10 new structured stations — haematuria, early pregnancy, scaphoid injury, rheumatoid hand, cricothyroidotomy, ear foreign body, interpreter consent, police disclosure, long QT syndrome and warfarin reversal.
0/ 10 completed
10Stations
5Domain types
8Min / station
0/10 completed
📋 History Taking
📋
Haematuria History — Suspected Bladder Cancer
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. Mr David Okonkwo, 68 years old, is referred by his GP with a 2-week history of painless visible haematuria. He has no urinary tract infection symptoms and his urine dipstick shows blood +++, no nitrites, no leucocytes.
Triage obs: HR 76, BP 138/84, RR 14, SpO₂ 98% on air, Temp 36.8°C. He looks well.
Please take a focused history and explain to Mr Okonkwo your initial management plan. You have 8 minutes.
Critical safety point: Painless visible haematuria in a patient >45 years old = bladder transitional cell carcinoma (TCC) or renal cell carcinoma until proven otherwise. Must not be attributed to anticoagulants, UTI or benign causes without full investigation.
SOCRATES for haematuria: Onset and duration (2 weeks — new onset). Character — colour (bright red/claret/smoky). Timing in urinary stream — initial (urethral/prostatic), terminal (bladder neck/trigone), total (bladder/upper tract). Clot passage (clot shape: worm-like = upper tract; irregular = bladder). Any associated pain (painless = high-risk for malignancy). Volume — gross vs microscopic.
Associated LUTS: Frequency, urgency, nocturia, hesitancy, poor stream, terminal dribble, incomplete emptying (suggest prostate involvement or LUTS from BPH — can coexist with malignancy). Dysuria suggests UTI or stone. Suprapubic or flank pain.
Systemic symptoms: Weight loss, anorexia, malaise, night sweats (systemic malignancy). Flank pain ± loin mass (renal cell carcinoma — classic triad: haematuria, loin pain, loin mass in only 10%).
Smoking history — strongest modifiable risk factor: Pack-year history. Current or ex-smoker. Bladder TCC: smoking doubles to quadruples risk. Duration and pack-years most important.
Medications: Anticoagulants (warfarin, DOACs, heparin — haematuria on anticoagulants still requires full investigation, never assume anticoagulant is the cause). Cyclophosphamide (haemorrhagic cystitis). Phenacetin-containing analgesics (transitional cell of renal pelvis). NSAIDs (nephritis).
PMH: Previous UTIs, renal stones (calcium oxalate — RBC on dip without infection). Renal disease (IgA nephropathy — commonest cause of glomerular haematuria; Alport's syndrome). Previous pelvic radiotherapy. BPH.
NICE 2-week wait (urgent suspected cancer) criteria: Age >45 + unexplained visible haematuria without UTI or in addition to UTI. Age >60 + unexplained non-visible haematuria + dysuria or raised PSA. Any age + visible haematuria + concurrent urological abnormalities on imaging or dipstick. Unexplained recurrent or persistent non-visible haematuria in 60+ year olds.
Investigations: Urine MC&S (exclude infection), urine cytology ×3 (sensitivity 50% for TCC), USS KUB (first-line upper tract imaging), FBC (anaemia of chronic disease), U&Es (renal function), PSA in males, flexible cystoscopy (gold standard for bladder pathology — organised via urology 2WW).
⚠️ Examiner / Role-player Instructions — Not for Candidate
You are Mr David Okonkwo. You are quietly worried you have cancer but haven't said so. You have smoked 20 cigarettes/day for 40 years. You worked in a rubber factory in your 30s and 40s. You are on no anticoagulants. No LUTS symptoms. No weight loss. The diagnosis in this scenario is bladder TCC until proven otherwise — 2-week wait urology referral appropriate.
🎭 Patient Script ▼
Haematuria: Noticed blood in the urine about 2 weeks ago. Bright red. Happens every time he passes urine. No pain at all. Has passed a couple of dark clots. No burning, no frequency. Urine smells normal.
Systemic: No weight loss, no fevers, appetite normal. No loin pain. No swelling anywhere.
Smoking: Smoked 20 a day since age 28 — so about 40 years. Tried to stop but never managed it.
