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Practice case P2-15 · Face-to-face · examination of a simulated patient

“My face has dropped” — examining the cranial nerves

A 42-year-old teacher woke yesterday with a drooping face. He thinks he has had a stroke. You have eight minutes, a pen torch, a tuning fork and an otoscope.

Reviewed and kept current

Station family: Focused neurological examination · 8-minute station · 1 min 30 s reading · Last editorial review: 19 September 2026.

Candidate instructions

Read this as you would outside the room

You have 1 minute 30 seconds to read, then 8 minutes. Candidates: everything below this section is folded away — leave it closed until you have finished the station.

	Information
Your role	Foundation Year 2 doctor in a general practice, same-day clinic. Your supervising GP is available.
Patient	Mr Kwame Mensah, 42, secondary school teacher
Triage note	“Woke yesterday morning with the left side of his face drooping. His left eye keeps watering. Worried he has had a stroke.”
Observations (healthcare assistant)	BP 132/80, pulse 74 regular, temperature 36.7 °C, capillary glucose 5.4 mmol/L.
Records	No past medical history. No regular medication. No known allergies. Non-smoker.
Equipment	Pen torch, cotton wool, 512 Hz tuning fork, otoscope with disposable specula, tongue depressor, Snellen chart on the wall.

Your task

•

Examine Mr Mensah’s cranial nerves — and anything else you need to examine to find the cause of his facial weakness.

•

Ask only the questions you need as you go; a full history is not required.

•

Tell him what you have found, your working diagnosis and why, and agree a plan.

Folded away

For the actor and the examiner

1 · Actor script — role player only

Candidates: do not open until you have consulted.

Persona and manner

Kwame Mensah, 42, head of year and science teacher; married to Abena, two children.
Articulate and usually calm — today frightened, and holding a tissue to your left eye, which keeps streaming.

Opening line — say this verbatim

“Doctor, my face has dropped. I’ve had a stroke, haven’t I? I’ve seen the adverts.”

How to show the weakness — left side only

At rest: let the left corner of your mouth droop a little.
“Raise your eyebrows”: raise only the right. If you cannot raise one eyebrow on its own, keep both still and say “the left one won’t go up” — never let the left forehead wrinkle; the finding is then read out.
“Close your eyes tightly”: close the right firmly; leave the left partly open and, if you can, roll that eye upwards.
“Show me your teeth” or “smile”: move only the right side.
“Puff out your cheeks”: let the air escape on the left.
Everything else — eye movements, hearing, tongue, shoulders, arms, legs, walking, the content of your speech — is normal. If you cannot show a sign, the findings at the end of this script are read out.

Volunteer freely if given the space

You went to bed fine the night before last and woke yesterday morning with the left side of your face “not working”. It got a little worse over the day and has stayed the same since.
Drinks dribble out of the left corner of your mouth; your left eye streams and will not shut.

Only if asked

No weakness, numbness or clumsiness of your arms or legs. Words with ‘p’ and ‘b’ feel clumsy because your lip is floppy, but you have no trouble finding words or understanding. No double vision or loss of vision. No sudden or severe headache. No dizziness or spinning.
Your hearing is normal. No blisters or rash on your ear, face or in your mouth that you have noticed. No discharge from the ear; no ear operations.
If asked about ear pain: a dull ache behind the left ear the day before it started — mild, no painkillers needed, easing now. If asked about loud sounds: yes, louder on the left.
Food tastes dull on the left front of your tongue.
No head injury. You had a cold last week. No tick bites, camping or walking holidays, no round rash, no joint pains.
This has never happened before.
No diabetes or high blood pressure; no HIV or medicines that lower immunity. No stomach ulcers; no depression or mental illness in the past; no infection at the moment.

Impact on daily life — home and work (only if asked)

You cannot drink without dribbling and you keep biting your cheek when you eat.
Your eye streams all day and feels dry by the evening, but it is not painful or red and your sight is normal; you drove here with it streaming.
You teach five lessons a day and there is a parents’ evening tomorrow — you cannot face a class looking like this.
Abena was in tears this morning and the children keep staring.

