10 new structured stations — venous thromboembolism, paediatric orthopaedics, musculoskeletal examination, safeguarding, suicide risk assessment and paediatric DKA.
You are the ED doctor. Mr Peter Collins, 52 years old, presents with a 3-day history of right calf swelling and pain. He returned from a 12-hour flight from Australia 5 days ago.
Triage obs: HR 88, BP 134/82, RR 16, SpO₂ 98% on air, Temp 37.2°C. Right calf visibly swollen.
Please take a focused history and calculate a Wells DVT score. You have 8 minutes.
⚠️ Examiner / Role-player Instructions — Not for Candidate
You are Mr Peter Collins. You are concerned but not distressed. The diagnosis is a right popliteal-femoral DVT. No PE symptoms. Wells score in this scenario = 4 (DVT likely): flight immobility, calf >3cm, localised deep vein tenderness, entire leg swollen, no alternative diagnosis more likely.
| Criterion | Marks |
|---|---|
| Swelling History | |
| Onset, duration, progression, character of swelling elicited | 2 |
| Warmth, erythema, tenderness along deep venous distribution asked | 1 |
| Wells DVT Score | |
| Immobility — long-haul flight identified and scored | 1 |
| Active cancer, recent surgery, previous DVT, plaster cast all screened | 2 |
| Calf swelling >3cm differential, entire leg swelling, collateral veins asked | 1 |
| Correct Wells score calculated — 4 (DVT likely). States USS required, not D-dimer first. | 2 |
| Risk Factors | |
| Medications — OCP, HRT, anticoagulants asked | 1 |
| Family history of VTE or thrombophilia asked — positive family history identified | 2 |
| PE Screening | |
| PE symptoms screened — chest pain, dyspnoea, haemoptysis | 2 |
| Differentials and Communication | |
| Differentials considered — cellulitis, ruptured Baker's cyst, muscular tear | 1 |
| Systematic, structured history. Explains to patient what next steps involve. | 2 |
| Total | 20 |
You are the ED doctor. Miss Amara Osei, 24 years old, was brought in by ambulance after collapsing in a supermarket. A bystander witnessed a generalised tonic-clonic event lasting approximately 2 minutes. She has no prior history of seizures.
She is now alert, GCS 15, mildly confused. Obs: HR 96, BP 118/72, RR 16, SpO₂ 99%, BM 5.2 mmol/L, Temp 37.0°C.
Please take a focused history from Miss Osei and a brief collateral history from the witness (the examiner will role-play both). You have 8 minutes.
⚠️ Examiner / Role-player Instructions — Not for Candidate
Play both roles sequentially: (1) Amara Osei — post-ictal, mildly confused, cannot recall the event itself, remembers a brief "funny smell" warning. (2) Witness — the bystander who saw the event. No previous seizures, no significant PMH, no medications. The diagnosis is a first unprovoked generalised tonic-clonic seizure.
| Criterion | Marks |
|---|---|
| Pre-ictal | |
| Aura elicited from patient — olfactory aura (burning smell) identified | 2 |
| Ictal (Collateral History) | |
| Collateral history actively sought from witness | 1 |
| Duration, tonic and clonic phases, eye deviation elicited | 2 |
| Urinary incontinence and lateral tongue biting confirmed — key seizure features | 2 |
| Cyanosis during event noted — distinguishes from pseudoseizure | 1 |
| Post-ictal | |
| Post-ictal confusion duration, headache, Todd's paresis screened | 1 |
| Differentials and Precipitants | |
| Key differentials considered — syncope, hypoglycaemia (BM checked), pseudoseizure | 1 |
| Precipitants screened — sleep deprivation, alcohol, drugs, threshold-lowering medications | 2 |
| Social Implications | |
| DVLA advice given — must not drive, must inform DVLA, 6 months seizure-free minimum | 2 |
| Work and safety advice — avoid heights, machinery, swimming alone, baths | 1 |
| Documents that DVLA advice was given | 1 |
| Empathic, clear communication throughout — addresses patient's concern and confusion | 1 |
| Total | 20 |
A 12-year-old boy is referred to ED by his GP with a 3-week history of left hip and groin pain and a limp. He is overweight. He has been playing less sport recently. He is otherwise well with no fever.
