NRE Step 2 Mandatory Stations 2026 — BLS, Abdominal Examination & Paediatrics

A candidate sitting NRE Step 2 scores above the pass mark in 18 out of 20 stations. She handles the history taking stations confidently, performs a clean cardiovascular examination, breaks bad news with empathy, and interprets the blood tests correctly. But in the BLS station she places her hands too high on the sternum and her compression depth is insufficient. She fails the mandatory station. She fails the entire exam.

This is not a hypothetical. Failing a mandatory station in NRE Step 2 is the single most common reason candidates fail the examination despite performing well overall. The mandatory stations are not the hardest stations — they are stations that test fundamental clinical competencies that every licensed doctor in Pakistan must be able to perform without error. PM&DC does not permit compensation: a high score elsewhere cannot save a candidate who cannot perform CPR, cannot conduct an abdominal examination, or cannot assess a sick child.

This article covers all three mandatory stations in precise detail — the exact sequence, the common failure points, and the preparation strategy that eliminates the risk of failing on exam day.

Mandatory Station 1: Basic Life Support (BLS)

The BLS station presents a collapsed manikin in a simulated environment. You are told a person has been found collapsed and you must respond. The examiner observes and marks against a structured checklist — they do not guide you, prompt you, or indicate whether you are performing correctly. Every step you skip or perform incorrectly loses marks. Performing steps in the wrong sequence loses marks even if each individual step is technically correct.

The Complete BLS Sequence — Step by Step

• 1
  Scene Safety Before approaching the patient, visually assess the environment. Say out loud: “I am checking the scene is safe.” In the NRE exam the scene will be safe — but this step is marked. Candidates who rush directly to the patient without a safety check lose this mark.
• 2
  Assess Responsiveness Approach and tap both shoulders firmly. Shout: “Hello! Can you hear me? Are you alright?” Use both shoulders — not just one. Tapping only one shoulder is a commonly marked error. Wait briefly for a response before proceeding.
• 3
  Call for Help If unresponsive: shout for help immediately — before opening the airway or checking breathing. “Help! Call an ambulance! Get the AED!” In a hospital: “Call the crash team! Get the resuscitation trolley!” This sequence — call BEFORE assessing airway — is the most common sequencing error in NRE BLS stations.
• 4
  Open the Airway Head-tilt chin-lift: place one hand on the forehead, tilt the head back firmly, lift the chin with two fingers under the bony part of the jaw (not the soft tissue — this obstructs the airway). If spinal injury is suspected: jaw thrust only — grasp the angles of the jaw with both hands and displace forward without moving the neck. NRE will specify if spinal injury should be assumed.
• 5
  Look, Listen, Feel for Breathing — Maximum 10 Seconds While maintaining airway opening: look for chest rise, listen for breath sounds, feel for airflow on your cheek. Do this for no more than 10 seconds. Say out loud: “The patient is not breathing normally.” Agonal gasps (occasional irregular gasps) = treat as no breathing. Do not spend more than 10 seconds on this step — examiners mark prolonged assessment as an error.
• 6
  Start Chest Compressions — 30 Compressions Position: heel of dominant hand on lower half of sternum (not xiphoid, not mid-sternum). Interlock fingers of other hand on top. Arms straight, elbows locked. Compress straight down — depth 5–6 cm (adults). Allow full chest recoil between compressions — do not lean on the chest. Rate: 100–120 per minute (faster than most candidates expect — approximately 2 per second). Count out loud. Complete 30 compressions before giving breaths.
• 7
  Give 2 Rescue Breaths Maintain head tilt — pinch the nose closed with thumb and forefinger. Seal your lips around the patient’s mouth. Give a breath over 1 second — watch for chest rise. Remove your mouth. Allow passive exhalation. Give a second breath. If the first breath does not produce chest rise: re-tilt the head and retry once. If still no chest rise: do not keep attempting — return to compressions (one failed attempt only). Total time for 2 breaths: no more than 5 seconds.
• 8
  Continue CPR — 30:2 Ratio Continue cycles of 30 compressions : 2 breaths without interruption. Minimise interruptions to compressions — pauses should be less than 10 seconds. If an AED arrives: attach it and follow prompts without stopping CPR until the AED is ready to analyse.
• 9
  AED — Attach and Use Power on the AED (press button or open lid). Attach pads: one below right clavicle, one on left lateral chest (V6 position — “below the armpit”). Ensure no one is touching the patient during analysis: “Stand clear — analysing now.” If shock advised: “Stand clear — shocking now” → deliver shock → immediately resume CPR (do not check pulse). If no shock advised: immediately resume CPR. Continue until: patient shows signs of life, qualified help arrives, or you are physically unable to continue.
• 10
  Reassess After 2 Minutes After approximately 5 cycles (2 minutes) of CPR: pause briefly (<10 seconds) to reassess for signs of life — normal breathing, movement, coughing. If signs of life: stop CPR, place in recovery position, monitor. If no signs: resume CPR immediately. The examiner marks whether you perform this reassessment.

