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MRCEM Part C · OSCE Preparation

OSCE Station Bank 10

10 new structured stations — delirium, paracetamol overdose, fractured NOF, foot drop, tension pneumothorax, capacity assessment, breaking bad news, adult safeguarding, ABG interpretation and sepsis management.

0/ 10 completed
10Stations
5Domain types
8Min / station
0/10 completed
📋 History Taking
📋
Confusion History — Delirium in the Elderly
History · 8 minStation 1 of 10
✓
▼
8:00
Station type
History Taking
Time allowed
8 minutes
Pass mark
12 / 20
📄 Candidate Briefing
👁 Examiner Instructions
✅ Mark Scheme

📄 Candidate Instructions

You are the ED doctor. Mrs Edna Briggs, 82 years old, has been brought to ED by her daughter, who is concerned about a 2-day history of confusion. Mrs Briggs is normally sharp and lives independently. She has no known dementia.

Triage obs: HR 96, BP 118/74, RR 20, SpO₂ 94% on air, Temp 38.1°C, BM 6.2 mmol/L. She is alert but disoriented to time and place. Daughter is present.

Please take a focused history from both Mrs Briggs and her daughter, apply the 4AT delirium screening tool, and outline your investigation and management plan. You have 8 minutes.

💡 Delirium — Collateral History, 4AT, PINCH ME, Risk ▼
  • Delirium vs dementia — critical distinction: Delirium: acute onset (hours to days), fluctuating course, impaired attention as cardinal feature, often reversible. Dementia: insidious onset (months to years), progressive, relatively stable day-to-day unless delirium is superimposed. Delirium can be superimposed on dementia (most common scenario in elderly ED attenders). Always establish the baseline and the timeline.
  • Collateral history — essential: From daughter: What is Mrs Briggs normally like? (Baseline cognition — "she does the crossword every day, goes shopping alone.") When exactly did this start? Was the onset sudden or gradual? Has it fluctuated? Has she been worse at night (sundowning — common in delirium)? Has she been seeing things that aren't there (visual hallucinations — more common in delirium and Lewy body dementia than Alzheimer's)?
  • 4AT screening tool (validated delirium screen — score 0–12; score ≥4 = delirium):
    • Alertness (0–4): Is the patient lethargic/agitated/drowsy (abnormal)? Score 4 if unresponsive/very drowsy, score 1 if mildly drowsy/agitated.
    • AMT4 (0–2): Ask 4 questions: age, date of birth, place, year. Score 2 if 2+ errors, score 1 if 1 error, 0 if all correct.
    • Attention (0–2): Ask patient to name the months of the year backwards from December. Score 2 if <7 months correct or refuses/unable, score 1 if 7–11 correct with 1 error.
    • Acute change or fluctuating course (0–4): Is there evidence of significant change in alertness, cognition, or behaviour over the last 2 weeks, and is this fluctuating? Score 4 if yes.
  • PINCH ME mnemonic — precipitating causes of delirium:
    • P — Pain: Unrecognised pain is a very common precipitant — especially in patients who cannot communicate well. Urine retention, constipation, fracture, pressure sore.
    • I — Infection: UTI (most common in elderly women — dysuria may be absent), pneumonia (SpO₂ 94% + Temp 38.1 here), cellulitis, meningitis (rare), any infection.
    • N — Nutrition: Dehydration (most common metabolic cause), malnutrition, thiamine deficiency (Wernicke's encephalopathy if alcohol history).
    • C — Constipation: Very common in elderly — ask specifically. Can cause significant delirium especially in dementia patients.
    • H — Hydration: Dehydration — ask about fluid intake, urine output, signs of dehydration (dry mouth, concentrated urine, skin turgor).
    • M — Medication: Recent new medications or dose changes. High-risk drugs — opioids (morphine, codeine), anticholinergics (oxybutynin, amitriptyline, antihistamines, hyoscine), benzodiazepines, antipsychotics, steroids, digoxin toxicity, alcohol withdrawal (if alcohol dependent).
    • E — Environment: Unfamiliar environment, sensory impairment (glasses, hearing aids — are they being used?), change in routine, ward moves, sleep deprivation, urinary catheter (discomfort/infection), restraints.
  • Medication review: Obtain full medication list. Look specifically for: anticholinergics (any drug with anticholinergic burden — calculate ACB score), opioids, benzodiazepines, newly started medications in the last week, over-the-counter medications, herbal remedies. Recent changes including dose increases.
  • Falls risk: Has she fallen? Delirium is the strongest independent risk factor for falls in the elderly. Document falls and any injuries.
  • Capacity and safeguarding: In acute delirium — patient almost certainly lacks capacity for complex decisions. This is time-limited and should be reassessed as delirium resolves. Best interests decision-making under MCA 2005. If delirium is chronic or recurrent — safeguarding concerns if carer stress or neglect.
  • Investigations: Urine dip and MC&S. FBC, U&E, LFT, TFT (hypothyroidism), CRP, calcium (hypercalcaemia), glucose. Blood cultures if Temp 38.1. ECG (arrhythmia, conduction abnormality). CXR (pneumonia). CT head if new focal neurology, head injury, first episode with no clear cause, or anticoagulated.

⚠️ Examiner / Role-player Instructions — Not for Candidate

Play both roles — switch between Mrs Briggs and her daughter when prompted. Mrs Briggs: disorientated, answers questions with effort, says her daughter's name when asked where she is. AMT4 — scores 2/4 (knows her age, doesn't know the date, doesn't know where she is, knows her birth year). Months backwards — stops at October, gets confused. Daughter (Susan): Normally Mum is "sharp as a tack." Confusion started 2 days ago. Started suddenly, worse at night, fluctuating. Mum started a new urinary antibiotic (trimethoprim) last week for recurrent UTIs — then got confused and stopped drinking. No falls yet. Baseline: no dementia, independent, does crossword.

🎭 Patient and Daughter Script ▼
  • Mrs Briggs: Cooperative but muddled. "I'm at home, aren't I? Where's Susan?" Answers slowly. Gets agitated if rushed. Knows her name and age. Can't say the date or where she is. Stops months backwards at October. Mild visual disturbance — "who are those people by the window?" (mild visual hallucination — delirium feature).
  • Susan (daughter): "She was absolutely fine on Monday — I spoke to her on the phone. Tuesday she sounded a bit odd. Wednesday she called me at 2am saying someone was in her house. She hasn't been eating or drinking properly for 2 days." New medication: trimethoprim 200mg BD started 7 days ago by the GP. Mum's normal medications: amlodipine, atorvastatin, omeprazole, amitriptyline 10mg (for pain — started 3 months ago).
  • PINCH ME positives in this scenario: I — possible ongoing UTI or trimethoprim side effect. N — not eating/drinking for 2 days. M — trimethoprim (can cause neuropsychiatric effects in elderly), amitriptyline (anticholinergic burden). E — unfamiliar environment, glasses left at home.
🔔 Examiner Cues ▼
  • If candidate doesn't obtain collateral history from daughter by 3 minutes: "Is there someone with Mrs Briggs who might be able to give you more information?"
  • If candidate applies 4AT but forgets the acute change domain: "Is there one more component of the 4AT you haven't assessed?"
  • If candidate misses amitriptyline anticholinergic burden: "Susan mentions Mum was started on a tablet for pain 3 months ago — does that feature in your differential?"
  • At 7 minutes: "What is Mrs Briggs' 4AT score, and what does it mean for management?"
CriterionMarks
Collateral History
Collateral history actively sought from daughter — baseline cognition, timeline, onset (acute vs gradual), fluctuation, nocturnal worsening2
Delirium vs dementia distinction made — acute onset identified as key differentiator2
4AT Application
4AT correctly applied — all 4 domains assessed (Alertness, AMT4, Attention/months backwards, Acute change)2
Score ≥4 interpreted as delirium; documents fluctuating course1
PINCH ME Assessment
PINCH ME mnemonic applied or equivalent — screens systematically for infection, dehydration, constipation, pain, medications2
Medication review — amitriptyline (anticholinergic burden) and trimethoprim (neuropsychiatric in elderly) both identified as contributing2
Environmental factors — glasses absent, unfamiliar environment, sensory deprivation noted1
Risk and Management
Falls risk acknowledged; capacity assessment — states patient likely lacks capacity in delirium, best interests under MCA2
Investigations planned — urine dip/MC&S, bloods (U&E, TFT, Ca, CRP), blood cultures, CXR2
Carer stress acknowledged — daughter's wellbeing asked about, signposted to support2
Total20
📋
Paracetamol Overdose — Late Presentation (18 Hours)
History · 8 minStation 2 of 10
✓
▼
8:00
Station type
History Taking
Time allowed
8 minutes
Pass mark
12 / 20
📄 Candidate Briefing
👁 Examiner Instructions
✅ Mark Scheme

📄 Candidate Instructions

You are the ED doctor. Mr Aaron Reid, 28 years old, presents having taken a paracetamol overdose. He is alert and cooperative. He says he took the tablets "last night" — approximately 18 hours ago.

Obs: HR 92, BP 118/76, RR 16, SpO₂ 99% on air, Temp 36.9°C. He looks pale and reports nausea and right-sided abdominal pain.

Please take a focused history, identify all high-risk features, and explain your immediate management plan. You have 8 minutes.

