10 structured stations with candidate briefings, examiner instructions and full mark schemes — covering core clinical presentations across all five domains.
You are the Emergency Medicine doctor in a busy ED. Mr James Carter, 58 years old, has been brought in by ambulance with a 2-hour history of central chest pain.
He is currently haemodynamically stable. Observations: BP 148/92, HR 96, RR 16, SpO₂ 97% on air, Temp 37.1°C.
Please take a focused history from Mr Carter. You will be expected to explore the presenting complaint fully, relevant past medical history, medications, allergies, and social history relevant to this presentation. You have 8 minutes.
⚠️ Examiner / Role-player Instructions — Not for Candidate
You are playing James Carter, a 58-year-old retired teacher. You are anxious but cooperative. You have been having crushing central chest pain for 2 hours, which started at rest while watching television.
| Criterion | Marks |
|---|---|
| Presenting Complaint — SOCRATES | |
| Site — correctly identifies central/retrosternal location | 1 |
| Onset — clarifies sudden onset at rest, 2 hours ago | 1 |
| Character — identifies crushing/pressure quality | 1 |
| Radiation — asks about and elicits left arm and jaw radiation | 1 |
| Associated symptoms — nausea, diaphoresis, dyspnoea | 2 |
| Severity — numerical or descriptive scale used | 1 |
| Timing — duration, constant vs intermittent | 1 |
| Exacerbating/relieving factors — effect of position, movement, GTN | 1 |
| Differentials Screened | |
| Asks about pleuritic component (PE / pericarditis exclusion) | 1 |
| Asks about tearing/ripping quality or unequal BP symptoms (dissection) | 1 |
| Risk Factors & Background | |
| Identifies hypertension, diabetes, hypercholesterolaemia | 2 |
| Previous cardiac history / angiogram / family history | 1 |
| Smoking history — quantified in pack years | 1 |
| Medications & Allergies | |
| Correctly elicits all current medications | 1 |
| Asks about sildenafil / PDE-5 inhibitors (GTN contraindication) | 1 |
| Correctly documents penicillin allergy and nature of reaction | 1 |
| Communication & Professionalism | |
| Introduces self, confirms name/DOB, gains consent to proceed | 1 |
| Empathic, organised, does not interrupt patient unnecessarily | 1 |
| Total | 20 |
You are the ED doctor. Mrs Priya Sharma, 34 years old, has been brought in after a witnessed collapse in the supermarket. A bystander performed CPR briefly before she regained consciousness spontaneously.
She is now alert and orientated. Observations: BP 110/70, HR 88 regular, SpO₂ 99%, RR 14.
Please take a focused history from the patient to determine the most likely cause of her collapse. You have 8 minutes.
⚠️ Examiner Instructions — Not for Candidate
You are Priya Sharma, 34, a nurse. You are shaken but cooperative. This was a vasovagal syncope in the context of not eating and standing in a hot queue for 20 minutes. There is no sinister aetiology but the candidate should systematically exclude dangerous causes.
| Criterion | Marks |
|---|---|
| Pre-syncopal History | |
| Elicits prodrome — nausea, visual changes, weakness | 2 |
| Identifies trigger — prolonged standing, hot environment, fasting | 2 |
| Asks about palpitations prior to event | 1 |
| Asks about preceding chest pain or dyspnoea | 1 |
| The Event | |
| Duration of loss of consciousness | 1 |
| Jerking movements / tonic-clonic activity | 1 |
| Tongue biting / urinary incontinence | 1 |
| Colour change — pallor vs cyanosis | 1 |
| Post-event Recovery | |
| Speed of recovery — rapid vs prolonged postictal confusion | 2 |
| Excluding Dangerous Causes | |
| Family history of sudden cardiac death or arrhythmia | 1 |
| Previous syncopal episodes or cardiac investigations | 1 |
| Exercise-induced collapse specifically asked | 1 |
| Gynaecological & Social | |
| LMP and pregnancy status asked | 1 |
| Medications including OCP documented | 1 |
| Communication | |
| Professional introduction and consent | 1 |
| Empathic, systematic, does not alarm patient unnecessarily | 1 |
| Total | 20 |
You are asked to perform a focused cardiovascular examination on this manikin / standardised patient. The examiner will tell you the findings as you examine.
Please talk through your examination as you go. At the end, present your findings and give a differential diagnosis.
Assume the patient has consented and appropriate exposure has been obtained.