Occupation: Retired. Worked in a rubber factory in Birmingham for 20 years. If asked specifically about chemicals: "There were all sorts of chemicals around — I didn't really ask questions in those days."
Medications: Amlodipine, atorvastatin. No blood thinners. No cyclophosphamide.
Hidden concern (if asked what worries him): "My brother had cancer of the bladder, doctor. Is that what this is?"
🔔 Examiner Cues ▼
If candidate hasn't asked about smoking by 3 minutes: "Are there any lifestyle factors that could be relevant to this presentation?"
If candidate attributes haematuria to medications (amlodipine/statin): Challenge — "Should we still investigate this fully even if a medication might be contributing?"
At 7 minutes: "What is your management plan and does he need a 2-week wait referral?"
Criterion
Marks
Haematuria Characterisation
Painless nature identified — states significance: malignancy until excluded (2WW criteria)
2
Timing in urinary stream (initial/terminal/total), colour, clot passage asked
Empathic communication — patient's cancer concern addressed sensitively and honestly
2
Total
20
📋
PV Bleeding — Early Pregnancy (Exclude Ectopic)
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. Miss Jade Moreau, 23 years old, presents with a 2-day history of light PV bleeding and right-sided lower abdominal pain. Her LMP was 7 weeks ago and she has had a positive home pregnancy test.
Triage obs: HR 104, BP 98/62, RR 18, SpO₂ 99% on air, Temp 37.1°C.
Please take a focused history, assess haemodynamic stability, and explain your management plan. You have 8 minutes.
💡 Key areas — Ectopic Pregnancy Red Flags, Differentials, Management ▼
Critical safety point — ectopic pregnancy is the diagnosis until excluded: Ectopic = life-threatening. Presentation can be indolent. Haemodynamic instability (tachycardia, hypotension) is a late sign. This patient has HR 104 and BP 98/62 — she is compromised. Do NOT delay IV access, fluids and gynaecology.
SOCRATES for pain: Site — right iliac fossa / right lower quadrant. Onset — 2 days, gradual. Character — dull ache, crampy. Radiation — shoulder tip pain (diaphragmatic irritation from haemoperitoneum = pathognomonic of ruptured ectopic — ask specifically). Severity. Timing. Relieving/exacerbating factors.
PV bleeding assessment: Amount (spotting vs soaking pads), colour (dark brown = old blood; fresh red = active), clots, passage of tissue (grey/white — products of conception suggest miscarriage, not ectopic). Ectopic typically gives irregular, scanty dark bleeding rather than heavy red bleeding of miscarriage.
Pregnancy history: LMP and gestational age (7 weeks). Method of confirmation — home test, GP, USS. This pregnancy planned? IVF? Previous pregnancies (G_P_): miscarriages, ectopics, terminations. The single biggest risk factor for ectopic is previous ectopic (10-fold increased risk).
Risk factors for ectopic: Previous ectopic, previous PID or STI (Chlamydia — tubal scarring), previous tubal surgery (salpingotomy, sterilisation reversal), IUCD in situ (if IUD and pregnant = ectopic until excluded — IUD prevents IUP but not ectopic), IVF (increased ectopic rate), current progesterone-only pill or Mirena (decreased peristalsis), smoking.
Sexual health history (sensitively): Number of partners, previous STIs (Chlamydia — most common cause of PID and tubal factor infertility), previous pelvic infections, history of PID treatment.
Haemodynamic status — CRITICAL: This patient is tachycardic (HR 104) and hypotensive (BP 98/62). This suggests haemoperitoneum from a ruptured or leaking ectopic. Immediate intervention required.
Immediate management: Two large-bore IV cannulae, blood for FBC, group and save (crossmatch if unstable), βhCG quantitative, USS pelvis (transvaginal by gynaecology), IV fluid resuscitation, gynaecology team urgently. Rhesus status — anti-D if Rh negative. Do NOT give analgesia and send home without TVS.
Differentials: Ectopic pregnancy (most dangerous — rule out first), threatened miscarriage, incomplete miscarriage, corpus luteum cyst rupture, appendicitis (can coexist with early pregnancy), ovarian torsion.
