10 new structured stations with candidate briefings, examiner instructions and full mark schemes — covering advanced clinical scenarios across all five domains.
You are the Emergency Medicine doctor. Mr Daniel Okafor, 42 years old, presents with the worst headache of his life, which came on suddenly 3 hours ago while lifting weights at the gym. He describes it as "like being hit over the head with a bat."
Observations: BP 162/94, HR 80, RR 14, SpO₂ 99%, Temp 37.2°C, GCS 15/15.
Please take a focused history from Mr Okafor. You have 8 minutes.
⚠️ Examiner / Role-player Instructions — Not for Candidate
You are playing Daniel Okafor, a 42-year-old gym instructor. You are visibly distressed and holding your head. The headache started instantaneously during a Valsalva manoeuvre (heavy deadlift) — classic presentation of subarachnoid haemorrhage.
| Criterion | Marks |
|---|---|
| Onset & Character | |
| Correctly identifies instantaneous / thunderclap onset | 2 |
| Quantifies severity — "worst headache of life" elicited | 1 |
| Site and radiation fully explored (global/occipital) | 1 |
| Precipitating factor — Valsalva/exertion at gym elicited | 2 |
| Associated Symptoms | |
| Vomiting, nausea asked and elicited | 1 |
| Photophobia / phonophobia asked | 1 |
| Loss of consciousness — asked and established brief LOC | 1 |
| Neck stiffness / meningism asked | 1 |
| Red Flag Differentiation | |
| Asks about preceding sentinel headache in past weeks | 2 |
| Asks about fever / rash (meningitis excluded) | 1 |
| Asks about focal neurological symptoms (CVST / space-occupying lesion) | 1 |
| Background & Risk | |
| Family history of aneurysm / SAH / PKD elicited | 2 |
| Medications including anticoagulants and cocaine asked | 1 |
| Communication | |
| Introduces self, confirms identity, compassionate approach | 1 |
| Organised and systematic — does not alarm patient unnecessarily | 1 |
| Total | 20 |
You are the ED doctor. Miss Lauren Ashby, 26 years old, presents with 18-hour history of right iliac fossa pain, initially periumbilical and migrating. She has been vomiting and is anorexic.
Obs: BP 118/74, HR 102, Temp 38.1°C, RR 18, SpO₂ 98%.
Take a focused history. You have 8 minutes.
⚠️ Examiner Instructions — Not for Candidate
Lauren has acute appendicitis. She is anxious but cooperative. If candidate asks about gynaecological history sensitively, she will disclose relevant information. Pregnancy test will be negative.
| Criterion | Marks |
|---|---|
| Pain History | |
| Elicits periumbilical-to-RIF migration of pain | 2 |
| Character — constant, worsened by movement/coughing/breathing | 1 |
| Onset, timing and duration correctly established | 1 |
| Associated GI Symptoms | |
| Anorexia specifically asked and elicited | 2 |
| Nausea and vomiting — frequency and timing | 1 |
| Bowel habit — diarrhoea vs constipation asked | 1 |
| Gynaecological History | |
| LMP — date, regularity, character elicited | 2 |
| PV discharge and bleeding asked | 1 |
| Pregnancy status — test offered / discussed | 1 |
| Ectopic pregnancy and PID considered as differentials | 1 |
| Urological & Background | |
| Urinary symptoms excluded — dysuria, haematuria, frequency | 1 |
| Medications and allergies — OCP documented | 1 |
| Communication | |
| Gynaecological history obtained sensitively and professionally | 2 |
| Organised structure, appropriate clinical urgency | 1 |
| Total | 20 |
You are asked to perform a focused abdominal examination on this patient. The examiner will tell you the findings as you examine each area.
Please talk through your examination throughout. At the end, present your findings, state the most likely diagnosis, and suggest appropriate investigations and management.
Assume consent has been obtained and appropriate exposure is in place.
⚠️ Examiner Instructions — Not for Candidate
Findings represent decompensated alcoholic liver disease (cirrhosis with ascites). Feed findings as candidate examines each area.
| Criterion | Marks |
|---|---|
| Peripheral Signs | |
| Hands — leukonychia, palmar erythema, Dupuytren's, asterixis identified | 2 |
| Face — scleral jaundice, parotid enlargement, spider naevi noted | 2 |
| Abdominal Examination | |
| Inspection — correctly identifies distension and caput medusae | 2 |
| Systematic light and deep palpation of all 9 regions | 1 |
| Liver — size quantified, consistency described (firm) | 2 |
| Spleen — correctly palpated with patient tilted | 1 |
| Ascites — shifting dullness demonstrated correctly | 2 |
| Auscultation — bowel sounds and bruits assessed | 1 |
| Presentation | |
| Correct diagnosis — decompensated cirrhosis with ascites | 2 |
| Mentions completing exam — PR, herniae, lymphadenopathy | 1 |
| Appropriate investigations — LFTs, clotting, U&E, ascitic tap, USS | 1 |
| Identifies encephalopathy — asterixis, confusion | 1 |
| Total | 20 |
A 62-year-old woman presents with right arm weakness and clumsiness which came on suddenly this morning while having breakfast. It lasted for 2 hours and has now partially resolved.