⚠️ Examiner Instructions — Not for Candidate
The simulated findings represent aortic stenosis. Feed findings to the candidate only when they examine the correct area.
| Criterion | Marks |
|---|---|
| Systematic Approach | |
| Positions patient correctly (45°), exposes appropriately, washes hands | 1 |
| General inspection from end of bed — comments on distress, obvious signs | 1 |
| Peripheral Examination | |
| Examines hands — clubbing, splinter haemorrhages, CRT, temperature | 2 |
| Pulse — rate, rhythm, AND character correctly identified (slow-rising) | 2 |
| Blood pressure measured / requested | 1 |
| JVP assessed — height and character | 1 |
| Face — pallor, xanthelasma, corneal arcus | 1 |
| Precordium | |
| Inspects for scars — correctly notes sternotomy scar | 1 |
| Apex beat — locates and correctly describes as heaving, non-displaced | 1 |
| Palpates for heaves and thrills — identifies systolic thrill | 1 |
| Auscultates all 4 areas systematically | 1 |
| Correctly characterises murmur — ejection systolic, aortic area | 1 |
| Radiates to carotids — listens over carotids | 1 |
| Completion | |
| Auscultates lung bases, checks for ankle oedema | 1 |
| Presents findings clearly and logically to examiner | 1 |
| Correctly identifies aortic stenosis as diagnosis | 1 |
| Suggests appropriate next steps — ECG, Echo, cardiology review | 1 |
| Total | 20 |
Perform a focused respiratory examination on this patient. The examiner will provide findings as you examine each area. Talk through your examination throughout.
At the end, present your findings and state the most likely diagnosis with two differential diagnoses. Suggest appropriate investigations.
⚠️ Examiner Instructions — Not for Candidate
Findings represent a right-sided pleural effusion. Feed findings as candidate examines each region.
| Criterion | Marks |
|---|---|
| General & Peripheral | |
| General inspection — respiratory distress, cyanosis, oxygen | 1 |
| Hands — clubbing, cyanosis, asterixis, nicotine staining | 1 |
| Tracheal position — correctly identifies left deviation | 2 |
| Chest Examination | |
| Chest expansion — identifies reduced right-sided movement | 2 |
| Percussion — systematically percusses all zones, identifies stony dullness right base | 3 |
| Auscultation — identifies absent breath sounds right base | 2 |
| Identifies bronchial breathing at upper border of effusion | 1 |
| Vocal resonance / aegophony assessed | 1 |
| Presentation & Reasoning | |
| Presents findings in structured, logical order | 1 |
| Correct diagnosis — right pleural effusion | 2 |
| Two differentials for cause — malignancy, heart failure, infection, TB | 1 |
| Appropriate investigations — CXR, USS, diagnostic tap, bloods | 2 |
| Professional manner throughout | 1 |
| Total | 20 |
A 62-year-old man with known lung cancer has a large right pleural effusion causing significant dyspnoea. He has consented to chest drain insertion. His clotting is normal and platelets are 210. He is not on anticoagulants.
You are asked to demonstrate Seldinger chest drain insertion on the manikin provided. Please talk through each step as you perform it. The examiner will prompt you if needed.
⚠️ Examiner Instructions
Observe the candidate performing the Seldinger technique on the manikin. Score according to the mark scheme. Prompt if candidate skips consent or safety steps. If candidate attempts trocar technique — stop and ask them to use Seldinger.
| Criterion | Marks |
|---|---|
| Preparation & Safety | |
| Confirms indication, consent and reviews imaging / US guidance | 1 |
| Correct patient positioning — arm raised, triangle of safety identified | 2 |
| Full aseptic technique — scrub, gloves, gown, drape, antiseptic | 2 |
| Local Anaesthesia | |
| Infiltrates over upper border of rib (avoids neurovascular bundle) | 2 |
| Aspirates while advancing — confirms position before infiltrating deeper | 1 |
| States maximum safe dose of lidocaine | 1 |
| Seldinger Technique | |
| Needle insertion with aspiration — confirms space entered | 1 |
| Guidewire threaded correctly, needle removed safely | 1 |
| Skin incision made, serial dilation performed | 1 |
| Drain threaded over wire, wire removed, drain connected to system | 2 |
| Confirms correct position — swinging, draining | 1 |
| Completion | |
| Secured with horizontal mattress suture (NOT purse-string) | 1 |
| Documents procedure, requests post-procedure CXR | 1 |
| States complications to monitor for — haemothorax, re-expansion pulmonary oedema, infection | 1 |
| Professional, methodical approach throughout | 1 |
| Total | 20 |
A 27-year-old woman presents with sudden onset severe headache, photophobia and neck stiffness. CT head is normal. Clotting is normal. You are asked to perform a lumbar puncture on the manikin to exclude bacterial meningitis.