Ideas, concerns and expectations

Idea: a stroke.
Concerns: that it is permanent; that a bigger stroke is coming; how you will teach.
Expectation: to be sent to hospital for a brain scan.

Cues to deliver, timed

Minute 1–2: “Shouldn’t I be in an ambulance?”
While your forehead and eye are being tested: “Why does it matter whether I can frown?”
If nothing has been said about your eye by minute 7: “What do I do about this eye? It won’t shut at night.”

If the doctor summarises and asks whether you want to add anything

If your ears have not been examined or asked about: “One thing — I had an ache behind that ear the day before it started. Does that matter?”
If they have: “Sounds seem louder on that side — is that part of it?”

How to respond to the doctor

If the doctor explains that a stroke leaves the forehead working, that your forehead and eye are affected, and that your arms, legs and speech are normal — so this is the nerve to the face itself, a Bell’s palsy: visible relief — “So it’s not my brain.”
If the doctor says “it’s just a Bell’s palsy” without saying why it is not a stroke: “But how do you know? You haven’t scanned me.”
If offered steroid tablets with a reason (they improve the chance of a full recovery if started within three days): “Yes — anything that helps.”
If eye care is explained — drops by day, ointment and taping the eye shut at night, no eye patch: you repeat it back.
If told that most people recover fully but that it takes weeks to months: “Weeks? I’ve got Year 11 mocks.” You would welcome a fit note or advice about work.
If sent to hospital as a stroke: you go, frightened.
If your open eye is touched without warning, or the otoscope is pushed in roughly: pull away — “Ow, careful.”
If your ears, arms or speech are not examined, do not prompt — except through the ‘anything to add’ line.

Do not

Volunteer the ache behind the ear or the loud sounds unless asked about your ears, or invited to add anything (apart from the timed cues).
Show any weakness of your arms or legs, any word-finding difficulty, or any weakness of the right side of your face.
Wrinkle the left side of your forehead — that single sign decides the diagnosis.

Findings to give the candidate — only if asked for

This is an examination station: give each finding as the candidate performs that step, or asks for it. Do not offer findings for steps the candidate has not performed. (Where a separate examiner is present, the examiner reads them.)

Always read out the forehead and eye-closure findings, whatever the role player manages to show. Face at rest: left forehead smooth, left eye wider, left nasolabial fold flat, mouth drooping on the left; no rash, scars or swelling. Facial nerve (VII): cannot raise the left eyebrow — no wrinkles on the left forehead; cannot close the left eye — a 2 mm gap, and the eye rolls upwards (Bell’s phenomenon); cannot show his teeth or puff out his cheek on the left. Right side normal. Other cranial nerves: acuity 6/6 in both eyes, fields full, pupils equal and reactive; eye movements full, no double vision or nystagmus; facial sensation and jaw power normal; hearing normal to whispered voice, Rinne positive on both sides, Weber central; palate rises centrally, voice and swallow normal; shoulder shrug and head turn full power; tongue central. Ears, mouth and neck: both pinnae, canals and drums normal — no vesicles; no vesicles on the palate; no mastoid tenderness; no parotid or neck lump. Left eye: watering, not red; cornea clear to the torch. Limbs and speech: no arm drift, grip and power equal; speech fluent with normal content — repeats a sentence accurately, and any slight slurring of ‘p’ and ‘b’ comes from the lip; walks normally. Corneal reflex, if offered: not required — corneal sensation is normal. Tonsils symmetrical.