Most Common BLS Failure Points in NRE

Mandatory Station 2: Abdominal Examination

The abdominal examination station uses a standardised patient — a real person trained to present specific findings or a normal examination. You are expected to perform a complete, systematic abdominal examination from inspection through to hernial orifice assessment, with clear communication to the patient at every step and a verbal summary of findings at the end.

Complete Abdominal Examination — The Full Sequence

• 1
  Wash Hands & Introduce Perform hand hygiene visibly. Introduce yourself: “My name is Dr. [name]. I’ve been asked to examine your abdomen today. Is that okay?” Confirm consent. This step is marked — do not skip it.
• 2
  Position the Patient Patient supine (lying flat), one pillow under the head only (more pillows tighten abdominal muscles and impair palpation). Arms by sides. Expose from nipple line to groin — explain this to the patient: “I need to examine your tummy, so I’ll need to expose from here to here — I’ll keep you covered as much as possible.”
• 3
  General Inspection — From the End of the Bed Stand at the foot of the bed. Look at the whole patient first: body habitus, jaundice, pallor, distress. Then inspect the abdomen: distension (generalised or localised — which quadrant?), visible peristalsis (bowel obstruction), visible pulsation (AAA — pulsatile mass in thin patients), caput medusae (dilated periumbilical veins — portal hypertension), surgical scars (note location and likely procedure), striae, hernias (ask patient to cough — accentuates reducible hernias).
• 4
  Hands — Peripheral Signs Inspect hands: leuconychia (white nails — hypoalbuminaemia/liver disease), koilonychia (spoon nails — iron deficiency), clubbing (IBD, cirrhosis, malabsorption), palmar erythema (liver disease), Dupuytren’s contracture (liver disease/alcohol), asterixis (liver flap — hepatic encephalopathy: ask patient to hold arms outstretched with wrists extended for 15 seconds).
• 5
  Arms, Face & Neck Arms: spider naevi (liver disease — >5 on upper body = significant), scratch marks (cholestatic pruritus). Eyes: jaundice (scleral icterus — yellow sclera), anaemia (conjunctival pallor — pull lower eyelid down gently), Kayser-Fleischer rings (Wilson’s disease — requires slit lamp but mention). Mouth: glossitis, angular stomatitis (B12/iron deficiency), fetor hepaticus (musty smell — hepatic failure), mouth ulcers (Crohn’s). Neck: lymphadenopathy — specifically Virchow’s node (left supraclavicular — gastric carcinoma), JVP elevated (right heart failure causing hepatic congestion).
• 6
  Auscultation — BEFORE Palpation This sequence is critical and frequently tested. Auscultate BEFORE palpating — palpation can alter bowel sounds. Place the stethoscope in the right iliac fossa (where bowel sounds are loudest) and listen for at least 15–30 seconds. Normal bowel sounds: 5–35 gurgling sounds per minute. Absent bowel sounds (>2 minutes of listening) = ileus or peritonitis. Tinkling/high-pitched sounds = bowel obstruction. Bruit over aorta or renal arteries (listen in epigastrium and flanks) = renal artery stenosis, AAA.
• 7
  Light Palpation — All 9 Regions Kneel to the patient’s level (or lower the bed). Warn the patient: “I’m going to press gently — please tell me if anything hurts.” Watch the patient’s face throughout — not your hands. Palpate all 9 regions systematically, starting away from any area of pain. Light palpation: detect tenderness, guarding (voluntary — patient tenses; involuntary — rigid abdomen = peritonism), rigidity, masses.
• 8
  Deep Palpation — All 9 Regions Repeat systematic palpation with firm pressure. Identify masses: location, size, shape, consistency, surface, mobility, tenderness, pulsatility. Ballot kidneys bimanually (one hand posteriorly, one anteriorly — “dipping” technique).
• 9
  Liver — Percussion Then Palpation Percuss first to map the liver: start at the right iliac fossa (RIF) and percuss upward in the midclavicular line — dullness indicates liver border. Then palpate: start from RIF with radial border of index finger pointing toward the right costal margin. Ask patient to breathe in deeply — the liver descends on inspiration and meets your hand. Move 2 cm toward the costal margin per breath. Normal liver: not palpable (or just palpable on deep inspiration). Hepatomegaly: note the number of fingerbreadths below costal margin. Assess surface (smooth vs irregular — irregular = malignancy or cirrhosis), consistency, tenderness.
• 10
  Spleen — Percussion Then Palpation Percuss: Traube’s space (left lower anterior chest — normally resonant; dull = splenomegaly). Palpate: start from the RIF (spleen can be massively enlarged — starting from the left side misses this). Point fingers toward the left costal margin. Ask the patient to breathe in — spleen descends on inspiration. Note size in fingerbreadths below left costal margin. Spleen characteristics that distinguish from kidney: cannot get above it (notched medial border), moves toward RIF on inspiration, not ballotable, dull to percussion.
• 11
  Ascites — Shifting Dullness Percuss from the umbilicus to the left flank — note where dullness begins (flanks dull = ascites). Keep your finger at the point of dullness. Ask the patient to roll toward you (away from your hand). Wait 15 seconds. Percuss again at the same point — if now resonant, the dullness has shifted (fluid moves with gravity). Positive shifting dullness = ascites (>1.5 litres required for detection). Fluid thrill (for massive ascites): tap one flank, feel for impulse on the other — an assistant must place the edge of their hand on the midline abdomen to damp abdominal wall transmission.
• 12
  Hernial Orifices & Genitalia Examine the inguinal regions for hernias: ask the patient to cough while you observe for a bulge at the inguinal canal. Palpate for inguinal lymphadenopathy. State: “I would also like to examine the external genitalia and perform a digital rectal examination” — you will usually not be asked to do so in the OSCE but mentioning it completes the examination and earns the mark.
• 13
  Summarise Findings Cover the patient and thank them. Present your findings clearly to the examiner: “On examination of the abdomen, I found [findings]. The most likely diagnosis is [diagnosis]. I would like to investigate with [investigations].” A structured summary earns marks for communication and clinical reasoning even if your findings were incomplete.