Talk through each step. State what you would send CSF samples for. The examiner will tell you the CSF results at the end — be prepared to interpret them.
⚠️ Examiner Instructions
Observe the full procedure on the manikin. At the end of the procedure, tell the candidate the following CSF results and ask them to interpret: Opening pressure 28 cmH₂O (↑), Appearance: turbid/cloudy, WBC 3,400 (neutrophil predominant), Protein 1.8 g/L (↑), Glucose 1.2 mmol/L (serum glucose 7.4 — ratio <0.5), Gram stain: Gram-positive diplococci.
| Criterion | Marks |
|---|---|
| Pre-procedure Safety | |
| States contraindications checked — CT normal, no papilloedema, clotting normal | 2 |
| Correct positioning — lateral with maximal flexion or seated | 1 |
| Correct landmark — L3/4 or L4/5, iliac crest reference used | 2 |
| Full aseptic technique | 1 |
| Procedure Technique | |
| Local anaesthetic infiltrated correctly | 1 |
| Correct needle choice — atraumatic/pencil-point preferred, bevel direction stated | 1 |
| Opening pressure measured with manometer | 2 |
| 4 bottles collected correctly — states correct labelling and purpose of each | 2 |
| Stylet replaced before needle withdrawal | 1 |
| CSF Interpretation | |
| Correctly identifies results as bacterial meningitis | 2 |
| Identifies organism — Streptococcus pneumoniae (Gram-positive diplococcus) | 1 |
| Correct immediate management — ceftriaxone IV + dexamethasone | 2 |
| Mentions public health notification / contact prophylaxis | 1 |
| Professional, safe, methodical approach | 1 |
| Total | 20 |
You are the ED senior doctor. Mr David Singh, 54, was brought to ED after a seizure. A CT head has been performed urgently and has shown a large right temporal mass with surrounding oedema, highly suspicious for a primary brain tumour.
Neurosurgery has been consulted and confirmed this is almost certainly a high-grade glioma. Mr Singh has recovered from his seizure and is with his wife. He is asking to speak to the doctor to find out what the scan showed.
Please have this conversation with the patient. You are not expected to give a definitive prognosis, but you should explain the finding honestly and sensitively.
⚠️ Examiner / Role-player Instructions — Not for Candidate
You are playing David Singh. Start calm and slightly anxious. When told about the mass, become visibly distressed and ask "Is it cancer? Am I going to die?" Allow appropriate silences. If the candidate tries to give a definitive prognosis, push back with "But roughly, how long do I have?" — observe how the candidate handles uncertainty.
| Criterion | Marks |
|---|---|
| Setting & Preparation | |
| Introduces self, confirms identity, checks if patient wants family present | 1 |
| Ensures appropriate private setting, sits down at patient level | 1 |
| Exploring Perception & Invitation | |
| Asks what patient already knows / understands before breaking news | 2 |
| Seeks permission before delivering — checks patient is ready | 1 |
| Delivering the News | |
| Uses warning shot — "I'm afraid I have some difficult news" | 1 |
| Delivers information clearly, without excessive jargon | 2 |
| Gives information in small chunks, pauses to check understanding | 1 |
| Responding to Emotion | |
| Acknowledges distress — empathic verbal and non-verbal response | 2 |
| Allows silence — does not fill silence with unnecessary information | 1 |
| Handles "how long have I got?" appropriately — honest about uncertainty, does not give false hope or dismissive answer | 2 |
| Strategy & Support | |
| Explains next steps — neurosurgery review, MDT, biopsy | 1 |
| Offers written information and follow-up contact | 1 |
| Asks about support at home, signposts to support services | 1 |
| Does not abandon patient — arranges clear next contact/follow-up | 1 |
| Overall — compassionate, unhurried, patient-centred approach | 1 |
| Total | 20 |
You are the ED registrar. Mrs Angela Thompson is waiting to speak to you. Her 78-year-old mother was brought to ED 6 hours ago with confusion. She has been in a cubicle for 4 hours without anyone coming to explain what is happening.
Mrs Thompson is visibly angry in the corridor and has told the nurse she "wants to make a formal complaint." The nurse has asked you to speak to her.
The patient (her mother) has a UTI — bloods and urine are back, antibiotics have been started. She is currently stable.
Please speak to Mrs Thompson and manage this situation professionally.