💡 Paracetamol OD — Timing, High-Risk Features, NAC Treatment ▼
  • Precise timing is critical: The standard treatment nomogram (Rumack-Matthew) applies only between 4 and 15 hours post-ingestion. At 18 hours, the nomogram is no longer applicable. MHRA/TOXBASE guidance: if time of ingestion is unknown or >15 hours, treat with IV NAC (N-acetylcysteine) immediately without waiting for the plasma paracetamol level. Start NAC now — do not wait for level results.
  • Overdose characterisation: Exact number of tablets (32 × 500mg = 16g). Time of last ingestion. Was this a single acute ingestion or staggered over several hours/days? Staggered overdose is high risk regardless of level or timing — each dose adds cumulative hepatotoxic burden and the standard nomogram does NOT apply. Any other medications taken (especially hepatotoxic drugs, anticoagulants, other analgesics).
  • Alcohol co-ingestion: Chronic alcohol use is an enzyme inducer — CYP2E1 is induced by chronic alcohol, increasing production of the toxic paracetamol metabolite NAPQI (N-acetyl-p-benzoquinone imine). This lowers the treatment threshold: in chronic heavy drinkers, some guidelines advise treatment at a lower threshold. Acute alcohol at time of overdose may provide some paradoxical mild hepatoprotective effect by competing for CYP2E1 — but this is unreliable and should not alter management. Always ask specifically: chronic drinker (how many units/week) vs alcohol taken at time of ingestion.
  • High-risk features that mandate treatment regardless of level or timing: Late presentation (>15h). Unknown time. Staggered overdose. Chronic alcohol use / enzyme inducers (rifampicin, carbamazepine, phenytoin, St John's Wort). Malnourished / eating disorder / low body weight (reduced glutathione stores — less able to neutralise NAPQI). Pre-existing liver disease (any cause). HIV/AIDS (reduced glutathione). Cystic fibrosis.
  • Symptoms of developing hepatotoxicity: Nausea, vomiting (first 24h — non-specific). RUQ pain and tenderness (24–72h — hepatic swelling/inflammation). Jaundice, coagulopathy, encephalopathy (72–96h — liver failure). Anuria/oliguria (AKI — rare without hepatotoxicity). This patient has RUQ pain at 18 hours = concerning.
  • Suicide risk assessment (Columbia C-SSRS): Why did he take the tablets? Was this intended to end his life, or was it impulsive? Did he tell anyone / did he plan not to be found? Did he take other steps (suicide note, gave away possessions)? What changed — trigger event? Current thoughts now — does he still want to die? Previous attempts. Any plans now? Mental health history (depression, BPD, previous self-harm).
  • Immediate investigations: Paracetamol plasma level (interpret with timing — at 18h, level confirms overdose but does not determine treatment since NAC has already been started). LFTs — ALT/AST rising = hepatotoxicity. INR/PT — most sensitive marker of liver synthetic function impairment. U&E and creatinine — AKI. VBG/arterial pH — metabolic acidosis = liver failure. FBC. Blood glucose. Blood cultures if septic. Urine dip.
  • IV NAC (N-acetylcysteine) regimen — MHRA 2021 simplified 2-bag: Bag 1: 100mg/kg in 200mL 5% dextrose over 2 hours. Bag 2: 200mg/kg in 1000mL 5% dextrose over 16 hours. Total duration 18 hours. Anaphylactoid reactions can occur — usually within first 15 minutes (flushing, wheeze, rash) — slow infusion, give antihistamine, continue NAC as soon as reaction settles. NAC does NOT cause true anaphylaxis.
  • Paracetamol King's College Criteria for liver transplant listing: Arterial pH <7.3 after resuscitation (most sensitive). Or all three of: INR >6.5, creatinine >300 μmol/L, grade III–IV encephalopathy. Contact liver centre early if concerned about trajectory.

⚠️ Examiner / Role-player Instructions — Not for Candidate

You are Mr Aaron Reid. You are subdued and cooperative. You took 32 paracetamol 500mg tablets at approximately 10pm last night (18 hours ago). You also drank a bottle of wine before taking them. You have been a heavy drinker for 3 years (30+ units/week). You took the tablets impulsively after an argument with your girlfriend. You did not tell anyone. You woke feeling sick with right-sided abdominal pain and got scared. You are now ambivalent about dying. No previous attempts. History of depression on sertraline.

🎭 Patient Script ▼
  • Timing and amount: "About 10pm last night — so about 18 hours ago I suppose." Took 32 tablets (two boxes of 16). "I took them all at once with a bottle of wine."
  • Staggered vs single: Taken all at once. (Single ingestion — but high dose + alcohol.)
  • Alcohol history: "I drink most nights — probably a bottle of wine a night, more at weekends." When asked about chronic use: "A few years now — it got worse after I lost my job." (This is enzyme induction — high-risk feature.)
  • Symptoms: "I feel really sick and my tummy hurts on the right side." (RUQ pain = developing hepatotoxicity.)
  • Suicide intent: "I just wanted it to stop. I didn't think about what would happen, I just took them." Did not leave a note. Did not tell anyone — woke up this morning and got scared. "I don't want to die now. I don't know what I was thinking."
  • If asked about other tablets: Just paracetamol. Also takes sertraline 100mg — did not take extra sertraline.
🔔 Examiner Cues ▼
  • If candidate waits for paracetamol level before starting NAC: "The level will take 1 hour to come back — does that change your management, given he's now 18 hours post-ingestion?"
  • If candidate uses the nomogram for a late-presentation patient: "Is the nomogram applicable at 18 hours?"
  • If candidate misses chronic alcohol as high-risk: "He tells you he drinks a bottle of wine every night — does that change the treatment threshold?"
  • At 7 minutes: "His INR comes back at 1.9 and ALT 420 U/L — what does this tell you and what do you do next?"
CriterionMarks
Overdose Characterisation
Precise timing (18 hours), amount (32 × 500mg = 16g), and single vs staggered ingestion confirmed2
Alcohol co-ingestion — acute and chronic use explored; chronic heavy use (enzyme inducer) identified as high-risk feature2
High-Risk Features
Late presentation (>15h) — states nomogram not applicable; NAC started immediately without waiting for level2
Other high-risk features screened — malnourishment, liver disease, enzyme-inducing drugs1
RUQ pain at 18 hours — identifies as sign of developing hepatotoxicity; investigations escalated2
Suicide Risk Assessment
Intent, planning, and precipitant explored — impulsive, no note, scared now; current risk assessed2
Mental health history — depression, sertraline; previous attempts asked1
Management
IV NAC started immediately — correct 2-bag MHRA regimen described (100mg/kg over 2h then 200mg/kg over 16h)2
Investigations: paracetamol level, LFTs, INR (liver synthetic function), U&E, creatinine, VBG, glucose2
Rising ALT + INR 1.9 interpreted — hepatotoxicity developing; early liver centre contact; King's College Criteria awareness2
Total20
🩺 Clinical Examination
🩺
Hip Examination — Fractured Neck of Femur
Examination · 8 minStation 3 of 10
✓
▼
8:00
Station type
Examination
Time allowed
8 minutes
Pass mark
12 / 20
📄 Candidate Briefing
👁 Examiner Instructions
✅ Mark Scheme

📄 Candidate Instructions

You are the ED doctor. Mrs Doris Chan, 81 years old, has been brought to ED after a mechanical fall from standing height at home. She has right hip pain and is unable to weight bear. She lives alone and was found by her neighbour 3 hours later.

Obs: HR 88, BP 128/76, RR 16, SpO₂ 96% on air, Temp 36.7°C. She is on the trolley. Her right leg appears shortened and externally rotated.

Please perform a focused hip examination. The examiner will provide findings. Present your working diagnosis, Garden classification, and management plan. You have 8 minutes.

🔑 NOF Fracture Examination and Management ▼
  • Classic clinical presentation of displaced NOF fracture: Shortened leg (pull of iliopsoas and rectus femoris shortens the limb). Externally rotated leg (the weight of the limb causes external rotation — the greater trochanter falls laterally). Unable to weight bear. Groin pain and tenderness. These findings are pathognomonic of displaced intracapsular or intertrochanteric fracture. Note: impacted (Garden I/II) fractures may have minimal deformity and the patient may have walked after the fall.
  • Inspection (patient supine): Compare both legs. Right shorter than left (true shortening). Right leg externally rotated (foot pointing outward). Bruising may be absent acutely. Skin integrity — pressure sores from lying on floor (she was found 3 hours later — important). Dehydration signs (dry mucous membranes, reduced skin turgor).
  • Palpation: Greater trochanter tenderness (intertrochanteric fracture — most common NOF fracture site in elderly). Groin/inguinal tenderness (intracapsular fracture). Axial compression — press on the knee with hip and knee extended — reproduces groin pain = significant. Palpate along femoral shaft. Log roll — rotate the entire limb — pain = fracture.
  • Leg length measurement: True leg length — ASIS (anterior superior iliac spine) to medial malleolus — measures true bone length. Apparent leg length — umbilicus to medial malleolus — affected by pelvic tilt or adduction/abduction contracture. In NOF fracture: true shortening on affected side.
  • Range of movement: Limited and painful in all directions. Do NOT force ROM — it causes pain and may displace an undisplaced fracture. Passive movement only, gently. Document what is achieved.
  • Neurovascular assessment — distal limb: Dorsalis pedis pulse (dorsum of foot between 1st and 2nd metatarsals). Posterior tibial pulse (behind medial malleolus). Capillary refill (nail beds). Sensation (dorsum of foot — L5; sole — S1; first web space — L5; medial calf — saphenous nerve L4). Power — ankle and toe movements. Femoral nerve (L2–L4): knee extension, anterior thigh sensation. Sciatic nerve: foot dorsiflexion, plantarflexion. Neurovascular injury is uncommon with NOF # but must be documented.
  • Garden classification (intracapsular NOF fractures — Pauwels for intertrochanteric):
    • Garden I: Incomplete/impacted — valgus impacted, trabecular lines intact. May have walked. Lowest AVN risk.
    • Garden II: Complete, undisplaced — trabecular lines disrupted but alignment maintained.
    • Garden III: Complete, partially displaced — trabecular lines misaligned.
    • Garden IV: Complete, fully displaced — no trabecular continuity. Highest AVN risk.
    • Garden I/II = undisplaced → internal fixation. Garden III/IV = displaced → hemiarthroplasty (or total hip replacement if mobile, cognitively intact patient).
  • Management (NICE NG124 — Hip Fracture 2017): Fascia iliaca block urgently — best ED analgesia for NOF fracture (ultrasound-guided). IV access, bloods, ECG, group and save. NBM for surgery. Surgery within 36 hours of admission (target 24 hours) unless medically unfit. VTE prophylaxis — LMWH (enoxaparin) within 12 hours of admission unless haemorrhage risk. Orthogeriatric co-management. Falls assessment. Bone protection (calcium/vitamin D, bisphosphonate). Pressure area care (she was on the floor for 3 hours). Nutritional support. Delirium prevention.

⚠️ Examiner Instructions — Not for Candidate

Feed findings: Right leg shortened and externally rotated. Greater trochanter tenderness +++. Groin tenderness ++. Axial compression — positive (groin pain). Log roll — painful. True leg length: right 75cm, left 78cm (3cm true shortening right). ROM — limited and painful in all directions, not forced. Neurovascular: DP and PT pulses present bilaterally. Capillary refill <2 seconds. Sensation intact. Skin: 2cm superficial sacral pressure sore (3 hours on floor). If candidate forces ROM: "Mrs Chan cries out in pain — was that necessary?"

