10 new structured stations — paediatric emergencies, toxicology, orthopaedics, psychiatry and more. Covering advanced MRCEM Part C domains not in Banks 1 or 2.
You are the ED doctor. Mrs Fatima Malik has brought her 18-month-old son Aiden to the ED. He has been unwell for 2 days with a high temperature. She is visibly worried.
Triage obs: Temp 39.4°C, HR 168, RR 44, SpO₂ 96% on air, capillary refill 2 sec centrally.
Please take a focused history from the parent. You have 8 minutes.
⚠️ Examiner / Role-player Instructions — Not for Candidate
You are Mrs Fatima Malik, Aiden's mother. You are anxious and tearful. The working diagnosis is UTI with early sepsis. No meningococcal features. He has had very few wet nappies today (2 in 12 hours, normally 6). He is less playful than normal and not feeding well.
| Criterion | Marks |
|---|---|
| Fever History | |
| Duration, height, pattern, response to antipyretics | 2 |
| Rigors asked | 1 |
| Red Flag Screen (NICE) | |
| Non-blanching rash specifically asked | 2 |
| Neck stiffness, bulging fontanelle, photophobia, abnormal cry asked | 2 |
| Altered consciousness / reduced activity level elicited | 1 |
| Source of Infection | |
| Urinary symptoms — offensive urine, crying on micturition, wet nappies elicited | 2 |
| URTI and LRTI symptoms screened | 1 |
| Hydration & Feeding | |
| Wet nappies — frequency and last one elicited | 2 |
| Oral intake and feeding assessed | 1 |
| Background | |
| Immunisation history — up to date confirmed | 1 |
| Travel history and contacts asked | 1 |
| Birth history and PMH including prematurity/heart disease | 1 |
| Communication | |
| Addresses parental concern — validates worry, empathic approach | 1 |
| Clear, structured history in appropriate language for parent | 1 |
| Total | 20 |
You are the ED doctor. Miss Chloe Reid, 19 years old, has been brought in by ambulance after her flatmate found her unconscious. She has now regained consciousness and GCS is 15. An empty blister pack of paracetamol 500mg (32 tablets) and an empty bottle of wine were found at the scene.
Obs: GCS 15, HR 96, BP 108/72, RR 16, SpO₂ 99%.
Please take a focused history. You have 8 minutes. Be mindful of the patient's emotional state.
⚠️ Examiner / Role-player Instructions — Not for Candidate
You are Chloe Reid. You are tearful and embarrassed. You took 16 paracetamol tablets (not 32 — she didn't count) approximately 4 hours ago after a relationship breakdown. You drank half a bottle of wine. This was impulsive — no note, no plan. You feel ashamed and say "I just didn't want to feel anything anymore." You are not actively suicidal now but feel hopeless.
| Criterion | Marks |
|---|---|
| Toxicology History | |
| Exact substance confirmed — paracetamol 500mg standard release | 1 |
| Amount taken — establishes ~16 tablets (not assumed 32) | 2 |
| Time of ingestion — 4 hours ago (critical for nomogram) | 2 |
| Alcohol co-ingestion and other substances asked | 1 |
| Vomiting after ingestion asked (affects absorption) | 1 |
| Fasting status / liver disease asked (risk stratification) | 1 |
| Intent & Risk | |
| Intent explored sensitively — precipitant elicited (relationship breakdown) | 2 |
| Planned vs impulsive — establishes impulsive act, no note | 1 |
| Current suicidal ideation assessed directly but compassionately | 2 |
| Protective factors identified — no current intent, support network | 1 |
| Psychiatric Background | |
| Previous attempts and self-harm history elicited | 1 |
| Current medications — sertraline documented | 1 |
| Communication | |
| Non-judgemental, empathic approach throughout | 2 |
| Introduces self, creates safe space before asking sensitive questions | 1 |
| Total | 20 |
A 24-year-old male footballer presents after twisting his right knee during a match 2 hours ago. He felt a "pop" and immediate pain. The knee has rapidly swollen. He cannot weight-bear.
