10 new structured stations — ACS risk stratification, eating disorders, hernia and testicular torsion, AED defibrillation, DAS failed intubation, DNACPR, SBAR handover, blood film and FAST scan interpretation.
You are the ED doctor. Mr Hassan Malik, 61 years old, presents with a 90-minute history of central crushing chest pain radiating to the left arm. He is diaphoretic and pale.
Triage obs: HR 96, BP 154/92, RR 20, SpO₂ 96% on air, Temp 36.9°C. 12-lead ECG has been performed — the nurse tells you it shows ST depression in leads V4–V6 and lateral leads.
Please take a focused chest pain history, calculate a HEART score, and explain your management plan to Mr Malik. You have 8 minutes.
⚠️ Examiner / Role-player Instructions — Not for Candidate
You are Mr Hassan Malik. You are frightened. You have hypertension (on amlodipine), type 2 diabetes (on metformin), and you smoke 10 cigarettes/day. Your father died of a heart attack aged 58. You had a PTCA (stent) in 2018 for angina. You are on aspirin 75mg daily but have NOT had GTN in the last year. No sildenafil. ECG as described. This is an NSTEMI. HEART score = History 2 + ECG 1 + Age 1 + Risk 2 (previous atherosclerotic disease) + Troponin TBD = at least 6 without troponin = high risk.
| Criterion | Marks |
|---|---|
| SOCRATES | |
| Full SOCRATES elicited — character (crushing), radiation (left arm/jaw), associated features (diaphoresis, nausea), severity, onset, relieving factors | 2 |
| GTN use asked — prior use and effectiveness | 1 |
| HEART Score | |
| HEART score components named and applied — History, ECG, Age, Risk factors, Troponin | 2 |
| Correctly calculates score ≥6 (high risk) from available data: History 2, ECG 1, Age 1, Risk factors 2 (previous atherosclerotic disease) | 2 |
| Risk Factors | |
| Risk factors elicited — hypertension, DM, smoking, family history, previous stent (2018) — all identified | 2 |
| PDE5 inhibitors asked before planning nitrates | 1 |
| Differentials | |
| Aortic dissection excluded — no interscapular radiation, no BP differential, no tearing character | 2 |
| STEMI vs NSTEMI vs UA differentiated — states this patient NSTEMI (ST depression, awaiting troponin, no ST elevation) | 1 |
| Management | |
| Aspirin 300mg + ticagrelor 180mg loading — dual antiplatelet stated | 2 |
| Serial hs-troponin, serial ECG, IV access, analgesia, anticoagulation (LMWH/fondaparinux) planned | 1 |
| Cardiology referral — urgent (GRACE >140 or high HEART = catheterisation within 24h) | 1 |
| Empathic response to patient's fear — addresses concern about heart attack sensitively | 1 |
| Total | 20 |
You are the ED doctor. Miss Charlotte Webb, 17 years old, has been brought to ED by her mother, who is worried about significant weight loss over the past 6 months. Charlotte was previously a healthy weight. Her current BMI is 15.2 kg/m².
Obs: HR 52, BP 96/60 (postural drop 18mmHg on standing), RR 14, Temp 35.9°C, BM 3.6 mmol/L. She is alert, thin, and appears cold.
Charlotte's mother has stepped out of the room. Please take a focused history from Charlotte and outline your immediate assessment and management plan. You have 8 minutes.
⚠️ Examiner / Role-player Instructions — Not for Candidate
You are Miss Charlotte Webb. You are quiet, guarded and slightly defensive at the start. You do not think you have a problem — "I'm just eating healthily." You will open up if the candidate is warm, non-judgmental, and asks open questions. You are frightened of gaining weight. You have not had a period for 4 months. You do not vomit but do excessive exercise (2 hours/day minimum). You score 4/5 on SCOFF. Escalate distress if candidate focuses on weight numbers or uses alarming language.