Please perform a focused upper limb neurological examination, talk through your findings, and present a differential diagnosis with immediate management plan.
⚠️ Examiner Instructions — Not for Candidate
Findings represent a resolving right-sided TIA — subtle UMN signs persisting. Feed findings as candidate examines.
| Criterion | Marks |
|---|---|
| Inspection | |
| Correctly inspects for wasting and fasciculations | 1 |
| Tests for pronator drift — correctly identifies right-sided drift | 2 |
| Tone | |
| Assesses tone bilaterally — correctly notes increased right-sided tone | 1 |
| Power | |
| Tests all major muscle groups — uses MRC grading 0–5 | 2 |
| Identifies right-sided weakness (grip and finger extension 4/5) | 1 |
| Reflexes | |
| Tests biceps, brachioradialis, triceps bilaterally | 1 |
| Correctly identifies brisk right-sided reflexes (UMN pattern) | 1 |
| Tests Hoffman's reflex — correctly notes positive on right | 1 |
| Coordination and Sensation | |
| Finger-nose test performed bilaterally | 1 |
| Sensation — light touch and proprioception assessed | 1 |
| Presentation | |
| Correctly identifies right UMN pattern — left hemisphere lesion | 2 |
| Correct diagnosis — TIA. Mentions ABCD² score | 2 |
| Immediate management — aspirin 300mg, urgent TIA clinic / brain imaging, ABCD² ≥4 → same-day specialist review | 1 |
| Total | 20 |
A 58-year-old woman presents to the resus bay with rapid AF with a ventricular rate of 160 bpm. She is haemodynamically compromised: BP 82/50, reduced consciousness (GCS 12), and severe chest pain. She has been in AF for less than 48 hours.
Please demonstrate emergency DC cardioversion on this manikin. Talk through each step. The team is assembled and anaesthetics are present for sedation.
⚠️ Examiner Instructions — Not for Candidate
The critical teaching point is synchronised mode. If candidate attempts to cardiovert in defibrillation (unsynchronised) mode, stop them and ask why synchronisation matters.
| Criterion | Marks |
|---|---|
| Assessment & Indication | |
| Correctly identifies haemodynamic compromise as indication for emergency cardioversion | 2 |
| Recognises duration <48 hours — addresses anticoagulation implications | 1 |
| Preparation | |
| Calls for anaesthetic support — safe sedation before procedure | 2 |
| IV access confirmed, monitoring applied, resus equipment checked | 1 |
| Correct pad placement stated — anterolateral or anteroposterior | 1 |
| Procedure | |
| Selects SYNCHRONISED mode — confirms R-wave markers visible on ECG | 3 |
| Correct energy selection — 120–200J biphasic | 1 |
| Clear warning — "Stand clear" — checks all staff clear before shock | 2 |
| Delivers shock correctly | 1 |
| Post-Procedure | |
| Reassesses rhythm and haemodynamics immediately | 1 |
| Anticoagulation plan stated post-cardioversion | 1 |
| Explains why synchronisation critical — avoids R-on-T VF | 1 |
| Documents, clear communication with team throughout | 1 |
| Total | 20 |
A 45-year-old man is in cardiac arrest following anaphylaxis. The resuscitation team is performing CPR. Three peripheral IV attempts have been unsuccessful. You are asked to establish intraosseous access using the EZ-IO device on this manikin.
Talk through each step, state your chosen site, and explain how you will confirm correct placement. State what drugs you can administer via this route.
⚠️ Examiner Instructions — Not for Candidate
Assess whether candidate chooses an appropriate site, uses correct needle length, confirms placement properly, and knows what can be administered IO. If candidate goes to tibia: appropriate. Ask about humeral site as alternative.
| Criterion | Marks |
|---|---|
| Indication & Site Selection | |
| States indication — failed IV access in time-critical situation | 1 |
| Correct site — proximal tibia or proximal humerus with accurate landmark | 2 |
| Correct needle length selection for patient size | 1 |
| Procedure | |
| Limb stabilised, site cleaned aseptically | 1 |
| Perpendicular 90° angle to bone — does not angle | 1 |
| Drills until sudden decrease in resistance — does not over-advance | 2 |
| Removes stylet, attempts aspiration to confirm marrow return | 1 |
| Flushes with 10 mL 0.9% saline — confirms free flow without extravasation | 2 |
| Knowledge | |
| States drugs that can be given IO — includes adrenaline, amiodarone, fluids | 2 |
| Mentions lidocaine flush if patient conscious (prior to saline flush) | 1 |
| Complications listed — extravasation/compartment syndrome, osteomyelitis | 1 |
| States IO removed as soon as IV access established (24-48 hour max) | 1 |
| Safe, systematic, communicates with team throughout | 1 |
| Total | 20 |
Mr Graham Holt, 55 years old, presents to ED with a deep laceration to his arm following a fall. The wound requires suturing under local anaesthetic — a routine, low-risk procedure. He is refusing all treatment and wants to go home.
