Examination Stations

Before we begin

Welcome. This is the frontal lobe examination. In front of you is a patient, and a card that asks you to perform, to examine, to elicit signs. These are the most reliably passable stations in the whole exam, and the most reliably failed by the candidate who never rehearsed the running commentary.

A patient is sent to you with a change in personality, or disinhibition, or a suspected frontal process, and the card asks you to test frontal function at the bedside. There is no scanner in the room. You have your voice, a pen, a piece of paper, and a fixed set of tasks, and each task is a small window onto the executive brain.

You will not fail for missing a rare sign. You will fail for silence, for turning to the examiner, or for finishing with nothing to report. So two habits carry every one of these. Keep them close.

One. Talk to the patient, and only the patient. Every instruction is addressed to the person in front of you, never the examiner. You say what you are about to do, and why, in plain words, before you touch. Your running commentary is instructional, not interpretive, you tell them what is coming, not what you are concluding. You do not turn to the examiner and you do not present your findings to them, unless the card itself uses the word present or discuss.

Two. Every sign names the target it localises to, and you finish on a findings table. You never just see a sign. You hold what it tests and where it comes from, the lobe, the tract, the gland, in your head as a bracket, not a blurt. And you close every station the same way, with a spoken findings table, in the order you performed the steps, at least one relevant negative named, and a plain pass or fail verdict.

Ready. Wash in, and let us begin.

What this station looks like

Picture the room, and the card on the door. Near enough, this.

You are asked to perform a frontal lobe examination on this patient. Talk to the patient throughout.

Here is the shape of it, and it is the same skeleton every time. The fixed opening. A framework named out loud so the examiner hears your structure. The steps, in a fixed order, each one spoken to the patient. The signs, localised in your head. Then the spoken findings table to close.

The framework you say out loud is: fluency, abstraction, estimates, judgement, then the motor programming tests, the three-step hand sequence and the alternating pattern, and finally the frontal release signs. Name those domains before you start, and the examiner hears a candidate who knows what a frontal lobe does.

Check. The shape is clear. Let us take the opening.

The opening, the fixed fifteen seconds

The opening is fixed, and it is the same on every examination station. Six moves, all said to the patient, all before you touch them. Every one is a printed mark. Do not drop them for the sake of the clock, they take fifteen seconds together.

One. Clean your hands, out loud.

I am just going to clean my hands before we begin.

Two. Introduce yourself, and confirm who they are.

Hello, my name is Doctor, and I am one of the psychiatry doctors. Can I just check your name and date of birth with you?

Three. Explain what the examination involves, in plain words. This line is the one that changes from station to station.

I would like to run through some quick pen-and-paper tasks, a bit of thinking, some words, and a couple of hand movements. None of it is painful. Some of it is meant to be tricky, so please do not worry if a bit of it is hard.

Four. Ask permission.

Is it alright with you if I go ahead?

Five. Offer a chaperone.

I can ask one of my colleagues to sit in with us if you would prefer, would that be alright?

Six. Ask about pain, and position and expose only as much as you need.

Before I start, are you sore or in any pain anywhere?

One warning that is worth a mark. For the word task, tell the patient plainly not to repeat words and not to use names of people or places, because the frontal patient repeats, and you want that to show as their finding, not your instruction.

Check. Six moves, fifteen seconds, every mark banked, and not one word to the examiner. Now the examination itself.

Who is in front of you

In front of you is a patient who is alert and cooperative and whose ordinary conversation may sound entirely normal. The deficits here do not show in chat, they show only when you set a task that needs planning, inhibition or a switch. That is the whole point of the examination, and it is why you must actually run the tasks rather than talk around them.

Check. You know who you are examining, and what the card wants. Now the sequence, one step at a time.

The examination, in order

Seven tasks, in a fixed order. Each is a sentence to the patient, then a thing you watch for, then where it localises. Move briskly, this is a ninety-second style examination inside a seven-minute station, so leave time for the table at the end.

The traps that fail this station

Half the marks in an examination station are in the traps. Here are the ones that sink this one.

Check. Name the trap you just avoided. That is the mark.

The findings table, read aloud

Now the close, and it is the same on every station. You read a findings table aloud, in the order you performed the steps. What you did, what it tests, where it localises, what this patient did, and a verdict. At least one relevant negative goes in, because a named negative is a scored finding.

For a patient with a genuine frontal process, the table might read like this.

Row 1. Verbal fluency, letter F, one minute. What it tests, executive word generation. Where it localises, dorsolateral prefrontal cortex. This patient, only five words, two repeated, then dried up. Verdict, fail, reduced and perseverative.

Row 2. Proverb interpretation. What it tests, abstract thinking. Where it localises, frontal lobe. This patient, concrete, stayed on literal moss. Verdict, fail.

Row 3. Cognitive estimates. What it tests, self-monitored estimation. Where it localises, frontal lobe. This patient, said a thousand elephants in London, unbothered. Verdict, fail.

Row 4. Judgement, the found letter. What it tests, social reasoning. Where it localises, frontal lobe. This patient, logical, would post it. Verdict, pass, a relevant negative.

Row 5. Luria three-step hand sequence. What it tests, motor programming. Where it localises, premotor and frontal region. This patient, stuck on fist, could not alternate. Verdict, fail, motor perseveration.

Row 6. Alternating square-triangle. What it tests, set-shifting. Where it localises, frontal lobe. This patient, continued with triangles only. Verdict, fail, perseveration.

Row 7. Grasp, pout and palmomental reflexes. What it tests, frontal release. Where it localises, frontal inhibitory control. This patient, grasp and pout present. Verdict, fail, release signs positive.

Row 8. General orientation and conversation. What it tests, global cognition. Where it localises, diffuse cortex. This patient, alert, orientated, conversant. Verdict, pass, the intact base that makes the frontal signs meaningful.

So the verdict out loud is a consistent frontal picture, perseveration across the motor tasks, concrete abstraction, poor estimates, and positive release signs, sitting on an intact and orientated base.

That table, read aloud, is the finish. It is the difference between a candidate who did an examination and a candidate who reported one.

The two habits, again

Carry these two out of the room.

One. Talk to the patient, and only the patient. Every instruction is addressed to the person in front of you, never the examiner. You say what you are about to do, and why, in plain words, before you touch. Your running commentary is instructional, not interpretive, you tell them what is coming, not what you are concluding. You do not turn to the examiner and you do not present your findings to them, unless the card itself uses the word present or discuss.

Two. Every sign names the target it localises to, and you finish on a findings table. You never just see a sign. You hold what it tests and where it comes from, the lobe, the tract, the gland, in your head as a bracket, not a blurt. And you close every station the same way, with a spoken findings table, in the order you performed the steps, at least one relevant negative named, and a plain pass or fail verdict.

The thread of this station is one word, perseveration. The frontal patient cannot let go of the last response to switch to the next, and every task you run is a different way of catching that.

Do those two things and any examination station in this exam is yours to pass.

Before we begin

Welcome. This is the parietal lobe examination. In front of you is a patient, and a card that asks you to perform, to examine, to elicit signs. These are the most reliably passable stations in the whole exam, and the most reliably failed by the candidate who never rehearsed the running commentary.

A patient on an older-adult ward, or after a stroke, is sent to you and the card asks for a parietal lobe examination. The parietal lobe is where the brain builds the sense of where the body is, where numbers and letters live, and where the map of the left half of the world is drawn. Damage it and the patient can be alert, chatty and orientated, and still unable to calculate, write, dress, or see the left side of a clock.

You will not fail for missing a rare sign. You will fail for silence, for turning to the examiner, or for finishing with nothing to report. So two habits carry every one of these. Keep them close.

One. Talk to the patient, and only the patient. Every instruction is addressed to the person in front of you, never the examiner. You say what you are about to do, and why, in plain words, before you touch. Your running commentary is instructional, not interpretive, you tell them what is coming, not what you are concluding. You do not turn to the examiner and you do not present your findings to them, unless the card itself uses the word present or discuss.

Two. Every sign names the target it localises to, and you finish on a findings table. You never just see a sign. You hold what it tests and where it comes from, the lobe, the tract, the gland, in your head as a bracket, not a blurt. And you close every station the same way, with a spoken findings table, in the order you performed the steps, at least one relevant negative named, and a plain pass or fail verdict.

Ready. Wash in, and let us begin.

What this station looks like

Picture the room, and the card on the door. Near enough, this.

You are asked to perform a parietal lobe examination on this patient. Talk to the patient throughout, and explain each task before you set it.

Here is the shape of it, and it is the same skeleton every time. The fixed opening. A framework named out loud so the examiner hears your structure. The steps, in a fixed order, each one spoken to the patient. The signs, localised in your head. Then the spoken findings table to close.