Please perform a focused right knee examination. The examiner will provide findings as you examine. Present your diagnosis and management plan.
⚠️ Examiner Instructions — Not for Candidate
Findings represent an ACL tear with haemarthrosis. Feed findings as candidate examines each area.
| Criterion | Marks |
|---|---|
| Look | |
| Inspects both knees — correctly identifies diffuse swelling and bruising right | 1 |
| Notes no deformity, checks for muscle wasting | 1 |
| Feel | |
| Assesses temperature and effusion — patellar tap and/or bulge sign | 2 |
| Systematic joint line palpation — medial and lateral | 1 |
| Bony landmarks palpated — patella, tibial tuberosity, fibular head | 1 |
| Move | |
| Active and passive ROM assessed — flexion limited documented | 1 |
| Special Tests | |
| Lachman test performed correctly — most sensitive ACL test, positive identified | 3 |
| Anterior drawer test performed | 1 |
| Collateral ligament stability — valgus/varus stress at 30° | 1 |
| McMurray's test attempted for meniscus | 1 |
| Completion & Diagnosis | |
| Neurovascular status checked — DP pulse, sensation | 1 |
| Ottawa knee rules applied — XR indicated, correctly ordered | 2 |
| Correct diagnosis — ACL tear with haemarthrosis. MRI recommended. | 2 |
| Management — analgesia, aspiration if tense, orthopaedic referral, crutches | 1 |
| Total | 20 |
A 68-year-old man presents with a sudden onset acutely painful red right eye, blurred vision and he describes seeing halos around lights. He has been vomiting.
Please perform a focused eye examination, talk through your findings, and state your diagnosis and immediate management.
⚠️ Examiner Instructions — Not for Candidate
Findings represent acute angle closure glaucoma. This is an ophthalmic emergency. If candidate does not recognise it or does not urgently refer to ophthalmology, prompt with: "The patient says his vision is getting worse and the eye feels rock hard — what do you think is happening?"
| Criterion | Marks |
|---|---|
| Vision | |
| Visual acuity tested each eye separately — reduced right VA documented | 2 |
| Visual fields tested by confrontation | 1 |
| Pupils | |
| Pupil size, shape and reactivity assessed bilaterally | 1 |
| Correctly identifies mid-dilated, oval, fixed right pupil | 2 |
| Swinging flashlight test — RAPD assessed | 1 |
| Anterior Segment | |
| Ciliary flush pattern identified — correctly distinguished from diffuse injection | 2 |
| Corneal haziness / steamy cornea noted | 1 |
| Anterior chamber depth assessed — shallow noted | 1 |
| IOP | |
| IOP assessed — palpation or tonometry — right eye hard/raised | 2 |
| Diagnosis & Management | |
| Correct diagnosis — acute angle closure glaucoma | 2 |
| Immediate management — urgent ophthalmology referral, IV acetazolamide 500mg, pilocarpine 2% drops, analgesia and antiemetic, supine position | 2 |
| States this is an ophthalmic emergency — do not delay | 1 |
| Total | 20 |
A 32-year-old man presents with a right anterior shoulder dislocation following a fall onto an outstretched arm. XR confirms anterior dislocation with no fracture. Neurovascular status is intact pre-procedure.
Please describe and demonstrate on the manikin how you would reduce this shoulder dislocation. Include your choice of analgesia/sedation, technique, and post-reduction management.