| Criterion | Marks |
|---|---|
| Approach and Communication | |
| Non-judgmental, compassionate opening — uses open questions; does not use weight-focused or triggering language throughout | 2 |
| Eating and Compensatory Behaviour History | |
| Dietary restriction explored — food rules, calorie counting, avoidance of food groups | 2 |
| Compensatory behaviours explored — purging, laxatives, excessive compulsive exercise (identified here) | 2 |
| Body image distortion explored — feels fat despite low BMI, frequent weighing | 1 |
| Physical and Psychiatric Screening | |
| Weight history and rate of loss, amenorrhoea (4 months) elicited | 2 |
| Physical symptoms — dizziness, palpitations, cold intolerance, syncope asked | 1 |
| SCOFF questionnaire applied — score 4/5 obtained; ≥2 = possible eating disorder confirmed | 2 |
| Risk Assessment | |
| Medical investigations — electrolytes (hypokalaemia risk), ECG (QTc), blood glucose, FBC; identifies BM 3.6 and bradycardia 52 as concerning | 2 |
| Physical signs mentioned — lanugo, Russell's sign, dental erosion, parotid swelling | 1 |
| Management and Safeguarding | |
| MARSIPAN admission criteria identified — bradycardia, postural drop, hypothermia, low BMI; states admission required | 2 |
| CAMHS referral, Gillick competence considered, parent involvement discussed sensitively with Charlotte | 1 |
| Total | 20 |
You are the ED doctor. Mr George Patel, 72 years old, presents with a right groin lump that has been present for 3 months. He notices it appears when he stands and disappears when he lies down. He has occasional discomfort on straining. No pain at rest, no vomiting, no change in bowel habit.
Obs: Afebrile, HR 72, BP 134/80. Comfortable at rest. A reducible right groin lump is visible when standing.
Please perform a focused groin/hernia examination. The examiner will provide findings. Present your diagnosis and management plan.
⚠️ Examiner Instructions — Not for Candidate
Feed these findings: Right groin lump above and medial to the right pubic tubercle. Cough impulse present. Reducible when supine. Percussion: tympanic. Auscultation: bowel sounds present. Transillumination: negative. Deep ring occlusion test: controls hernia — indirect inguinal hernia. No tenderness, no erythema, no strangulation features. Left groin — no lump, no cough impulse. If candidate doesn't perform deep ring occlusion test: "How would you distinguish a direct from an indirect inguinal hernia on examination?"
| Criterion | Marks |
|---|---|
| Inspection | |
| Examination performed with patient standing — lump inspected, location relative to pubic tubercle identified | 2 |
| Cough impulse assessed; descent into scrotum noted | 1 |
| Palpation and Reducibility | |
| Reducibility tested — patient supine, hernia reduced manually | 1 |
| Deep ring occlusion test performed — distinguishes indirect from direct inguinal hernia | 2 |
| Percussion (tympanic = bowel) and auscultation (bowel sounds) over hernia | 1 |
| Transillumination — negative (distinguishes from hydrocele) | 1 |
| Completeness | |
| Contralateral groin examined | 1 |
| Femoral hernia specifically assessed — below and lateral to pubic tubercle | 2 |
| Strangulation signs assessed — tender, irreducible, erythema; states strangulation = surgical emergency, do not reduce | 2 |
| Diagnosis and Management | |
| Correct diagnosis — right indirect inguinal hernia, reducible, no strangulation | 2 |
| Management — elective surgical repair (Lichtenstein mesh or laparoscopic); femoral hernia = all require repair due to strangulation risk | 2 |
| Clear, structured examination with patient explanation | 1 |
| Total | 20 |
You are the ED doctor. Mr Liam O'Brien, 16 years old, presents with a 3-hour history of sudden onset severe right scrotal pain that woke him from sleep. He feels nauseated. No urinary symptoms, no fever, no recent sexual activity.
Obs: HR 108 (pain), Temp 37.0°C, BP 122/76. Right scrotal swelling and redness visible. He is clearly in pain.
Please perform a focused scrotal examination. The examiner will provide findings. Present your immediate management plan.