Say the structure out loud as four headings and you cannot get lost: dominant function, non-dominant function, bilateral function, and vision. The dominant tasks are the Gerstmann group, finger recognition, right-left orientation, calculation and writing. The non-dominant tasks are dressing, drawing and neglect. Bilateral is the sensory cortex. Vision is the lower quadrant of the field.

Check. The shape is clear. Let us take the opening.

The opening, the fixed fifteen seconds

The opening is fixed, and it is the same on every examination station. Six moves, all said to the patient, all before you touch them. Every one is a printed mark. Do not drop them for the sake of the clock, they take fifteen seconds together.

One. Clean your hands, out loud.

I am just going to clean my hands before we begin.

Two. Introduce yourself, and confirm who they are.

Hello, my name is Doctor, and I am one of the psychiatry doctors. Can I just check your name and date of birth with you?

Three. Explain what the examination involves, in plain words. This line is the one that changes from station to station.

I would like to give you a set of short tasks, some sums, a bit of writing and drawing, and a couple where I ask you to point or to feel something with your eyes closed. Some of them look simple and are meant to be, please just do your best and tell me if anything is unclear.

Four. Ask permission.

Is it alright with you if I go ahead?

Five. Offer a chaperone.

I can ask one of my colleagues to sit in with us if you would prefer, would that be alright?

Six. Ask about pain, and position and expose only as much as you need.

Before I start, are you sore or in any pain anywhere?

If the patient is irritable, and after a stroke they often are, add one line, because the case will punish you for skipping it: explain each task clearly and briefly before you ask for it, since a patient with parietal damage will refuse a task they do not understand and you will lose the finding along with the rapport.

Check. Six moves, fifteen seconds, every mark banked, and not one word to the examiner. Now the examination itself.

Who is in front of you

In front of you is a patient who is alert, attentive and orientated. That intact base is not incidental, it is the precondition for the whole examination, because a focal higher-function deficit only means something when the general state underneath it is clear. They may be grudging, and they may quietly omit the left side of anything you ask them to draw.

Check. You know who you are examining, and what the card wants. Now the sequence, one step at a time.

The examination, in order

Four headings, said out loud, then the tasks under each. Keep the narration going, this is where the marks are.

The traps that fail this station

Half the marks in an examination station are in the traps. Here are the ones that sink this one.

Check. Name the trap you just avoided. That is the mark.

The findings table, read aloud

Now the close, and it is the same on every station. You read a findings table aloud, in the order you performed the steps. What you did, what it tests, where it localises, what this patient did, and a verdict. At least one relevant negative goes in, because a named negative is a scored finding.

For a patient with a dominant-side parietal lesion, say, the table might read like this.

Row 1. Right index finger, left ear with right hand. What it tests, finger recognition and right-left orientation. Where it localises, dominant parietal, angular gyrus. This patient, confused right and left. Verdict, fail, two of the Gerstmann four.

Row 2. Serial sevens from a hundred. What it tests, calculation. Where it localises, dominant parietal. This patient, could not proceed past ninety-three. Verdict, fail, dyscalculia.

Row 3. Write a sentence. What it tests, writing. Where it localises, dominant parietal. This patient, unable to complete a sentence. Verdict, fail, dysgraphia.

Row 4. Turn and don the jacket. What it tests, dressing praxis. Where it localises, non-dominant parietal. This patient, managed it slowly. Verdict, pass, a relevant negative.

Row 5. Clock face to ten past five. What it tests, construction and neglect. Where it localises, non-dominant parietal. This patient, numbers preserved, hands roughly correct. Verdict, pass.

Row 6. Coin in hand, letters on palm, eyes shut. What it tests, stereognosis and graphaesthesia. Where it localises, contralateral sensory cortex. This patient, identified both. Verdict, pass, a second relevant negative.

Row 7. Confrontation fields. What it tests, visual field. Where it localises, optic radiation through parietal lobe. This patient, full to confrontation. Verdict, pass.

Row 8. Awareness of the weak side. What it tests, anosognosia. Where it localises, non-dominant parietal. This patient, aware of the weakness. Verdict, pass.

So the verdict out loud is a dominant parietal picture, the Gerstmann elements failing, on an alert and orientated base, with the non-dominant and bilateral functions intact, which is exactly what makes the dominant-side localisation clean.

That table, read aloud, is the finish. It is the difference between a candidate who did an examination and a candidate who reported one.

The two habits, again

Carry these two out of the room.

One. Talk to the patient, and only the patient. Every instruction is addressed to the person in front of you, never the examiner. You say what you are about to do, and why, in plain words, before you touch. Your running commentary is instructional, not interpretive, you tell them what is coming, not what you are concluding. You do not turn to the examiner and you do not present your findings to them, unless the card itself uses the word present or discuss.

Two. Every sign names the target it localises to, and you finish on a findings table. You never just see a sign. You hold what it tests and where it comes from, the lobe, the tract, the gland, in your head as a bracket, not a blurt. And you close every station the same way, with a spoken findings table, in the order you performed the steps, at least one relevant negative named, and a plain pass or fail verdict.

The thread here is intact base, focal deficit. Alert, attentive, orientated, and yet cannot calculate or write, is the only situation in which lobe testing means anything at all. Prove the base first, then the focal loss lands.

Do those two things and any examination station in this exam is yours to pass.

Before we begin

Welcome. This is the bedside cognitive examination. In front of you is a patient, and a card that asks you to perform, to examine, to elicit signs. These are the most reliably passable stations in the whole exam, and the most reliably failed by the candidate who never rehearsed the running commentary.

A patient with memory trouble, or confusion, or a query dementia, is in front of you, and the card asks you to examine cognition at the bedside. The trap that swallows candidates is treating this as a single number to chase. It is not. It is a tour of separable domains, each of which localises somewhere different, and your job is to visit each one in order and out loud.

You will not fail for missing a rare sign. You will fail for silence, for turning to the examiner, or for finishing with nothing to report. So two habits carry every one of these. Keep them close.

One. Talk to the patient, and only the patient. Every instruction is addressed to the person in front of you, never the examiner. You say what you are about to do, and why, in plain words, before you touch. Your running commentary is instructional, not interpretive, you tell them what is coming, not what you are concluding. You do not turn to the examiner and you do not present your findings to them, unless the card itself uses the word present or discuss.

Two. Every sign names the target it localises to, and you finish on a findings table. You never just see a sign. You hold what it tests and where it comes from, the lobe, the tract, the gland, in your head as a bracket, not a blurt. And you close every station the same way, with a spoken findings table, in the order you performed the steps, at least one relevant negative named, and a plain pass or fail verdict.

Ready. Wash in, and let us begin.

What this station looks like

Picture the room, and the card on the door. Near enough, this.

You are asked to perform a cognitive examination on this patient. Talk to the patient throughout.

Here is the shape of it, and it is the same skeleton every time. The fixed opening. A framework named out loud so the examiner hears your structure. The steps, in a fixed order, each one spoken to the patient. The signs, localised in your head. Then the spoken findings table to close.

The order you announce and follow is: orientation, registration, attention and calculation, recall, then language in its parts, naming, repetition, comprehension, reading, writing and copying, and finally the frontal add-ons, fluency, abstraction, estimates and judgement. Domain by domain, never a jumble.

Check. The shape is clear. Let us take the opening.

The opening, the fixed fifteen seconds

The opening is fixed, and it is the same on every examination station. Six moves, all said to the patient, all before you touch them. Every one is a printed mark. Do not drop them for the sake of the clock, they take fifteen seconds together.

One. Clean your hands, out loud.

I am just going to clean my hands before we begin.

Two. Introduce yourself, and confirm who they are.

Hello, my name is Doctor, and I am one of the psychiatry doctors. Can I just check your name and date of birth with you?

Three. Explain what the examination involves, in plain words. This line is the one that changes from station to station.

I would like to ask you some questions to check different parts of your memory and thinking. Some are very easy and some are meant to be harder, and it is completely normal not to get them all. Please just try each one and do not worry about the ones that are tricky.

Four. Ask permission.

Is it alright with you if I go ahead?

Five. Offer a chaperone.

I can ask one of my colleagues to sit in with us if you would prefer, would that be alright?

Six. Ask about pain, and position and expose only as much as you need.

Before I start, are you sore or in any pain anywhere?

Two habits inside this station protect the whole thing. Test registration before you rely on recall, because if the patient never registered the words, the later recall failure is not a memory sign. And keep the patient at ease, because anxiety and low mood both flatten performance and you must not read them as dementia.

Check. Six moves, fifteen seconds, every mark banked, and not one word to the examiner. Now the examination itself.

Who is in front of you

In front of you may be a patient whose conversation is preserved but whose memory is not, or the reverse, a fluent confabulator whose orientation is gone. You cannot tell from chat, which is exactly why the examination is a fixed sequence. Run it the same way every time and the pattern of what is spared and what is lost becomes the diagnosis.