⚠️ Examiner / Role-player Instructions — Not for Candidate
You are Miss Jade Moreau. You are anxious and in pain. The diagnosis is a right-sided ectopic pregnancy — leaking but not yet fully ruptured. You had Chlamydia treated 3 years ago. No previous pregnancies. No IUCD. This pregnancy was unplanned. If candidate asks about shoulder tip pain: "Actually yes — when I lie flat I get this strange ache in my right shoulder." Escalate distress if candidate tries to take a prolonged history without first acknowledging your haemodynamic compromise.
🎭 Patient Script ▼
Pain: Right side, lower tummy. Came on 2 days ago. Dull ache, getting worse. "About 6/10." Worse when lying flat. On direct questioning about shoulder — right shoulder ache when lying down (diaphragmatic irritation from blood).
Bleeding: Light. Brown, like old blood. No tissue passed. Nowhere near a normal period. "Not much at all — just on the tissue."
Pregnancy: LMP 7 weeks ago. Did a home test 2 weeks ago — positive. Was going to book a GP appointment. Unplanned pregnancy. First pregnancy (G1P0). No IVF, no IUCD. Not on the pill.
Sexual health: Had Chlamydia 3 years ago — treated with antibiotics. One sexual partner currently. No other STIs. No PID treatment.
PMH: Otherwise well. No previous surgery. NKDA.
Signs of haemodynamic compromise: "I feel a bit lightheaded when I stand up." "I feel really cold."
🔔 Examiner Cues ▼
If candidate takes history without first acknowledging haemodynamic instability: "While you're taking the history, the nurse tells you the repeat BP is now 90/58 — what do you do?"
If candidate hasn't asked about shoulder tip pain: "Is there any other location of pain that would be particularly significant?"
At 7 minutes: "What is your working diagnosis and your immediate management?"
Criterion
Marks
Safety Recognition
Identifies haemodynamic compromise (HR 104, BP 98/62) — states immediate action required, not protracted history first
2
States ectopic pregnancy is working diagnosis until excluded — not reassured by light bleeding
2
Pain and Bleeding History
SOCRATES for pain — right-sided, character, onset; specifically asks for shoulder tip pain (diaphragmatic irritation)
Risk factors: previous Chlamydia/PID identified, IUCD, IVF, previous tubal surgery
2
Immediate Management
IV access ×2, IV fluids, FBC, βhCG quantitative, G&S stated
2
Urgent gynaecology referral and TVS USS stated
2
Rhesus status and anti-D considered
1
Sensitive, empathic communication — addresses patient's anxiety and explains urgency clearly
2
Total
20
🩺 Clinical Examination
🩺
Wrist Examination — Scaphoid Injury
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. A 19-year-old male fell on his outstretched right hand playing football 2 days ago. He continued playing but his wrist has remained painful. His initial X-ray, reported by the radiographer, is "no fracture identified."
Obs: Afebrile, otherwise well. The right wrist is mildly swollen with no deformity.
Please perform a focused wrist examination directed at the scaphoid. The examiner will provide findings. Present your diagnosis and management plan.
🔑 Scaphoid Examination — Structured Approach ▼
Look: Swelling (diffuse vs localised to anatomical snuffbox), bruising, deformity, skin changes. Compare both wrists. Check alignment of the hand with the forearm.
Feel — anatomical snuffbox tenderness: The anatomical snuffbox is the triangular depression on the dorsoradial aspect of the wrist, bounded by: extensor pollicis longus (posterior), extensor pollicis brevis and abductor pollicis longus (anterior), radial styloid (proximal), base of first metacarpal (distal). Tenderness here has sensitivity ~90% for scaphoid fracture. Wrist should be in slight ulnar deviation to open the snuffbox.
Feel — scaphoid tubercle tenderness: Palpate on the palmar (volar) aspect — the scaphoid tubercle is distal to the radial styloid on the palmar surface. Tenderness here — specificity higher than ASB tenderness alone.
Special test — axial compression (scaphoid compression test): Apply firm axial pressure along the axis of the thumb (longitudinal compression). Pain reproduced in the anatomical snuffbox region = positive — specific for scaphoid fracture.
Range of movement: Active and passive — flexion (normal 80°), extension (normal 70°), radial deviation (normal 20°), ulnar deviation (normal 45°). Pain on radial deviation is particularly significant. Compare with unaffected side.
