reduced facial expression
  • Excluding drug-induced parkinsonism: checking for neuroleptics, metoclopramide, prochlorperazine
  • Addressing the fear of dementia in a widower who watched his wife die of cancer: acknowledging this fear as legitimate while providing proportionate information

How to use your 8 minutes

  • 0-1 min — Introduction: Introduce yourself, confirm identity, open question. 'What's brought you in today?'
  • 1-4 min — Systematic History: Presenting complaint detail (SOCRATES for pain, timeline, severity). Systems review. PMH, medications, allergies.
  • 4-6 min — Context and ICE: Social history (smoking, alcohol, occupation, living situation). Family history. Ideas, Concerns, Expectations.
  • 6-7 min — Summary and Plan: Summarise findings back to patient. Share differential/working diagnosis. Outline investigation and management plan.
  • 7-8 min — Closing: Safety netting with specific red flags. Arrange follow-up. Check for questions.

Consultation approach

The opening

Parkinson's disease stations test whether the candidate can identify the clinical tetrad (tremor, rigidity, bradykinesia, postural instability), distinguish it from other causes of tremor, and sensitively discuss a progressive neurological diagnosis with a patient who fears losing independence. Mr Williams is 72, retired, widowed, presenting with 18 months of right hand tremor and increasing stiffness. His daughter encouraged him to come. Open with: 'Mr Williams, tell me about the tremor and the stiffness, and how they have been affecting your daily life.' Impact matters as much as symptoms.

Core approach

Characterise the tremor. It is in the right hand, present at rest, stops when he picks something up (rest tremor, the Parkinson's pattern). It is worse when anxious or concentrating. It is rhythmic and regular. There is no tremor when reaching for objects (no intention tremor, which would suggest cerebellar disease). The tremor started unilaterally, which is typical of Parkinson's (essential tremor is usually bilateral).

Assess for the other cardinal features. Stiffness: he describes his arms and legs feeling stiff, 'like the muscles are tight,' worse in the morning, with resistance throughout the range of movement (lead-pipe rigidity, not the clasp-knife spasticity of UMN lesions). Bradykinesia: his writing has become smaller (micrographia, his grandchildren joke about it), he is slower with buttons, shaving is harder, and his movements are generally slower. Gait: reduced arm swing, shorter shuffling steps, his daughter noticed he moves differently.

Screen for non-motor features, which candidates often miss. Anosmia (reduced sense of smell for 2 to 3 years), constipation (worsening), sleep disturbance (acting out dreams, suggesting REM sleep behaviour disorder), low mood, and reduced facial expression. These non-motor features often precede the motor symptoms and support the diagnosis.

Exclude drug-induced parkinsonism: check medications for neuroleptics, metoclopramide, prochlorperazine. ICE: his friend has Parkinson's and he suspects it. He is terrified of losing independence and of developing dementia ('my wife had cancer but at least she was sharp until the end. I'm more frightened of losing my mind').

Closing and safety netting

Communicate the suspected diagnosis with care. 'Mr Williams, the combination of the resting tremor in your right hand, the stiffness, the slower movements, and the changes in your handwriting all point toward Parkinson's disease. I would like to refer you to a neurologist who specialises in movement disorders to confirm the diagnosis and discuss treatment options.'

Provide realistic hope: 'Parkinson's is a progressive condition, but it progresses slowly, and there are effective medications that can significantly improve your symptoms, particularly the tremor and stiffness.' Address his dementia fear honestly: 'Not everyone with Parkinson's develops cognitive problems, and there is a lot of research into this area. The neurologist can discuss this in more detail.'

Driving: he drives to the shops and to see his grandchildren. He does not need to stop immediately, but DVLA must be notified, and his fitness to drive will be assessed. Arrange neurology referral. Practical support: Parkinson's UK provides excellent resources and local support groups. Safety net: 'If you have any falls, significant balance problems, or difficulty swallowing, come back sooner.'

How examiners mark this station

Examiners will focus on the thoroughness and structure of your history taking for parkinson's disease. Domain 1 (Data Gathering) carries the most weight: expect marks for systematic coverage of presenting complaint, red flags, PMH, medications, social and family history. Domain 2 (Clinical Management) requires a clear differential, appropriate investigations, and a safe management plan with safety netting. Domain 3 (Interpersonal Skills) is assessed throughout: genuine exploration of ICE, active listening, empathic responses, and clear communication without jargon.