🔔 Examiner Cues ▼
  • If candidate doesn't measure leg length: "How would you formally document the shortening you've observed?"
  • If candidate doesn't perform fascia iliaca block: "What is the recommended first-line analgesic intervention for NOF fracture in the ED?"
  • If candidate doesn't mention NICE NG124 surgical timing: "What is the NICE guideline target for time to surgery in hip fracture?"
  • At 7 minutes: "The XR confirms a displaced intracapsular NOF fracture — what Garden grade do you expect and what surgery will she likely need?"
CriterionMarks
Inspection
Shortened and externally rotated right leg identified and correctly interpreted as displaced NOF fracture2
Skin integrity assessed — sacral pressure sore identified (3 hours on floor); dehydration noted1
Palpation and Leg Length
Greater trochanter and groin tenderness; axial compression and log roll performed gently2
True leg length measured (ASIS to medial malleolus) — right shorter; distinguishes true vs apparent shortening2
ROM not forced — documents limited painful movement only; avoids iatrogenic displacement1
Neurovascular Assessment
Distal pulses (DP, PT), capillary refill, sensation, and motor function assessed and documented2
Diagnosis and Management
Garden classification explained — I–IV; states displaced fracture (III/IV) = hemiarthroplasty2
Fascia iliaca block prescribed — best ED analgesia for NOF fracture (NICE NG124)2
Surgery within 36 hours per NICE NG124; VTE prophylaxis, orthogeriatric co-management, bone protection stated2
Holistic management — falls assessment, nutrition, pressure area care, delirium prevention mentioned2
Total20
🩺
Neurological Examination — Foot Drop
Examination · 8 minStation 4 of 10
✓
▼
8:00
Station type
Examination
Time allowed
8 minutes
Pass mark
12 / 20
📄 Candidate Briefing
👁 Examiner Instructions
✅ Mark Scheme

📄 Candidate Instructions

You are the ED doctor. Mr James Brierly, 55 years old, presents with a 3-week history of right foot drop that developed after a period of prolonged squatting during tiling work. He now walks with a high-stepping gait to avoid tripping.

Obs: Afebrile, otherwise well. Right foot drop visible on walking.

Please perform a focused lower limb neurological examination. The examiner will provide findings. Localise the lesion and explain the diagnosis to the patient. You have 8 minutes.

🔑 Foot Drop — Neurological Examination and Localisation ▼
  • Gait inspection first: High-stepping gait (steppage gait) — patient lifts foot excessively to prevent toe dragging. Toe scuffing on floor. Compare with normal side. Is there any Trendelenburg gait (hip abductor weakness — L5 or hip pathology)?
  • Inspection: Wasting of anterior compartment (tibialis anterior, extensor digitorum longus, extensor hallucis longus) — in common peroneal nerve palsy and L4/L5 root lesion. In common peroneal (CPN) palsy — only anterior compartment and peroneus muscles affected; gastrocnemius/soleus (posterior compartment) preserved. Palpate fibular head — point tenderness at neck of fibula = CPN compression site.
  • Power testing (MRC grading 0–5) — key movements and their roots:
    • Ankle dorsiflexion (L4/L5 — tibialis anterior, deep peroneal nerve): WEAK in CPN palsy and L4/5 root.
    • Foot eversion (L5/S1 — peroneus longus/brevis, superficial peroneal nerve): WEAK in CPN palsy and L5 root.
    • Foot inversion (L4 — tibialis posterior, tibial nerve): PRESERVED in CPN palsy (tibial nerve intact). WEAK in L4 root lesion — this distinguishes the two.
    • Plantarflexion (S1/S2 — gastrocnemius, tibial nerve): PRESERVED in CPN palsy.
    • Knee flexion (L5/S1 — hamstrings): PRESERVED in CPN palsy. WEAK in L5/S1 root.
    • Knee extension (L3/L4 — quadriceps): PRESERVED in both CPN palsy and L5 root lesion.
    • Hip abduction (L5 — gluteus medius): Can test — weakness with L5 root lesion.
  • Reflexes: Ankle jerk (S1/S2) — may be reduced in CPN palsy if the S1 component is involved (less common). Usually normal in isolated CPN palsy. Knee jerk (L3/L4) — normal. Plantar response — should be flexor (downgoing). An extensor plantar (Babinski) = UMN lesion — this is NOT CPN palsy.
  • Sensation: Common peroneal nerve sensory territory: dorsum of foot (deep peroneal nerve — first web space), lateral aspect of lower leg and dorsum of foot (superficial peroneal nerve). In CPN palsy: impaired sensation dorsum of foot and lateral lower leg. First web space specifically = deep peroneal (L5). Medial calf = saphenous nerve = femoral nerve = L3/L4 — PRESERVED in CPN palsy. Posterior leg and sole = tibial nerve — PRESERVED in CPN palsy. L4/L5 root lesion — sensory loss may extend to medial calf (L4) or lateral calf/thigh (L5).
  • Localisation — CPN palsy vs L4/5 root lesion (key differences):
    • CPN palsy: foot inversion preserved, knee movements preserved, no back pain, sensory loss limited to CPN territory (dorsum/lateral lower leg only — not extending above knee). Fibular head tenderness.
    • L4/5 root lesion: may have back pain (radiation down lateral leg), foot inversion may also be weak (tibialis posterior — L4), sensory loss may extend above knee or into buttock, possible knee/hip muscle involvement. Straight leg raise positive (L5).
  • Investigations: Nerve conduction studies (NCS) and EMG — localise to CPN at fibular head (slowed conduction at fibular neck). MRI lumbar spine if root lesion suspected. Blood glucose (diabetic neuropathy can mimic mononeuropathy). Vasculitis screen if multifocal neuropathy.
  • Management: Ankle-foot orthosis (AFO) to prevent tripping. Physiotherapy. Identify and remove compression — avoid prolonged squatting, crossing legs. Recovery may take weeks to months (axonotmesis or neuropraxia). Neurophysiology outpatient referral. If no recovery or progressive worsening — MRI and neurosurgery referral. Safety advice — fall prevention.

⚠️ Examiner Instructions — Not for Candidate

Feed findings: High-stepping gait right. Anterior compartment wasting right. Fibular head tender to palpation. Power: dorsiflexion 2/5 right, eversion 2/5 right, inversion 5/5 right, plantarflexion 5/5, knee movements 5/5 bilaterally. Reflexes: ankle jerk reduced right (otherwise normal). Plantar: downgoing bilaterally. Sensation: reduced dorsum right foot and lateral right lower leg, normal medial calf and above knee. No back pain. Ask: "How does the preserved inversion and the sensory loss pattern help you localise the lesion?"

🔔 Examiner Cues ▼
  • If candidate says L4/5 root lesion without testing inversion: "Foot inversion is normal — does that change your localisation?"
  • If candidate says UMN lesion (central cause): "The plantar response is downgoing and there is no spasticity — does that fit with a central lesion?"
  • If candidate doesn't mention fibular head palpation: "Is there a specific anatomical point you should palpate in suspected peroneal nerve compression?"
  • At 7 minutes: "How do you explain this diagnosis and its likely recovery to Mr Brierly?"
CriterionMarks
Inspection and Gait
High-stepping (steppage) gait identified; anterior compartment wasting right noted2
Fibular head palpated — tender, identifies as compression site of common peroneal nerve2
Power
Ankle dorsiflexion (L4/5, deep peroneal) and eversion (L5/S1, superficial peroneal) weak — correctly identified2
Foot inversion tested — 5/5 (tibialis posterior, tibial nerve, L4) — PRESERVED; plantarflexion and knee movements normal2
Reflexes and Sensation
Reflexes — ankle jerk reduced right, knee jerk normal, plantar downgoing (no UMN features)1
Sensation — dorsum of foot and lateral lower leg impaired; medial calf and above-knee normal (limits lesion to CPN territory)2
Localisation and Diagnosis
Correctly localises to common peroneal nerve at fibular head — distinguishes from L4/5 root (inversion preserved, no back pain, sensory loss below knee only)2
Investigations — NCS/EMG, blood glucose, MRI spine if root lesion not excluded1
Management — AFO, physio, remove compression, neurophysiology referral, safety advice2
Clear explanation to patient — diagnosis, mechanism, expected recovery, fall prevention2
Total20
🔧 Practical Procedures
🔧
Tension Pneumothorax — Needle Decompression and Finger Thoracostomy
Procedure · 8 minStation 5 of 10
✓
▼
8:00
Station type
Practical Procedure
Time allowed
8 minutes
Pass mark
12 / 20
📄 Candidate Briefing
👁 Examiner Instructions
✅ Mark Scheme

📄 Candidate Instructions

You are the trauma team leader. An intubated 40-year-old male trauma patient suddenly deteriorates 5 minutes after intubation. He was intubated for a GCS of 6 following a road traffic collision.

Current obs: SpO₂ 72% on 100% O₂, HR 140, BP 70/40, absent breath sounds left side, trachea deviated to the right, distended neck veins. Ventilator peak pressures are very high.

Please recognise this emergency, perform needle decompression on the manikin, and describe when and how you would proceed to finger thoracostomy. Verbalise every step. You have 8 minutes.

