10 advanced stations covering toxicology, obstetric emergencies, psychiatric assessment, major trauma, dermatology and more — all new topics not covered in Banks 1–3.
You are the ED doctor. Mr Ewan McBride, 44 years old, presents with a 3-day history of worsening low back pain. He has had back pain before but says this episode feels different. He is a builder and lifts heavy loads regularly.
Obs: BP 132/80, HR 78, apyrexial, GCS 15.
Please take a focused history. You have 8 minutes.
⚠️ Examiner / Role-player Instructions — Not for Candidate
You are Ewan McBride. You have cauda equina syndrome. You have not volunteered the bladder symptoms because you are embarrassed. Only disclose if directly and specifically asked. You noticed you couldn't fully empty your bladder yesterday and had a brief episode of leaking. You also have numbness "down below" which you didn't think was related.
| Criterion | Marks |
|---|---|
| Pain History | |
| SOCRATES applied — bilateral radiation, constant character, onset with lifting | 2 |
| Bilateral leg symptoms — weakness and radiation below knee elicited | 1 |
| Cauda Equina Screen — each symptom scores individually | |
| Bladder symptoms specifically asked — urinary retention / incontinence elicited | 3 |
| Bowel symptoms specifically asked — constipation / faecal incontinence | 2 |
| Saddle anaesthesia specifically asked — perineal / genital numbness elicited | 2 |
| Bilateral leg weakness specifically asked and elicited | 1 |
| Red Flag Screen | |
| Cancer history, weight loss, night sweats asked | 2 |
| Fever, IVDU, recent infection asked (discitis / epidural abscess) | 1 |
| Steroid / anticoagulant use, previous back surgery asked | 1 |
| Diagnosis & Management | |
| Correctly identifies cauda equina syndrome as working diagnosis | 2 |
| States emergency MRI spine + neurosurgical referral + catheterisation | 2 |
| Does not discharge — states patient must be admitted | 1 |
| Total | 20 |
You are the ED doctor. Mrs Amira Hassan, 29 years old, is 32 weeks pregnant and has arrived by ambulance with a 30-minute history of painless bright red vaginal bleeding. She is conscious and distressed.
Obs: BP 96/58, HR 128, RR 22, SpO₂ 98%, Temp 36.9°C.
Please take a focused obstetric history. You have 8 minutes. Do NOT perform a vaginal examination.
⚠️ Examiner / Role-player Instructions — Not for Candidate
You are Amira Hassan. You are frightened and tearful. This is placenta praevia — painless bright red bleeding, known low-lying placenta on 20-week scan (she will tell this if asked about scan findings). She is Rhesus negative. She has felt reduced fetal movement today. No contractions.
| Criterion | Marks |
|---|---|
| Bleeding History | |
| Onset, amount (pads soaked), colour, clots elicited | 2 |
| Painless nature confirmed — distinguishes from abruption | 2 |
| Precipitating factors asked — trauma, intercourse | 1 |
| Obstetric Assessment | |
| Gestation confirmed — 32 weeks | 1 |
| Scan history asked — elicits known low-lying placenta | 2 |
| Fetal movement asked — reduced movement elicited | 2 |
| Contractions / preterm labour asked | 1 |
| Rhesus status asked — Rh-negative elicited (anti-D required) | 2 |
| Obstetric & Medical History | |
| Parity, previous CS, previous APH asked | 1 |
| Complications this pregnancy — hypertension, pre-eclampsia, diabetes | 1 |
| Diagnosis & Actions | |
| Working diagnosis — placenta praevia | 1 |
| States: no PV examination, urgent obstetric review, USS, large-bore IV, crossmatch, anti-D | 2 |
| Empathic, calm approach to frightened patient | 1 |
| Total | 20 |
A 38-year-old woman presents to the ED with palpitations, heat intolerance and a 6kg weight loss over 3 months despite a good appetite. On examination she looks anxious and tremulous.
Please perform a focused thyroid examination. The examiner will provide findings as you examine. Present your diagnosis and immediate management plan.
