10 new structured stations — respiratory emergencies, neurology, critical care procedures, difficult communication scenarios and advanced ECG interpretation.
You are the ED doctor. Miss Sarah Ahmed, 32 years old, presents with acute breathlessness and audible wheeze. She is a known asthmatic.
Triage obs: RR 28, SpO₂ 90% on air, HR 112, BP 126/80, PEFR 38% predicted. Speaking in short sentences.
Please take a focused history. You have 8 minutes.
⚠️ Examiner / Role-player Instructions — Not for Candidate
You are Sarah Ahmed. You are visibly breathless and speak in short phrases — pause between sentences. The diagnosis is acute severe asthma triggered by cat allergen exposure. You have been forgetting your preventer inhaler for the past 2 weeks.
| Criterion | Marks |
|---|---|
| Breathlessness History | |
| Onset, duration, progression and severity of breathlessness elicited | 2 |
| Associated wheeze, cough, chest tightness, fever asked | 1 |
| Severity Assessment | |
| Correctly applies BTS classification — identifies acute severe (PEFR 38%, RR 28, HR 112, short sentences) | 2 |
| Life-threatening features screened — SpO₂, silent chest, exhaustion, altered consciousness | 2 |
| Triggers and Risk Factors | |
| Cat allergen trigger identified | 1 |
| Other triggers screened — aspirin/NSAID allergy specifically asked | 1 |
| Medication History | |
| ICS compliance assessed — non-compliance with Clenil identified | 2 |
| SABA frequency today elicited — 4 uses (poor response) | 1 |
| Background History | |
| Previous ED attendances and ITU admission asked — key risk marker | 2 |
| Oral steroid use in past year asked | 1 |
| Written action plan and last asthma review asked | 1 |
| Communication | |
| Adapts communication to breathless patient — brief questions, allows pauses | 1 |
| Total | 20 |
You are the ED doctor. Mr David Chen, 58 years old, presents with a 2-hour history of palpitations and mild breathlessness.
Triage obs: HR 138 irregularly irregular, BP 112/74, SpO₂ 96%, RR 18. ECG shows atrial fibrillation.
Please take a focused history. You have 8 minutes.
⚠️ Examiner / Role-player Instructions — Not for Candidate
You are Mr David Chen. You are anxious but comfortable at rest. This is your first episode of AF. CHA₂DS₂-VASc score is 2 (hypertension, diabetes). No previous anticoagulation. Admit to significant alcohol intake if asked directly.
| Criterion | Marks |
|---|---|
| Palpitations History | |
| Onset, duration and character of palpitations fully elicited | 2 |
| Associated symptoms — chest pain, syncope, dyspnoea asked | 1 |
| CHA₂DS₂-VASc Assessment | |
| Hypertension and diabetes identified as risk factors | 2 |
| Stroke/TIA history, heart failure, vascular disease screened | 2 |
| Age risk stratification applied — correctly scores 2 (HTN + DM, age <65) | 1 |
| Precipitants | |
| Alcohol intake asked — significant excess identified | 2 |
| Thyroid symptoms systematically screened | 2 |
| Caffeine, drugs, infection, recent surgery asked | 1 |
| Previous Episodes and Medications | |
| First episode vs recurrent confirmed — first episode established | 1 |
| Current medications and anticoagulation status clarified | 1 |
| Communication | |
| Systematic, structured history. Checks understanding and addresses concern | 2 |
| Total | 20 |
A 55-year-old man presents with right leg weakness and an abnormal gait after a road traffic accident 6 hours ago. CT head and cervical spine have been performed.
Please perform a focused lower limb neurological examination. The examiner will provide findings. Present your findings and localise the lesion.
⚠️ Examiner Instructions — Not for Candidate
Findings represent a right-sided UMN lesion — consistent with contralateral hemisphere or ipsilateral cord pathology. Feed findings progressively as candidate examines each component.
| Criterion | Marks |
|---|---|
| Inspection | |
| Inspects both limbs — correctly notes no wasting, no fasciculations | 1 |
| Tone | |
| Tone assessed correctly both sides — spasticity and clonus identified right | 2 |
| Power | |
| All major muscle groups tested with correct MRC grading both sides | 2 |
| Correct root values stated for tested muscles (at least 3 correct) | 1 |
| Reflexes | |
| Knee and ankle reflexes elicited bilaterally — hyperreflexia right documented | 2 |
| Plantar responses tested — Babinski positive right, flexor left | 2 |
| Sensation and Coordination | |
| Light touch and pin-prick tested dermatomally — sensory loss right documented | 1 |
| Vibration and JPS tested — impaired right | 1 |
| Heel-shin coordination tested — right ataxia noted | 1 |
| Gait and Diagnosis | |
| Gait assessed — circumduction (spastic gait) described | 1 |
| Correctly identifies UMN pattern and localises lesion — contralateral hemisphere or ipsilateral cord | 2 |
| States need for urgent MRI spine/CT/MRI brain as appropriate | 1 |
| Total | 20 |
A 45-year-old woman presents to ED with a 2-day history of right facial weakness and horizontal diplopia. She is otherwise systemically well. GCS 15.