Check. You know who you are examining, and what the card wants. Now the sequence, one step at a time.

The examination, in order

Domain by domain, in order. Announce each domain, then the task, then hold the finding for the table.

The traps that fail this station

Half the marks in an examination station are in the traps. Here are the ones that sink this one.

Check. Name the trap you just avoided. That is the mark.

The findings table, read aloud

Now the close, and it is the same on every station. You read a findings table aloud, in the order you performed the steps. What you did, what it tests, where it localises, what this patient did, and a verdict. At least one relevant negative goes in, because a named negative is a scored finding.

For a patient with an early amnestic dementia, the table might read like this.

Row 1. Orientation, time and place. What it tests, global orientation. Where it localises, diffuse and frontal-subcortical. This patient, lost the date and the season, place intact. Verdict, partial, time disorientation.

Row 2. Registration, three words. What it tests, attention gate. Where it localises, frontal-subcortical loop. This patient, repeated all three immediately. Verdict, pass, the gate is open.

Row 3. World backwards, serial sevens. What it tests, attention and working memory. Where it localises, frontal-subcortical and parietal. This patient, mild difficulty, two errors. Verdict, borderline.

Row 4. Delayed recall, three words. What it tests, episodic memory. Where it localises, medial temporal lobe, hippocampus. This patient, recalled none of the three. Verdict, fail, the amnestic core.

Row 5. Naming, repetition, three-stage command. What it tests, language. Where it localises, dominant temporoparietal. This patient, all intact. Verdict, pass, a relevant negative.

Row 6. Sentence and pentagons. What it tests, writing and construction. Where it localises, temporoparietal and parietal. This patient, sentence fine, pentagons simplified. Verdict, borderline.

Row 7. Animal fluency, proverb, judgement. What it tests, executive function. Where it localises, frontal lobe. This patient, fluency low, judgement preserved. Verdict, partial.

Row 8. General conversational level. What it tests, global cognition. Where it localises, diffuse cortex. This patient, fluent, socially preserved. Verdict, pass, the spared surface that hides the deficit.

So the verdict out loud is a selective amnestic picture, delayed recall failing against intact registration and intact language, which points to a medial temporal, hippocampal, process rather than a global or frontal one.

That table, read aloud, is the finish. It is the difference between a candidate who did an examination and a candidate who reported one.

The two habits, again

Carry these two out of the room.

One. Talk to the patient, and only the patient. Every instruction is addressed to the person in front of you, never the examiner. You say what you are about to do, and why, in plain words, before you touch. Your running commentary is instructional, not interpretive, you tell them what is coming, not what you are concluding. You do not turn to the examiner and you do not present your findings to them, unless the card itself uses the word present or discuss.

Two. Every sign names the target it localises to, and you finish on a findings table. You never just see a sign. You hold what it tests and where it comes from, the lobe, the tract, the gland, in your head as a bracket, not a blurt. And you close every station the same way, with a spoken findings table, in the order you performed the steps, at least one relevant negative named, and a plain pass or fail verdict.

The thread here is registration before recall, and domains before a number. A memory failure only counts once you have proved the words went in, and a cognitive examination is a map of what is spared and what is lost, not a single score.

Do those two things and any examination station in this exam is yours to pass.

Before we begin

Welcome. This is the cerebellar examination. In front of you is a patient, and a card that asks you to perform, to examine, to elicit signs. These are the most reliably passable stations in the whole exam, and the most reliably failed by the candidate who never rehearsed the running commentary.

A patient with a long alcohol history, and a concern about a Wernicke-Korsakoff picture, is in front of you, and the card asks for a cerebellar examination. This is the tremor station that is not a drug station. Its whole reason for being here is so that you never say the word tremor again without saying which tremor, because the rest tremor of the drug-induced parkinsonism and the intention tremor of the cerebellum lead to opposite decisions.

You will not fail for missing a rare sign. You will fail for silence, for turning to the examiner, or for finishing with nothing to report. So two habits carry every one of these. Keep them close.

One. Talk to the patient, and only the patient. Every instruction is addressed to the person in front of you, never the examiner. You say what you are about to do, and why, in plain words, before you touch. Your running commentary is instructional, not interpretive, you tell them what is coming, not what you are concluding. You do not turn to the examiner and you do not present your findings to them, unless the card itself uses the word present or discuss.

Two. Every sign names the target it localises to, and you finish on a findings table. You never just see a sign. You hold what it tests and where it comes from, the lobe, the tract, the gland, in your head as a bracket, not a blurt. And you close every station the same way, with a spoken findings table, in the order you performed the steps, at least one relevant negative named, and a plain pass or fail verdict.

Ready. Wash in, and let us begin.

What this station looks like

Picture the room, and the card on the door. Near enough, this.

You are asked to conduct a cerebellar examination on this patient. Talk to the patient throughout, and remember he may forget what you have said and need it repeated.

Here is the shape of it, and it is the same skeleton every time. The fixed opening. A framework named out loud so the examiner hears your structure. The steps, in a fixed order, each one spoken to the patient. The signs, localised in your head. Then the spoken findings table to close.

Say the mnemonic out loud so the examiner hears the structure, DANISH: dysdiadochokinesia, ataxia of gait and posture, nystagmus, intention tremor, slurred and staccato speech, and heel-to-shin with hypotonia. Then look before you touch, then work through the limbs, then stand him up.

Check. The shape is clear. Let us take the opening.

The opening, the fixed fifteen seconds

The opening is fixed, and it is the same on every examination station. Six moves, all said to the patient, all before you touch them. Every one is a printed mark. Do not drop them for the sake of the clock, they take fifteen seconds together.

One. Clean your hands, out loud.

I am just going to clean my hands before we begin.

Two. Introduce yourself, and confirm who they are.

Hello, my name is Doctor, and I am one of the psychiatry doctors. Can I just check your name and date of birth with you?

Three. Explain what the examination involves, in plain words. This line is the one that changes from station to station.

I would like to check your balance and coordination. I will ask you to say a couple of phrases, follow my finger with your eyes, do some hand and leg movements, and then walk a few steps. None of it is uncomfortable, and I will guide you through each bit.

Four. Ask permission.

Is it alright with you if I go ahead?

Five. Offer a chaperone.

I can ask one of my colleagues to sit in with us if you would prefer, would that be alright?

Six. Ask about pain, and position and expose only as much as you need.

Before I start, are you sore or in any pain anywhere?

Two things specific to this patient. Look before you touch, at the mobility aids around the bed, the posture in the chair, any truncal ataxia. And be ready to repeat your instructions in plain language, because his short-term memory is impaired and he may not hold what you just asked, that patience is the scored communication domain.

Check. Six moves, fifteen seconds, every mark banked, and not one word to the examiner. Now the examination itself.

Who is in front of you

In front of you is a man who is cooperative and able to follow simple commands, but who has memory difficulty he is unaware of, and who fills the gaps with confabulation when asked general questions. The cerebellar signs are the examination. The unawareness and the confabulation are the psychiatry, and the examiner is watching how you handle a man who does not know what he has lost.

Check. You know who you are examining, and what the card wants. Now the sequence, one step at a time.

The examination, in order, on DANISH

Say DANISH aloud, then work through it. Introduce, look, then limbs, then stance and gait.

The traps that fail this station

Half the marks in an examination station are in the traps. Here are the ones that sink this one.

Check. Name the trap you just avoided. That is the mark.

The findings table, read aloud

Now the close, and it is the same on every station. You read a findings table aloud, in the order you performed the steps. What you did, what it tests, where it localises, what this patient did, and a verdict. At least one relevant negative goes in, because a named negative is a scored finding.

For a patient with alcohol-related cerebellar degeneration and a Korsakoff state, the table might read like this.

Row 1. British constitution, baby hippopotamus. What it tests, speech. Where it localises, cerebellum. This patient, slurred and staccato. Verdict, fail, cerebellar dysarthria.

Row 2. Following the finger. What it tests, eye movements. Where it localises, cerebellum. This patient, horizontal nystagmus present. Verdict, fail, positive sign.

Row 3. Rapid alternating hands. What it tests, coordination rhythm. Where it localises, cerebellar hemisphere. This patient, irregular, broke down. Verdict, fail, dysdiadochokinesia.

Row 4. Finger-to-nose. What it tests, intention tremor and dysmetria. Where it localises, cerebellar hemisphere. This patient, tremor grew towards target, past-pointing. Verdict, fail, intention tremor, not rest.

Row 5. Heel-to-shin, tone. What it tests, lower-limb coordination. Where it localises, cerebellum. This patient, clumsy, hypotonic. Verdict, fail.

Row 6. Gait and Romberg. What it tests, stance and midline balance. Where it localises, midline cerebellum. This patient, wide-based, short-stepped, swayed on eye closure. Verdict, fail, cerebellar not proprioceptive.