⚠️ Examiner Instructions — Not for Candidate
Findings represent Graves' disease with thyrotoxicosis. Feed findings as candidate examines. At the end, ask: "Her HR is 148 and she is now vomiting and her temperature is 39.2°C — what do you think is happening and how do you manage it?"
| Criterion | Marks |
|---|---|
| Peripheral Signs | |
| Hands — fine tremor, warm moist palms, onycholysis identified | 2 |
| Pulse — rate, rhythm, character — AF correctly identified | 2 |
| Eye Signs | |
| Proptosis / exophthalmos identified | 1 |
| Lid retraction identified — sclera visible above iris | 1 |
| Lid lag tested correctly — von Graefe's sign | 1 |
| VA and ophthalmoplegia assessed — optic nerve compromise excluded | 1 |
| Thyroid Examination | |
| Inspects neck for goitre — swallowing test performed | 1 |
| Palpates from behind — size, consistency, nodularity, tenderness | 2 |
| Thyroid bruit auscultated — correctly identified | 2 |
| Pretibial myxoedema checked — identified on shins | 1 |
| Diagnosis & Thyroid Storm | |
| Correct diagnosis — Graves' disease with thyrotoxicosis in AF | 1 |
| Thyroid storm recognised — criteria met (Burch-Wartofsky) | 1 |
| Thyroid storm management — propranolol, carbimazole, iodine, hydrocortisone, supportive | 2 |
| Reflexes tested — brisk reflexes noted | 1 |
| Total | 20 |
A 68-year-old man with known AF (not anticoagulated) presents with sudden onset severe pain in his right leg 3 hours ago. The leg looks pale and he says it feels numb.
Please perform a focused lower limb vascular examination. The examiner will provide findings. Present your diagnosis and immediate management.
⚠️ Examiner Instructions — Not for Candidate
Findings represent right acute limb ischaemia (Rutherford IIb — immediately threatened). Feed findings as candidate examines. Critical point: immediate heparin and vascular surgery — this is a surgical emergency.
| Criterion | Marks |
|---|---|
| Inspection & Temperature | |
| Inspects both legs — pallor and mottling right correctly identified | 1 |
| Temperature comparison both sides — right cold identified | 1 |
| CRT compared — right >5 seconds identified | 1 |
| Neurology | |
| Sensation tested — reduced light touch/pinprick right lower limb | 2 |
| Power tested — right dorsiflexion weakness identified | 1 |
| Pulses | |
| All four pulses palpated bilaterally — femoral, popliteal, PT, DP | 3 |
| Correctly identifies absent right popliteal, PT and DP pulses | 2 |
| Femoral bruit auscultated | 1 |
| Special Tests & Diagnosis | |
| Buerger's test performed — angle approximately 20° noted | 1 |
| Correct diagnosis — acute right limb ischaemia, Rutherford IIb | 2 |
| Identifies AF as likely embolic source | 1 |
| Immediate management — IV heparin, urgent vascular surgery, analgesia, time-critical | 2 |
| States irreversibility risk after 6 hours | 1 |
| Total | 20 |
A 74-year-old man with benign prostatic hypertrophy presents in acute urinary retention. He has not passed urine for 12 hours and has a palpable, tender bladder to the umbilicus. Bladder scan confirms 900 mL.
Please demonstrate male urethral catheterisation on this manikin. Talk through each step. State the catheter type, size and how you confirm correct placement.
⚠️ Examiner Instructions — Not for Candidate
Critical safety checks: (1) does candidate advance to the hilt before inflating balloon? (2) does candidate replace the foreskin? Ask mid-procedure: "You're advancing the catheter and feel resistance — what do you do?"