He has a known history of paranoid schizophrenia, currently on depot antipsychotic. He is alert, speaking coherently and does not appear acutely psychotic.
Please assess Mr Holt's mental capacity to refuse treatment and manage this situation appropriately. You have 8 minutes.
⚠️ Examiner / Role-player Instructions — Not for Candidate
You are Graham Holt. You have capacity in this scenario. You understand the risks of not having your wound sutured but distrust the hospital — "they put things in the needles." Remain firm in refusal unless candidate is exceptionally empathic and addresses your fears sensitively — in which case you can become ambivalent but still cautious.
| Criterion | Marks |
|---|---|
| Approach & Presumption | |
| States presumption of capacity — does not assume incapacity from diagnosis | 2 |
| Approaches patient with respect, introduces self, creates rapport | 1 |
| Capacity Assessment — 4-Stage Test | |
| Tests understanding — asks patient to explain information in own words | 2 |
| Tests retention — checks patient can recall key points after brief delay | 1 |
| Tests weighing — explores reasoning, asks patient to articulate balance of risks | 2 |
| Tests communication — patient can express decision clearly | 1 |
| Outcome & Documentation | |
| Correctly determines patient has capacity in this scenario | 2 |
| Respects capacitous refusal — does not coerce or threaten | 2 |
| Informs patient of consequences of refusal clearly and without pressure | 1 |
| Offers compromise / alternative (e.g., steri-strips, wound closure) | 1 |
| States will document decision and patient's reasoning thoroughly | 1 |
| Offers return to ED if patient changes mind — leaves door open | 1 |
| Non-judgemental, empathic throughout despite patient's suspicion | 1 |
| Total | 20 |
You have been managing a trauma patient in resus for the last 20 minutes. The trauma surgery registrar has now arrived and you need to give a structured handover.
Patient summary: Mr Tariq Hussain, 38, motorcyclist. High-speed RTC. GCS 14 on scene, now 12/15 (E3V4M5). Tachycardic (HR 128), BP 88/60. Two large-bore IV cannulae. 1L crystalloid given. CXR — left haemothorax. Pelvis film — left pubic ramus fracture. Abdomen soft but tender. FAST scan — free fluid in Morrison's pouch. Blood products activated. No known allergies. Lives alone.
Please give a structured handover to the surgical registrar using an appropriate framework. You have 8 minutes.
⚠️ Examiner / Surgical Registrar Role
You are the surgical registrar. You are focused and efficient. Ask at least 2 questions: "What's his current GCS trend?" and "Has orthopaedics been called for the pelvis?" Assess whether the candidate gives a structured, complete, efficient handover without being prompted.
| Criterion | Marks |
|---|---|
| Structure & Framework | |
| Uses named framework — SBAR or ATMIST explicitly or implicitly structured | 2 |
| Clear patient ID — name, age, mechanism of injury | 1 |
| Clinical Content | |
| Current GCS stated and trend described (14 → 12 — deteriorating) | 2 |
| Haemodynamic status — BP, HR, shock recognised and stated | 2 |
| Injuries — haemothorax, pelvic fracture, positive FAST all mentioned | 3 |
| Interventions to date — IV access, fluids, imaging results summarised | 2 |
| Blood products — activation of major haemorrhage protocol mentioned | 1 |
| Recommendation & Teamwork | |
| Clear recommendation — states patient needs urgent surgical review and likely operative intervention | 2 |
| Mentions orthopaedics for pelvis, ITU awareness | 1 |
| Confident, concise delivery — does not waffle or omit critical information | 1 |
| Responds appropriately to surgical registrar's questions | 1 |
| Total | 20 |
An 80-year-old man with known COPD presents with sudden onset breathlessness and sharp right-sided chest pain following a coughing fit. He is on home oxygen.
Obs: RR 28, SpO₂ 82% on 2L O₂, HR 118, BP 134/88.
The examiner will describe the CXR findings. Please interpret them systematically, state your diagnosis and immediate management. You will then be asked two follow-up questions.
⚠️ Examiner Instructions — Not for Candidate
Read the following CXR description aloud, then ask the two follow-up questions.