⚠️ Examiner Instructions — Not for Candidate
Any evidence-based technique is acceptable. Assess pre/post neurovascular checks, analgesia adequacy, and whether candidate confirms success with XR. Ask: "The patient is very anxious and cannot relax — what do you do?" (Procedural sedation or intra-articular block).
| Criterion | Marks |
|---|---|
| Pre-procedure | |
| Reviews XR — confirms anterior dislocation, excludes fracture | 1 |
| Full neurovascular examination — axillary nerve (regimental badge), radial nerve, brachial pulse | 2 |
| Consent obtained, procedure explained clearly | 1 |
| Analgesia / Sedation | |
| Appropriate analgesia chosen — IV opioid, Entonox, intra-articular lidocaine, or procedural sedation | 2 |
| If sedation — monitoring, IV access, resuscitation equipment and trained assistant stated | 2 |
| Reduction Technique | |
| Correct technique chosen and described — Cunningham, Stimson, external rotation or equivalent | 3 |
| Technique performed smoothly, without force — gentle continuous traction/rotation | 2 |
| Recognises successful reduction — palpable clunk, restored shoulder contour | 1 |
| Post-procedure | |
| Post-reduction XR requested — confirms reduction, excludes Hill-Sachs/Bankart | 2 |
| Repeat neurovascular examination documented | 1 |
| Sling, analgesia, orthopaedic follow-up, activity restrictions given | 1 |
| Total | 20 |
A 45-year-old man with a GCS of 8 (E2V2M4) following a head injury is deteriorating. He has no gag reflex and his airway is at risk. SpO₂ is 91% on 15L O₂ via NRB. He is haemodynamically stable.
You have an experienced team available. Please talk through how you would perform a Rapid Sequence Induction (RSI) on this patient, including preparation, drug choices and post-intubation management.
⚠️ Examiner Instructions — Not for Candidate
Ask: "After your first intubation attempt you cannot see the cords — what do you do?" (CICO scenario). Expected: Call for help, optimise position/external laryngeal manipulation, second attempt with VL or bougie, SGA rescue, surgical airway as last resort — "can't intubate can't oxygenate" drill.
| Criterion | Marks |
|---|---|
| Preparation | |
| Team briefing — roles assigned, plan B and C airway stated | 2 |
| MILS applied — C-spine not cleared in head injury | 1 |
| Pre-oxygenation — min 3 minutes high-flow O₂, target EtO₂ stated | 1 |
| Drug Choices | |
| Induction agent — appropriate choice and dose (ketamine or thiopentone) with rationale for head injury | 2 |
| Suxamethonium 1.5 mg/kg or rocuronium 1.2 mg/kg with rationale | 2 |
| Cricoid pressure — applied at correct time with correct force | 1 |
| Intubation | |
| Correct ETT size, cuff inflation, depth stated | 1 |
| Waveform capnography as gold standard confirmation method | 2 |
| CICO response — calls for help, VL/bougie, SGA rescue, surgical airway | 2 |
| Post-intubation | |
| Sedation and analgesia infusion started | 1 |
| Ventilator targets — SpO₂ 94–98%, EtCO₂ 4.5–5 kPa (avoid hyperventilation) | 2 |
| ITU referral and CT head planned | 1 |
| Total | 20 |
You are the ED registrar. Miss Abigail Turner, 34 years old, presented with pleuritic chest pain and breathlessness 3 days after a long-haul flight. A CTPA has confirmed a right-sided pulmonary embolism. She is haemodynamically stable and has been started on anticoagulation.
She is asking what the scan showed and what happens next. Please explain her diagnosis and management plan. She has no medical background.
⚠️ Examiner / Role-player Instructions — Not for Candidate
You are Abigail Turner. You are frightened. You are on the OCP (combined pill — risk factor candidate should pick up). Ask: "Will I have to stop my pill?" "Can I fly again?" "How long do I have to take the tablets?" "Could I have died?" If candidate communicates well, become visibly calmer. If rushed or uses jargon, remain anxious.