| Criterion | Marks |
|---|---|
| Preparation | |
| Correct catheter size and type stated (12–16Fr Foley, Tiemann if BPH difficulty) | 1 |
| Checks allergies — latex, lidocaine. Consent obtained. | 1 |
| Full aseptic technique — sterile gloves, drape, sterile pack | 2 |
| Cleans meatus correctly — 3 swabs, each used once, front to back | 1 |
| Instillagel inserted and appropriate wait time stated (3–5 min) | 2 |
| Technique | |
| Penis held at 90° to straighten urethra | 1 |
| Catheter advanced to the hilt before balloon inflation — critical step | 3 |
| Confirms urine flow before inflating balloon | 1 |
| Inflates balloon with correct volume (10 mL sterile water) | 1 |
| Retracts catheter until resistance felt | 1 |
| Completion | |
| Foreskin replaced — paraphimosis prevention stated | 2 |
| Drainage bag connected, urine output documented, MSU sent | 1 |
| Resistance encountered — states do not force, Tiemann/urology referral | 1 |
| Complications listed — urethral trauma, UTI, paraphimosis | 1 |
| Total | 20 |
A 35-year-old man presents with a 4 cm laceration to his right forearm following a fall onto broken glass 2 hours ago. He is otherwise well. You have assessed that the wound is clean, does not involve tendon or bone, and is suitable for primary closure.
Please demonstrate wound assessment and interrupted suturing technique on the manikin. Talk through each step including anaesthesia, cleaning, closure choice and aftercare.
⚠️ Examiner Instructions — Not for Candidate
Assess LA technique (aspirate, correct dose, no end arteries), wound irrigation, suture technique (eversion, 90° needle, knot technique), and aftercare including tetanus. Ask: "Is this a bite wound — would you manage it differently?" (Yes — leave open or delayed primary closure.)
| Criterion | Marks |
|---|---|
| Wound Assessment | |
| Mechanism, time since injury, contamination, depth assessed | 1 |
| Neurovascular status distal to wound checked | 1 |
| Foreign body considered — XR ordered for glass | 1 |
| Anaesthesia | |
| Correct LA agent and dose — 1% lidocaine, max 3 mg/kg (without adrenaline) | 2 |
| Aspirates before injecting. States no adrenaline near end arteries. | 1 |
| Injects into wound edges correctly, warns patient of sting | 1 |
| Wound Preparation | |
| Irrigates with saline under pressure — states volume ≥500 mL | 2 |
| Foreign body removal / debridement of devitalised tissue stated | 1 |
| Suturing Technique | |
| Needle enters at 90° to skin surface | 1 |
| Wound edges everted — not inverted | 2 |
| Correct instrument tie technique — 2+1 throws, knot to side | 2 |
| Appropriate suture material and size stated (3/0 Prolene forearm) | 1 |
| Aftercare | |
| Tetanus prophylaxis asked and addressed | 1 |
| Suture removal timing stated — 7–10 days for forearm | 1 |
| Bite wound — correctly states delayed/open closure | 1 |
| Total | 20 |
You are the ED registrar. Mr Patrick Walsh, 66, presented to your ED last week with chest pain. He was assessed and discharged with a diagnosis of musculoskeletal pain. He has now been re-admitted by his GP — troponins taken at his GP today show a markedly elevated result, and his ECG shows established Q waves. He had an NSTEMI that was missed.
He is now haemodynamically stable. You have been asked to speak to him. He doesn't yet know the diagnosis was missed.
Please speak to Mr Walsh, disclose what happened, and manage this conversation in accordance with your duty of candour. You have 8 minutes.
⚠️ Examiner / Role-player Instructions — Not for Candidate
You are Patrick Walsh. Start calm but confused. When told the diagnosis was missed, become upset and angry. "I told them it was my heart. I said to the doctor — are you sure? And they said it was just muscular." If candidate apologises sincerely and is open, soften. If defensive or uses jargon, escalate: "So what you're telling me is your department nearly killed me?"