Domain 1: Data Gathering, Technical and Assessment Skills (Primary focus)

Scores well: Rest tremor established (stops with action). Rigidity characterised (lead-pipe). Bradykinesia documented (micrographia, slow movements). Gait assessment. Non-motor screening: anosmia, constipation, sleep disturbance, mood. Drug-induced parkinsonism excluded. Functional impact assessed.

Costs marks: Not characterising the tremor type. Missing bradykinesia. Not screening non-motor features. Not checking medications.

Domain 2: Clinical Management Skills (Secondary focus)

Scores well: Neurology referral (movement disorder specialist). DVLA notification advised. Parkinson's UK resources signposted. Correct not to start medication in primary care (specialist initiation). Safety netting for falls and swallowing.

Costs marks: Starting levodopa in primary care without specialist input. Not advising DVLA notification. Not mentioning support resources. No safety netting.

Domain 3: Interpersonal Skills (Primary focus)

Scores well: Communicating the diagnosis sensitively to a widower living alone. Addressing the dementia fear with honesty and proportionality. Providing hope about symptom management. Acknowledging the impact on independence (driving, shopping, grandchildren). Acknowledging his daughter's role and involving her.

Costs marks: Delivering the diagnosis bluntly. Ignoring the dementia fear. Being falsely reassuring about progression. Not acknowledging his isolation and independence concerns.

Common examiner feedback (and how to fix it)

Did not gather sufficient information to make an adequate assessment of the patient's condition

Fix: Use a consistent framework for every history. After covering the presenting complaint, systematically move through PMH, drug history, social history, family history, and ICE. Keep a mental checklist.

Did not identify the patient's problems and/or did not develop a management plan adequately

Fix: Reserve the final 2 minutes to summarise your findings, share your working diagnosis with the patient, and outline your investigation and management plan including safety netting.

Common mistakes in this station

  1. Not distinguishing rest tremor from action tremor. Parkinson's tremor is present at rest and stops with purposeful movement. Essential tremor is present with action and posture. Candidates who do not ask 'does the tremor stop when you pick something up?' cannot make this distinction.
  2. Not screening for non-motor features. Anosmia, constipation, REM sleep behaviour disorder, and mood changes often precede the motor symptoms of Parkinson's and strongly support the diagnosis. Candidates who focus only on tremor, rigidity, and bradykinesia miss the broader clinical picture.
  3. Not addressing the dementia fear. Mr Williams explicitly fears losing his mind more than losing his mobility. Candidates who discuss the motor aspects of Parkinson's without acknowledging this core concern leave him with his greatest fear unaddressed.

Resitting PLAB 2?

If you have previously struggled with history taking stations, focus on building a consistent systematic framework that you apply to every case. Practise structuring your history into clear phases (presenting complaint, systems review, PMH, social, ICE) so that even under pressure, you cover all domains. Many resitters lose marks not on knowledge but on organisation and time management.

Example opening

Good morning/afternoon, my name is Dr [Name], I'm one of the doctors here today. Could I confirm your name and date of birth please? Thank you. So, what's brought you in to see me today?

Frequently asked questions

What is the best way to take a parkinson's disease history in PLAB 2?

Parkinson's disease stations test whether the candidate can identify the clinical tetrad (tremor, rigidity, bradykinesia, postural instability), distinguish it from other causes of tremor, and sensitively discuss a progressive neurological diagnosis with a patient who fears losing independence. Mr Williams is 72, retired, widowed, presenting with 18 months of right hand tremor and increasing stiffness. His daughter encouraged him to come.

Where are marks won and lost in this parkinson's disease station?

Examiners reward: Rest tremor established (stops with action). Rigidity characterised (lead-pipe). Bradykinesia documented (micrographia, slow movements). Gait assessment. Non-motor screening: anosmia, constipation, sleep disturbance, mood. Candidates are penalised for: Not characterising the tremor type. Missing bradykinesia. Not screening non-motor features. Not checking medications.

Where do candidates most often go wrong in this station?

Not distinguishing rest tremor from action tremor. Parkinson's tremor is present at rest and stops with purposeful movement. Essential tremor is present with action and posture.

Can I do well in this station without real-world experience of parkinson's disease?

Structure beats experience here. Focus on distinguishing Parkinson's rest tremor from essential tremor (bilateral, postural, improved by alcohol) and cerebellar intention tremor (worse on reaching). Use the domain breakdown on this page to target your preparation, then practise the station aloud so your structure survives exam pressure.

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