Row 7. Rest tremor screen. What it tests, basal ganglia. Where it localises, nigrostriatal pathway. This patient, no rest tremor, no cogwheel. Verdict, pass, the relevant negative that rules out parkinsonism.

Row 8. Orientation and memory in conversation. What it tests, episodic memory. Where it localises, mammillary bodies and thalamus. This patient, confabulated, unaware of the gap. Verdict, fail, the Korsakoff core.

So the verdict out loud is a clear cerebellar syndrome on DANISH, with no parkinsonian rest tremor, sitting alongside an amnestic confabulating state, both explained by the alcohol history and localising to two different places at once.

That table, read aloud, is the finish. It is the difference between a candidate who did an examination and a candidate who reported one.

The two habits, again

Carry these two out of the room.

One. Talk to the patient, and only the patient. Every instruction is addressed to the person in front of you, never the examiner. You say what you are about to do, and why, in plain words, before you touch. Your running commentary is instructional, not interpretive, you tell them what is coming, not what you are concluding. You do not turn to the examiner and you do not present your findings to them, unless the card itself uses the word present or discuss.

Two. Every sign names the target it localises to, and you finish on a findings table. You never just see a sign. You hold what it tests and where it comes from, the lobe, the tract, the gland, in your head as a bracket, not a blurt. And you close every station the same way, with a spoken findings table, in the order you performed the steps, at least one relevant negative named, and a plain pass or fail verdict.

The thread here is which tremor, and be kind to the man who does not know what he has lost. Intention tremor localises to the cerebellum and means the opposite of the parkinsonian rest tremor, and the confabulation is handled with patience, never a challenge.

Do those two things and any examination station in this exam is yours to pass.

Before we begin

Welcome. This is the extrapyramidal side effects examination. In front of you is a patient, and a card that asks you to perform, to examine, to elicit signs. These are the most reliably passable stations in the whole exam, and the most reliably failed by the candidate who never rehearsed the running commentary.

A patient on an antipsychotic has become stiff, or slow, or restless, and the card asks for a brief history and an examination for extrapyramidal side effects. This is described as a core skill, so being unable to run it is viewed uncharitably. The framing that saves you is to treat it as a movement-disorder screen rather than only a parkinsonism screen, because the four effects are separable and you are hunting all four.

You will not fail for missing a rare sign. You will fail for silence, for turning to the examiner, or for finishing with nothing to report. So two habits carry every one of these. Keep them close.

One. Talk to the patient, and only the patient. Every instruction is addressed to the person in front of you, never the examiner. You say what you are about to do, and why, in plain words, before you touch. Your running commentary is instructional, not interpretive, you tell them what is coming, not what you are concluding. You do not turn to the examiner and you do not present your findings to them, unless the card itself uses the word present or discuss.

Two. Every sign names the target it localises to, and you finish on a findings table. You never just see a sign. You hold what it tests and where it comes from, the lobe, the tract, the gland, in your head as a bracket, not a blurt. And you close every station the same way, with a spoken findings table, in the order you performed the steps, at least one relevant negative named, and a plain pass or fail verdict.

Ready. Wash in, and let us begin.

What this station looks like

Picture the room, and the card on the door. Near enough, this.

You are asked to take a brief history and offer an examination for extrapyramidal side effects. You do not need to assess mental state or risk. Talk to the patient throughout.

Here is the shape of it, and it is the same skeleton every time. The fixed opening. A framework named out loud so the examiner hears your structure. The steps, in a fixed order, each one spoken to the patient. The signs, localised in your head. Then the spoken findings table to close.

Say the four out loud first: akathisia, motor restlessness; dystonia, sustained abnormal contraction; pseudoparkinsonism, tremor, rigidity and bradykinesia; and tardive dyskinesia, the abnormal movements of long exposure. Then a short history dated to the drug and the dose, then five examination moves in order, rest, tone, face and mouth, stand, walk.

Check. The shape is clear. Let us take the opening.

The opening, the fixed fifteen seconds

The opening is fixed, and it is the same on every examination station. Six moves, all said to the patient, all before you touch them. Every one is a printed mark. Do not drop them for the sake of the clock, they take fifteen seconds together.

One. Clean your hands, out loud.

I am just going to clean my hands before we begin.

Two. Introduce yourself, and confirm who they are.

Hello, my name is Doctor, and I am one of the psychiatry doctors. Can I just check your name and date of birth with you?

Three. Explain what the examination involves, in plain words. This line is the one that changes from station to station.

I would like to ask you a few quick questions about any stiffness, slowness, shakiness or restlessness, and then look at your hands, your face and your mouth, and watch you stand and take a few steps. It will not hurt, and I will tell you what I am doing as I go.

Four. Ask permission.

Is it alright with you if I go ahead?

Five. Offer a chaperone.

I can ask one of my colleagues to sit in with us if you would prefer, would that be alright?

Six. Ask about pain, and position and expose only as much as you need.

Before I start, are you sore or in any pain anywhere?

Before the hands, take the brief history and date it to the dose change, because the timeline is half the diagnosis: dystonia arrives in hours, akathisia in hours to weeks, parkinsonism over weeks, and tardive dyskinesia over months to years and can appear when a dose comes down.

Check. Six moves, fifteen seconds, every mark banked, and not one word to the examiner. Now the examination itself.

Who is in front of you

In front of you is a patient who, since a dose change a fortnight or so ago, has become stiffer, slower and less expressive, and whom the family describe as slow and blank. Do not mistake that flat, slowed, monotone picture for the negative symptoms of the illness, the fortnight and the dose change are what tell you it is the drug. And ask about the inner restlessness, because a still patient can be in agony.

Check. You know who you are examining, and what the card wants. Now the sequence, one step at a time.

The examination, in order

Five moves, and the observation periods are timed, roughly fifteen seconds each. Talk the whole way through, never treat the patient as a mannequin to be pushed and prodded.

The traps that fail this station

Half the marks in an examination station are in the traps. Here are the ones that sink this one.

Check. Name the trap you just avoided. That is the mark.

The findings table, read aloud

Now the close, and it is the same on every station. You read a findings table aloud, in the order you performed the steps. What you did, what it tests, where it localises, what this patient did, and a verdict. At least one relevant negative goes in, because a named negative is a scored finding.

For a patient with drug-induced parkinsonism on a raised antipsychotic dose, the table might read like this.

Row 1. Hands at rest, paper on outstretched hands. What it tests, tremor screen. Where it localises, nigrostriatal pathway. This patient, fine rest tremor, dampened on movement. Verdict, fail, parkinsonian tremor.

Row 2. Passive tone, both arms. What it tests, rigidity. Where it localises, basal ganglia. This patient, cogwheel rigidity present. Verdict, fail.

Row 3. Face. What it tests, hypomimia. Where it localises, nigrostriatal parkinsonism. This patient, reduced expression, mask-like. Verdict, fail.

Row 4. Tongue at rest and protruded. What it tests, tardive dyskinesia. Where it localises, chronic striatal supersensitivity. This patient, no abnormal tongue or facial movement. Verdict, pass, a relevant negative.

Row 5. Standing still, and the inner-restlessness question. What it tests, akathisia. Where it localises, the inner-experience effect. This patient, no urge to move, denies inner restlessness. Verdict, pass, a second relevant negative.

Row 6. Gait. What it tests, parkinsonian gait. Where it localises, nigrostriatal pathway. This patient, shuffling, reduced arm swing. Verdict, fail.

Row 7. History dated to the dose. What it tests, timeline. Where it localises, drug and dose. This patient, began a fortnight after the dose doubled. Verdict, confirms drug cause.

Row 8. Sudden abnormal posturing screen. What it tests, acute dystonia. Where it localises, nigrostriatal pathway. This patient, none, no oculogyric or torticollis. Verdict, pass, a third relevant negative.

So the verdict out loud is drug-induced pseudoparkinsonism, tremor, rigidity, hypomimia and a shuffling gait, dated to the dose increase, with no tardive dyskinesia, no akathisia and no acute dystonia, which points management towards a dose reduction or an anticholinergic rather than the wrong treatment for the wrong effect.

That table, read aloud, is the finish. It is the difference between a candidate who did an examination and a candidate who reported one.

The two habits, again

Carry these two out of the room.

One. Talk to the patient, and only the patient. Every instruction is addressed to the person in front of you, never the examiner. You say what you are about to do, and why, in plain words, before you touch. Your running commentary is instructional, not interpretive, you tell them what is coming, not what you are concluding. You do not turn to the examiner and you do not present your findings to them, unless the card itself uses the word present or discuss.

Two. Every sign names the target it localises to, and you finish on a findings table. You never just see a sign. You hold what it tests and where it comes from, the lobe, the tract, the gland, in your head as a bracket, not a blurt. And you close every station the same way, with a spoken findings table, in the order you performed the steps, at least one relevant negative named, and a plain pass or fail verdict.