⚠️ Examiner Instructions — Not for Candidate
Feed these findings: Right testis high-riding, horizontal lie, diffusely tender, erythematous scrotum. Cannot identify posterior epididymis separately. Cremasteric reflex: ABSENT right. Transillumination: negative. Left testis: normal position and tenderness, horizontal lie noted (Bell clapper bilateral). Prehn's sign: if candidate performs — pain not relieved. If candidate requests Doppler USS before surgical referral: "Theatre is available now — will you wait for Doppler USS first?"
| Criterion | Marks |
|---|---|
| Inspection | |
| Inspection — high-riding testis and horizontal lie identified; erythema, swelling noted | 2 |
| Palpation | |
| Diffuse testicular tenderness identified; loss of posterior groove; distinguishes from posterior epididymal-only tenderness of epididymo-orchitis | 2 |
| Cremasteric reflex absent — correctly elicited and identified as significant positive finding for torsion | 2 |
| Transillumination negative; contralateral testis examined — Bell clapper deformity bilateral noted | 1 |
| Prehn's sign — candidate knows the test, explicitly states it is unreliable and must NOT be used to exclude torsion | 2 |
| Diagnosis and Safety | |
| Testicular torsion diagnosed as working diagnosis — states surgical emergency | 2 |
| Does NOT request Doppler USS before surgical referral — delay risks testis | 2 |
| 6-hour salvage window stated — current 3-hour history = urgent | 1 |
| Management and Communication | |
| NBM, IV access, analgesia, urology called urgently for emergency exploration | 2 |
| Consent — patient (16, Gillick competent) and parents involved; exploration ± bilateral orchidopexy ± orchiectomy explained | 2 |
| Total | 20 |
You are walking through the ED waiting room when a 56-year-old man collapses in front of you. He was waiting to be seen for chest pain. He is now on the floor and unresponsive. An AED is mounted on the wall 3 metres away. A nurse and a healthcare assistant are nearby.
Please manage this witnessed cardiac arrest, demonstrate BLS and correct AED use on the manikin, and verbalise all your actions. The examiner will play the roles of the nurse and healthcare assistant.
⚠️ Examiner Instructions — Not for Candidate
Manikin on the floor. AED available. Initial rhythm: VF (shockable). After first shock + 2 minutes CPR: AED advises second shock — patient still in VF. After second shock + 2 minutes CPR: crash team arrives. The nurse (examiner) will say "I've called the crash team — what do you want me to do?" Assign her to start CPR if candidate is solo. Check key safety moments: does candidate check for pacemaker/patches before pad placement? Do they stand clear and do a visual sweep before shocking? Do they restart CPR immediately after shock without pulse check?
| Criterion | Marks |
|---|---|
| BLS Initiation | |
| Scene safety checked; patient stimulated (shout + shake); unresponsive confirmed | 1 |
| Help called — crash team activated, AED retrieved simultaneously; CPR started without delay | 2 |
| Airway opened — head tilt/chin lift; no breathing confirmed ≤10 seconds (agonal gasps recognised as arrest) | 1 |
| CPR Quality | |
| CPR rate 100–120/min, depth 5–6cm, full recoil, 30:2 ratio | 2 |
| Interruptions minimised — pauses <5 seconds; does not stop for pulse check post-shock | 2 |
| AED Use | |
| Pads correctly placed — right clavicle and left axilla; checks for pacemaker, patches, wet chest before application | 2 |
| Stand clear for analysis — visual sweep of team performed; shock delivered safely | 2 |
| CPR resumed immediately post-shock — no pulse check | 2 |
| Knowledge | |
| Shockable (VF/pVT) vs non-shockable (PEA/asystole) — correct management for each arm described | 2 |
| ALS transition — handover, 4Hs and 4Ts, adrenaline timing, amiodarone after 3rd shock | 2 |
| Total | 20 |
You are the ED consultant managing a 35-year-old male trauma patient requiring emergency RSI for a GCS of 7 following a road traffic collision. RSI drugs have been given. Your first direct laryngoscopy attempt reveals a Cormack-Lehane grade 3 view. SpO₂ is falling — now 86%.