⚠️ Examiner / Role-player Instructions — Not for Candidate
You are Angela Thompson. Start very angry and confrontational. Begin with: "Finally! I've been waiting for hours. This is absolutely disgraceful — my mother is elderly and confused and nobody has come to see us. I want to make a complaint right now." Gradually de-escalate if the candidate is empathic, listens well and apologises appropriately without being defensive. Remain angry if candidate is defensive, dismissive or makes excuses.
| Criterion | Marks |
|---|---|
| Opening & De-escalation | |
| Introduces self, finds appropriate private place to speak | 1 |
| Allows relative to express concern fully without interrupting | 2 |
| Acknowledges and validates frustration — empathic response | 2 |
| Apologises sincerely for the wait — does not make excuses or become defensive | 2 |
| Clinical Information Sharing | |
| Confirms identity and relationship before sharing information | 1 |
| Explains diagnosis clearly — UTI causing confusion (delirium) | 2 |
| Explains treatment plan — antibiotics, monitoring, fluid | 1 |
| Reassures that mother is stable and being looked after | 1 |
| Complaint Handling | |
| Takes complaint seriously — does not dismiss or minimise | 2 |
| Explains formal complaints process — PALS, written complaint pathway | 1 |
| Does not make promises that cannot be kept | 1 |
| Professionalism | |
| Remains calm and professional throughout — not defensive or dismissive | 2 |
| Offers clear next steps and follow-up contact | 1 |
| Total | 20 |
You are the ED doctor. A 61-year-old man presents with severe central chest pain for 45 minutes. The examiner will describe the ECG findings to you.
Please systematically interpret the ECG using a structured approach, state your diagnosis, and outline your immediate management plan. You will also be asked two further questions about this ECG.
⚠️ Examiner Instructions
Read the following ECG description to the candidate when they are ready to interpret. Then ask the two follow-up questions at the end.
| Criterion | Marks |
|---|---|
| Systematic Interpretation | |
| States rate — approximately 98 bpm | 1 |
| States rhythm — regular, sinus | 1 |
| Correctly identifies pathological Q waves in inferior leads (II, III, aVF) | 2 |
| Correctly identifies ST elevation ≥1 mm in II, III, aVF | 2 |
| Identifies reciprocal changes in I and aVL | 2 |
| Diagnosis & Territory | |
| Correct diagnosis — Inferior STEMI | 2 |
| Correctly identifies territory — inferior wall | 1 |
| Immediate Management | |
| Activates PPCI pathway / calls cath lab | 1 |
| Dual antiplatelet — aspirin 300 mg + ticagrelor 180 mg (or prasugrel) | 1 |
| Anticoagulation stated | 1 |
| Follow-up Questions | |
| Correctly identifies RCA as culprit artery | 1 |
| Identifies right ventricular infarction as key complication + management implications (avoid nitrates) | 2 |
| States bradyarrhythmia / complete heart block risk | 1 |
| Total | 20 |
A 72-year-old man with known COPD is brought to ED by ambulance acutely breathless. He is on 10L O₂ via non-rebreathe mask which was applied by the paramedics. GCS 14/15 (slightly confused). RR 28.
The examiner will give you his ABG results. Please interpret them systematically, state your diagnosis and immediate management plan.
⚠️ Examiner Instructions
Read ABG results aloud. Ask follow-up questions. Key teaching point: candidate must identify that 10L O₂ is harmful in this COPD patient and must immediately wean oxygen.
| Criterion | Marks |
|---|---|
| Systematic ABG Interpretation | |
| Correctly identifies acidosis (pH 7.28) | 1 |
| Identifies primary respiratory acidosis (↑PaCO₂ 9.2 kPa) | 2 |
| Identifies metabolic compensation (↑HCO₃ 34 = chronic) | 2 |
| Notes PaO₂ is paradoxically normal/high due to supplemental O₂ | 1 |
| Lactate normal — no evidence of tissue hypoperfusion | 1 |
| Diagnosis | |
| Correct diagnosis — Type II respiratory failure, acute-on-chronic respiratory acidosis in COPD | 2 |
| Immediate Management | |
| Immediately identifies danger of high-flow O₂ and reduces to Venturi 24–28% | 3 |
| Target SpO₂ 88–92% in COPD stated | 1 |
| Considers / initiates NIV — states BIPAP with starting pressures | 2 |
| States criteria for NIV correctly — pH 7.25–7.35 with CO₂ retention | 1 |
| Plans repeat ABG in 1 hour to assess response | 1 |
| Total | 20 |