💡 Tension Pneumothorax — Recognition, Needle Decompression, Finger Thoracostomy ▼
  • Recognition — do NOT wait for CXR: Tension pneumothorax is a clinical diagnosis and a cardiac arrest-equivalent emergency. CXR confirmation wastes life-saving time. Classic signs: (1) Absent/reduced breath sounds ipsilateral side. (2) Tracheal deviation AWAY from tension (away from side of pneumothorax — trachea deviates RIGHT = left tension). (3) Distended neck veins (raised JVP from obstructed venous return). (4) Haemodynamic compromise — hypotension, tachycardia. (5) Hypoxia despite adequate O₂. (6) High ventilator peak airway pressures (if intubated). Note: tracheal deviation is a late sign — do not wait for it. The triad of absent breath sounds + hypotension + hypoxia in trauma = tension pneumothorax until proven otherwise.
  • Mechanism in intubated patients: Positive pressure ventilation dramatically accelerates tension pneumothorax — the ventilator forces air through the pleural defect with each breath. Tension can develop within minutes of intubation in a patient with a pneumothorax. Always reassess after intubation.
  • Needle decompression — technique:
    1. Identify the 2nd intercostal space, mid-clavicular line (MCL) on the affected side (left in this case).
    2. Insert a 14–16G IV cannula (at least 8cm long in obese patients — chest wall thickness). Direct perpendicular to skin, just over the superior border of the 3rd rib (avoids neurovascular bundle which runs under inferior border of each rib).
    3. A hiss of air = successful decompression. Remove the needle, leave the cannula.
    4. SpO₂ and BP should improve rapidly.
    5. Limitations: may be ineffective in obese patients (chest wall too thick — 14G cannula may not reach pleura). Cannula can kink or clot. If no improvement — proceed immediately to finger thoracostomy.
  • Alternative 2nd site for needle decompression: 4th/5th ICS anterior axillary line (AAL) — preferred in some systems (TCCC — military). Less likely to fail in muscular/obese patients, less risk of cardiac/lung injury, same efficiency. ATLS 10th edition endorses both sites.
  • Finger thoracostomy — indications and technique:
    • Indications: Traumatic cardiac arrest (bilateral thoracostomies as part of arrest protocol). Failed needle decompression (no improvement after needle). Pre-hospital setting before formal chest drain. Obese or muscular patients where needle may not reach pleura.
    • Technique:
      1. 4th or 5th ICS, anterior axillary line on affected side. (Landmark: level of nipple in males, inframammary fold in females — 5th ICS AAL.)
      2. Prep skin (gloves, antiseptic if time allows).
      3. Horizontal incision through skin, approximately 3cm.
      4. Blunt dissection through subcutaneous tissue, intercostal muscles using curved forceps (artery forceps) or finger.
      5. Puncture pleura — feel the "give." Gush of air confirms entry into pleural space.
      6. Insert finger — sweep 360° to confirm pleural space, no lung adherence, clear any clot.
      7. Leave open (finger thoracostomy remains open). In traumatic arrest — bilateral thoracostomies done immediately, before formal drains.
      8. Proceed to formal intercostal chest drain insertion once patient stabilised.
  • Why finger thoracostomy is preferred in traumatic cardiac arrest: Speed — immediately decompresses. No equipment failure (needle kinking). Confirms entry visually and tactilely. Bilateral thoracostomies as part of the traumatic cardiac arrest protocol are mandatory — tension PTX is a reversible cause. In ROSC after traumatic arrest — convert to formal chest drains.
  • Complications: Needle decompression — pneumothorax if not present, cardiac puncture (too medial), subclavian vessel injury, cannula kinking. Finger thoracostomy — intercostal vessel damage (stay over rib superior border), lung laceration, infection (in non-sterile emergency), wrong site.

⚠️ Examiner Instructions — Not for Candidate

This is a manikin station. After candidate recognises tension PTX and starts needle decompression: "The cannula is in — there was a hiss of air. SpO₂ now climbing to 85%." After 30 seconds: "SpO₂ has dropped back to 74% — the cannula appears to have kinked." Expect candidate to proceed to finger thoracostomy. Key check points: Did they diagnose clinically without requesting CXR? Correct landmark (2nd ICS MCL)? Did they insert over the superior rib border? Did they describe the finger sweep? Do they know bilateral thoracostomies in traumatic arrest?

🔔 Examiner Cues ▼
  • If candidate requests CXR before treatment: "While you're waiting for the portable CXR the patient arrests — was CXR the right first step?"
  • If candidate inserts needle below the rib: "Which border of the rib should you insert over, and why?"
  • If finger thoracostomy succeeds but candidate doesn't mention formal drain: "Is finger thoracostomy a definitive treatment?"
  • At 7 minutes: "This patient arrests — what do you do to the chest in a traumatic arrest, and why?"
CriterionMarks
Recognition
Tension pneumothorax diagnosed clinically — absent breath sounds left, tracheal deviation right, distended neck veins, high vent pressures; does NOT wait for CXR2
Identifies left-sided tension from findings — trachea deviates away from tension1
Needle Decompression
Correct site — 2nd ICS, mid-clavicular line, left side (or 4th/5th ICS AAL)2
Inserted over superior border of 3rd rib — avoids neurovascular bundle2
14–16G cannula, appropriate length for chest wall; hiss of air confirms decompression1
Finger Thoracostomy
Proceeds to finger thoracostomy when needle fails — correct indication stated2
Correct site — 4th/5th ICS, anterior axillary line, affected side2
Blunt dissection, finger sweep to confirm pleural entry and clear clot2
States bilateral thoracostomies in traumatic arrest — mandatory part of protocol2
Formal chest drain after stabilisation; complications of each technique stated2
Total20
🔧
Ketamine Sedation — Procedural Sedation (Paediatric Fracture)
Procedure · 8 minStation 6 of 10
✓
▼
8:00
Station type
Practical Procedure
Time allowed
8 minutes
Pass mark
12 / 20
📄 Candidate Briefing
👁 Examiner Instructions
✅ Mark Scheme

📄 Candidate Instructions

You are the ED registrar. Callum, an 8-year-old boy, has a displaced distal radius fracture following a fall from a climbing frame. Orthopaedics have reviewed and request closed reduction in the ED. Both parents are present and have given consent.

Obs: HR 102, BP 98/64, SpO₂ 99% on air, RR 18, Weight 28 kg. GCS 15. Last ate 2 hours ago.

The examiner will play the role of a nurse assistant. Please talk through your pre-sedation assessment, equipment checklist, drug dosing, administration, monitoring, complications management, and recovery criteria. You have 8 minutes.

💡 Ketamine Procedural Sedation — Full Framework ▼
  • Why ketamine is the agent of choice for paediatric procedural sedation in the ED: Dissociative anaesthetic — provides analgesia, sedation, and amnesia simultaneously while maintaining airway reflexes and spontaneous respiration. Bronchodilator (useful in asthmatic patients). Does NOT cause hypotension (mild sympathomimetic — increases HR and BP). Preserves laryngeal reflexes. Widely used for painful procedures in paediatrics: fracture reduction, burn dressing, laceration repair, joint aspiration.
  • Pre-sedation assessment:
    • Airway assessment — Mallampati classification: Ask child to open mouth and protrude tongue. Class I (uvula, faucial pillars, soft palate visible) — easy airway. Class II (upper uvula obscured). Class III (only soft palate visible). Class IV (hard palate only). Higher class = potentially difficult airway. For procedural ketamine sedation, class I–II is ideal. If III–IV — senior input and anaesthetic involvement before proceeding.
    • Fasting status: Standard fasting guidance: 6 hours for solids, 4 hours for breast milk, 2 hours for clear fluids (6-4-2 rule). Callum ate 2 hours ago — not fasted for solids. Ketamine is unique: can be used in non-fasted emergency cases. Risk-benefit discussion: the risk of delayed reduction (ongoing pain, further soft tissue injury, neurovascular compromise) outweighs aspiration risk in well-titrated ketamine sedation. Ketamine preserves laryngeal reflexes — aspiration risk lower than with propofol or opioids. Must be discussed with parents and documented. Risk of laryngospasm — have suction ready.
    • ASA physical status: ASA I–II ideal for ED ketamine sedation. ASA III+ — consider anaesthetic involvement. Callum appears healthy (ASA I).
    • Contraindications to ketamine: Age <3 months (relatively). Procedures involving posterior pharynx (stimulates laryngospasm). Uncontrolled hypertension or tachycardia. Raised ICP (raises cerebral blood flow and ICP — avoid in head injury). Psychosis, schizophrenia. Thyrotoxicosis (relative — ketamine is sympathomimetic). Known allergy to ketamine.
    • RSVP checklist — equipment preparation before administration:
      • Monitoring: Continuous SpO₂, continuous ETCO₂ (end-tidal CO₂ via nasal cannula capnography — detects apnoea/hypoventilation early, more sensitive than SpO₂ alone), HR, RR, BP every 5 minutes, ECG in older patients.
      • Suction: Yankauer connected and working — within arm's reach. Ketamine increases secretions (sialorrhoea) — this is the most common side effect. Atropine (0.02 mg/kg IV) or glycopyrrolate (0.005 mg/kg) can be given pre-emptively to dry secretions, though not routinely needed.
      • Oxygen: Nasal cannula at 2 L/min via capnography cannula. Or face mask oxygen. Goal: maintain SpO₂ >94%.
      • BVM: Appropriately sized bag-valve-mask connected to oxygen at 15 L/min, positioned at head of bed, tested.
      • IV access: 22G cannula in situ (dorsum of hand). Flush confirmed. Second IV access available if needed.
      • Resuscitation drugs drawn up: Suxamethonium 2 mg/kg IV (for laryngospasm rescue — 28 kg → 56 mg drawn up). Atropine 0.02 mg/kg (bradycardia/vagal/secretion management). Flumazenil (if midazolam given for emergence phenomena — 0.01 mg/kg IV, max 0.2 mg). Adrenaline 10 mcg/kg IV for cardiac arrest.
      • Personnel: Minimum 2 people — one administers drug/monitors, one performs the procedure. A third person (nurse) to manage family and document. Senior support immediately available.
  • Ketamine dosing:
    • IV route (preferred for in-hospital procedures): 1–2 mg/kg IV. For fracture reduction: typically 1.5 mg/kg IV. In a 28 kg child: 1.5 × 28 = 42 mg IV. Administer slowly over 60 seconds (rapid bolus increases risk of apnoea and laryngospasm). Onset: 30–60 seconds. Duration: 10–20 minutes. Top-up dose: 0.5 mg/kg IV if sedation inadequate after 3–5 minutes.
    • IM route (if no IV access or uncooperative child): 4–6 mg/kg IM. In 28 kg child: 4 × 28 = 112–168 mg IM. Onset: 3–5 minutes. Duration: 20–30 minutes. Useful if IV access would cause more distress than the procedure.
    • Do NOT give IV ketamine as rapid bolus — risk of apnoea and chest wall rigidity.
    • Pre-medication options: Midazolam 0.05 mg/kg IV (reduces emergence phenomena, anxiolysis, anticonvulsant). Ondansetron 0.1 mg/kg IV (antiemetic — nausea and vomiting occur in up to 15%). Glycopyrrolate/atropine if secretions likely.
  • Monitoring during sedation: Continuous SpO₂ and ETCO₂. HR and BP every 5 minutes. Observe chest wall excursion. Level of sedation scoring (UMSS — University of Michigan Sedation Scale): 0 = awake, 1 = mild (responds to voice), 2 = moderate (arouses with stimulation), 3 = deep (arouses with deep stimulation), 4 = unresponsive. Target level 3 for fracture reduction.
  • Emergence phenomena — incidence and management:
    • Incidence: Up to 30% in adults, less common in children under 10. Vivid, sometimes frightening dreams, hallucinations, confusion on emergence.
    • Prevention: Minimise external stimuli during recovery — quiet environment, dim lights, limit unnecessary touch/noise. Do NOT talk to child unnecessarily during deep sedation phase. Allow recovery in a quiet side room where possible.
    • Management if emergence reactions occur: Reassure gently. Midazolam 0.05 mg/kg IV — titratable, effective. Allow sufficient time — most resolve within 15–30 minutes without intervention.
  • Laryngospasm — recognition and management:
    • Recognition: High-pitched inspiratory stridor or complete silence with chest/abdominal paradox (see-saw breathing). SpO₂ drops. ETCO₂ drops to zero. Patient becomes cyanosed. Most commonly triggered by secretions, suction, pharyngeal stimulation.
    • Management (stepwise):
      1. Remove stimulation immediately (stop procedure, remove suction if in oropharynx).
      2. Jaw thrust and repositioning — open airway, extend neck.
      3. Suction oropharynx gently (blood/secretions).
      4. 100% oxygen via tight-fitting mask and BVM — gentle positive pressure (20–25 cmH₂O).
      5. If partial laryngospasm — may resolve with above steps. SpO₂ climbing.
      6. If complete laryngospasm or SpO₂ <80%: Suxamethonium 0.1–0.5 mg/kg IV (low-dose 'laryngospasm notch dose') — 28 kg child: 2.8–14 mg. This relaxes the larynx without full neuromuscular blockade. If unsuccessful: full dose suxamethonium 1–2 mg/kg IV (28 kg: 28–56 mg) + intubation.
      7. Call for senior anaesthetic support immediately if ETCO₂ zero and SpO₂ not improving.
  • Recovery criteria — when to discharge/return to ward: Modified Aldrete Score ≥9 (out of 10). Domains: Activity (moves all extremities — 2 pts), Respiration (deep breathe, cough — 2 pts), Circulation (BP ±20% pre-op — 2 pts), Consciousness (fully awake — 2 pts), Oxygen saturation (SpO₂ >92% on air — 2 pts). Additionally for paediatrics: Back to pre-procedure baseline (responding to parents, recognises surroundings). Tolerating fluids without vomiting. Adequate pain control. Neurovascular status of reduced limb checked and documented.
  • Post-procedure documentation and parental instructions:
    • Document: Time of drug administration, dose given, route, lot number. Monitoring observations throughout. Level of sedation achieved. Any complications (laryngospasm, emergence reactions, vomiting). Time to recovery. Aldrete score at discharge. Operator and supervising clinician names.
    • Parental instructions: No driving for 24 hours (not relevant here but for teenagers). No school next day. Return to ED if: child not fully awake in 1 hour, vomiting unable to keep fluids down, limb pain or neurovascular compromise (white fingers, numb fingers, unable to move fingers). Follow-up with fracture clinic documented. Plaster care instructions.