"The film is adequately exposed and rotated. There is a complete absence of lung markings on the right side. A clear visceral pleural line is visible parallel to the right chest wall. The right hemithorax appears hyperinflated and the trachea is deviated to the left. The left lung field shows hyperinflation consistent with COPD. Cardiac size is normal. No rib fractures. No effusion on left."
Follow-up Q1: "What is your immediate management?"
Expected: This is a tension pneumothorax clinically — DO NOT wait for imaging before treatment if haemodynamically compromised. Immediate needle thoracostomy — 2nd ICS, mid-clavicular line (or 4th/5th ICS anterior axillary line per latest ATLS) — then definitive chest drain.
Follow-up Q2: "The patient deteriorates — BP drops to 60/40 and he loses consciousness. What do you do?"
Expected: Immediate needle decompression without waiting — this is now life-threatening tension pneumothorax. Call for help, commence ABCDE resuscitation simultaneously. If needle decompression fails, consider finger thoracostomy.
| Criterion | Marks |
|---|---|
| Systematic Interpretation | |
| States RIPE or equivalent systematic approach before describing findings | 1 |
| Correctly identifies absent lung markings on right | 2 |
| Identifies visceral pleural line on right | 1 |
| Notes tracheal deviation to the left (mediastinal shift) | 2 |
| Identifies background COPD — bilateral hyperinflation | 1 |
| Diagnosis & Urgency | |
| Correct diagnosis — large right pneumothorax / tension pneumothorax | 2 |
| Recognises this is life-threatening — tension pattern with mediastinal shift | 2 |
| Management | |
| Immediate needle decompression — correct site (2nd ICS MCL or 4th/5th AAL) | 2 |
| States not to await imaging if clinical diagnosis of tension pneumothorax | 2 |
| Definitive management — chest drain insertion planned | 1 |
| Appropriate response to deterioration — immediate decompression without hesitation | 1 |
| Total | 20 |
A 22-year-old woman with Type 1 diabetes presents confused and vomiting. She has not taken her insulin for 2 days after her insulin pen was lost.
Obs: GCS 13/15, RR 28 (deep Kussmaul breathing), HR 116, BP 96/62, Temp 37.8°C. Capillary glucose 28 mmol/L.
The examiner will read you her blood results. Please interpret them systematically, confirm the diagnosis and outline your immediate management using the DKA protocol.
⚠️ Examiner Instructions — Not for Candidate
Read the blood results aloud, then ask the follow-up questions. Key assessment point: potassium management before insulin initiation.
"pH 7.18, HCO₃ 9 mmol/L, PaCO₂ 2.8 kPa (compensatory hyperventilation), Glucose 28 mmol/L, Ketones 5.4 mmol/L, Na 132 mmol/L, K⁺ 3.2 mmol/L, Cl 98, Urea 11.2, Creatinine 132. WBC 16.4. CRP 42. Urine dipstick — ketones 3+, glucose 3+, no nitrites."
Follow-up Q1: "You are about to start the FRIII insulin infusion. What do you need to check first?"
Expected: K⁺ — must be ≥3.5 before starting insulin. This patient's K⁺ is 3.2 — replace first. IV KCl supplementation before commencing insulin infusion.
Follow-up Q2: "When can you stop the insulin infusion and what precautions must you take?"
Expected: Resolution criteria met (pH >7.3, HCO₃ >18, ketones <0.3). Patient must be eating and drinking. Give SC insulin 30–60 minutes before stopping IV insulin to prevent rebound ketosis.
| Criterion | Marks |
|---|---|
| Interpretation | |
| Identifies metabolic acidosis — pH 7.18, HCO₃ 9 | 1 |
| Identifies compensatory respiratory alkalosis — low PaCO₂ 2.8, Kussmaul breathing | 1 |
| Notes hyperglycaemia 28 and ketonaemia 5.4 — confirms DKA triad | 2 |
| Correctly classifies severity — severe DKA (pH <7.0 threshold missed — moderate: pH 7.18) | 1 |
| Identifies low sodium 132 — likely pseudohyponatraemia. Corrected Na calculated | 1 |
| Identifies low potassium 3.2 — recognises critical significance | 2 |
| Immediate Management | |
| IV fluid resuscitation — 0.9% NaCl, correct rate and sequence stated | 2 |
| FRIII insulin — 0.1 unit/kg/hr. States no bolus dose | 2 |
| Potassium replacement BEFORE starting insulin — critical safety point | 2 |
| Dextrose added when glucose <14 mmol/L | 1 |
| Resolution & Monitoring | |
| States resolution criteria and transition to SC insulin correctly | 2 |
| 30–60 min overlap between IV and SC insulin before stopping infusion | 1 |
| Complications monitored — hypokalaemia, hypoglycaemia, cerebral oedema | 1 |
| Total | 20 |