The Neurology Station in MRCP PACES (Station 3)

What this station tests and how the time runs

Station 3 pairs two examination encounters, each observed by two examiners: the cardiovascular case and the nervous system case. For the neurology encounter you get 6 minutes of examination followed by 4 minutes of discussion — ten minutes in total, within a wider twenty-minute block shared with the cardiology case.

The instruction is usually regional rather than a full neurological survey: "examine this patient's legs", "examine the upper limbs", "examine the cranial nerves", or "look at this patient's eye movements". You are not expected to do everything — you are expected to do the region you are given thoroughly, spot the abnormal signs, and pull them together into a localising statement. The discussion then probes whether you can name the lesion, offer a sensible differential, and outline investigation and management.

The examiners are watching two things above all: did you find the signs, and did you reach the right place in the neuraxis. A tidy, unhurried technique that still finishes on time is what separates a comfortable pass from a scramble.

The marking skills that apply, and what satisfactory looks like

Like the other short-case examination encounters, the neurology station is marked on five skills: A, B, D, E and G. Skills C and F (clinical communication and managing patients' concerns) are not assessed here — they belong to the communication and consultation encounters.

• A — Physical Examination. Satisfactory means a complete, fluent regional examination that looks for every sign that matters — tone, power, reflexes, coordination, sensation, gait — without omitting the manoeuvre that clinches it. Completeness matters far more than the exact order you work in.
• B — Identifying Physical Signs. A heavily weighted skill. You must correctly read what is in front of you — pyramidal versus extrapyramidal tone, a pronator drift, a level of sensory loss, absent versus brisk reflexes — and, just as importantly, not claim signs that are not there.
• D — Differential Diagnosis. A sensible differential that contains the correct answer. Localise first (cortex, cord, root, nerve, junction, muscle), then let anatomy generate a short, ranked list rather than a scattergun of names.
• E — Clinical Judgement. Accurate knowledge translated into a relevant plan: the right investigations (imaging, nerve conduction studies, bloods, lumbar puncture as appropriate) and a management outline with a realistic timescale.
• G — Maintaining Patient Welfare. In practice terms, sensible safety-netting and disposition — handling the patient gently during power and gait testing and not jeopardising safety, for example being alert to falls risk in an unsteady patient.

A systematic routine that finds the diagnosis

Give yourself a fixed framework so nothing is forgotten under pressure. For a limb examination, move through inspection (wasting, fasciculation, posture, involuntary movements), tone, power (graded MRC 0–5), reflexes, coordination, sensation, and — for the legs — gait. Watching the patient walk early is often the single most informative manoeuvre and should not be skipped.

The real work is turning signs into a location. Ask yourself as you go: is this an upper motor neurone pattern (increased tone, hyperreflexia, extensor plantars, pyramidal weakness) or a lower motor neurone pattern (wasting, fasciculation, reduced tone, absent reflexes)? Is weakness proximal or distal, symmetrical or focal? Is sensory loss in a glove-and-stocking distribution, a dermatomal level, or a hemisensory pattern? Each answer narrows the neuraxis.

Rehearse a closing sentence you can deliver on demand: "This patient has a spastic paraparesis with a sensory level, localising to the thoracic cord, and I would investigate with MRI of the whole spine." A crisp localising summary reassures the examiners that you understood what you found, and it frames the discussion on your terms.

Common conditions and how to prepare

A handful of patterns recur again and again in this station, so drill them until the routine is automatic. Two recurring presentations have their own dedicated pages on PACES Buddy: spastic paraparesis (bilateral upper motor neurone leg signs, often with a sensory level, pointing you to the cord) and peripheral neuropathy (distal, symmetrical, lower motor neurone signs with glove-and-stocking sensory loss). Work through each so you can recognise the pattern in seconds and rattle off its differential.

Beyond these, be fluent in the classic limb and cranial-nerve cases: hemiparesis after stroke, Parkinsonism, cerebellar syndrome, myotonic dystrophy, motor neurone disease, hereditary sensorimotor neuropathy, and common ocular findings such as an internuclear ophthalmoplegia or a third-nerve palsy. For each, know the handful of signs that clinch it, the two or three differentials, and the first-line investigation.

Preparation is mostly about repetition against real feedback: examine, localise out loud, defend the diagnosis, and be challenged on it. That last step — the four minutes of discussion — is where marks are won or lost, so practise talking, not just examining.