Neurovascular: Radial pulse (present?), capillary refill. Median nerve — sensation over thenar eminence and palmar surface of thumb, index, middle, and radial half of ring finger. Thumb opposition (APB = purely median nerve). Radial nerve — first web space sensation.
Critical teaching point — normal X-ray does NOT exclude scaphoid fracture: Sensitivity of plain XR for acute scaphoid fracture is only 65–70%. Up to 20% of scaphoid fractures are occult on initial XR. MRI is gold standard (sensitivity ~95%). CT alternative if MRI unavailable. Bone scan at 3–4 days (high sensitivity, lower specificity).
Management: Treat as scaphoid fracture until proven otherwise. Apply thumb spica (scaphoid cast) from interphalangeal joint of thumb to just below elbow, wrist in slight extension and radial deviation. Arrange MRI or CT within 7 days. Do not discharge without a follow-up plan. Analgesia.
Risk of missed scaphoid fracture: Avascular necrosis of the proximal pole (blood supply retrograde — proximal pole at highest risk). Scaphoid non-union → wrist arthritis (SNAC wrist — Scaphoid Non-union Advanced Collapse). These complications are preventable with early diagnosis and immobilisation.
⚠️ Examiner Instructions — Not for Candidate
Feed these findings: Mild diffuse swelling right wrist, no deformity. Anatomical snuffbox tenderness +++. Scaphoid tubercle tenderness +. Axial compression test: positive (pain reproduced in snuffbox). ROM — reduced in all directions due to pain, particularly radial deviation. Neurovascular: radial pulse present, median nerve sensation and thumb opposition intact. If candidate plans to discharge without further imaging: "The patient wants to know if the X-ray being normal means he's fine to go back to playing football next week."
🔔 Examiner Cues ▼
If candidate does not test axial compression: "Is there any specific provocation test for the scaphoid you'd want to perform?"
If candidate accepts normal XR as ruling out fracture: "What is the sensitivity of plain XR for acute scaphoid fracture?"
If candidate applies scaphoid cast: "What range does the cast cover and in what position do you apply it?"
At 7 minutes: "What are the complications of a missed scaphoid fracture?"
Clear patient explanation — reasoning given for cast despite normal XR
1
Total
20
🩺
Hand Examination — Rheumatoid Arthritis
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. Mrs Margaret Thornton, 55 years old, attends with a flare of her known painful swollen hands. She was referred to ED by her GP as her joints are significantly more swollen and painful than usual. She has been on methotrexate for 5 years.
Obs: Afebrile, HR 78, BP 126/80. Bilateral hand swelling visible on inspection.
Please perform a structured hand and wrist examination. The examiner will provide findings as you proceed. Present your diagnosis and key findings.
🔑 Rheumatoid Hand Examination — Structured Approach ▼
Introduction and GALS screen: Begin with a brief GALS (Gait, Arms, Legs, Spine) screen. For the arm component: "Can you put your hands behind your head?" (shoulder abduction + external rotation). "Can you make a fist?" (grip). "Can you open your hands fully?" (extension). "Touch each fingertip with the thumb." (fine motor).
Look — dorsal: Joint pattern — RA classically spares DIP joints; involves MCPs and PIPs symmetrically. Ulnar deviation of fingers at MCPs (characteristic of RA). Swan neck deformity (PIP hyperextension + DIP flexion — intrinsic muscle tightness). Boutonnière deformity (PIP flexion + DIP hyperextension — central slip rupture). Z-thumb (thumb MCP flexion + IP hyperextension). Wasting of dorsal interossei (most obvious in first web space). Rheumatoid nodules over extensor surfaces (indicates seropositive RA).
Feel: Warmth (dorsum of hand — compare sides). Synovitis: boggy, non-tender fullness at MCPs and PIPs — "boggy" vs bony hard OA. MCP squeeze test (lateral compression of all MCPs together) — positive = pain = active synovitis. Specific joint palpation — MCP1–5, PIP, DIP, wrist. Tendon crepitus (extensor tendons over wrist).
Move: Active then passive ROM. Wrist flexion/extension. MCP flexion/extension. PIP flexion/extension. Power grip (ask to squeeze two of your fingers). Pinch grip (thumb and index). Fine motor (button, pen writing, coin picking).