Obs: SpO₂ 86% and falling, HR 118, BP 96/58. Patient is paralysed and apnoeic. A videolaryngoscope, LMA, and surgical airway kit are available.
Please manage this failed intubation scenario following the DAS 2015 difficult airway guidelines. Verbalise every decision. The examiner will act as your assistant. You have 8 minutes.
⚠️ Examiner Instructions — Not for Candidate
Feed real-time SpO₂ to create pressure. After candidate's Plan A 2nd attempt fails: "SpO₂ now 80%, dropping fast." After Plan B attempt (SGA): "i-gel inserted — SpO₂ recovering to 94%." If candidate tries more than 3+1 attempts at laryngoscopy: "Your 4th attempt — is that within the DAS guidelines?" If candidate moves directly to surgical airway without Plan B/C: "What does the DAS algorithm say about the order of plans?"
| Criterion | Marks |
|---|---|
| Plan A | |
| Failed intubation declared verbally after maximum 3 + 1 rescue attempts — no further laryngoscopy | 2 |
| Help called early — at Plan A failure, not at Plan D crisis | 1 |
| Optimisation attempted between attempts — VL, bougie, different blade, BURP, head position change | 2 |
| Plans B and C | |
| Plan B declared — second-generation SGA inserted (i-gel/ProSeal), SpO₂ recovery prioritised | 2 |
| Plan C — face mask, 2-person technique, OPA/NPA adjuncts if SGA fails | 2 |
| Considers waking patient — explicitly states "wake if possible unless CICO" | 2 |
| Plan D and Algorithm | |
| Plan D correctly described — CICO → scalpel-finger-bougie cricothyroidotomy; DAS 2015 algorithm named | 2 |
| Oxygenation prioritised over intubation stated at every decision point | 2 |
| Communication and Documentation | |
| Clear verbal declarations at each plan transition — team informed | 2 |
| Waveform capnography for confirmation at each successful airway placement | 1 |
| Post-event documentation, difficult airway alert card for patient, GP letter stated | 2 |
| Total | 20 |
You are the ED registrar. Mr Ernest Shaw, 84 years old, has been admitted with an acute exacerbation of his severe COPD — his fourth admission in six months. He has significant comorbidities: ischaemic heart disease, type 2 DM, moderate dementia, and NYHA class III heart failure. During this admission, Mr Shaw, who has capacity for this decision, agreed to a DNACPR order being completed with him. This is documented in his notes.
His son, Mr David Shaw, has just arrived. He is visibly upset and is demanding the DNACPR form be removed. He says: "You're giving up on my father. Remove that form right now. If his heart stops, I want everything done."
Please speak with Mr David Shaw. You have 8 minutes.
⚠️ Examiner / Role-player Instructions — Not for Candidate
You are Mr David Shaw. You are genuinely distressed — not aggressive for no reason. You feel helpless and afraid your father is going to die tonight. You have driven 3 hours to get here. You soften if the candidate sits down, acknowledges your feelings, and listens before explaining. You harden if the candidate is dismissive, clinical, or seems rushed. Key lines: "He's not ready to die. He's still got life in him." / "You don't know him like I do." / "If you don't try, I'll make a complaint." Soften completely if candidate explains DNACPR ≠ withdrawal of treatment, and that the patient himself agreed.