| Criterion | Marks |
|---|---|
| Setting & Opening | |
| Private setting, sits down, has support person for patient if possible | 1 |
| Introduces self and role — explains purpose of conversation clearly | 1 |
| Disclosure | |
| Discloses error clearly and honestly — does not minimise or use euphemisms | 3 |
| Explains in plain language — "the tests we did last week missed a heart attack" | 2 |
| Sincere apology — "I am sorry this happened" — not defensive or conditional | 2 |
| Current Situation & Next Steps | |
| Explains current diagnosis and what treatment he now needs | 2 |
| Explains steps being taken — internal review, incident report, preventing recurrence | 2 |
| Offers written summary of conversation | 1 |
| Handling Anger & Complaints | |
| Remains calm, does not become defensive when patient is angry | 2 |
| Does not blame individual colleagues — institutional accountability | 1 |
| Informs patient of formal complaints process — PALS | 1 |
| Allows patient to express feelings — does not rush or fill silence | 1 |
| Offers follow-up — named person patient can contact | 1 |
| Total | 20 |
You are an ED registrar. A nurse, Sarah, has pulled you aside during the shift. She tells you she is worried about your consultant, Dr Collins. She says she can smell alcohol on his breath, he has made two prescribing errors today that she has corrected, and he seems confused and unsteady on his feet. This is a busy Saturday evening shift.
Please speak to Sarah and manage this situation appropriately. You have 8 minutes.
⚠️ Examiner / Role-player Instructions (as Sarah the nurse) — Not for Candidate
You are worried and hesitant — "I don't want to get him in trouble, he's usually a lovely doctor." Test whether candidate takes the concern seriously, protects patients as primary concern, and escalates rather than trying to manage it alone. If candidate says "I'll just have a quiet word with him" — push: "But what if he carries on working? There are patients waiting to be seen."
| Criterion | Marks |
|---|---|
| Initial Response | |
| Takes concern seriously — thanks Sarah, does not dismiss or minimise | 2 |
| Clarifies specific observations — prescribing errors, smell, unsteadiness | 1 |
| Reassures Sarah she has done the right thing raising this | 1 |
| Patient Safety | |
| Identifies patient safety as immediate priority — explicitly states this | 2 |
| States Dr Collins must be removed from clinical care immediately | 2 |
| Does not attempt to manage the situation alone — escalates to senior | 2 |
| Escalation | |
| Identifies who to contact — clinical director / on-call consultant / medical director | 2 |
| States this will be done discreetly and respectfully — not publicly | 1 |
| Documentation — factual record of concern and actions taken | 1 |
| Support & Professional Duties | |
| References GMC duty to act on concerns about colleague fitness to practise | 1 |
| Mentions support for colleague once patient safety secured — Practitioner Health, Occupational Health | 1 |
| Addresses Sarah's worry about "getting him in trouble" — frames as patient protection not punishment | 2 |
| Remains calm and professional throughout | 1 |
| Total | 20 |
A 23-year-old woman is brought in by ambulance following a deliberate overdose of her grandmother's amitriptyline tablets. She took approximately 20 × 25mg tablets (500mg total) one hour ago. She is currently drowsy, GCS 10, with a HR of 136 and BP of 86/50.
The examiner will give you her ECG and blood results. Please interpret them systematically, state your diagnosis of the toxidrome, and outline immediate management.
⚠️ Examiner Instructions — Not for Candidate
Read the ECG description and bloods aloud. Key assessment: does candidate give sodium bicarbonate as first-line treatment? Ask: "The QRS is now 140ms and she has just had a generalised seizure — what do you give?"
ECG: Sinus tachycardia 136 bpm. QRS duration 118ms (widened). Terminal R wave in aVR 4mm. QTc 520ms. Right axis deviation. No ST elevation.
Bloods: pH 7.28, HCO₃ 14 (metabolic acidosis), Na 138, K 3.1, Glucose 6.8, Paracetamol level undetectable, Salicylate undetectable. ECG is the key investigation here.
Follow-up Q1: "What is the most important immediate treatment?"
Expected: IV sodium bicarbonate 1–2 mmol/kg — directly addresses QRS widening, hypotension, and metabolic acidosis. Target serum pH 7.50–7.55.
Follow-up Q2: "She seizes — what do you give and what do you avoid?"