2 · Examiner mark sheet — generic scheme plus the key facts for this case

Domain marks — with the key facts that earn a 4 at this station

Domain (GMC wording) · key facts for this case	1	2	3	4	Score
1 · Data gathering, technical and assessment skills Consent, position, inspects the face at rest; tests all of VII — eyebrows, eye closure, teeth, cheeks — and recognises that the forehead and eye closure are affected Screens the neighbours of VII — eye movements (VI), facial sensation (V), hearing (VIII) — then arm drift, grip and speech for a stroke (FAST); notes the normal glucose Looks for a cause: otoscopy of both ears; pinna and palate for vesicles; mastoid, parotid and neck Targeted questions while examining — red flags (limb, speech, vision, headache, ear pain, rash, tick bite), ICE (fears a stroke) and impact (eye, eating, teaching)	☐	☐	☐	☐	/4
2 · Clinical management skills Summary and check, then the working diagnosis: Bell’s palsy — a lower motor neurone palsy of the left facial nerve: the whole side including the forehead, nothing else abnormal Why not: stroke (forehead spared; limb or speech signs); Ramsay Hunt (no vesicles, hearing normal); ear disease, parotid tumour, Lyme disease — looked for, not found Prednisolone today, within 72 hours (50 mg daily for 10 days), cautions checked; eye protection — drops by day, ointment and tape at night, no patch; no scan needed; supervising GP told Safety-net: arm or leg weakness, speech or swallowing trouble, sudden severe headache → 999; blisters around the ear or mouth, hearing loss, vertigo, or a painful red eye or blurred vision → same day · Follow-up: review at 3 weeks — no improvement → referral	☐	☐	☐	☐	/4
3 · Interpersonal skills Takes the stroke fear seriously and answers it with the findings, not with “don’t worry” Clear instructions, demonstrating each movement; warns before touching the face, eye or ear Acknowledges what it means for his appearance, his teaching and his family Plain words — “the nerve that moves the face”; he can repeat the eye care and the warning signs	☐	☐	☐	☐	/4
Station total					/12

Examiner's overall judgement (standard-setting only — it does not decide your result): ☐ Unsatisfactory ☐ Borderline ☐ Satisfactory ☐ Good

Marks are 1 to 4 in each domain; the generic descriptor for each mark is on the mark scheme page, and the structure of the eight minutes is on the 8-minute station page. The full standard for this case is in section 3 and the GMC feedback statements, with examples from this case, are in section 4. The examination findings that the role player gives — only if the candidate asks for them — are at the end of section 1.

3 · Expanded station-specific marking standard — what earns 4, 3, 2 and 1 here

The top row is the full picture of what a competent F2 could do at this station, including the working diagnosis with its justified differentials, the safety-net and the follow-up; lower rows describe how performance falls away. It is a debriefing aid, not a checklist to recite: nobody says every line in eight minutes, and a 4 is a judgement that the essentials — the italic key facts on the mark sheet — were done well, in plain language and at the patient’s pace. Acumen training standard — the GMC does not publish station mark sheets.