The thread here is four separable effects, and the inner one you must ask about. Name all four, date them to the drug, and remember that akathisia is felt, not seen, and that anticholinergics help parkinsonism and dystonia but are useless in akathisia and worsen tardive dyskinesia, one class, different verdicts.

Do those two things and any examination station in this exam is yours to pass.

Before we begin

Welcome. This is the thyroid examination. In front of you is a patient, and a card that asks you to perform, to examine, to elicit signs. These are the most reliably passable stations in the whole exam, and the most reliably failed by the candidate who never rehearsed the running commentary.

A patient on lithium, or a patient whose depression or cognitive slowing will not lift, is in front of you, and the card asks you to examine the thyroid. Thyroid disease is one of the great psychiatric mimics, hypothyroidism misread as depression, thyrotoxicosis misread as anxiety, and lithium is a common driver of an underactive gland. So this is a psychiatry examination in every sense that matters.

You will not fail for missing a rare sign. You will fail for silence, for turning to the examiner, or for finishing with nothing to report. So two habits carry every one of these. Keep them close.

One. Talk to the patient, and only the patient. Every instruction is addressed to the person in front of you, never the examiner. You say what you are about to do, and why, in plain words, before you touch. Your running commentary is instructional, not interpretive, you tell them what is coming, not what you are concluding. You do not turn to the examiner and you do not present your findings to them, unless the card itself uses the word present or discuss.

Two. Every sign names the target it localises to, and you finish on a findings table. You never just see a sign. You hold what it tests and where it comes from, the lobe, the tract, the gland, in your head as a bracket, not a blurt. And you close every station the same way, with a spoken findings table, in the order you performed the steps, at least one relevant negative named, and a plain pass or fail verdict.

Ready. Wash in, and let us begin.

What this station looks like

Picture the room, and the card on the door. Near enough, this.

You are asked to examine this patient's thyroid. Talk to the patient throughout, and take care not to cause any discomfort at the neck.

Here is the shape of it, and it is the same skeleton every time. The fixed opening. A framework named out loud so the examiner hears your structure. The steps, in a fixed order, each one spoken to the patient. The signs, localised in your head. Then the spoken findings table to close.

The order is hands, then pulse, then eyes, then the neck by inspection and swallowing, then palpation from behind, then auscultation, then the completion signs, reflexes, proximal myopathy, pretibial myxoedema and signs of cardiac failure. Every finding you gather you sort into one bin, overactive or underactive.

Check. The shape is clear. Let us take the opening.

The opening, the fixed fifteen seconds

The opening is fixed, and it is the same on every examination station. Six moves, all said to the patient, all before you touch them. Every one is a printed mark. Do not drop them for the sake of the clock, they take fifteen seconds together.

One. Clean your hands, out loud.

I am just going to clean my hands before we begin.

Two. Introduce yourself, and confirm who they are.

Hello, my name is Doctor, and I am one of the psychiatry doctors. Can I just check your name and date of birth with you?

Three. Explain what the examination involves, in plain words. This line is the one that changes from station to station.

I would like to look at your hands and eyes, feel your pulse, and then examine your neck, and for that I will stand behind you and feel the gland while you swallow a sip of water. I will also check a couple of reflexes. It should not be uncomfortable, tell me if anything is.

Four. Ask permission.

Is it alright with you if I go ahead?

Five. Offer a chaperone.

I can ask one of my colleagues to sit in with us if you would prefer, would that be alright?

Six. Ask about pain, and position and expose only as much as you need.

Before I start, are you sore or in any pain anywhere?

Check. Six moves, fifteen seconds, every mark banked, and not one word to the examiner. Now the examination itself.

Who is in front of you

In front of you may be a patient whose lithium has quietly turned the gland down, so you are hunting the underactive signs, the slow pulse, the dry skin, the slow-relaxing reflexes, without a goitre. Or the reverse, a thyrotoxic picture driving what looks like anxiety. Let the signs tell you which, and do not decide before you have gathered them.

Check. You know who you are examining, and what the card wants. Now the sequence, one step at a time.

The examination, in order

Hands and pulse and eyes before the neck, then the neck from behind, then completion. Narrate each move.

The traps that fail this station

Half the marks in an examination station are in the traps. Here are the ones that sink this one.

Check. Name the trap you just avoided. That is the mark.

The findings table, read aloud

Now the close, and it is the same on every station. You read a findings table aloud, in the order you performed the steps. What you did, what it tests, where it localises, what this patient did, and a verdict. At least one relevant negative goes in, because a named negative is a scored finding.

For a patient with lithium-induced hypothyroidism, the table might read like this.

Row 1. Hands. What it tests, skin and tremor. Where it localises, thyroid status. This patient, dry, cool, no fine tremor. Verdict, points underactive.

Row 2. Pulse. What it tests, rate and rhythm. Where it localises, cardiovascular thyroid effect. This patient, bradycardia at fifty-six. Verdict, fail, underactive.

Row 3. Eyes. What it tests, autoimmune eye signs. Where it localises, Graves thyrotoxicosis. This patient, no exophthalmos, no lid lag. Verdict, pass, a relevant negative that rules out overactivity.

Row 4. Neck on swallowing. What it tests, goitre. Where it localises, thyroid gland. This patient, no goitre, gland not enlarged. Verdict, consistent with lithium hypothyroidism.

Row 5. Palpation from behind, bruit. What it tests, gland and blood flow. Where it localises, thyroid. This patient, no mass, no bruit. Verdict, pass, a second relevant negative.

Row 6. Ankle reflex. What it tests, relaxation phase. Where it localises, hypothyroidism. This patient, slow-relaxing, hung-up. Verdict, fail, underactive.

Row 7. Stand, arms crossed. What it tests, proximal myopathy. Where it localises, thyroid myopathy. This patient, rose slowly. Verdict, borderline.

Row 8. Shins. What it tests, pretibial change and skin. Where it localises, thyroid status. This patient, dry, no pretibial myxoedema. Verdict, consistent.

So the verdict out loud is a hypothyroid picture, bradycardia, dry skin and a slow-relaxing reflex, with none of the Graves eye or gland signs, in a patient on lithium, which names the cause as lithium-induced hypothyroidism and would take you to thyroid function tests next.

That table, read aloud, is the finish. It is the difference between a candidate who did an examination and a candidate who reported one.

The two habits, again

Carry these two out of the room.

One. Talk to the patient, and only the patient. Every instruction is addressed to the person in front of you, never the examiner. You say what you are about to do, and why, in plain words, before you touch. Your running commentary is instructional, not interpretive, you tell them what is coming, not what you are concluding. You do not turn to the examiner and you do not present your findings to them, unless the card itself uses the word present or discuss.

Two. Every sign names the target it localises to, and you finish on a findings table. You never just see a sign. You hold what it tests and where it comes from, the lobe, the tract, the gland, in your head as a bracket, not a blurt. And you close every station the same way, with a spoken findings table, in the order you performed the steps, at least one relevant negative named, and a plain pass or fail verdict.

The thread here is thyroid disease is a psychiatric mimic, and lithium turns the gland down. Sort every sign into over or under as you go, and in a psychiatric station the underactive picture on lithium is the one the case is usually built around.

Do those two things and any examination station in this exam is yours to pass.

Before we begin

Welcome. This is the cardiovascular examination. In front of you is a patient, and a card that asks you to perform, to examine, to elicit signs. These are the most reliably passable stations in the whole exam, and the most reliably failed by the candidate who never rehearsed the running commentary.

A patient with cognitive difficulties and vascular risk, or a patient whose chest pain has been written off as a panic attack, is in front of you, and the card asks for a cardiovascular examination. In psychiatry there are two reasons this station exists, to find the embolic and vascular source behind a vascular dementia, and to take a physical complaint seriously when it arrives wrapped in anxiety.

You will not fail for missing a rare sign. You will fail for silence, for turning to the examiner, or for finishing with nothing to report. So two habits carry every one of these. Keep them close.

One. Talk to the patient, and only the patient. Every instruction is addressed to the person in front of you, never the examiner. You say what you are about to do, and why, in plain words, before you touch. Your running commentary is instructional, not interpretive, you tell them what is coming, not what you are concluding. You do not turn to the examiner and you do not present your findings to them, unless the card itself uses the word present or discuss.

Two. Every sign names the target it localises to, and you finish on a findings table. You never just see a sign. You hold what it tests and where it comes from, the lobe, the tract, the gland, in your head as a bracket, not a blurt. And you close every station the same way, with a spoken findings table, in the order you performed the steps, at least one relevant negative named, and a plain pass or fail verdict.

Ready. Wash in, and let us begin.

What this station looks like

Picture the room, and the card on the door. Near enough, this.

You are asked to perform a cardiovascular examination on this patient. Talk to the patient throughout.