Please perform a systematic cranial nerve examination. The examiner will provide findings. State your diagnosis and management plan.
⚠️ Examiner Instructions — Not for Candidate
Findings represent right CN VII LMN palsy (Bell's palsy) and right CN VI palsy. If candidate does not differentiate UMN from LMN facial palsy, prompt: "Is the forehead spared or involved on the right side?"
| Criterion | Marks |
|---|---|
| CN II — Vision | |
| Visual acuity, fields and pupil reactions tested — all normal documented | 2 |
| CN III, IV, VI — Eye Movements | |
| Extra-ocular movements tested in H-pattern — diplopia elicited on right lateral gaze | 2 |
| Correctly identifies right CN VI palsy — failure to abduct right eye | 2 |
| CN V — Trigeminal | |
| Facial sensation tested V1–V3 bilaterally — correctly normal | 1 |
| Corneal reflex tested — reduced right blink (CN VII efferent) with intact left | 1 |
| CN VII — Facial | |
| Forehead, eye closure and lower face all tested separately | 2 |
| Correctly identifies LMN pattern — forehead involved (distinguishes from UMN/stroke) | 2 |
| Remaining Nerves | |
| CN VIII hearing tested — normal bilaterally | 1 |
| CN IX/X — palate, voice. CN XI — SCM, trapezius. CN XII — tongue. All tested systematically. | 1 |
| Diagnosis and Management | |
| Correct diagnosis — right Bell's palsy (LMN CN VII) and right CN VI palsy | 2 |
| Management — prednisolone within 72h, eye protection (lubricating drops, tape at night), ophthalmology if corneal exposure, MRI brain to exclude pontine lesion given CN VI also involved | 1 |
| Total | 20 |
A 67-year-old man presents with septic shock secondary to pneumonia. He has no peripheral venous access after multiple attempts. He requires central venous access for vasopressors and ongoing resuscitation.
Obs: HR 122, BP 78/44, RR 28, Temp 38.9°C, SpO₂ 94% on 15L O₂.
Please talk through how you would insert a right internal jugular central venous catheter using the Seldinger technique. You have 8 minutes.
⚠️ Examiner Instructions — Not for Candidate
Ask: "As you pass the guidewire you notice frequent ectopics on the monitor — what do you do?" (Expected: wire has entered right ventricle — withdraw wire to SVC level, ectopics should resolve). Also ask: "The post-procedure CXR shows a small right apical pneumothorax — what is your management?"
| Criterion | Marks |
|---|---|
| Preparation | |
| Indications confirmed, consent obtained (or documented if unable), coagulopathy checked | 1 |
| Site selection — RIJ chosen with justification. Trendelenburg positioning stated. | 2 |
| Full aseptic technique — sterile gown, gloves, large drape, chlorhexidine prep | 2 |
| USS guidance stated — real-time, per NICE guidance | 2 |
| Seldinger Technique | |
| Correct sequence — needle, wire, nick, dilator, CVC, wire removal, aspirate/flush | 3 |
| Venous blood confirmed before wire insertion — non-pulsatile, dark | 1 |
| Wire ectopics recognised — withdraws wire to SVC level | 2 |
| Confirmation and Complications | |
| CXR post-procedure — tip position at SVC/RA junction confirmed | 2 |
| Complications named — arterial puncture, pneumothorax, air embolism, infection | 2 |
| Pneumothorax management — if small and asymptomatic observe; if large or symptomatic drain | 1 |
| Total | 20 |
A 72-year-old man with a reduced GCS of 9 (E2V3M4) following a large right MCA stroke is being managed in resus. He has no swallow reflex. The neurology team have requested nasogastric tube insertion for enteral feeding and medications.
Please talk through how you would insert an NGT, including relevant checks, the procedure, and how you confirm correct placement. You have 8 minutes.