⚠️ Examiner Instructions — Not for Candidate

This is a structured viva/simulation station. Act as the assisting nurse. Prompt: "The IV is in, drug is drawn up — what are you going to give and how?" Then: "The drug is given — 3 minutes later you notice the SpO₂ dropping to 88% and you hear a high-pitched noise." Expect candidate to manage laryngospasm. Then: "SpO₂ now 94% after suxamethonium low-dose. The procedure is done. How do you assess recovery?" Key checkpoints: Did they assess fasting and articulate the risk-benefit? Did they state slow administration (60 seconds)? Did they correctly calculate the dose for 28 kg? Did they manage laryngospasm in steps? Did they state Aldrete score ≥9?

🔔 Examiner Cues ▼
  • If candidate states ketamine is contraindicated because not fasted: "What are the fasting guidelines for ketamine specifically, and when can it be used in the non-fasted patient?"
  • If candidate omits ETCO₂ from monitoring: "We have SpO₂ — is there any other monitoring you would add for procedural sedation?"
  • If candidate omits suxamethonium from resuscitation drugs: "Laryngospasm has occurred and ETCO₂ is now zero — what is your next drug and dose?"
  • At 7 minutes: "The procedure is done, child is waking up and seems agitated and distressed — how do you manage emergence phenomena?"
CriterionMarks
Pre-sedation Assessment
Mallampati airway assessment performed; fasting status assessed and risk-benefit rationale for proceeding in non-fasted emergency articulated2
Contraindications to ketamine screened — no raised ICP, no posterior pharynx procedure, no hypertension, no allergy1
Equipment and Monitoring
Full equipment checklist — suction, BVM with oxygen, IV access confirmed; monitoring: continuous SpO₂, ETCO₂, HR, BP every 5 minutes2
Resuscitation drugs prepared — suxamethonium and atropine correct doses for 28 kg drawn up; personnel — minimum 2 operators2
Drug Administration
Correct dose — 1–2 mg/kg IV (e.g. 1.5 mg/kg = 42 mg IV for 28 kg); administered slowly over 60 seconds2
IM alternative stated — 4–6 mg/kg IM if no IV access; emergence phenomena prevention — quiet/dim environment, midazolam 0.05 mg/kg if needed2
Laryngospasm Management
Laryngospasm recognised — high-pitched stridor or silent chest, SpO₂ drop, ETCO₂ zero; stimulation removed immediately2
Stepwise management — jaw thrust, suction, BVM 100% O₂; low-dose suxamethonium (0.1–0.5 mg/kg IV) for persistent laryngospasm; senior/anaesthetic call2
Recovery
Aldrete score ≥9 stated; back to pre-procedure baseline; neurovascular check of limb; parental instructions and follow-up documented3
Total20
💬
Breaking Bad News — Unexpected Death (SPIKES)
Communication · 8 minStation 7 of 10
✓
▼
8:00
Station type
Communication
Time allowed
8 minutes
Pass mark
12 / 20
📄 Candidate Briefing
👁 Examiner Instructions
✅ Mark Scheme

📄 Candidate Instructions

You are the ED registrar. Mr and Mrs Thornton have arrived at the ED asking about their son, Jamie, 19 years old, who was brought in by ambulance following a cardiac arrest during a sports match. The resuscitation team worked for 45 minutes. Jamie could not be resuscitated.

The family are in the relatives' room. You have been asked to speak with them. The examiner will play both parents. A nurse (not present in this scenario) would normally accompany you.

Please break the news to Mr and Mrs Thornton. Apply the SPIKES framework. You have 8 minutes.

💡 SPIKES Framework — Unexpected Death ▼
  • SPIKES framework — structured approach to breaking bad news:
    • S — Setting: Ensure privacy — relatives' room, door closed, no interruptions (hand bleep/phone to colleague or switch to silent). Sit down — at same level as family, not standing over them. Introduce yourself with full name and role. Ensure a support person is with the family if possible — ask "Is there anyone else you'd like to be here?" Tissue box in reach. Acknowledge you haven't met before: "I'm Dr [name], one of the emergency department doctors."
    • P — Perception: Explore what they already know before delivering news. "Before I tell you anything, can I ask — what have you been told so far?" or "What do you understand about why Jamie was brought in today?" This avoids shocking someone who already suspects the worst, and avoids underexplaining to someone who knows very little. If they already say "we know he collapsed on the pitch" — acknowledge that before proceeding.
    • I — Invitation: Ask how much information they want, or how they prefer to receive news. "Would you like me to tell you everything that happened, step by step?" Most family members will say yes. Some may want to wait for another family member to arrive. Respect this — but if they want to know, proceed.
    • K — Knowledge (Warning shot + delivery):
      • Warning shot: "I'm afraid I have some very difficult news for you." Pause. Allow them to prepare emotionally.
      • Deliver news clearly and plainly: Use the word "died" — not "passed away," "gone," "no longer with us," or "we lost him." Euphemisms cause confusion and sometimes false hope. "I'm so sorry — Jamie died. We did everything we could but we were unable to save him."
      • Brief explanation of what happened — keep it simple at this stage: "Jamie had a cardiac arrest — his heart stopped. Our team worked for 45 minutes trying to restart his heart. Despite everything we tried, we were unable to bring him back." Do NOT give a detailed medical explanation at this stage.
      • Silence: After delivering the news — stop talking. Allow silence. Do not fill the silence with words. Allow them to absorb and react.
    • E — Emotions (Empathy): Respond to emotional reactions with empathy before giving any more information. If Mrs Thornton collapses/cries: "I'm so sorry. Take as long as you need." If Mr Thornton becomes angry: "I understand you're angry — this is an incredibly shocking thing to be told. Your feelings make complete sense." Do NOT become defensive or explain the medicine in detail during emotional outburst. Acknowledge the feeling: "This must be completely devastating." Do not use the phrase "I know how you feel." Do not rush to provide facts while they are distressed.
    • S — Strategy and Summary: Once the initial shock has been received and emotions slightly settled (may take 2–5 minutes — do not rush), begin to explain next steps:
      • Viewing the body: "Would you like to see Jamie? We can take you to him whenever you're ready — there's no rush." Prepare them for how he looks if relevant (tubes still in if sudden death/post-resuscitation — explain gently: "There may still be some tubes in place from our attempts to help him — we can explain anything you see.").
      • Bereavement team: "We have a bereavement nurse/coordinator who will come and sit with you — they can help you with the next steps." Hand over to bereavement nurse at end of meeting.
      • Chaplaincy: "Would you like us to contact a chaplain or spiritual support for your family?" Offer proactively regardless of apparent religion.
      • Coroner process: "Because this was an unexpected death in a young person, Jamie's case will be referred to the coroner as a matter of course — this is standard procedure and does not mean anything sinister. The coroner will arrange a post-mortem to understand the cause of death. We cannot issue a death certificate until the coroner has completed this process." Do NOT speculate on cause of death (e.g. "probably a heart condition") before post-mortem — this is inaccurate and potentially harmful. Common cause in this scenario: hypertrophic cardiomyopathy, commotio cordis, arrhythmia — but you do not know yet.
      • GP notification: "We will contact Jamie's GP today to let them know." This is standard practice — GP may need to support other family members.
      • Who to call: Give the family the number for the ED bereavement co-ordinator or ward clerk, and the direct ward number. "If you have any questions at all, please don't hesitate to call this number."
      • Do NOT leave family alone — ensure nurse/support person stays with family after you leave. "I'm going to step out shortly but [name of nurse] will stay with you — please let us know if you need anything at all."
  • Handling father's anger: Normalise — "I completely understand why you feel this way. It's a completely natural reaction to something this terrible." Do not be defensive. Do not say "I did everything I could" as a first response (sounds self-serving). Focus: "This was totally unexpected. We are all shocked." If anger escalates: stay calm, use name ("Mr Thornton"), keep eye contact, do not move away. If physical threat — call security, leave room, return with support.
  • Handling mother's collapse: Immediate welfare — "Mrs Thornton — take your time, I'm right here." Offer water, tissues. Check she is physically okay (not fainted — dehydrated/vasovagal). If she has fainted, manage as a medical patient first. Ensure she is seated safely. Do not abandon the father while tending to the mother — involve nursing support.
  • Language to avoid: "Passed away," "gone," "we lost him," "no longer with us" — use died. "There was nothing we could do" — avoid (even if true, sounds dismissive). "I know how you feel." "At least he didn't suffer." "It was God's will." "He's in a better place." Avoid medical jargon.
  • Post-mortem and cause of death: Young person with sports-related cardiac arrest — most likely undiagnosed structural heart disease (HCM, ARVC, anomalous coronary artery), long QT syndrome, commotio cordis. Do NOT speculate. "We genuinely don't know yet — the post-mortem will give us much more information. We will make sure you are updated."