Disease activity: In a flare — tender joint count, swollen joint count, patient VAS, ESR/CRP, DAS28 score in rheumatology. ED management: analgesia, NSAID if tolerated (cautious with methotrexate — renal/GI), consider short course prednisolone for acute flare, urgent rheumatology review.
⚠️ Examiner Instructions — Not for Candidate
Feed these findings: Bilateral MCP and PIP synovitis (boggy swelling). DIP joints spared. Bilateral ulnar deviation. Swan neck deformity right index finger. First dorsal interosseous wasting bilateral. Palmar erythema. Thenar wasting right hand. Squeeze test positive bilaterally. ROM reduced throughout — power grip weak. No rheumatoid nodules. No nail fold infarcts today. If candidate diagnoses OA: "The DIP joints are spared and the swelling is boggy — does that change your diagnosis?"
🔔 Examiner Cues ▼
If candidate does not test for synovitis (squeeze test): "How specifically would you confirm active synovitis at the MCPs?"
If candidate doesn't mention extra-articular features: "What systemic complications of RA should you consider?"
At 7 minutes: "Mrs Thornton asks what is causing this flare and what can be done today. What do you tell her, and are there any specific concerns with her medications?"
You are the most senior doctor in the ED resuscitation room. A 44-year-old man has been involved in a road traffic collision. He has significant facial injuries and oropharyngeal swelling. The anaesthetist has made 3 failed intubation attempts. Videolaryngoscopy is unavailable. SpO₂ is 74% and falling. No supraglottic airway can be passed — the anatomy is distorted. There is a surgical airway kit on the trolley.
Please manage this CICO (Cannot Intubate, Cannot Oxygenate) emergency and perform a scalpel-finger-bougie cricothyroidotomy on the manikin. Verbalise your actions as you proceed.
Recognition and declaration: Verbalise "This is a CICO emergency." Declare loudly — all team members must hear. Do NOT attempt further laryngoscopy. Every attempt causes more oedema and makes the situation worse. Time to FONA (Front of Neck Airway) within 120 seconds of declaring CICO (DAS/NAP4 guidance).
Call for help: Call for surgical help (ENT/general surgery) even whilst proceeding — they may not arrive in time but the call should be made. Assign roles clearly — one person for airway drugs if needed, one to assist.
Patient positioning: Neck extended (shoulder roll or head of bed down). Neck in midline. Identify landmarks before incision.
Landmark identification: Palpate thyroid notch → run finger inferiorly along thyroid cartilage → feel the soft cricothyroid membrane (CTM) → inferior to CTM is the cricoid ring. The CTM is approximately 2.5 cm wide × 1 cm vertical. In females or obese patients — landmarks may be less distinct; use USS if immediately available.
Stabilise larynx with non-dominant hand (laryngeal handshake: thumb and middle finger either side, index finger identifies CTM).
Horizontal stab incision through skin and CTM — scalpel blade (#22 or #10) directed caudally. Single decisive incision — not tentative. Keep knife horizontal — avoid damage to cricothyroid arteries (run superior to CTM).
Hook technique — insert tracheal hook (or curved artery forceps) caudally into trachea to stabilise.
Finger sweep — insert small finger of non-dominant hand to confirm tracheal lumen. Feel the rings — confirms correct placement.
Bougie insertion — pass bougie through incision, angled caudally at 45°. Feel/hear clicks as bougie passes over tracheal rings — confirms correct passage. Resistance at 30–40 cm = carina (do not advance further).
Railroad tube — pass cuffed tracheal tube (6.0 mm ID) over bougie into trachea. Cuff inflated.
Needle cricothyroidotomy as bridge (if scalpel unavailable): 14G cannula through CTM, aspirate air, connect to high-pressure oxygen source (Sanders injector or BVM with 15L O₂). Provides ~30–45 minutes oxygenation but no ventilation — CO₂ rises. Do NOT use if there is complete upper airway obstruction — air trapping and barotrauma. Definitive surgical airway must follow immediately.
Common errors to avoid: Hesitation/not declaring CICO. Attempting further laryngoscopy. Inserting bougie without confirming lumen (false passage — subcutaneous emphysema, no ventilation). Inflating cuff before confirming with capnography. Not calling for surgical help.