Expected: IV benzodiazepine (lorazepam/diazepam). Avoid phenytoin — sodium channel blocker, worsens TCA toxicity. Avoid flumazenil.
| Criterion | Marks |
|---|---|
| Toxidrome Recognition | |
| Identifies TCA toxidrome — anticholinergic + Na channel blocking + α-blocking | 2 |
| Anticholinergic features listed — mydriasis, tachycardia, dry skin, urinary retention | 1 |
| ECG Interpretation | |
| Sinus tachycardia identified | 1 |
| QRS widening (>100ms) identified and significance stated | 2 |
| Terminal R wave in aVR identified — pathognomonic of TCA toxicity | 2 |
| QTc prolongation noted — VF/torsades risk | 1 |
| Management | |
| Sodium bicarbonate — first line, correct dose, target pH 7.50–7.55 | 3 |
| Airway — early intubation if GCS deteriorating stated | 1 |
| IV fluids and vasopressors for hypotension | 1 |
| Seizure management — benzodiazepines first line | 1 |
| Specifically avoids phenytoin — correctly explains why | 2 |
| Continuous monitoring — telemetry, ITU, lipid emulsion rescue mentioned | 1 |
| Activated charcoal — only if within 1 hour AND airway protected | 1 |
| Total | 20 |
A 4-year-old boy, Noah, is brought in by ambulance. He has been unwell for 8 hours with high fever, vomiting, and is now difficult to rouse. His mother noticed a rash on his legs 2 hours ago. On arrival he is obtunded (GCS 9), mottled, with a purpuric non-blanching rash on his legs and trunk.
Obs: HR 178, BP 62/38, RR 44, Temp 39.8°C, SpO₂ 91% on air, CRT 6 seconds centrally.
The examiner will read you his bloods. Interpret them, confirm your diagnosis, and give a time-critical management plan.
⚠️ Examiner Instructions — Not for Candidate
Read results aloud. Critical assessment: does candidate give antibiotics immediately without waiting for full results? Ask: "A junior doctor says we should wait for LP before giving antibiotics — what do you say?"
WBC 2.1 (↓↓ — consumption), Neutrophils 1.4, Platelets 42 (↓↓), Hb 96 (↓), CRP 284, PCT 88, Lactate 8.2 (↑↑), Glucose 2.1 (↓ — hypoglycaemia), Na 128, K 5.8, Creatinine 142 (↑ — AKI), PT 32s (↑), APTT 68s (↑), Fibrinogen 0.6 g/L (↓↓ — DIC), D-dimer >20, pH 7.08, HCO₃ 8, Base excess −18.
Follow-up Q1: "LP — yes or no right now?"
Expected: NO. Contraindicated — coagulopathy (DIC), haemodynamic instability, likely raised ICP. Do NOT delay antibiotics for LP. Treat first.
Follow-up Q2: "Blood glucose is 2.1 — what do you give and how?"
Expected: 2 ml/kg 10% dextrose IV/IO (not 50% dextrose in children). Recheck glucose 15 minutes later.
| Criterion | Marks |
|---|---|
| Clinical Recognition | |
| Identifies non-blanching rash + shock = meningococcal septicaemia — does not wait for results | 2 |
| Data Interpretation | |
| Low WBC and platelets — consumption in overwhelming sepsis | 1 |
| DIC recognised — low platelets, prolonged PT/APTT, low fibrinogen, high D-dimer | 2 |
| Lactate 8.2 — severe tissue hypoperfusion / shock | 1 |
| Metabolic acidosis — pH 7.08, BE −18 identified and severity recognised | 1 |
| Hypoglycaemia 2.1 identified — treatment stated (2 ml/kg 10% dextrose) | 2 |
| AKI recognised — creatinine 142 in a child | 1 |
| Management — Paediatric Sepsis Six | |
| High-flow oxygen immediately | 1 |
| Ceftriaxone 80 mg/kg IV/IO — correct drug and dose, not delayed for LP | 2 |
| 10 ml/kg 0.9% NaCl fluid bolus IV/IO — repeated as needed up to 40 ml/kg | 1 |
| LP contraindicated — correct reasoning stated (DIC, instability, raised ICP) | 2 |
| PICU referral — recognises severity | 1 |
| Public health notification and contact prophylaxis | 1 |
| Total | 20 |