Please perform a focused hip examination. The examiner will provide findings. Present your diagnosis and management plan.
⚠️ Examiner Instructions — Not for Candidate
Findings represent left SUFE (Slipped Upper Femoral Epiphysis). Feed findings as candidate examines. If candidate diagnoses Perthes, ask: "This boy is 12 and obese — does that change your differential?" If candidate does not check for bilateral involvement, prompt: "Is there anything about the other hip you'd want to check?"
| Criterion | Marks |
|---|---|
| Observation and Gait | |
| Gait assessed — antalgic and Trendelenburg gait identified on left | 2 |
| Notes left leg held in external rotation at rest | 1 |
| Specific Tests | |
| Trendelenburg test performed correctly — positive left | 2 |
| True and apparent leg lengths measured bilaterally | 1 |
| Range of Movement | |
| Internal and external rotation assessed — restricted internal rotation left identified | 2 |
| Drehmann sign tested — positive (obligatory external rotation on flexion) | 2 |
| Thomas test performed — fixed flexion deformity left noted | 1 |
| Neurovascular and Imaging | |
| Distal neurovascular status checked — pulses, sensation, CRT | 1 |
| AP pelvis and frog-leg lateral XR requested — Klein's line interpretation stated | 2 |
| Diagnosis and Management | |
| Correct diagnosis — SUFE. Differentiates from Perthes using age, body habitus, Drehmann sign. | 2 |
| Management — non-weight-bearing, urgent orthopaedic referral (same day), surgical fixation (in situ screw), check right hip (bilateral in 20–40%) | 1 |
| States SUFE is a surgical emergency — weight-bearing risks further slip and AVN | 1 |
| Total | 20 |
A 45-year-old male painter and decorator presents with a 6-week history of right shoulder pain, worse on overhead activity, and difficulty reaching behind his back. No acute trauma. No neck symptoms.
Please perform a focused right shoulder examination. The examiner will provide findings as you examine. Present your diagnosis and management plan.
⚠️ Examiner Instructions — Not for Candidate
Findings represent supraspinatus impingement syndrome with probable partial-thickness tear. Feed findings progressively. If candidate does not screen the cervical spine, prompt: "Is there anything else you'd want to exclude as a cause of shoulder pain?" If candidate omits neurovascular assessment, prompt at the end.
| Criterion | Marks |
|---|---|
| Look | |
| Inspects from front, side and behind — supraspinatus wasting and no deformity noted | 1 |
| Feel | |
| Systematic palpation — ACJ, bicipital groove, greater tuberosity, subacromial space | 2 |
| Move | |
| Active and passive ROM assessed — painful arc 70–110° identified on active abduction | 2 |
| States painful arc significance — supraspinatus impingement in subacromial space | 1 |
| Special Tests | |
| Hawkins-Kennedy performed correctly — positive | 2 |
| Empty can (Jobe) performed correctly — positive (supraspinatus) | 2 |
| Lift-off test performed — negative (subscapularis intact) | 1 |
| Drop arm test performed — negative (no full-thickness tear) | 1 |
| Cervical Spine and Neurovascular | |
| Cervical spine screened — Spurling's negative, referred pain excluded | 1 |
| Axillary nerve sensation (regimental badge area) checked | 1 |
| Diagnosis and Management | |
| Correct diagnosis — supraspinatus impingement with probable partial tear. Biceps tendinopathy also present. | 2 |
| Management — analgesia (NSAIDs), physiotherapy, subacromial steroid injection, USS/MRI shoulder, orthopaedic/MSK referral if fails conservative | 1 |
| Occupational advice — occupational health referral, modified duties while recovering | 1 |
| Total | 20 |
A 65-year-old man presents with an acutely hot, swollen, painful right knee. He is unable to weight-bear. He has a history of gout but this feels different to him — he has a fever of 38.6°C.
Obs: HR 102, BP 128/78, Temp 38.6°C, WBC 18.4 × 10⁹/L, CRP 186 mg/L.
Please talk through how you would perform a knee joint aspiration, including your indications, technique, and what you would do with the aspirated fluid. You have 8 minutes.