Abdominal Examination — Common Failure Points

• ✗ Palpating before auscultating — wrong sequence, marks lost
• ✗ Starting liver palpation from the right costal margin instead of the RIF — missing an enlarged liver
• ✗ Starting spleen palpation from the left flank instead of the RIF — missing massive splenomegaly
• ✗ Not watching the patient’s face during palpation — missing pain response
• ✗ Not warning the patient before pressing in a tender area
• ✗ Forgetting to check shifting dullness (ascites)
• ✗ Not examining hernial orifices or mentioning genital/rectal examination
• ✗ Skipping peripheral signs (hands, face, neck)
• ✓ Wash hands visibly before AND after
• ✓ Auscultate before palpating — every time
• ✓ Start both liver and spleen from the RIGHT ILIAC FOSSA
• ✓ Ask patient to breathe in during liver and spleen palpation
• ✓ Check shifting dullness in every examination — even if you see no ascites
• ✓ Summarise findings clearly with diagnosis and investigations

Mandatory Station 3: Paediatric Assessment

The paediatric station is the mandatory station most underestimated by candidates from China and Central Asia. The clinical exposure to paediatric patients in Chinese MBBS programmes is variable, and developmental milestone knowledge is rarely tested at the same depth in Chinese university examinations. NRE tests this directly and specifically.

Developmental Milestones — What NRE Tests

Developmental Red Flags — When to Refer

• No social smile by 10 weeks → investigate vision, autism spectrum
• No head control by 6 months → investigate hypotonia, cerebral palsy
• Not sitting by 9 months → investigate motor development
• Not walking by 18 months → investigate; normal range is 12–18 months
• Not using any words by 18 months → investigate hearing and autism
• Not using 2-word phrases by 2.5 years → speech and language referral
• Loss of previously acquired milestones at any age → urgent investigation for neurodegenerative condition

IMCI Danger Signs — The Core of Paediatric Assessment

The Integrated Management of Childhood Illness (IMCI) framework is PM&DC’s standard for assessing sick children under 5. The danger signs must be known by memory — a child with any danger sign requires urgent referral or hospital admission.

Growth Assessment — MUAC and Weight-for-Age

• MUAC (Mid-Upper Arm Circumference): Measured at midpoint between acromion and olecranon on left arm. Green ≥12.5 cm = normal. Yellow 11.5–12.4 cm = moderate acute malnutrition (MAM). Red <11.5 cm = severe acute malnutrition (SAM) → urgent referral.
• Weight-for-height Z-score < −3 SD = severe wasting → SAM
• Height-for-age Z-score < −2 SD = stunting (chronic malnutrition)
• Oedema of both feet in a child = kwashiorkor → SAM regardless of weight
• Head circumference: Macrocephaly (>98th centile) → hydrocephalus. Microcephaly (<2nd centile) → congenital infection (TORCH), genetic syndromes.

Paediatric Station — Preparation Strategy

Frequently Asked Questions