Mark	Domain 1 · Data gathering, technical and assessment skills	Domain 2 · Clinical management skills	Domain 3 · Interpersonal skills
4	Washes hands, introduces self, confirms identity; explains the examination and gains consent; sits him at eye level in good light Inspects the face at rest — forehead wrinkles, blink and width of the eye, nasolabial folds, angle of the mouth — and looks for a rash, vesicles, scars or swelling Facial nerve (VII): raise the eyebrows, close the eyes tightly (and gently tries to open them), show the teeth, puff out the cheeks — compares the two sides and recognises that the forehead and eye closure are affected; asks about taste, loud sounds and a dry or watering eye Screens the neighbours of VII first — eye movements and double vision (VI), facial sensation (V), hearing by whispered voice then tuning fork (VIII) — then palate and tongue; acuity, fields, pupils and shoulders only if time allows Looks for the cause: otoscopy of both ears; the pinna and the palate for vesicles; mastoid tenderness; the parotid and the neck Screens for a stroke: arm drift, grip and power, a test sentence, gait if time allows; notes the normal glucose and blood pressure Targeted questions while examining — red flags: limb weakness, speech, vision, headache, ear pain, hearing loss, vertigo, rash, tick bite, trauma, previous episodes; ICE: believes he has had a stroke, fears it is permanent, expects a scan Impact on daily living: drinking and eating, the streaming eye and driving, teaching and the parents’ evening, his family’s reaction	Presents the findings to him in two sentences and checks whether he wants to add anything Working diagnosis with justified differentials: Bell’s palsy — a lower motor neurone palsy of the left facial nerve that came on over hours and affects the whole of that side, including the forehead and eye closure, with nothing else abnormal. A stroke is very unlikely: it spares the forehead and usually affects an arm, a leg or speech — his forehead is involved, and his limbs, speech and other cranial nerves are normal. Ramsay Hunt syndrome is unlikely: no vesicles in the ear or on the palate and normal hearing — a dull ache behind the ear is common in Bell’s palsy. Middle ear disease, mastoiditis and a parotid tumour have been looked for and not found; Lyme disease is unlikely with no tick bite, rash or joint pains Explains that a typical Bell’s palsy needs no scan or blood test, and why Treatment today because he is within 72 hours: prednisolone 50 mg once daily for 10 days (or 60 mg daily for five days, then reducing by 10 mg a day), as a single dose after breakfast; checks for diabetes, peptic ulcer, previous steroid-related mood disturbance and current infection, and warns about indigestion, poor sleep and mood change; antivirals are not given on their own Eye protection: lubricating drops often through the day, ointment at night, the lid taped shut at night with microporous tape — no eye patch; sunglasses outdoors; care with driving while the eye streams Practical advice and honest prognosis: a straw and soft foods; most people start to improve within two to three weeks and about eight in ten recover fully — a complete palsy like his can be slower and is occasionally incomplete; written information; fit note if he wants one Tells the supervising GP; explains why he needs no ambulance, scan or hospital today Safety-net: new weakness or numbness of an arm or leg, difficulty speaking or swallowing, confusion or a sudden severe headache → 999; blisters or a rash in or around the ear or in the mouth, hearing loss, vertigo or severe ear pain → same-day appointment, because that would change the diagnosis and the treatment; a painful or red eye, or any change in vision → same-day appointment and urgent referral to ophthalmology. Follow-up: a booked review with the F2 or a named GP at three weeks — sooner if the eye gives trouble — to check that recovery has started; if there is no improvement by then he is referred to a facial nerve specialist (ENT or neurology), and also if recovery is incomplete at three months.	Responds to “I’ve had a stroke, haven’t I?” at the start — promises an answer once he has been examined, and gives it Clear, simple instructions, demonstrating each movement; warns before touching the face, the eye or the ear Explains why the forehead matters in words he could use to reassure his wife Acknowledges the effect on his appearance, his teaching and his children Avoids jargon (“lower motor neurone”, “House–Brackmann”); asks him to repeat the eye care and the three sets of warning signs
3	Systematic facial nerve examination with the forehead and eye closure correctly interpreted, plus a stroke screen; one of otoscopy, the parotid and mastoid, the other cranial nerves or the impact on his life missing.	Correct diagnosis explained with the forehead rule; steroids and eye care both covered; one of the dose or the 72-hour window, the Ramsay Hunt check, the prognosis or a specific follow-up missing.	Warm and clear; stroke fear addressed; one cue missed or understanding checked only with “is that OK?”.
2	Cranial nerves examined as a memorised list with no focus on VII; upper and lower face not compared; ears not examined or limbs not screened; few questions; findings not interpreted.	“Probably Bell’s palsy” with no reasoning or differentials; steroids or eye care omitted; or a precautionary brain scan or routine neurology referral arranged; safety-net generic.	Examines competently but mechanically; instructions unclear; fear of stroke answered late; some jargon.
1	Disorganised, incomplete examination; forehead not tested; no ears and no limbs. Or unsafe: no meaningful examination; or hurts him — touching the open eye, forcing the otoscope — and carries on.	No clear diagnosis, or the wrong one — calls it a stroke or TIA and dials 999 despite a clear lower motor neurone pattern with normal limbs and speech; or antivirals alone; or no eye advice at all; no safety-net and no follow-up. Or unsafe: reassures him that it is not a stroke without having tested the forehead, or without any check of his arms and speech — a guess, not a diagnosis; or advises an eye patch in place of lubricants and taping.	Examines in silence; brushes off his questions; leaves him frightened. Or unsafe: dismissive (“it’s only a Bell’s palsy”), or alarms him with talk of stroke without reason.