⚠️ Examiner / Role-player Instructions — Not for Candidate

Play both parents simultaneously — use different voices/positions if possible, or alternate. Mr Thornton: Initially quiet, then suddenly becomes angry: "What do you MEAN he died? He was FINE this morning! You should have saved him! He's 19 years old!" Stand up, raise voice. After candidate responds with empathy and calmness — gradually de-escalate. Mrs Thornton: Bursts into tears immediately on hearing the word "died," leans forward on the table, becomes almost non-responsive. After 2 minutes ask quietly: "Can I see him?" Key checks: Did candidate use the word "died" clearly? Did they not fill the silence? Did they manage anger without becoming defensive? Did they explain the coroner process? Did they NOT speculate on cause of death?

🎭 Role-player Script ▼
  • Mr Thornton (initially): "We got a call — Jamie had a collapse on the football pitch. Is he okay? We've been sitting here for 45 minutes — no one has told us anything." [If candidate says "He died" clearly] — long pause, then: "What? No. No that's not right. What do you mean? He's 19. He was playing football this morning." Then escalates to: "Why didn't you save him? You're doctors! That's your job!" [Expect candidate to de-escalate].
  • Mrs Thornton: Silent at first, then starts crying. After the word "died" — puts head in hands. After 2–3 minutes: "Can I see him? I want to see my son." [Expect candidate to acknowledge and offer to take her to see him].
  • If candidate speculates on cause: Mr Thornton: "So what happened to him? Did you do something wrong?" [Expect candidate to say they don't yet know, coroner will determine].
🔔 Examiner Cues ▼
  • If candidate uses "passed away" instead of "died": "Mrs Thornton looks confused — 'what do you mean passed away? Is he alive?'"
  • If candidate fills the silence after delivering news: "Is silence an important part of this conversation? When should you be silent?"
  • If candidate doesn't mention coroner: "Mr Thornton asks — when will we get a death certificate? How do we arrange the funeral?"
  • If candidate leaves family alone: "As you stand to leave, Mrs Thornton is alone and crying — what is your responsibility before you go?"
  • At 7 minutes: "Mr Thornton asks: what killed him? Do you know yet?"
CriterionMarks
Setting and Preparation
Private setting ensured; introduced self with name and role; sat down at same level; acknowledged no previous meeting2
Perception — explored what family already know before delivering news1
Delivering News
Warning shot used before delivering news; word "died" used clearly — not euphemism (passed away / gone / lost)3
Silence maintained after delivering news — did not fill silence with words; allowed emotional reaction2
Emotional Management
Father's anger acknowledged with empathy — did not become defensive; used name, maintained eye contact, stayed calm2
Mother's distress acknowledged — welfare checked, offer to see body, tissues/water offered2
Next Steps
Coroner process explained clearly — unexpected death in young person, post-mortem mandatory, no death certificate until coroner; did NOT speculate on cause of death3
Offer to view body; bereavement team/chaplaincy mentioned; family not left alone — nurse/support handed over before leaving3
Total20
💬
Capacity Assessment — Refusing Blood Transfusion (MCA 2005)
Communication · 8 minStation 8 of 10
✓
▼
8:00
Station type
Communication
Time allowed
8 minutes
Pass mark
12 / 20
📄 Candidate Briefing
👁 Examiner Instructions
✅ Mark Scheme

📄 Candidate Instructions

You are the ED registrar. Mrs Ruth Henley, 44 years old, Jehovah's Witness, has been admitted following a post-partum haemorrhage. She delivered 6 hours ago. Hb is 62 g/L. She is haemodynamically borderline — BP 92/60, HR 104, RR 18, SpO₂ 96% on 2L O₂. She is alert and talking.

She has presented a signed advance directive refusing all blood products. The haematology team have been called but are unavailable for 30 minutes. Your consultant is aware.

Please assess Mrs Henley's capacity formally under the Mental Capacity Act 2005, explore the validity of her advance directive, and discuss the available alternatives. You have 8 minutes.

💡 MCA 2005 — Capacity, Advance Directives, Blood Refusal ▼
  • Mental Capacity Act 2005 — key principles:
    • Principle 1: A person must be assumed to have capacity unless established otherwise.
    • Principle 2: A person is not to be treated as unable to make a decision unless all practicable steps to help them have been taken without success.
    • Principle 3: A person is not to be treated as lacking capacity merely because they make an unwise decision.
    • Principle 4: Any act done or decision made under the Act for a person without capacity must be in their best interests.
    • Principle 5: Before doing something or making a decision on behalf of someone without capacity, regard must be had to whether the purpose can be achieved in a less restrictive way.
  • 4-stage capacity assessment (MCA 2005, Section 3) — must be decision-specific and time-specific:
    • Does the patient have a disturbance of the mind or brain? If yes, proceed to functional test. (Post-partum haemorrhage with possible haemodynamic compromise — is there any altered consciousness? Here: alert and GCS 15 — proceed.)
    • Stage 1 — Can they UNDERSTAND the information relevant to the decision? Explain clearly: "Mrs Henley, your haemoglobin — the blood count — is very low at 62. The normal level is around 120–160. This means your blood is not carrying enough oxygen to your body. Without treatment, this puts your heart, brain, and kidneys at risk. The treatment I am recommending is a blood transfusion. Do you understand what I'm telling you?" Ask her to repeat it back in her own words.
    • Stage 2 — Can they RETAIN the information? "I know this is a lot to take in. Can you tell me again what the main concern is with your blood levels?" (Even briefly — capacity does not require long-term retention, just long enough to make the decision.)
    • Stage 3 — Can they USE AND WEIGH the information? This is the critical stage. "Do you understand that without a blood transfusion you may die?" She must demonstrate she understands the consequence of her refusal and has weighed it. "I understand that if I refuse the transfusion I might die. I accept that." This is sufficient — she can weigh the information even if you disagree with her conclusion.
    • Stage 4 — Can they COMMUNICATE their decision? Yes — she is speaking and writing.
    • Conclusion: If all 4 stages satisfied — she HAS capacity. An unwise decision does not equal incapacity (MCA Principle 3). Document the capacity assessment in full.
  • Advance directive (advance decision to refuse treatment — ADRT) — validity checklist: Under MCA 2005 ss.24–26, an ADRT refusing life-sustaining treatment must satisfy ALL of the following to be legally binding:
    • Made when the person had capacity (over 18, capacitous at time of writing).
    • Made in writing.
    • Signed by the person in the presence of a witness who also signed.
    • Specifically states that the refusal applies "even if life is at risk."
    • Specifies the treatment being refused and the circumstances in which it applies — must be this scenario (blood products, haemorrhage).
    • Not subsequently revoked (verbally or in writing).
    • Not made under duress or undue influence.
    If any of these are not met — the ADRT is not legally binding as a life-sustaining refusal, though it remains evidence of wishes. Ask to examine the document. Confirm date, signatures, witness, and specificity to this situation.
  • Check for duress: Ask whether the decision was made freely. "Is this your own personal decision, or has anyone encouraged you to refuse?" "Is there anyone pressuring you to maintain this directive today?" Jehovah's Witness elders or family may be present — ensure patient is assessed ALONE if possible, or at least given opportunity to confirm decision privately.
  • Consistency with long-standing beliefs: "How long have you held these beliefs regarding blood transfusion?" "Has this been a longstanding decision for you?" (If she has carried the document for years and renews it periodically — clearly long-standing.) A very recently-signed directive in the context of acute illness raises concern about whether it was made under pressure or at a time of impaired cognition — scrutinise more carefully.
  • If capacitous and valid ADRT — respect the refusal: NEVER administer blood against a valid, capacitous advance directive — this constitutes battery (trespass to the person) and is a criminal offence, regardless of clinical urgency. The patient has an absolute right to refuse any treatment, including life-sustaining treatment, if they have capacity.
  • Blood alternatives — what to offer:
    • Cell salvage (intraoperative autologous blood recovery): Collects shed blood during surgery and re-infuses after processing. Accepted by many (not all) Jehovah's Witnesses if the circuit remains in continuity with the patient — discuss specifically.
    • Intravenous iron: IV ferric carboxymaltose — stimulates erythropoiesis. Effect takes days to weeks. Not for acute haemorrhage management but useful once stabilised.
    • Tranexamic acid (TXA): 1g IV over 10 minutes — anti-fibrinolytic. Reduces ongoing haemorrhage. May be acceptable to Jehovah's Witnesses (not a blood product).
    • Volume expanders: Crystalloid (Hartmann's, 0.9% NaCl), colloid (Gelofusine, albumin — albumin is derived from blood so clarify acceptability). Maintain circulating volume without haemoglobin replacement.
    • Erythropoietin (EPO): Stimulates red cell production. Used pre-operatively to boost Hb. Not acutely useful.
    • Oxygen therapy: Maximise O₂ delivery — high-flow oxygen, consider intubation if deteriorating to reduce O₂ demand.
    • Haemostatic agents: Recombinant factor VIIa (NovoSeven) if massive haemorrhage with coagulopathy — not a blood product.
    • Artificial oxygen carriers (PFCs/HBOC): Not routinely available in most UK EDs — experimental.
  • Escalation: Inform consultant. Contact hospital legal team or Medical Defence Organisation if uncertainty about ADRT validity. Liaise with haematology. If ADRT is not clearly valid and she lacks capacity — treatment in best interests under MCA is appropriate, including blood products. Document every decision, discussion, and assessment meticulously.
  • Husband/family: Family cannot consent or refuse on behalf of a capacitous adult — their wishes are irrelevant to the legal decision. If she has a Health and Welfare Lasting Power of Attorney (LPA) — check if it specifically covers life-sustaining treatment decisions.