| Criterion | Marks |
|---|---|
| Explaining Diagnosis | |
| Explains PE clearly in plain language — blood clot in lung, how it got there | 2 |
| Links to flight and immobility as likely cause | 1 |
| Identifies OCP as additional risk factor — advises to discuss with GP/gynaecology | 2 |
| Treatment | |
| Explains anticoagulation — DOAC, duration (3–6 months), purpose | 2 |
| Bleeding risk explained — what to avoid, when to seek help | 2 |
| Addresses admission vs discharge question clearly | 1 |
| Answering Questions | |
| "Can I fly?" — answered sensibly (yes with precautions, compression stockings, mobility) | 1 |
| "Could I have died?" — answered honestly but reassuringly | 2 |
| Red flags for return explained clearly — breathlessness, haemoptysis, syncope | 1 |
| Communication | |
| No jargon — checks understanding throughout, chunks information | 2 |
| Written information offered, follow-up plan confirmed | 1 |
| Empathic, unhurried — addresses patient's fear | 1 |
| Total | 20 |
A 3-year-old boy, Thomas, has been brought to the ED by his mother with a bruised upper arm and a burn on his forearm. The mother says he "fell off the sofa" and "touched the oven." However, the nurse is concerned — the bruise is on the upper inner arm, the burn is circular, and Thomas has been withdrawn and non-communicative.
Please speak to the mother (Mrs Karen Dale) regarding the injuries and manage this situation appropriately. You have 8 minutes.
⚠️ Examiner / Role-player Instructions — Not for Candidate
You are Mrs Karen Dale. You give a vague, inconsistent account. For the bruise: "He just fell, kids bruise easily." For the burn: "He ran to the oven and touched it — I was right there." If asked if there is anyone else at home: "My partner, but he had nothing to do with this." Become defensive if candidate is accusatory. Remain co-operative if candidate is calm and professional. Do not volunteer that the partner has a history of domestic violence unless directly and sensitively asked about home safety.
| Criterion | Marks |
|---|---|
| History Taking | |
| Takes separate detailed account of each injury — mechanism, timing, witness | 2 |
| Notes developmental appropriateness — queries whether 3-year-old could reach oven | 1 |
| Identifies inconsistencies — records in exact words, non-confrontational | 2 |
| Asks about household members and home environment sensitively | 1 |
| Approach | |
| Non-accusatory — does not directly accuse or confront carer | 2 |
| Remains professional and calm when carer becomes defensive | 2 |
| Child-centred approach — prioritises Thomas's safety throughout | 1 |
| Clinical & Safeguarding Actions | |
| States full examination of Thomas — head to toe, body map, photograph | 2 |
| Does not discharge — states child must not leave until assessed | 2 |
| Refers to paediatrics and safeguarding lead | 1 |
| Checks child protection register / previous attendances | 1 |
| Documents accurately — exact quotes, body map, timeline | 1 |
| Total | 20 |
A 7-year-old girl is brought to the ED by her parents. She has been complaining of her "heart beating fast" for the last 45 minutes. She looks pale and is sweaty. She has had one previous episode that resolved spontaneously.
Obs: HR 240 bpm, BP 88/50, RR 28, SpO₂ 97%, GCS 15.
The examiner will describe the ECG. Interpret it systematically, state your diagnosis and outline your stepwise management.
⚠️ Examiner Instructions — Not for Candidate
Read the ECG description. Key assessment: does the candidate recognise haemodynamic compromise and go straight to cardioversion rather than adenosine? Ask: "A junior doctor suggests trying adenosine first — what do you think?"
"Rate approximately 240 bpm, completely regular. Narrow complex QRS — duration approximately 0.06 seconds. No discernible P waves. No ST changes. Axis normal."
Follow-up Q1: "You cardiovert at 1 J/kg — sinus rhythm is restored. The post-conversion ECG shows a short PR interval and a slurred upstroke on the QRS. What does this suggest?"
Expected: Wolff-Parkinson-White syndrome (WPW) — delta wave, short PR, wide QRS. Requires paediatric cardiology referral. Avoid AV nodal blocking agents (adenosine, digoxin, verapamil) in WPW with AF as may accelerate conduction via accessory pathway → VF.
Follow-up Q2: "Can this child go home today?"