⚠️ Examiner Instructions — Not for Candidate
This is a CICO simulation on a manikin. The candidate must verbalise their actions. Give real-time SpO₂ updates: "SpO₂ 68% and falling" at 30 seconds if no action. "SpO₂ 62% and bradycardic" at 60 seconds if still no action. Key decision points: Does the candidate declare CICO and stop further laryngoscopy immediately? Do they proceed to front-of-neck access within 2 minutes? Do they confirm placement with waveform capnography?
🔔 Examiner Cues ▼
If candidate attempts further laryngoscopy: "The anaesthetist says the view is now grade 4 and the oropharynx is filling with blood. SpO₂ is now 62%."
If candidate inserts cannula (needle cric): Award partial marks but ask — "Is needle cricothyroidotomy definitive management, and what are the limitations in this scenario?"
After tube placement: "How do you confirm correct placement?" (Expected: waveform capnography — not CO₂ colorimetric alone, not chest auscultation alone.)
At the end: "What happens next — is this a permanent airway?"
Criterion
Marks
Recognition and Team Management
Declares CICO emergency verbally — team informed; no further laryngoscopy attempted
2
Calls for help — surgical team, assigns roles to resus team
1
Patient positioned — neck extended, midline
1
Landmark Identification
Laryngeal handshake performed — thyroid notch, thyroid cartilage, CTM, cricoid identified in sequence
2
Scalpel-Finger-Bougie Technique
Horizontal stab incision through CTM — deliberate and decisive, caudal direction
2
Finger sweep performed — confirms tracheal lumen, feels rings
2
Bougie passed caudally at 45° — tracheal ring clicks sought or confirmed
2
Tube railroaded over bougie, cuff inflated, bougie removed
2
Confirmation and Post-Procedure
Placement confirmed — waveform capnography stated as gold standard
2
Needle cricothyroidotomy described as temporising bridge only — limitations in complete obstruction stated
1
Tube secured, surgical referral for tracheostomy, post-procedure monitoring stated
1
Total
20
🔧
Foreign Body Removal — Ear (Paediatric)
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
A 4-year-old girl is brought by her mother to ED. Her mother says she watched her daughter put a small plastic bead into her right ear approximately 2 hours ago. The child is otherwise well, no pain, no discharge. The child is cooperative with examination.
Obs: Afebrile. Observations normal for age. Right ear — no visible external swelling or redness.
Please examine the ear and manage the foreign body. You may talk through your approach with the examiner as if they are the parent. Appropriate equipment is available.
💡 Ear Foreign Body — Assessment and Removal ▼
History points before any attempt: Type of object (hard/smooth vs soft/organic vs live insect — significantly changes approach). Duration in ear. Any attempts at removal already — increases inflammation and chance of impaction. Hearing changes, pain, discharge, previous ear problems, TM perforation (history of grommets).
Otoscopy — EXAMINE FIRST: Use appropriate otoscope with good light. For a child, pull pinna posteriorly and slightly superiorly to straighten the EAC. Identify: object type, location (outer third vs inner two thirds — proximity to TM), TM status (intact or perforated), surrounding canal (inflamed, oedematous, bleeding). Document what you find before any attempt at removal.
Technique selection — crucial:
Smooth hard object (bead, stone, button battery): Jobson-Horne probe (wire loop/hook) or crocodile forceps (alligator forceps). Use hook to pass behind object and withdraw anteriorly. Crocodile forceps for objects with a graspable edge. Do NOT use forceps on smooth round objects — risk of pushing deeper.
Soft/organic object (pea, bean, sponge): Forceps are appropriate. Suction (Frazier suction). Do NOT irrigate organic matter — swells with water, impaction worsens.
Live insect: Instil mineral oil (or lidocaine) into EAC first to immobilise/kill insect — attempting removal of a live insect is distressing and risks bites/stings causing more injury. Then irrigate or forceps removal.
Irrigation (syringing): Contraindicated if organic FB (swells), suspected TM perforation, vegetable matter, batteries, or object tightly impacted. Otherwise useful for outer-canal objects.
Button battery — URGENT: Causes liquefactive necrosis within hours due to electrolysis. Must be removed immediately. Do NOT irrigate. ENT emergency.