Here is the shape of it, and it is the same skeleton every time. The fixed opening. A framework named out loud so the examiner hears your structure. The steps, in a fixed order, each one spoken to the patient. The signs, localised in your head. Then the spoken findings table to close.

Position the patient at forty-five degrees and expose the chest appropriately. Then general inspection, hands, pulse and blood pressure, carotids and the neck veins, then the praecordium by inspection and palpation, then auscultation in the four areas and the lung bases, then the legs for oedema and peripheral vascular disease.

Check. The shape is clear. Let us take the opening.

The opening, the fixed fifteen seconds

The opening is fixed, and it is the same on every examination station. Six moves, all said to the patient, all before you touch them. Every one is a printed mark. Do not drop them for the sake of the clock, they take fifteen seconds together.

One. Clean your hands, out loud.

I am just going to clean my hands before we begin.

Two. Introduce yourself, and confirm who they are.

Hello, my name is Doctor, and I am one of the psychiatry doctors. Can I just check your name and date of birth with you?

Three. Explain what the examination involves, in plain words. This line is the one that changes from station to station.

I would like to examine your heart and circulation. I will look at your hands and face, feel your pulse and take your blood pressure, feel and listen to your chest, and check your legs. I will need you to lie back at about forty-five degrees, and I will help you get comfortable. Tell me if anything is sore.

Four. Ask permission.

Is it alright with you if I go ahead?

Five. Offer a chaperone.

I can ask one of my colleagues to sit in with us if you would prefer, would that be alright?

Six. Ask about pain, and position and expose only as much as you need.

Before I start, are you sore or in any pain anywhere?

Check. Six moves, fifteen seconds, every mark banked, and not one word to the examiner. Now the examination itself.

Who is in front of you

In front of you may be an anxious patient, convinced her heart is being missed and that no one takes her seriously, so the examination is also a piece of reassurance done properly. Or a diabetic patient with falls and cognitive decline, in whom you are hunting atrial fibrillation, a carotid bruit and peripheral vascular disease as the vascular story behind the dementia. Examine thoroughly and narrate, because being examined carefully is itself therapeutic here.

Check. You know who you are examining, and what the card wants. Now the sequence, one step at a time.

The examination, in order

Forty-five degrees, chest exposed, then work inwards from the periphery. Narrate throughout.

The traps that fail this station

Half the marks in an examination station are in the traps. Here are the ones that sink this one.

Check. Name the trap you just avoided. That is the mark.

The findings table, read aloud

Now the close, and it is the same on every station. You read a findings table aloud, in the order you performed the steps. What you did, what it tests, where it localises, what this patient did, and a verdict. At least one relevant negative goes in, because a named negative is a scored finding.

For a diabetic patient with vascular cognitive impairment, the table might read like this.

Row 1. General and hands. What it tests, vascular risk signs. Where it localises, periphery. This patient, xanthelasma present, hands cool. Verdict, points vascular.

Row 2. Pulse and rhythm. What it tests, embolic source. Where it localises, cardiac. This patient, irregularly irregular, atrial fibrillation. Verdict, fail, the key vascular finding.

Row 3. Carotid auscultation. What it tests, carotid stenosis. Where it localises, carotid arteries. This patient, bruit on the left. Verdict, fail, a second vascular source.

Row 4. Jugular venous pressure. What it tests, right heart. Where it localises, venous system. This patient, not raised. Verdict, pass, a relevant negative.

Row 5. Apex and heaves. What it tests, ventricular hypertrophy. Where it localises, praecordium. This patient, apex not displaced, no heave. Verdict, pass, a second relevant negative.

Row 6. Auscultation, four areas and bases. What it tests, valves and failure. Where it localises, heart and lungs. This patient, no murmur, bases clear. Verdict, pass.

Row 7. Foot pulses and skin. What it tests, peripheral vascular disease. Where it localises, lower-limb arteries. This patient, absent posterior tibial pulses, shiny skin. Verdict, fail, peripheral vascular disease.

Row 8. Ankle oedema. What it tests, fluid status. Where it localises, lower limbs. This patient, no pitting oedema. Verdict, pass, a third relevant negative.

So the verdict out loud is a vascular picture, atrial fibrillation, a carotid bruit and peripheral vascular disease, without heart failure signs, which supplies the embolic and small-vessel story behind this patient's cognitive decline and points to rhythm control and anticoagulation.

That table, read aloud, is the finish. It is the difference between a candidate who did an examination and a candidate who reported one.

The two habits, again

Carry these two out of the room.

One. Talk to the patient, and only the patient. Every instruction is addressed to the person in front of you, never the examiner. You say what you are about to do, and why, in plain words, before you touch. Your running commentary is instructional, not interpretive, you tell them what is coming, not what you are concluding. You do not turn to the examiner and you do not present your findings to them, unless the card itself uses the word present or discuss.

Two. Every sign names the target it localises to, and you finish on a findings table. You never just see a sign. You hold what it tests and where it comes from, the lobe, the tract, the gland, in your head as a bracket, not a blurt. And you close every station the same way, with a spoken findings table, in the order you performed the steps, at least one relevant negative named, and a plain pass or fail verdict.

The thread here is find the vascular source, and take the anxious patient seriously. Atrial fibrillation, a carotid bruit and absent foot pulses tie the heart to the brain, and a careful, narrated examination is itself the reassurance the anxious patient came for.

Do those two things and any examination station in this exam is yours to pass.

Before we begin

Welcome. This is the abdominal examination for hepatic encephalopathy. In front of you is a patient, and a card that asks you to perform, to examine, to elicit signs. These are the most reliably passable stations in the whole exam, and the most reliably failed by the candidate who never rehearsed the running commentary.

A patient with an alcohol history is worried about his liver, and the card asks for an abdominal examination including the signs of hepatic encephalopathy. This is the station that proves the rule for the whole physical-consequences family, that in a patient who drinks, an abnormal mental state may be a hepatic sign. And where the patient genuinely does have liver disease, bodily preoccupation is not health anxiety, it is appropriate concern, and the right response is to examine him properly.

You will not fail for missing a rare sign. You will fail for silence, for turning to the examiner, or for finishing with nothing to report. So two habits carry every one of these. Keep them close.

One. Talk to the patient, and only the patient. Every instruction is addressed to the person in front of you, never the examiner. You say what you are about to do, and why, in plain words, before you touch. Your running commentary is instructional, not interpretive, you tell them what is coming, not what you are concluding. You do not turn to the examiner and you do not present your findings to them, unless the card itself uses the word present or discuss.

Two. Every sign names the target it localises to, and you finish on a findings table. You never just see a sign. You hold what it tests and where it comes from, the lobe, the tract, the gland, in your head as a bracket, not a blurt. And you close every station the same way, with a spoken findings table, in the order you performed the steps, at least one relevant negative named, and a plain pass or fail verdict.

Ready. Wash in, and let us begin.

What this station looks like

Picture the room, and the card on the door. Near enough, this.

You are asked to carry out an abdominal examination including any physical signs of hepatic encephalopathy. Talk to the patient throughout, and declare a finding at each step.

Here is the shape of it, and it is the same skeleton every time. The fixed opening. A framework named out loud so the examiner hears your structure. The steps, in a fixed order, each one spoken to the patient. The signs, localised in your head. Then the spoken findings table to close.

The order is: listen to the speech, inspect from the end of the bed, the hands including the liver flap, the pulse, the eyes and mouth, the neck, then the abdomen by inspection, palpation light then deep, percussion including shifting dullness, and auscultation, then the legs. And you state aloud that a rectal and genital examination would normally complete it but is not appropriate here.

Check. The shape is clear. Let us take the opening.

The opening, the fixed fifteen seconds

The opening is fixed, and it is the same on every examination station. Six moves, all said to the patient, all before you touch them. Every one is a printed mark. Do not drop them for the sake of the clock, they take fifteen seconds together.

One. Clean your hands, out loud.

I am just going to clean my hands before we begin.

Two. Introduce yourself, and confirm who they are.

Hello, my name is Doctor, and I am one of the psychiatry doctors. Can I just check your name and date of birth with you?

Three. Explain what the examination involves, in plain words. This line is the one that changes from station to station.

I would like to examine your tummy, and also your hands, face and legs, to check your liver. I will talk you through each thing as I do it so you always know what is happening. I will need you to lie fairly flat with your tummy exposed. Are you sore anywhere before I start?

Four. Ask permission.

Is it alright with you if I go ahead?

Five. Offer a chaperone.

I can ask one of my colleagues to sit in with us if you would prefer, would that be alright?

Six. Ask about pain, and position and expose only as much as you need.

Before I start, are you sore or in any pain anywhere?

Two things this station rewards. Talk the whole way through and say at each step whether you have found anything, because the running commentary is what settles the worried patient. And state, out loud, that a full abdominal examination would normally include a rectal and genital examination but that it is not appropriate here, that single sentence is a printed mark.