⚠️ Examiner Instructions — Not for Candidate
Ask: "The aspirated fluid is thick, yellow-white and turbid — what does this suggest and what is your immediate next step?" (Expected: highly suspicious of septic arthritis — send MC&S immediately, start IV antibiotics without waiting for result, urgent orthopaedic referral for washout.) Also ask: "Would you inject corticosteroid into this joint?" (Expected: No — absolute contraindication if septic arthritis suspected.)
| Criterion | Marks |
|---|---|
| Indications and Contraindications | |
| Indications stated — diagnostic (septic arthritis vs gout) and therapeutic | 1 |
| Overlying infection as absolute contraindication — specifically asks about skin before proceeding | 2 |
| Prosthetic joint — orthopaedic team required, not routine ED aspiration | 1 |
| Technique | |
| Correct landmark — superolateral approach (1cm above and lateral to superior patella pole) | 2 |
| Full aseptic technique — chlorhexidine prep, sterile gloves, ANTT, no-touch of needle | 2 |
| Appropriate equipment selected — 21G needle, adequate syringe, specimen pots | 1 |
| Fluid Analysis | |
| MC&S (sterile pot), crystal microscopy, glucose and LDH — all three investigations named | 2 |
| Interprets turbid yellow-white fluid correctly — suspicion for septic arthritis | 2 |
| Correctly refuses steroid injection if septic arthritis suspected | 2 |
| Management and Complications | |
| Aspiration does not delay antibiotics — states start IV flucloxacillin/vancomycin immediately | 2 |
| Complications named — iatrogenic infection, haemarthrosis, vasovagal | 1 |
| Orthopaedic referral for washout stated | 1 |
| Total | 20 |
A 70-year-old woman presents after a fall onto her outstretched right hand (FOOSH). XR confirms an undisplaced distal radius fracture (Colles type). Neurovascular status is intact. Hock plastered orthopaedic team have reviewed and request you apply a dorsal backslab plaster of Paris for temporary immobilisation.
Please talk through the procedure and demonstrate on the manikin arm. You have 8 minutes.
⚠️ Examiner Instructions — Not for Candidate
Ask: "24 hours later the patient returns with severe pain, her fingers are swollen and she cannot move them — what do you suspect?" (Expected: Cast too tight / compartment syndrome — bivalve the cast immediately, elevate, reassess neurovascular status, urgent orthopaedic review.) Also ask: "Why backslab rather than full cast acutely?" (Expected: allows for post-injury swelling, prevents compartment syndrome.)
| Criterion | Marks |
|---|---|
| Pre-procedure | |
| Neurovascular status checked before application — radial pulse, sensation, CRT, finger movement | 2 |
| Correctly chooses backslab over full cast — explains swelling risk | 1 |
| Position | |
| Correct wrist position — 10° dorsiflexion and 5–10° ulnar deviation stated and demonstrated | 2 |
| Explains rationale — counters Colles deformity (dorsal angulation, radial deviation) | 1 |
| Application Technique | |
| Correct order — stockinette, wool/padding (with extra over bony prominences), POP slabs, bandage | 3 |
| Dorsal application — MCPJs to below elbow, thumb free, 6–8 POP layers | 1 |
| Smooths and moulds plaster evenly — no ridges or pressure points created | 1 |
| Post-procedure | |
| Neurovascular status re-checked after application — documented | 2 |
| Patient instructions given — elevation, finger movement, warning signs for urgent return | 2 |
| Compartment syndrome scenario managed correctly — bivalve immediately | 2 |
| Fracture clinic referral and definitive management plan stated | 1 |
| Total | 20 |
You are the ED doctor. Mrs Sofia Andrade, 34 years old, attends with facial bruising and a split lip. She says she "walked into a door." You note the injuries are inconsistent with this mechanism. Her partner is in the waiting room.
During your consultation, seen alone, she discloses that her partner hits her. She asks you: "Please don't tell anyone — he'll know I talked."
Please respond to Mrs Andrade's disclosure and manage this situation. You have 8 minutes.