⚠️ Examiner Instructions — Not for Candidate
Ask: "The pH aspirate comes back as 6.2 — what do you do?" (Expected: cannot confirm safe — request CXR before using. Do not feed.) Also ask: "Why is the 'whoosh test' not acceptable as sole confirmation?"
| Criterion | Marks |
|---|---|
| Indications and Contraindications | |
| Indication stated — dysphagia/reduced GCS requiring enteral nutrition | 1 |
| Base of skull fracture as key contraindication — orogastric route alternative named | 2 |
| Checks for mid-face trauma, oesophageal pathology | 1 |
| Preparation and Technique | |
| NEX measurement performed to estimate correct depth | 1 |
| Correct positioning — 30–45° upright. Lubrication. Insertion along floor of nasal passage. | 2 |
| Does not force if resistance. Swallowing manoeuvre mentioned if applicable. | 1 |
| Confirmation of Position | |
| pH testing of aspirate as primary method — pH ≤5.5 = safe | 2 |
| pH 6.2 scenario — correctly states CXR required before use | 2 |
| Correctly rejects "whoosh test" as unreliable sole confirmation — explains rationale | 2 |
| Documentation and Complications | |
| Documents position, depth at nostril, confirms before each feed/medication | 1 |
| Pulmonary placement as key complication — recognition and management | 2 |
| Nasal trauma, aspiration, coiling in pharynx mentioned | 1 |
| Total | 20 |
You are the ED registrar. Mr Kieran Walsh, 44 years old, was brought in by ambulance 90 minutes ago with a 3-hour history of central chest pain. His first troponin is pending (result due in 30 minutes). His ECG shows sinus rhythm with non-specific changes. He is currently pain-free.
The nurse has informed you that Mr Walsh is asking to self-discharge as he needs to get to work. He is alert and oriented.
Please speak with Mr Walsh. You have 8 minutes.
⚠️ Examiner / Role-player Instructions — Not for Candidate
You are Mr Kieran Walsh. You are anxious but not angry. You are worried about your job — you manage a team and have a critical presentation at 2pm. You are not chest-pain-free but feel "fine now." You have no medical knowledge. If the candidate takes time to listen to your concerns and explains clearly what troponin is, you will agree to wait for the result. You are capacitous throughout.
| Criterion | Marks |
|---|---|
| Engagement and Exploration | |
| Introduces self, establishes rapport — does not immediately start with risks | 1 |
| Explores and addresses the specific reason for leaving — work concern acknowledged | 2 |
| Capacity Assessment | |
| Mental capacity assessed — all four MCA criteria addressed (understand, retain, weigh up, communicate) | 3 |
| Correctly identifies patient as capacitous — right to leave respected | 1 |
| Risk Communication | |
| Troponin explained in plain English — "a heart protein released if heart muscle is damaged" | 2 |
| Risks of leaving explained clearly — cardiac arrest, missed MI, need for urgent intervention | 2 |
| Compromise offered — wait 30 minutes for result, practical offer to help | 2 |
| If Patient Still Insists on Leaving | |
| Does not detain or coerce. DAMA form offered but not forced. | 1 |
| Safety-netting provided — return if pain, breathlessness, sweating, collapse | 2 |
| Documentation | |
| States will document conversation, capacity assessment, risks explained and safety-netting in notes. Informs senior. | 1 |
| Empathic, non-confrontational throughout. Does not use jargon. | 1 |
| Total | 20 |
You are the ED registrar. You receive a phone call from Dr Priya Sharma, a GP, regarding a patient she saw in surgery 30 minutes ago. She is calling for advice about whether to send the patient to ED or manage in the community.
The patient is Mr James Norton, 62 years old. He presents with a 2-day history of central chest pain, worse on exertion, partially relieved by rest. New T-wave inversions in V4–V6 on the GP's ECG. He has not been sent in yet.
Please take the necessary history over the phone, risk-stratify the patient, give clear advice, and safety-net. You have 8 minutes.
⚠️ Examiner / Role-player Instructions — Not for Candidate
You are Dr Priya Sharma. You are a competent GP seeking specialist advice. Risk factors to disclose if asked: hypertension (controlled), type 2 diabetes, ex-smoker 10 years, no previous cardiac history. Patient is currently pain-free and stable in your surgery. You ask at the end: "Can I just give him an urgent cardiology OPD appointment instead of sending him to ED?"
| Criterion | Marks |
|---|---|
| Communication Structure | |
| Introduces self clearly — name and grade. Confirms patient details before proceeding. | 1 |
| Structured telephone history — systematic, not disorganised | 1 |
| History Taking | |
| Cardiac character of pain elicited — exertional, radiation, associated symptoms | 2 |
| Risk factors systematically assessed — HTN, DM, smoking, family history, previous cardiac events | 2 |
| Current haemodynamic status and symptom status confirmed | 1 |
| Risk Stratification | |
| HEART score applied or equivalent systematic risk assessment — intermediate/high risk identified | 2 |
| Correctly identifies need for serial troponins — cannot risk-stratify without this | 2 |
| Advice and Safety-netting | |
| Clear recommendation — send to ED today, not OPD. Justification given. | 2 |
| Rejects cardiology OPD suggestion — explains serial troponin and monitoring requirement | 2 |
| Safety-netting — if deteriorates call 999. Aspirin 300mg if ongoing pain, no contraindication. | 2 |
| States will document the call — time, advice, clinician names | 1 |
| Total | 20 |
A 78-year-old man is brought in by ambulance after a syncopal episode at home. His wife reports he collapsed without warning and was unresponsive for approximately 2 minutes. He has regained consciousness but is drowsy and confused. He is on no cardiac medications.