Expected: No — needs paediatric cardiology review, possible electrophysiology study and catheter ablation. Admit under paediatrics. Parents educated on vagal manoeuvres and when to return.
| Criterion | Marks |
|---|---|
| ECG Interpretation | |
| Rate — correctly identifies ~240 bpm | 1 |
| Rhythm — regular, narrow complex | 1 |
| No P waves (or retrograde) — identifies SVT pattern | 1 |
| Correct diagnosis — SVT | 1 |
| Haemodynamic Assessment | |
| Correctly identifies haemodynamic compromise — BP 88/50, pallor, sweating | 2 |
| States vagal manoeuvres/adenosine NOT first line given compromise | 2 |
| Management | |
| Synchronised DC cardioversion — correct energy 1 J/kg, then 2 J/kg | 3 |
| Sedation/analgesia before cardioversion if time permits and child conscious | 1 |
| Post-conversion 12-lead ECG — identifies WPW features (delta wave, short PR) | 2 |
| WPW — avoids adenosine/digoxin/verapamil, explains risk | 2 |
| Paediatric cardiology referral — does not discharge | 1 |
| Communicates clearly with team and family throughout | 1 |
| Total | 20 |
A 72-year-old man on warfarin (AF) has been brought in following a fall downstairs. GCS was 14 at scene, now 11/15 (E3V3M5) and deteriorating. He has a boggy scalp haematoma over the right temporal region.
The CT head has been reported by the radiographer as "abnormal." The examiner will describe the CT findings to you. Please interpret them, state your diagnosis, and outline immediate management.
⚠️ Examiner Instructions — Not for Candidate
Read the CT description aloud. The critical management point is immediate anticoagulation reversal and urgent neurosurgical referral. Ask: "The neurosurgeon asks about his INR — it's 4.2. What do you do?"
"There is a hyperdense crescent-shaped collection overlying the right cerebral hemisphere, maximum thickness 18mm, consistent with an acute subdural haematoma. There is approximately 8mm of midline shift to the left. Sulci are effaced on the right. No skull fracture visible on bone windows. Basal cisterns are present but reduced on the right. Left hemisphere appears normal."
Follow-up Q1: "INR is 4.2. What do you do?"
Expected: Immediate reversal — Vitamin K 5–10mg IV + 4-factor PCC (Prothrombin Complex Concentrate, e.g. Beriplex) dosed by weight and INR. Target INR <1.5 before surgery. Do NOT wait for FFP alone. Contact haematology for guidance.
Follow-up Q2: "While waiting for neurosurgery the patient's right pupil becomes fixed and dilated. What is happening and what do you do?"
Expected: Uncal herniation — CN III compression by expanding haematoma. This is pre-terminal. Immediately: call neurosurgery for emergency burr hole. Temporising: head of bed 30°, osmotherapy (mannitol 0.5–1g/kg IV or hypertonic saline 3%), avoid hypoxia/hypotension/hypercapnia. Consider intubation if GCS deteriorating.
| Criterion | Marks |
|---|---|
| CT Interpretation | |
| States systematic approach — confirms patient details, date, side marker | 1 |
| Correctly identifies hyperdense crescent-shaped collection — subdural haematoma | 2 |
| Correctly lateralises — right-sided | 1 |
| Identifies midline shift — direction and approximate magnitude (8mm to left) | 2 |
| Notes sulcal effacement — cerebral oedema / mass effect | 1 |
| Correctly distinguishes SDH from EDH — crescent shape, crosses sutures | 1 |
| Immediate Management | |
| Urgent neurosurgical referral — does not delay | 2 |
| Anticoagulation reversal — Vitamin K + PCC (Beriplex). Not FFP alone. Target INR <1.5 | 3 |
| Herniation Response | |
| Correctly identifies uncal herniation — CN III palsy, ipsilateral fixed dilated pupil | 2 |
| Appropriate temporising measures — osmotherapy, head up, avoid secondary insults | 2 |
| States emergency surgical decompression required — burr hole | 1 |
| Airway management — considers RSI for GCS deterioration | 1 |
| Total | 20 |