⚠️ Examiner / Role-player Instructions — Not for Candidate

Play Mrs Henley — calm, articulate, and clear. She is not confused. She understands she may die and accepts this. "I know what you're telling me — my blood is very low and I could die. I've known this might happen. I made that decision years ago and I stand by it. My faith is everything to me." She has a signed, witnessed, dated advance directive specifying refusal of all blood and blood products in any circumstances, including life-threatening haemorrhage, signed 3 years ago. She renews it annually. No duress — husband is supportive of her decision. Key checks: Did candidate formally apply all 4 MCA stages? Did they check ADRT validity correctly? Did they explore duress? Did they offer blood alternatives? Did they NOT threaten to give blood anyway?

🎭 Patient Script ▼
  • Understanding: "Yes — I understand. My blood count is low, I might die without a transfusion. I understand all of that."
  • Retention: If asked to repeat back: "You're saying my haemoglobin is 62, very low, and without treatment there is a risk to my life."
  • Weighing: "I've weighed this up. I would rather die than receive blood. That is my sincere religious belief."
  • Duress: "No one has pressured me. My husband supports me. This is my own decision — I've carried that card for 3 years."
  • Cell salvage question: "I would need to think about that — can you explain whether the blood stays connected to my body the whole time?" (If candidate explains the circuit and offers this as an option — she will say "I would consider that if the circuit is in continuity.")
🔔 Examiner Cues ▼
  • If candidate skips formal 4-stage MCA test: "Can you tell me precisely how you assessed her capacity? Which legal framework are you using?"
  • If candidate says they would give blood anyway: "What are the legal and ethical implications of giving blood against a valid capacitous ADRT?"
  • If candidate doesn't check ADRT validity: "How do you know this advance directive is legally binding? What must it contain to refuse life-sustaining treatment?"
  • At 7 minutes: "BP has dropped to 80 systolic. You believe she still has capacity and the ADRT is valid. What do you do now?"
CriterionMarks
MCA 2005 Capacity Assessment
Formal 4-stage capacity test applied — Understand, Retain, Use and Weigh, Communicate; correctly concludes she has capacity3
MCA Principle 3 applied — unwise decision does not equal incapacity; her refusal respected on this basis2
Advance Directive Validity
ADRT validity checklist applied — written, signed, witnessed, specifically states life-sustaining treatment refusal, made when capacitous, not revoked3
Duress excluded — asked whether decision was made freely and independently; checked for coercion from religious community or family2
Alternatives and Escalation
Blood alternatives offered — cell salvage, IV iron, TXA, volume expanders; cell salvage acceptability with Jehovah's Witnesses discussed (circuit continuity)3
Escalation — consultant informed, legal/MDO contact if uncertainty, haematology liaiseed; meticulous documentation stated2
Clear statement: NEVER administer blood against valid capacitous ADRT — constitutes battery; patient's autonomy is absolute3
Total20
📊
ECG Interpretation — AF with Fast Ventricular Rate (NICE NG196)
Data Interpretation · 8 minStation 9 of 10
✓
▼
8:00
Station type
Data Interpretation
Time allowed
8 minutes
Pass mark
12 / 20
📄 Candidate Briefing
👁 Examiner Instructions
✅ Mark Scheme

📄 Candidate Instructions

You are the ED registrar. Mrs Sylvia Park, 66 years old, has been brought to ED with palpitations and mild breathlessness for approximately 6 hours. She feels dizzy but is not syncopal. She has a history of hypertension and type 2 diabetes. No known cardiac history. Current medications: amlodipine, metformin, ramipril.

Obs: HR 148, BP 112/74, RR 20, SpO₂ 95% on air, GCS 15. Chest clear. HS I+II. No signs of heart failure.

The ECG has been performed. The examiner will describe the findings to you. Please interpret the ECG, make a diagnosis, and walk through your management plan including rate vs rhythm control, anticoagulation, and admission vs discharge decision. You have 8 minutes.

💡 AF Management — NICE NG196, CHA₂DS₂-VASc, Rate vs Rhythm ▼
  • ECG description in this station: Irregularly irregular rhythm throughout. No discernible P waves (fibrillatory baseline). Ventricular rate 148 bpm. QRS complexes narrow (≤120 ms). No ST depression or elevation. No delta waves (no pre-excitation/WPW). QTc normal. Diagnosis: Atrial Fibrillation with fast ventricular rate (AF-RVR).
  • Systematic ECG interpretation approach: Rate (148 — tachycardic). Rhythm (irregularly irregular). P waves (absent — fibrillatory). QRS width (narrow — no bundle branch block or aberrant conduction). ST changes (none). QT interval (normal). Axis (normal). R wave progression (normal). Conclusion: AF with fast ventricular response, narrow complex, no ischaemia.
  • Key differentials for irregularly irregular tachycardia: AF (most common). Atrial flutter with variable block (usually "regularly irregular" — sawtooth flutter waves at 300/min). Multifocal atrial tachycardia (MAT — at least 3 different P wave morphologies, more common in COPD). AF wins here — no P waves, truly irregular.
  • NICE NG196 (2021) — AF Management in ED:
    • Is the patient haemodynamically compromised? Haemodynamic instability = shock (SBP <90, signs of organ hypoperfusion, severe heart failure, syncope). If yes → emergency electrical cardioversion (DCCV) without waiting for anticoagulation, under sedation/anaesthesia. Call anaesthetics. Synchronised shock 120–200J biphasic. If Mrs Park: BP 112/74, alert — NOT compromised. Medical management appropriate.
    • Duration of AF — critical for treatment decisions:
      • Onset <48 hours AND patient clearly knows onset: Rhythm control option available — risk of cardioversion-triggered thromboembolism is low (clot hasn't had time to form in LAA). Can offer DCCV or pharmacological cardioversion (flecainide if no structural disease, amiodarone if HF/structural).
      • Onset >48 hours, or onset UNKNOWN: Assume thrombus may be present in LAA. Cardioversion risks systemic embolism (stroke). Options: (A) Rate control first, anticoagulate for ≥3 weeks, then elective DCCV. (B) TOE-guided cardioversion (exclude LAA thrombus by TOE, then cardiovert with anticoagulation). Rate control while awaiting.
      • Mrs Park: 6 hours of symptoms — onset <48 hours. Rhythm control option is available — but she is haemodynamically stable, so not an emergency. Discuss options with patient.
    • Rate control — first-line in most patients (>48h or unknown onset, or patient elects rate control over rhythm control):
      • Bisoprolol 2.5–5 mg oral — first-line in most patients without significant lung disease. Or metoprolol IV 2.5–5 mg slow IV bolus if urgent.
      • Diltiazem 60–120 mg oral — useful in asthma/COPD (where beta-blockers relatively contraindicated). Avoid diltiazem and verapamil in heart failure (negative inotropy).
      • Digoxin — rate control in AF with heart failure; slower onset. Loading dose 0.5–1 mg IV over 2 hours, then 0.25 mg IV. Target rate <80–110 at rest.
      • Verapamil — avoid in HF, in combination with beta-blockers (profound bradycardia/hypotension), and absolutely avoid in pre-excitation/WPW (can accelerate conduction down accessory pathway → VF).
      • Target heart rate: <110 bpm at rest initially (permissive rate control). Stricter <80 bpm in symptomatic patients or if HF present.
    • Rhythm control — options for new-onset AF <48 hours:
      • Flecainide 300 mg oral (pill-in-pocket) — highly effective for pharmacological cardioversion in paroxysmal AF without structural heart disease. Must have no IHD, structural disease, or conduction abnormalities. Requires ECG monitoring for 1–2 hours post-dose.
      • IV flecainide 2 mg/kg — more rapid but requires monitoring.
      • Amiodarone 300 mg IV over 1 hour then 900 mg over 23 hours — preferred if LV dysfunction or structural disease. More reliable rate AND rhythm control. Slower than flecainide.
      • DCCV (DC cardioversion) — synchronised electrical shock 120–200J biphasic under sedation. Elective DCCV preferred if medication fails or patient elects. Requires minimum 4 hours anticoagulation pre-DCCV (or TOE exclusion of thrombus), then 4+ weeks anticoagulation post-DCCV.
    • Anticoagulation — CHA₂DS₂-VASc scoring (for stroke risk):
      • C — Congestive heart failure: 1 (No)
      • H — Hypertension: 1 (Yes — +1)
      • A₂ — Age ≥75: 2 (No — 66)
      • D — Diabetes mellitus: 1 (Yes — +1)
      • S₂ — Stroke/TIA history: 2 (No)
      • V — Vascular disease (IHD, PVD, MI): 1 (No)
      • A — Age 65–74: 1 (Yes — +1)
      • Sc — Sex category (female): 1 (Yes — +1)
      • Total: 4. Female sex category is counted as a modifier — actual stroke risk score = 3 (excluding Sc). NICE recommends anticoagulation for score ≥2 in males, ≥3 in females (i.e. at least 2 non-sex-category risk factors). Mrs Park qualifies — start DOAC (apixaban, rivaroxaban, edoxaban, or dabigatran).
    • HAS-BLED bleeding risk score: H — Hypertension (uncontrolled SBP >160): 1. A — Abnormal renal/liver function: 1 each. S — Stroke history: 1. B — Bleeding history: 1. L — Labile INR: 1. E — Elderly (>65): 1. D — Drugs (antiplatelet, NSAIDs) or alcohol: 1 each. Score ≥3 = high bleeding risk — does NOT contraindicate anticoagulation but identifies modifiable bleeding risk factors to address. Never withhold anticoagulation based on HAS-BLED alone.
    • Admit vs discharge decision: Consider for discharge if: rate controlled, haemodynamically stable, no underlying precipitant requiring admission (no ACS, no sepsis, no PE), anticoagulation started or plan in place, outpatient cardiology follow-up arranged, reliable and can return if symptomatic. Admit if: haemodynamic compromise, significant comorbidity, precipitant requiring inpatient treatment, rhythm control planned as inpatient, uncertain diagnosis. Safety netting: Return if worsening breathlessness, chest pain, pre-syncope, palpitations return or worsen.