Check. Six moves, fifteen seconds, every mark banked, and not one word to the examiner. Now the examination itself.

Who is in front of you

In front of you is a man, some days into an admission and off alcohol, who has become preoccupied with whether he has done lasting damage, and who has been told before that his liver is affected. He has not noticed specific symptoms. Because the liver disease is real, his worry is reasonable, so you examine thoroughly, narrate reassuringly, and let the findings, not a diagnosis of health anxiety, lead.

Check. You know who you are examining, and what the card wants. Now the sequence, one step at a time.

The examination, in order

Speech and flap first, because they carry the encephalopathy, then the classic abdominal sequence. Narrate and declare at each step.

The traps that fail this station

Half the marks in an examination station are in the traps. Here are the ones that sink this one.

Check. Name the trap you just avoided. That is the mark.

The findings table, read aloud

Now the close, and it is the same on every station. You read a findings table aloud, in the order you performed the steps. What you did, what it tests, where it localises, what this patient did, and a verdict. At least one relevant negative goes in, because a named negative is a scored finding.

For a patient with chronic alcohol-related liver disease and early encephalopathy, the table might read like this.

Row 1. Speech and end-of-bed inspection. What it tests, encephalopathy and stigmata. Where it localises, metabolic brain function and liver. This patient, mildly slurred, spider naevi, mild jaundice. Verdict, fail, early encephalopathy.

Row 2. Held-back wrists. What it tests, asterixis. Where it localises, hepatic encephalopathy. This patient, coarse flap present. Verdict, fail, the specific sign.

Row 3. Eyes and mouth. What it tests, jaundice and nutrition. Where it localises, liver and nutrition. This patient, scleral jaundice, glossitis. Verdict, fail.

Row 4. Palpation of the liver. What it tests, hepatomegaly. Where it localises, liver. This patient, firm, enlarged two finger-breadths. Verdict, fail.

Row 5. Shifting dullness. What it tests, ascites. Where it localises, portal system. This patient, present. Verdict, fail, portal hypertension.

Row 6. Bowel sounds. What it tests, obstruction screen. Where it localises, gut. This patient, present and normal. Verdict, pass, a relevant negative.

Row 7. Ankle oedema and reflexes. What it tests, albumin and encephalopathy. Where it localises, periphery and brain. This patient, mild pitting oedema, brisk reflexes. Verdict, fail.

Row 8. Rectal and genital. What it tests, completeness. Where it localises, lower gastrointestinal tract. This patient, deferred as not appropriate, stated aloud. Verdict, pass, the scored omission.

So the verdict out loud is chronic liver disease with early hepatic encephalopathy, slurred speech, a positive flap, jaundice, hepatomegaly and ascites, which reframes any change in his mental state as a metabolic sign to be treated, not a psychiatric one.

That table, read aloud, is the finish. It is the difference between a candidate who did an examination and a candidate who reported one.

The two habits, again

Carry these two out of the room.

One. Talk to the patient, and only the patient. Every instruction is addressed to the person in front of you, never the examiner. You say what you are about to do, and why, in plain words, before you touch. Your running commentary is instructional, not interpretive, you tell them what is coming, not what you are concluding. You do not turn to the examiner and you do not present your findings to them, unless the card itself uses the word present or discuss.

Two. Every sign names the target it localises to, and you finish on a findings table. You never just see a sign. You hold what it tests and where it comes from, the lobe, the tract, the gland, in your head as a bracket, not a blurt. And you close every station the same way, with a spoken findings table, in the order you performed the steps, at least one relevant negative named, and a plain pass or fail verdict.

The thread here is the abnormal mental state that is a liver sign. Listen to the speech, ask for the flap, and remember that in a man who genuinely has liver disease, worry about it is reasonable and the answer is to examine him well and talk the whole way through.

Do those two things and any examination station in this exam is yours to pass.

Before we begin

Welcome. This is the fundoscopy station. In front of you is a patient, and a card that asks you to perform, to examine, to elicit signs. These are the most reliably passable stations in the whole exam, and the most reliably failed by the candidate who never rehearsed the running commentary.

A patient with sudden loss of vision in one eye, where the medical team suspect a psychological cause, is in front of you, and the card asks for a brief history and a fundoscopy. This is a two-part station, a focused history that gently screens for the functional picture and the stress behind it, and then a genuine, correctly performed fundoscopy, because you cannot call a visual loss functional until you have looked and found the back of the eye normal.

You will not fail for missing a rare sign. You will fail for silence, for turning to the examiner, or for finishing with nothing to report. So two habits carry every one of these. Keep them close.

One. Talk to the patient, and only the patient. Every instruction is addressed to the person in front of you, never the examiner. You say what you are about to do, and why, in plain words, before you touch. Your running commentary is instructional, not interpretive, you tell them what is coming, not what you are concluding. You do not turn to the examiner and you do not present your findings to them, unless the card itself uses the word present or discuss.

Two. Every sign names the target it localises to, and you finish on a findings table. You never just see a sign. You hold what it tests and where it comes from, the lobe, the tract, the gland, in your head as a bracket, not a blurt. And you close every station the same way, with a spoken findings table, in the order you performed the steps, at least one relevant negative named, and a plain pass or fail verdict.

Ready. Wash in, and let us begin.

What this station looks like

Picture the room, and the card on the door. Near enough, this.

You are asked to take a history of this patient's symptoms and perform a fundoscopy examination. Talk to the patient throughout, and narrate the fundoscopy as you go.

Here is the shape of it, and it is the same skeleton every time. The fixed opening. A framework named out loud so the examiner hears your structure. The steps, in a fixed order, each one spoken to the patient. The signs, localised in your head. Then the spoken findings table to close.

First a brief history, onset and progression, associated symptoms like headache or pain, the manner in which they hold the loss, and a short mood and risk screen. Then the fundoscopy proper, darken the room, red reflex, in to the disc, the vessels, the macula, and offer the completing tests, acuity, colour vision and the pupil reflexes.

Check. The shape is clear. Let us take the opening.

The opening, the fixed fifteen seconds

The opening is fixed, and it is the same on every examination station. Six moves, all said to the patient, all before you touch them. Every one is a printed mark. Do not drop them for the sake of the clock, they take fifteen seconds together.

One. Clean your hands, out loud.

I am just going to clean my hands before we begin.

Two. Introduce yourself, and confirm who they are.

Hello, my name is Doctor, and I am one of the psychiatry doctors. Can I just check your name and date of birth with you?

Three. Explain what the examination involves, in plain words. This line is the one that changes from station to station.

I would like to ask you a few questions about your eye, and then look into the back of it with this light, the ophthalmoscope. To do that I will dim the room and come in quite close to your face, and I will use my right eye to look into your right eye, and my left to your left. It will not hurt. Please keep looking at a fixed point on the wall behind me.

Four. Ask permission.

Is it alright with you if I go ahead?

Five. Offer a chaperone.

I can ask one of my colleagues to sit in with us if you would prefer, would that be alright?

Six. Ask about pain, and position and expose only as much as you need.

Before I start, are you sore or in any pain anywhere?

Check. Six moves, fifteen seconds, every mark banked, and not one word to the examiner. Now the examination itself.

Who is in front of you

In front of you is a patient who woke with the vision gone in one eye and who is, strikingly, not very worried about it, a lack of concern out of proportion to the deficit. Behind the presentation there is real recent stress and loss, and low mood with some fleeting thoughts that life is not worth living. So the history is done gently, the mood and risk are screened, and the examination is done properly, because the diagnosis rests on the negatives you gather.

Check. You know who you are examining, and what the card wants. Now the sequence, one step at a time.

The history, then the examination, in order

History first, briefly, then the fundoscopy technique, then the completing tests. Keep talking to the patient the whole time.

The traps that fail this station

Half the marks in an examination station are in the traps. Here are the ones that sink this one.

Check. Name the trap you just avoided. That is the mark.

The findings table, read aloud

Now the close, and it is the same on every station. You read a findings table aloud, in the order you performed the steps. What you did, what it tests, where it localises, what this patient did, and a verdict. At least one relevant negative goes in, because a named negative is a scored finding.

For a patient with a functional visual loss, the table might read like this.

Row 1. Onset and manner of the loss. What it tests, history. Where it localises, functional versus organic. This patient, sudden, painless, markedly unconcerned. Verdict, points functional.

Row 2. Mood and risk screen. What it tests, psychiatric context. Where it localises, mood and safety. This patient, low mood, fleeting passive thoughts, no plans. Verdict, noted and safety-netted.

Row 3. Red reflex. What it tests, media clarity. Where it localises, lens and vitreous. This patient, present and symmetric. Verdict, pass, a relevant negative.

Row 4. Optic disc. What it tests, optic nerve head. Where it localises, optic nerve. This patient, sharp margins, healthy colour. Verdict, pass, argues against organic loss.