4 · GMC feedback statements — where underperformance was identified — with case-specific examples

A feedback statement marks where underperformance was identified in the consultation. With PLAB 2 results the GMC may attach any combination of the ten statements to a station — none, one or several. The right-hand column shows what each one looks like at this station. Record the statements that applied in the practice log.

GMC feedback statement	Underperformance it signals (generic)	Case-specific examples
1 · Consultation	Disorganised or unstructured consultation	Recites cranial nerves I to XII as a list with no link to the problem; the ears and arms are an afterthought or forgotten; the findings are never pulled together before a diagnosis is offered.
2 · Issues	Key issues or priorities not recognised	Does not see that the station has one question — upper or lower motor neurone? — and one fear to answer — stroke; spends two minutes on smell and fundoscopy.
3 · Time	Poor time management	Six minutes of examination; the diagnosis blurted at the bell; no steroids, no eye care, no safety-net.
4 · Findings	Abnormal findings or results, or their implications, not identified	Does not notice — or is told and ignores — that the left forehead does not wrinkle and the left eye does not close; cannot interpret Bell’s phenomenon, a central Weber with positive Rinne, or the normal glucose on the page.
5 · Examination	Physical examination or use of instruments not competent	Tests the smile but never the forehead or eye closure; does not compare sides; no otoscopy, no look at the pinna or palate, no parotid; no arm drift or speech; tests the corneal reflex without warning or consent; no hand washing or explanation.
6 · Diagnosis	Working diagnosis or differential diagnoses not correct	“It’s a mini-stroke” — or “it’s Bell’s palsy” with no reason given; cannot explain forehead sparing; does not consider Ramsay Hunt, ear disease or a parotid lump.
7 · Management	Management plan not reflecting current best practice	An urgent CT, or home with “it will get better”; no prednisolone although he is within 72 hours — or aciclovir alone; no drops, ointment or taping — or an eye patch; nothing said about new limb weakness, blisters in the ear or a painful red eye; no review at three weeks.
8 · Rapport	Rapport and sensitivity to the patient’s feelings and concerns not shown	“Don’t worry, it’s nothing serious” to a man who thinks he has had a stroke; no acknowledgement of his face, his class or his family.
9 · Listening	Verbal and non-verbal cues not used; poor active listening	Ignores “shouldn’t I be in an ambulance?” and “why does it matter whether I can frown?”; never invites him to add anything, so the ache behind the ear is never heard and the ear is never examined.
10 · Language	Language or explanations not understandable; understanding not checked	“You have a left lower motor neurone seventh nerve palsy, House–Brackmann four, so I’ll start pred” — and he still believes he has had a stroke.