⚠️ Examiner Instructions — Not for Candidate

Read the ECG findings aloud to the candidate: "Irregularly irregular rhythm. No P waves visible — fibrillatory baseline. Ventricular rate 148. QRS complexes are narrow. No ST changes. No delta waves." Pause for candidate to diagnose. Then: "What is your management plan? Rate control or rhythm control, and why?" Then: "Calculate her stroke risk. Should she be anticoagulated?" Key checks: Correct diagnosis (AF-RVR, narrow complex)? Did they assess for haemodynamic compromise before deciding on management? Did they discuss duration (onset <48 hours → rhythm control option)? Did they correctly calculate CHA₂DS₂-VASc ≥3 (female) and recommend DOAC? Did they avoid verapamil in this patient (on amlodipine — calcium channel blocker interaction)?

🔔 Examiner Cues ▼
  • If candidate jumps to rate control without assessing haemodynamic stability: "Before you start medication — is there a scenario where your management would be completely different?"
  • If candidate recommends verapamil: "She is already on amlodipine — are there any drug interactions or concerns with verapamil in this context?"
  • If candidate uses CHA₂DS₂-VASc ≥2 threshold for females: "NICE NG196 adjusted the anticoagulation threshold for females — what is the correct threshold for a female patient?"
  • At 7 minutes: "You have rate-controlled her to 88 bpm. She feels better. Can she go home tonight?"
CriterionMarks
ECG Interpretation
Systematic interpretation — rate, rhythm, P waves, QRS width, ST changes; diagnosis: AF with fast ventricular rate, narrow complex, no ischaemia3
Haemodynamic assessment performed first — distinguishes compromised (DCCV) from stable (medical) management2
Rate vs Rhythm Control
Duration assessed — onset <48 hours → rhythm control option discussed; onset >48h or unknown → rate control first with anticoagulation ≥3 weeks before DCCV3
Rate control agent correct — bisoprolol or diltiazem stated; verapamil avoided in combination with amlodipine; digoxin for HF context mentioned2
Rhythm control options — flecainide (no structural disease), amiodarone (with HF/structural), DCCV; anticoagulation before DCCV stated2
Anticoagulation
CHA₂DS₂-VASc calculated correctly — score 4 (hypertension +1, diabetes +1, age 65–74 +1, female +1); anticoagulation threshold for females ≥3 applied; DOAC recommended3
HAS-BLED mentioned — modifiable bleeding risk factors; does not withhold anticoagulation based on HAS-BLED alone1
Admit vs discharge criteria; safety netting provided2
Total20
📊
X-Ray Interpretation — Pneumothorax Sizing and Management (BTS 2023)
Data Interpretation · 8 minStation 10 of 10
✓
▼
8:00
Station type
Data Interpretation
Time allowed
8 minutes
Pass mark
12 / 20
📄 Candidate Briefing
👁 Examiner Instructions
✅ Mark Scheme

📄 Candidate Instructions

This is a two-part station. You are the ED registrar.

Part 1: Mr Daniel Farrow, 24 years old, tall, thin male, non-smoker. Presents with sudden-onset left-sided pleuritic chest pain and mild breathlessness. Obs: HR 88, BP 122/78, SpO₂ 97% on air. The examiner will describe the CXR findings.

Part 2: The same patient returns 48 hours later acutely unwell. The examiner will describe the repeat CXR findings.

For each part: interpret the imaging, make a diagnosis, and walk through management per BTS 2023 guidelines. You have 8 minutes.

💡 Pneumothorax — BTS 2023 Sizing and Management ▼
  • Part 1 — CXR description from examiner: "Left visceral pleural line visible and clearly separated from the chest wall. Rim of air between pleura and chest wall at the level of the hilum measures 2.5 cm. Lung partially collapsed. No mediastinal shift. No haemothorax."
  • Part 1 — Diagnosis and classification (BTS 2023 guidelines):
    • Primary spontaneous pneumothorax (PSP): Occurs in the absence of underlying lung disease. Typical patient — young, tall, thin male. Often caused by rupture of apical pleural blebs.
    • BTS 2023 sizing: Measure the rim of air between the visceral pleural line and the chest wall at the level of the hilum on the PA CXR. Rim ≥2 cm at hilum level = large pneumothorax. Rim <2 cm = small. Here: 2.5 cm = large.
    • Management decision for PSP (BTS 2023):
      • Large (≥2 cm) OR symptomatic: Intervention required. Options: (A) Needle aspiration (first-line for PSP — simple, less invasive): 16–18G cannula at 2nd ICS MCL, aspirate air, remove cannula, repeat CXR after 1 hour. If successful (lung re-expands) and patient stable — can consider discharge with follow-up. (B) Small-bore chest drain (8–14 Fr Seldinger drain) if aspiration fails or secondary pneumothorax.
      • Small (<2 cm) and minimally symptomatic: Conservative management — discharge with safety netting and 2-week outpatient follow-up CXR. Do NOT routinely aspirate all pneumothoraces — the 2023 BTS guidelines moved away from blanket intervention. Discharge with advice.
      • Here: 2.5 cm = large PSP with mild symptoms → offer needle aspiration.
  • Part 2 — CXR description from examiner (48 hours later): "Complete collapse of the left lung. The trachea is deviated to the right. Mediastinal shift to the right. Left hemithorax appears hyperlucent. Patient looks distressed — HR 132, BP 88/60, SpO₂ 84%."
  • Part 2 — Diagnosis: Tension pneumothorax.
    • Complete lung collapse + mediastinal shift + haemodynamic compromise = tension pneumothorax. This is a clinical diagnosis — do NOT wait for further imaging.
    • Immediate management:
      • Call for senior help / crash team immediately.
      • High-flow oxygen (15L/min via non-rebreathe mask).
      • Needle decompression: 14–16G cannula, 2nd ICS MCL left side (or 4th/5th ICS AAL). Hiss of air confirms. Remove needle, leave cannula.
      • Definitive treatment: Chest drain — large-bore (28–32 Fr) chest drain via Seldinger or surgical technique. 4th or 5th ICS, anterior axillary line (safe triangle). Connect to underwater seal drain.
      • IV access, fluid resuscitation if hypotensive, monitoring, blood cultures, FBC/CRP if infective cause.
      • Admit under respiratory/thoracic surgery.
  • Recurrence prevention after pneumothorax:
    • After a second ipsilateral pneumothorax — refer to thoracic surgery for pleurodesis (chemical or mechanical) or VATS (video-assisted thoracoscopic surgery) with blebectomy and pleurodesis. BTS 2023: refer after first episode if contralateral, bilateral, or high-risk job (pilot, diver, remote worker).
    • Smoking cessation: Smoking is the strongest modifiable risk factor for PSP recurrence — smoking cessation advice mandatory at every encounter.
    • Flying restriction: Do NOT fly until CXR confirms full resolution, and wait a further 6 weeks post-resolution before flying (risk of expansion at altitude in hypopressurised cabin). BTS 2023 guidance.
    • Diving: Diving is permanently contraindicated following PSP unless patient has had successful bilateral surgical pleurodesis. The pressure changes during diving carry extreme risk of recurrence and tension pneumothorax at depth.
  • Secondary spontaneous pneumothorax (SSP) — different management: Occurs with underlying lung disease (COPD, asthma, CF, IPF, malignancy). ANY SSP with rim ≥1 cm or symptomatic → chest drain (not just aspiration — aspiration has lower success rate in SSP). All SSP should be admitted. Even small SSP in breathless patient → chest drain. Higher mortality than PSP due to underlying disease.
  • Traumatic pneumothorax: All rib fractures/penetrating chest trauma — CXR is insensitive (detect only ~40% pneumothoraces) — USS or CT more sensitive. Even small traumatic PTX may require drain if patient needs PPV (positive pressure ventilation converts to tension PTX under PPV). Bilateral thoracostomies in traumatic arrest (as covered in Station 5).

⚠️ Examiner Instructions — Not for Candidate

Part 1: Read aloud: "Left visceral pleural line 2.5 cm from the chest wall at the level of the hilum. No mediastinal shift. No pleural effusion. Contralateral lung normal." Allow candidate to diagnose and manage. Part 2: Read aloud: "Complete collapse of the left lung. Trachea deviated to the right. Mediastinal shift right. The patient is now HR 132, BP 88/60, SpO₂ 84%." Key checks: Did they correctly size the pneumothorax using BTS 2023 (rim ≥2 cm at hilum = large)? Did they know NOT to aspirate all pneumothoraces — only ≥2 cm or symptomatic? Did they diagnose tension PTX clinically in Part 2 without asking for more imaging? Did they know needle decompression then definitive drain? Did they advise no flying for 6 weeks and no diving?

🔔 Examiner Cues ▼
  • If candidate aspirates the small (<2 cm) PSP: "BTS 2023 advises against routine aspiration of all pneumothoraces — what is the current threshold for intervention?"
  • If candidate waits for CXR in Part 2 before treating: "While you're waiting for the CXR, SpO₂ drops to 74% and BP 76/40. Was CXR the right first step?"
  • If candidate performs only needle decompression and declares Part 2 complete: "Needle decompression is a temporising measure — what is the definitive treatment for this patient?"
  • At 7 minutes: "The patient is recovering on the ward. He asks: can he go skiing next month? What about diving — he is a PADI open water diver?"
CriterionMarks
Part 1 — Primary Spontaneous Pneumothorax
Correct diagnosis — primary spontaneous pneumothorax; systematic CXR interpretation (pleural line, rim measurement at hilum, no mediastinal shift)2
BTS 2023 sizing applied correctly — rim 2.5 cm at hilum = large (≥2 cm threshold); knows NOT to aspirate all PSP — only ≥2 cm or symptomatic3
Management — needle aspiration (2nd ICS MCL) as first-line for large PSP; repeat CXR after 1 hour; small-bore drain if aspiration fails; considers discharge if successful2
Part 2 — Tension Pneumothorax
Clinical diagnosis of tension PTX — complete collapse, mediastinal shift, haemodynamic compromise; does NOT wait for further imaging before treating3
Immediate management — high-flow O₂, needle decompression (14–16G, 2nd ICS MCL or 4th/5th ICS AAL); hiss of air confirms; leave cannula2
Definitive treatment — large-bore chest drain in safe triangle (4th/5th ICS AAL), underwater seal; senior call, IV access, fluids; admit under thoracic/respiratory2
Recurrence Prevention and Follow-up
Smoking cessation counselling; flying restriction — 6 weeks post full resolution (BTS 2023); diving permanently contraindicated without bilateral surgical pleurodesis3
Thoracic surgery referral for recurrence prevention (pleurodesis/VATS) — after 2nd ipsilateral or 1st if bilateral/contralateral/high-risk occupation1
Total20
Continue to OSCE Bank 11 →