| Criterion | Marks |
|---|---|
| Approach and Rapport | |
| Welcomes son, sits down, acknowledges his distress empathically before explaining — listens first | 2 |
| Explores son's concerns — asks "What are you most worried about?" rather than immediately defending the decision | 2 |
| Explaining DNACPR | |
| DNACPR is a medical decision — not overridable by family; son cannot demand CPR | 2 |
| DNACPR does NOT mean withdrawal of all treatment — clearly explains what continues (antibiotics, nebulisers, fluids, symptom control) | 2 |
| CPR futility and harm explained in plain language — low chance of ROSC, rib fractures, no meaningful recovery likely | 2 |
| Explains patient has capacity and agreed to DNACPR — his autonomous decision must be respected | 2 |
| Management of Conflict | |
| Does NOT remove DNACPR under family pressure — maintains position calmly | 2 |
| Non-defensive, non-aggressive throughout — does not become dismissive or lecture son | 2 |
| Support and Escalation | |
| Palliative care team and chaplaincy offered; consultant involvement offered if conflict unresolved | 2 |
| Documents conversation; offers follow-up family meeting with more time | 2 |
| Total | 20 |
You are the ED registrar. Mrs Priya Nair, 58 years old, was admitted 2 hours ago with severe community-acquired pneumonia. Despite your management — 3L IV fluid, IV co-amoxiclav and clarithromycin, 15L O₂ via non-rebreathe mask — she is deteriorating.
Current obs: HR 128, BP 82/44 (MAP 57), RR 34, SpO₂ 87% on 15L O₂, GCS 13 (E3V4M6), Temp 39.2°C. Lactate 4.8 mmol/L. CXR — bilateral consolidation. NEWS score 18. Vasopressors not yet started.
You are calling the ITU registrar to request urgent review and ITU admission. The examiner will play the ITU registrar. Please give a structured SBAR handover. You have 8 minutes.
⚠️ Examiner / Role-player Instructions — Not for Candidate
You are the ITU registrar. You are busy but not hostile. After the handover, ask these three challenge questions: (1) "What was her lactate?" (Expected: 4.8 mmol/L — if candidate didn't include it, they should know it). (2) "When did antibiotics go in?" (Expected: within 1 hour of presentation — candidate should know exact time). (3) "Is the family aware of how serious this is?" (Expected: yes/no — candidate should state what has or hasn't been communicated to family). If the handover is structured and clear, say: "I'll be there in 3 minutes." If it's disorganised, ask: "Can you start again using SBAR — Situation, Background, Assessment, Recommendation?"
| Criterion | Marks |
|---|---|
| Situation | |
| Self-introduction, patient name/age, location, reason for call stated concisely in opening | 2 |
| Background | |
| Admission story, relevant PMH, CXR findings, key bloods, antibiotic timing stated | 2 |
| Assessment | |
| Current observations stated — HR, BP, MAP, SpO₂, RR, GCS, Temp, NEWS 18 | 2 |
| Diagnosis stated — severe sepsis / septic shock (MAP <65 despite fluid); trajectory — deteriorating | 2 |
| Recommendation | |
| Specific recommendation — urgent ITU review and admission; vasopressors, intubation, central access, arterial line anticipated | 2 |
| States urgency clearly — "I need you to come now" | 1 |
| Challenge Questions | |
| Lactate 4.8 mmol/L stated correctly when challenged | 2 |
| Antibiotic timing answered correctly — within 1 hour of presentation | 2 |
| Family awareness addressed — states whether family has been informed and if not, that this should happen urgently | 2 |
| Delivery | |
| Structured, confident, concise — not reading verbatim; uses SBAR framework correctly | 1 |
| Total | 20 |
This is a two-part data interpretation station. The examiner will describe two blood film findings from two different patients. For each, state your diagnosis, the key film findings, and your immediate management.
Part 1: A 28-year-old Afro-Caribbean man presents with severe bilateral leg and lower back pain and increasing breathlessness. He is known to have sickle cell disease. Hb 68 g/L, WBC 18, platelets 420.
Part 2: A 32-year-old woman returns from 3 weeks in West Africa with a 5-day history of fever, rigors and headache. Hb 94, WBC 6, platelets 72. Parasitaemia 4%.
The examiner will describe the blood film for each. You have 8 minutes total for both parts.