⚠️ Examiner / Role-player Instructions — Not for Candidate
You are Mrs Sofia Andrade. You are frightened but willing to talk if the candidate is kind and non-judgemental. You have two young children at home (aged 4 and 7). Your partner has threatened you with a knife on one occasion. You are not ready to leave him but want to know your options. Escalate distress if candidate is dismissive or promises complete confidentiality.
| Criterion | Marks |
|---|---|
| Initial Response | |
| Validates disclosure — thanks patient, acknowledges bravery, does not minimise | 2 |
| Ensures privacy — confirms partner is not present, offers interpreter if needed | 1 |
| Risk Assessment | |
| DASH high-risk indicators asked — escalating violence, weapon use (knife threat identified) | 2 |
| Children in household asked — safeguarding dimension identified | 2 |
| Confidentiality | |
| Explains confidentiality honestly — cannot promise complete confidentiality if risk to life or children | 2 |
| Does NOT promise complete confidentiality — would be incorrect and dangerous | 1 |
| Safety Planning and Referral | |
| Safety planning offered — safe place, emergency bag, trusted contact, code word | 2 |
| National DVA helpline number provided (0808 2000 247) | 1 |
| IDVA referral offered and explained | 1 |
| MARAC threshold identified — knife threat + escalation = high risk, referral appropriate | 1 |
| Documentation | |
| Documents injuries accurately with body map, photographs with consent, patient's exact words in quotes, inconsistency noted | 2 |
| Non-confrontational, empathic, non-judgemental throughout. Does not pressure to leave. | 1 |
| Total | 20 |
You are the ED doctor. Mr Thomas Reilly, 29 years old, has been brought to ED by a friend after posting concerning messages on social media suggesting he did not want to be alive. He is alert and cooperative. He denies any overdose or self-harm today.
He is not acutely psychotic. He has a background of depression. He is not currently under CMHT but is on sertraline prescribed by his GP.
Please conduct a structured suicide risk assessment and develop a safety plan with Mr Reilly. You have 8 minutes.
⚠️ Examiner / Role-player Instructions — Not for Candidate
You are Mr Thomas Reilly. You are quiet and withdrawn but cooperative. You have passive ideation — "I just don't see the point any more... I don't want to be here." But no active plan or intent today — "I wouldn't actually do anything." Recent relationship breakdown 2 weeks ago. One previous overdose at age 22 (paracetamol, minor). Has a full bottle of sertraline at home. No alcohol today. Ambivalent about the future — mentions his dog as something that keeps him going.
| Criterion | Marks |
|---|---|
| Rapport and Approach | |
| Introduces self, establishes rapport before asking about suicidality — non-judgemental and warm | 1 |
| Asks directly but sensitively about ideation — does not avoid the topic | 1 |
| Risk Assessment | |
| Ideation characterised correctly — passive (no active plan or intent) identified | 2 |
| Previous attempt elicited — paracetamol overdose age 22, method and lethality explored | 2 |
| Precipitants identified — relationship breakdown, job loss | 1 |
| Protective factors identified — dog, sister, ambivalence | 2 |
| Means Restriction | |
| Access to means asked — full sertraline bottle at home identified | 2 |
| Means restriction arranged — asks patient/sister to remove or secure medication | 2 |
| Safety Planning | |
| Collaborative safety plan developed with patient — warning signs, coping strategies, support contacts, crisis line | 2 |
| Samaritans (116 123) or equivalent crisis line provided | 1 |
| Disposition | |
| Appropriate disposition — CRHT assessment, CMHT urgent referral, GP letter. Explains to patient clearly. | 2 |
| Does not discharge without safety plan, crisis contact and follow-up arranged | 1 |
| Empathic, non-judgemental and collaborative throughout | 1 |
| Total | 20 |
The examiner will read you descriptions of three X-rays in sequence. For each one, give a systematic interpretation using ABCS, state your diagnosis, and describe immediate management and key pitfalls. You have 8 minutes for all three.