Obs: HR 38, BP 78/46, RR 18, SpO₂ 96% on air, GCS 13 (E3V4M6).
The ECG shows: ventricular rate 38bpm, regular QRS complexes; atrial rate 76bpm, regular P waves; P waves and QRS complexes appear unrelated to each other; QRS broad at 160ms.
Please interpret this ECG and describe your immediate management. You have 8 minutes.
⚠️ Examiner Instructions — Not for Candidate
Ask: "You give atropine 500mcg IV — the rate does not improve. What do you do next?" (Expected: transcutaneous pacing — set rate 70–80bpm, increase current until capture, check for mechanical capture with pulse check). Also ask: "What additional investigation would change your immediate management priority?" (Expected: urgent 12-lead to look for inferior MI — STEMI with CHB = primary PCI immediately).
| Criterion | Marks |
|---|---|
| ECG Interpretation | |
| Systematic approach — rate, rhythm, axis, P waves, QRS, ST/T stated | 1 |
| Ventricular rate (38) and atrial rate (76) identified separately | 2 |
| Complete AV dissociation identified — P waves and QRS unrelated | 2 |
| Broad QRS escape rhythm — ventricular origin (below bundle of His) | 1 |
| Correct diagnosis — complete (third-degree) AV block | 2 |
| Causes | |
| At least 3 causes named — inferior MI, drugs, Lyme disease, fibrosis, anterior MI | 2 |
| Recognises inferior MI association — states urgent 12-lead + troponin to exclude STEMI | 1 |
| Management | |
| ABC, IV access, monitoring, urgent cardiology | 1 |
| Atropine 500mcg IV — states may not work in infranodal (broad QRS) block | 2 |
| Transcutaneous pacing — technique described correctly (rate 70–80, increase current until capture, check pulse) | 2 |
| Temporary transvenous pacing and permanent pacemaker as definitive treatment | 1 |
| Offending medications withheld — AV-nodal blocking drugs | 1 |
| Total | 20 |
A 65-year-old man with a history of previous MI presents with a 20-minute history of palpitations and presyncope. He is pale and diaphoretic. He is conscious and talking in full sentences.
Obs: HR 182, BP 88/54, RR 22, SpO₂ 96% on air.
The ECG shows: broad complex tachycardia, rate 182bpm, regular; QRS width 160ms; AV dissociation visible (P waves independent of QRS); fusion beats present in leads II and III; capture beats visible; positive concordance in chest leads V1–V6.
Please interpret this ECG, differentiate from SVT with aberrancy, and describe your management. You have 8 minutes.
⚠️ Examiner Instructions — Not for Candidate
Ask: "A colleague suggests this could be SVT with aberrancy and recommends verapamil — what do you say?" (Expected: Do NOT give verapamil to broad complex tachycardia of uncertain origin. If VT — verapamil causes profound hypotension and VF. Treat as VT.) Also ask: "The patient suddenly becomes unresponsive with no palpable pulse — what is your next step?" (Expected: Unsynchronised defibrillation — pVT/VF, start ALS protocol.)
| Criterion | Marks |
|---|---|
| ECG Interpretation | |
| Systematic approach — rate, rhythm, QRS width, axis documented | 1 |
| Broad complex tachycardia at 182bpm correctly described | 1 |
| AV dissociation identified — P waves independent of QRS | 2 |
| Fusion beats and/or capture beats identified — pathognomonic of VT | 2 |
| Positive concordance in V1–V6 identified as VT feature | 1 |
| Correct diagnosis — ventricular tachycardia | 2 |
| VT vs SVT Differentiation | |
| Brugada criteria applied or equivalent systematic approach | 2 |
| Correctly rejects verapamil — explains risk of cardiovascular collapse in VT | 2 |
| Management | |
| Haemodynamically unstable — synchronised DC cardioversion 200J stated (not amiodarone first) | 2 |
| If pulseless — unsynchronised defibrillation, ALS protocol | 2 |
| Electrolyte correction — K⁺ and Mg²⁺ targets stated. Cardiology involvement. | 1 |
| Post-conversion — identify cause, ICD consideration in structural heart disease | 1 |
| Does not use adenosine as first-line in unstable broad complex tachycardia | 1 |
| Total | 20 |