⚠️ Examiner Instructions — Not for Candidate
Part 1 — read aloud: "Blood film shows sickle cells, target cells, and Howell-Jolly bodies. Reticulocytes elevated." Then ask: "He is now SpO₂ 88% on air with new bilateral crackles — what complication do you suspect and when would you exchange transfuse?" Part 2 — read aloud: "Thin film shows small ring-form trophozoites with double chromatin dots, some appliqué forms, multiple rings within single RBCs, and banana-shaped gametocytes." Then ask: "What is the treatment, and is this a notifiable disease?"
| Criterion | Marks |
|---|---|
| Part 1 — Sickle Cell Film | |
| Sickle cells, target cells, and Howell-Jolly bodies all correctly identified | 2 |
| Howell-Jolly bodies explained — functional asplenia; encapsulated organism infection risk stated | 2 |
| Acute chest syndrome suspected from SpO₂ 88% + bilateral crackles — mechanism explained | 2 |
| ACS management: O₂, analgesia, IV antibiotics (co-amoxiclav + azithromycin), haematology, careful fluids | 2 |
| Exchange transfusion indication — SpO₂ <95% on O₂ or rapid deterioration; target HbS <30% | 2 |
| Part 2 — Malaria Film | |
| Ring-form trophozoites, double chromatin dots, appliqué forms, banana-shaped gametocytes identified — P. falciparum confirmed | 2 |
| Parasitaemia 4% + thrombocytopenia + clinical picture — severe malaria criteria assessed | 2 |
| IV artesunate named as first-line treatment in UK — quinine correctly identified as second-line only | 2 |
| Malaria declared as statutory notifiable disease — PHE / local HPT notification stated | 2 |
| Supportive management — glucose monitoring, haematology/ID referral, ITU if severe criteria | 2 |
| Total | 20 |
You are the trauma team leader. Mr Callum Fraser, 35 years old, arrives by ambulance following a high-speed motorcycle collision. He was wearing a helmet but has significant abdominal bruising from the handlebars. GCS 14.
Primary survey: Airway patent. RR 28, bilateral air entry. HR 132, BP 84/50, Cap refill 4 seconds. GCS 14 (E3V5M6), pupils equal and reactive. Temp 35.8°C.
A FAST scan has been performed. The examiner will describe each window in sequence. Please interpret the findings, state your diagnosis, and give your immediate management. You have 8 minutes.
⚠️ Examiner Instructions — Not for Candidate
Describe FAST findings window by window: (1) "Morrison's pouch — I can see a large anechoic stripe between the liver and right kidney." (2) "Splenorenal — anechoic stripe present on the left." (3) "Pericardial window — no pericardial effusion, heart contracting well." (4) "Pelvic — anechoic free fluid posterior to bladder." Then ask: (a) "He's now BP 78/44 — your SHO suggests taking him for CT — what do you say?" (b) "What blood product ratio are you requesting from the blood bank?" (c) "Is there a time limit for TXA?"
| Criterion | Marks |
|---|---|
| FAST Interpretation | |
| Each of the 4 FAST windows correctly interpreted — Morrison's (positive), splenorenal (positive), pericardial (negative — no tamponade), pelvic (positive) | 4 |
| Synthesis: 3 of 4 abdominal windows positive = significant haemoperitoneum correctly stated | 2 |
| Clinical Decision | |
| Haemodynamically unstable + positive FAST = immediate operative intervention — NOT CT scan | 2 |
| ATLS principle stated — "unstable to theatre, stable to scanner" | 1 |
| Trauma surgery called immediately for emergency laparotomy | 1 |
| Damage Control Resuscitation | |
| Major haemorrhage protocol activated — 1:1:1 RBC:FFP:platelets requested | 2 |
| TXA given within 3 hours of injury — 1g IV loading dose stated | 2 |
| Permissive hypotension — target SBP 90–100 mmHg blunt trauma until haemostasis | 2 |
| Avoids aggressive crystalloid — states dilutional coagulopathy, lethal triad risk | 2 |
| Concise 30-second surgeon handover — mechanism, FAST findings, interventions, TXA status | 2 |
| Total | 20 |