5 · Examiner points of fact and guidelines

Points of fact the examiner should have to hand

Upper or lower motor neurone: the upper face is supplied from both sides of the brain, so a stroke (an upper motor neurone lesion) spares the forehead and largely spares eye closure, while a lesion of the facial nerve itself weakens the whole of that side. NICE CKS: stroke — forehead spared, extremities often affected. A brainstem stroke can rarely give a lower motor neurone pattern, but with other signs — a sixth nerve palsy, limb weakness or ataxia — which is why eye movements, limbs and gait are screened.
Bell’s palsy is an acute, unilateral facial nerve palsy of rapid onset (under 72 hours) and unknown cause — diagnosed when the rest of the examination is normal. Routine blood tests and imaging are not needed in primary care (NICE CKS Bell’s palsy, revised 2023).
The examination CKS asks for: the cranial nerves; the ear canal and drum by otoscopy, with Weber’s and Rinne’s tests; the parotid and the oropharynx; the skin of the head, face, mouth and mastoid for vesicles, rash or swelling; the eye.
Ramsay Hunt syndrome (varicella zoster of the facial nerve): ear pain followed by vesicles on the pinna, in the canal or on the palate, often with sensorineural hearing loss or vertigo. Shingles of the head and neck needs admission or immediate specialist advice, and antivirals are part of treatment (NICE CKS Shingles). Mild ear or postauricular pain occurs in about half of people with Bell’s palsy, altered taste in about a third and hyperacusis (nerve to stapedius) in under 5% (NICE CKS); severe pain, hearing loss, tinnitus or vertigo point to Ramsay Hunt. Vesicles can appear days after the palsy, occasionally never (zoster sine herpete) — hence the blister safety-net. A candidate who offers to discuss adding an antiviral with the supervising GP should not lose marks.
Treatment (NICE CKS): within 72 hours of onset consider prednisolone — 50 mg daily for 10 days, or 60 mg daily for five days then reducing by 10 mg a day. Antivirals alone are not recommended; combined treatment only on specialist advice. With prednisolone started within 72 hours about 83% recover full facial function, against about 72% without.
Prednisolone practicalities (BNF; NICE CKS Corticosteroids — oral): a single morning dose after breakfast; cautions include diabetes, peptic ulcer, previous steroid-related psychiatric reactions and active infection; a proton pump inhibitor is not routine with a short course on its own; a blue steroid treatment card is for courses longer than three weeks. None of this carries marks beyond “cautions checked”.
Eye care (NICE CKS; NICE NG127): lubricating drops frequently by day, ointment at night, the lid taped closed at night with microporous tape; eye patches are contraindicated because the eye can open under the patch. Eye pain, irritation or a change in vision → refer to ophthalmology.
Prognosis and referral: most people begin to recover within two to three weeks and recover completely within three to four months. Refer if there is no improvement after three weeks, if recovery is incomplete at three months, or if features are atypical — gradual onset, other cranial nerves involved, a parotid or neck lump, a bilateral or recurrent palsy. Do not routinely refer an uncomplicated Bell’s palsy (NICE NG127).
Suspected stroke: screen with FAST, exclude hypoglycaemia and arrange immediate emergency transfer by 999 to a hyperacute stroke unit (NICE NG128; NICE CKS Stroke and TIA). Sudden facial weakness with the forehead spared, or with limb or speech signs, is a stroke until proved otherwise.
Driving: Bell’s palsy does not have to be reported to the DVLA, but he must not drive if watering, blurring or eye ointment stops him reading a number plate at 20 metres.
Also ask about tick bites and rashes (Lyme disease, which can be bilateral), head injury, ear surgery or discharge, pregnancy, diabetes and immunosuppression.

Where candidates lose marks at this station

Testing the smile and forgetting the forehead.
“It’s not a stroke” — with no reason given.
No otoscope: Ramsay Hunt never looked for.
Prednisolone forgotten — or aciclovir on its own.
An eye patch instead of drops, ointment and tape.
A brain scan “to be safe”.

Guidelines for this station

6 · MLA content map tags for this case

MLA content map	This station
Domain 1 · Areas of clinical practice	Neurosciences · Ear, nose and throat · Ophthalmology
Domain 3 · Clinical and professional capabilities	History, examination and differential diagnosis · Safe prescribing · Communication with patients, relatives and carers · Complexity, uncertainty and prioritisation
Domain 5 · Patient presentations	Facial weakness · Eye pain/ discomfort
Domain 6 · Conditions	Bell palsy · Stroke · Varicella zoster virus
Station family	Clinical examination — Focused neurological examination

7 · My marks and reflection — practice log form

Record your three domain marks, your station total, the GMC feedback statements that applied (where underperformance was identified), and what you will keep and change. The form is already labelled with this case and its web address; a copy of your entry is emailed to you, so your practice log builds up in your inbox and can be downloaded.

Record my marks and reflection for P2-15

Revision link for this case: acumenprimarycare.com/plab-2-osce/case-15-facial-weakness-cranial-nerve-examination

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Independence & scope. Independent, formative training material from MD Acumen Ltd. Not affiliated with, endorsed by, or delivered on behalf of the General Medical Council. The GMC does not publish its station mark sheets: every mark scheme and descriptor on these pages is an Acumen training tool calibrated to the GMC's published marking domains, feedback statements and the MLA content map. Practice scores are not a prediction of examination performance. Clinical content reflects UK guidance at the date of editorial review — always check the current guideline. All patients are fictional.

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