Row 5. Retinal vessels and macula. What it tests, retina. Where it localises, retina. This patient, normal. Verdict, pass.

Row 6. Visual acuity on a chart. What it tests, central acuity. Where it localises, visual pathway. This patient, inconsistent with the claimed density of loss. Verdict, points functional.

Row 7. Colour vision. What it tests, optic nerve function. Where it localises, optic nerve. This patient, preserved. Verdict, pass, a further negative.

Row 8. Swinging-light test. What it tests, afferent pupil pathway. Where it localises, optic nerve. This patient, no relative afferent pupillary defect. Verdict, pass, the decisive negative.

So the verdict out loud is a normal fundus, normal disc, preserved colour vision and, decisively, no relative afferent pupillary defect, in a patient with dense but painless monocular loss and marked indifference on a background of acute stress, a picture that points to a functional cause while the mood and risk are screened and safety-netted.

That table, read aloud, is the finish. It is the difference between a candidate who did an examination and a candidate who reported one.

The two habits, again

Carry these two out of the room.

One. Talk to the patient, and only the patient. Every instruction is addressed to the person in front of you, never the examiner. You say what you are about to do, and why, in plain words, before you touch. Your running commentary is instructional, not interpretive, you tell them what is coming, not what you are concluding. You do not turn to the examiner and you do not present your findings to them, unless the card itself uses the word present or discuss.

Two. Every sign names the target it localises to, and you finish on a findings table. You never just see a sign. You hold what it tests and where it comes from, the lobe, the tract, the gland, in your head as a bracket, not a blurt. And you close every station the same way, with a spoken findings table, in the order you performed the steps, at least one relevant negative named, and a plain pass or fail verdict.

The thread here is you cannot call it functional until you have looked, and the negatives carry it. Do the fundoscopy correctly, right eye to right eye, and never skip the swinging-light test, because the absent afferent pupillary defect is what tells organic from functional, kindly, without ever labelling the patient to their face.

Do those two things and any examination station in this exam is yours to pass.

Before we begin

Welcome. This is the cranial nerve examination. In front of you is a patient, and a card that asks you to perform, to examine, to elicit signs. These are the most reliably passable stations in the whole exam, and the most reliably failed by the candidate who never rehearsed the running commentary.

A psychiatric patient with a neurological question, a possible space-occupying lesion, a functional weakness, an odd visual or facial symptom, is in front of you, and the card asks for a cranial nerve examination. The examiner is not expecting you to diagnose a rare palsy. They are watching whether you can run all twelve nerves in order, out loud, without getting lost, addressing every instruction to the patient.

You will not fail for missing a rare sign. You will fail for silence, for turning to the examiner, or for finishing with nothing to report. So two habits carry every one of these. Keep them close.

One. Talk to the patient, and only the patient. Every instruction is addressed to the person in front of you, never the examiner. You say what you are about to do, and why, in plain words, before you touch. Your running commentary is instructional, not interpretive, you tell them what is coming, not what you are concluding. You do not turn to the examiner and you do not present your findings to them, unless the card itself uses the word present or discuss.

Two. Every sign names the target it localises to, and you finish on a findings table. You never just see a sign. You hold what it tests and where it comes from, the lobe, the tract, the gland, in your head as a bracket, not a blurt. And you close every station the same way, with a spoken findings table, in the order you performed the steps, at least one relevant negative named, and a plain pass or fail verdict.

Ready. Wash in, and let us begin.

What this station looks like

Picture the room, and the card on the door. Near enough, this.

You are asked to perform a cranial nerve examination on this patient. Talk to the patient throughout.

Here is the shape of it, and it is the same skeleton every time. The fixed opening. A framework named out loud so the examiner hears your structure. The steps, in a fixed order, each one spoken to the patient. The signs, localised in your head. Then the spoken findings table to close.

One nerve at a time, in order, one to twelve. Announce the group as you reach it so the examiner hears the structure, and offer the specialised tests, fundoscopy, Weber and Rinne, formal smell and colour testing, as offers rather than performing every one. Keep it moving so all twelve fit inside the station.

Check. The shape is clear. Let us take the opening.

The opening, the fixed fifteen seconds

The opening is fixed, and it is the same on every examination station. Six moves, all said to the patient, all before you touch them. Every one is a printed mark. Do not drop them for the sake of the clock, they take fifteen seconds together.

One. Clean your hands, out loud.

I am just going to clean my hands before we begin.

Two. Introduce yourself, and confirm who they are.

Hello, my name is Doctor, and I am one of the psychiatry doctors. Can I just check your name and date of birth with you?

Three. Explain what the examination involves, in plain words. This line is the one that changes from station to station.

I would like to check the nerves that supply your face, your eyes, your hearing and your mouth. I will ask you to look at things, follow my finger, feel some light touches, and make some faces and movements. None of it is uncomfortable, and I will guide you through each part.

Four. Ask permission.

Is it alright with you if I go ahead?

Five. Offer a chaperone.

I can ask one of my colleagues to sit in with us if you would prefer, would that be alright?

Six. Ask about pain, and position and expose only as much as you need.

Before I start, are you sore or in any pain anywhere?

Check. Six moves, fifteen seconds, every mark banked, and not one word to the examiner. Now the examination itself.

Who is in front of you

In front of you is a patient who may have a genuine neurological sign, or a functional one, and the examination is how you tell. Your job is completeness and order, not a dramatic diagnosis. Run the twelve the same way every time and any real deficit will surface in its place, localised to its nerve.

Check. You know who you are examining, and what the card wants. Now the sequence, one step at a time.

The examination, one nerve at a time

Announce each nerve or group, give the task to the patient, hold the sign for the table. Offer the specialised tests rather than doing all of them.

The traps that fail this station

Half the marks in an examination station are in the traps. Here are the ones that sink this one.

Check. Name the trap you just avoided. That is the mark.

The findings table, read aloud

Now the close, and it is the same on every station. You read a findings table aloud, in the order you performed the steps. What you did, what it tests, where it localises, what this patient did, and a verdict. At least one relevant negative goes in, because a named negative is a scored finding.

For a patient with a left facial weakness that spares the forehead, the table might read like this.

Row 1. Smell, asked. What it tests, first nerve. Where it localises, olfactory nerve. This patient, unchanged. Verdict, pass, a relevant negative.

Row 2. Acuity, fields, pupils. What it tests, second nerve. Where it localises, optic nerve and pathway. This patient, normal, no neglect. Verdict, pass.

Row 3. Eye movements in an H. What it tests, third, fourth, sixth. Where it localises, ocular motor nerves. This patient, full, no diplopia or nystagmus. Verdict, pass.

Row 4. Face sensation and jaw. What it tests, fifth nerve. Where it localises, trigeminal nerve. This patient, intact. Verdict, pass.

Row 5. Facial movement. What it tests, seventh nerve. Where it localises, facial nerve. This patient, left lower face weak, forehead spared. Verdict, fail, an upper motor neurone pattern.

Row 6. Whispered numbers. What it tests, eighth nerve. Where it localises, vestibulocochlear nerve. This patient, heard both sides. Verdict, pass, a second relevant negative.

Row 7. Palate, cough, swallow. What it tests, ninth and tenth. Where it localises, glossopharyngeal and vagus. This patient, palate rises symmetrically. Verdict, pass.

Row 8. Shrug, head turn, tongue. What it tests, eleventh and twelfth. Where it localises, accessory and hypoglossal. This patient, normal, tongue central. Verdict, pass, a third relevant negative.

So the verdict out loud is an isolated left facial weakness that spares the forehead, an upper motor neurone seventh nerve pattern, with every other cranial nerve intact, which localises above the facial nucleus and would take you towards imaging of the brain rather than a diagnosis of Bell's palsy.

That table, read aloud, is the finish. It is the difference between a candidate who did an examination and a candidate who reported one.

The two habits, again

Carry these two out of the room.

One. Talk to the patient, and only the patient. Every instruction is addressed to the person in front of you, never the examiner. You say what you are about to do, and why, in plain words, before you touch. Your running commentary is instructional, not interpretive, you tell them what is coming, not what you are concluding. You do not turn to the examiner and you do not present your findings to them, unless the card itself uses the word present or discuss.

Two. Every sign names the target it localises to, and you finish on a findings table. You never just see a sign. You hold what it tests and where it comes from, the lobe, the tract, the gland, in your head as a bracket, not a blurt. And you close every station the same way, with a spoken findings table, in the order you performed the steps, at least one relevant negative named, and a plain pass or fail verdict.

The thread here is order and completeness, not a dramatic diagnosis. Announce each nerve, offer the specialised tests rather than performing all of them, and remember that on the seventh nerve the forehead is the whole story, sparing means central, whole-side means peripheral.

Do those two things and any examination station in this exam is yours to pass.