⚠️ Examiner Instructions — Not for Candidate
Read the three XR descriptions below in sequence, pausing after each to allow candidate to respond. Time approximately 2.5 minutes per XR. After XR 2 (scaphoid), specifically ask: "The XR looks entirely normal to you — what do you do?" After XR 3 (Toddler's fracture), ask: "The parent's story is that the child tripped on a rug — is this mechanism consistent with the injury?"
| Criterion | Marks |
|---|---|
| XR 1 — Colles Fracture | |
| Systematic ABCS approach stated before describing findings | 1 |
| Distal radius fracture, dorsal angulation, ulnar styloid fracture — all identified | 2 |
| Management — backslab, orthopaedic review. Median nerve complication named. | 1 |
| XR 2 — Scaphoid Fracture | |
| Normal XR with clinical suspicion — does NOT discharge. States treat as scaphoid fracture. | 2 |
| Early MRI or CT recommended as gold standard / repeat XR at 10–14 days acceptable | 1 |
| AVN of proximal fragment as consequence of missed diagnosis — explains blood supply | 2 |
| Thumb spica / scaphoid cast applied and orthopaedic review arranged | 1 |
| XR 3 — Toddler's Fracture and NAI | |
| Identifies subtle spiral tibial fracture — Toddler's fracture in ambulatory child | 2 |
| Mechanism assessment — trip on rug at 18 months is plausible for ambulatory toddler. Mechanism consistent. | 1 |
| NAI consideration raised — spiral tibial fracture in non-ambulant infant = high concern. Here — 18 months, ambulatory = lower concern but still document. | 2 |
| Management — below-knee cast, non-weight-bearing, paediatric orthopedics, safeguarding documented | 2 |
| States key principle — if history inconsistent with injury, escalate safeguarding regardless | 1 |
| Total | 20 |
An 8-year-old girl with known Type 1 diabetes is brought in by her parents. She has been vomiting for 12 hours, has abdominal pain, and is increasingly drowsy. Weight is 28 kg.
Obs: HR 134, BP 88/54, RR 32 (Kussmaul), SpO₂ 97%, GCS 12 (E3V4M5), Temp 37.8°C.
Results: pH 7.11, HCO₃⁻ 7 mmol/L, glucose 24 mmol/L, ketones 4.8 mmol/L (blood), Na⁺ 131 mmol/L, K⁺ 4.1 mmol/L.
Please interpret these results and describe your management using the appropriate paediatric protocol. You have 8 minutes.
⚠️ Examiner Instructions — Not for Candidate
Ask: "A junior colleague suggests starting insulin at 0.1 units/kg/hr as they've read the adult DKA guideline — what do you say?" (Expected: paediatric DKA uses 0.05 units/kg/hr — BSPED protocol, NOT adult JBDS. 0.1 units/kg/hr risks hypoglycaemia and cerebral oedema.) Also ask: "30 minutes after starting treatment, the nurse tells you the child has developed a headache and her GCS has dropped to 10 — what do you do?" (Expected: cerebral oedema — hypertonic saline or mannitol immediately, restrict fluids, PICU, do not wait for CT.)
| Criterion | Marks |
|---|---|
| Data Interpretation | |
| Correctly identifies DKA — hyperglycaemia + ketosis + acidosis (all three) | 2 |
| Severity classified as moderate (pH 7.11, HCO₃ 7) per BSPED — but states clinical picture (GCS 12, haemodynamic instability) makes this severe in behaviour | 2 |
| Correctly names BSPED paediatric protocol — NOT adult JBDS | 1 |
| Fluid Management | |
| Fluid bolus only if shocked — 10 ml/kg 0.9% saline — patient is haemodynamically compromised, states bolus appropriate here | 2 |
| Deficit replacement over 48 hours (NOT 24 hours). Correct fluid used — 0.9% NaCl with glucose added when BG <14. | 2 |
| Avoids large up-front fluid bolus — states risk of cerebral oedema | 1 |
| Insulin | |
| Insulin 0.05 units/kg/hr — specifically states NOT 0.1 units/kg/hr. Rejects junior's suggestion. | 2 |
| Insulin started after initial fluid — not simultaneously or before | 1 |
| Cerebral Oedema | |
| Cerebral oedema identified from scenario — falling GCS + headache after treatment started | 2 |
| Immediate treatment — hypertonic saline or mannitol. Restrict fluids. PICU call. Does not wait for CT. | 2 |
| PICU and Monitoring | |
| PICU referral criteria identified — GCS 12 qualifies. States referral required. | 1 |
| Monitoring stated — hourly BM, 2-hourly gas, 4-hourly electrolytes, target BG fall 3–5 mmol/hr | 1 |
| Potassium management — add KCl to fluids, monitor ECG, do not give if K⁺ >5.5 | 1 |
| Total | 20 |