Child positioning: Parent holds child — child sits on parent's lap, parent's arm across child's body to prevent movement, parent's other hand holds child's head firmly against parent's chest. Never attempt removal without adequate restraint in an uncooperative child. Sedation may be required for uncooperative children rather than risk trauma.
Maximum attempts in ED: 2. If unsuccessful after 2 attempts — do not persist. Refer to ENT. Each failed attempt increases inflammation, pain, and chance of injury or impaction.
ENT referral criteria: Failed removal after 2 attempts. Live insect if mineral oil not available. Sharp object. Button battery (urgent regardless). Impacted object. TM perforation. Child who cannot be adequately restrained.
Post-removal: Repeat otoscopy to confirm complete removal, inspect TM and canal integrity. Advise parent — no cotton wool, no eardrops unless instructed. Return if pain, discharge, or hearing change develops.
⚠️ Examiner / Role-player Instructions — Not for Candidate
Play the role of the mother. The object is a smooth plastic bead, approximately 5mm, visible in the right outer third of EAC on otoscopy. TM is intact. No previous ear problems. No grommets. No hearing loss before this episode. If candidate attempts irrigation without asking about TM: "She had a grommet in that ear 2 years ago — does that matter?" (Expected: check TM integrity first, grommets mean TM was previously not intact — approach changes.)
🎭 Parent Script ▼
If asked about type of FB: "It's a small round plastic bead from her craft set. About 5mm — I saw her put it in."
If asked about previous attempts: "I tried to get it out with a cotton bud at home — I know I shouldn't have." (This may have pushed it slightly deeper.)
If asked about TM history: "She had a grommet in that ear 2 years ago — the ENT said it fell out naturally."
If asked about battery risk: "No, it's definitely not a battery, I can see it's a plastic bead."
If candidate explains plan clearly: "Thank you — she's normally very good with doctors, she'll sit still."
🔔 Examiner Cues ▼
If candidate selects forceps for a smooth round bead: "What's the risk of using forceps on a smooth round object?"
If candidate plans irrigation: Reveal grommet history — ask candidate if this changes management.
If candidate makes 2 failed attempts and wants to try again: "Is there a maximum number of attempts you should make in the ED?"
At the end: "What advice do you give to the mother after successful removal?"
Criterion
Marks
Assessment
Otoscopy performed first — FB confirmed, location, type, TM integrity assessed before any attempt
2
History of previous attempts and grommet history asked before proceeding
2
Technique Selection
Correct instrument selected — Jobson-Horne probe or hook for smooth round bead; explains why not forceps (risk of pushing deeper)
2
States irrigation contraindicated — previous grommet (potential TM defect) and not appropriate for smooth hard objects
2
Live insect management — mineral oil first to immobilise insect before removal
1
Button battery identified as ENT emergency requiring immediate removal
1
Safe Technique and Limits
Child correctly positioned — parent holds, head immobilised, good lighting secured
2
Maximum 2 attempts in ED — does not persist if unsuccessful; ENT referral if failed
2
Post-Removal and Communication
Post-removal otoscopy — confirms complete removal, TM and canal checked
2
Parent communication — clear explanation throughout, post-procedure advice, safety net
2
Total
20
💬 Communication
💬
Obtaining Consent via Interpreter — Emergency Surgery
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 doctor. Mrs Fatima Al-Rashid, 45 years old, has presented with a 24-hour history of severe right iliac fossa pain, fever, and vomiting. CT abdomen has confirmed acute appendicitis. She requires an emergency appendicectomy tonight. She speaks Arabic only and no family members are present.
Obs: HR 108, Temp 38.4°C, BP 112/72. Alert and communicating through gestures.
You have arranged a professional telephone interpreter (Arabic). The examiner will play the role of Mrs Al-Rashid. Please obtain informed consent for the appendicectomy. You have 8 minutes.
💡 Consent via Interpreter — Key Principles ▼
Professional interpreter — NOT family or digital tools: A family member acting as interpreter has a conflict of interest, may filter or modify information, and their own distress may affect accuracy. Google Translate and apps are not validated for medical consent. Use a professional telephone or in-person interpreter service (e.g. Language Line, Capita). Record the interpreter's name and ID number in the notes.
Introduction and setup: Introduce yourself to the patient (via interpreter). Introduce the interpreter — name, role. Ask the interpreter to interpret everything said, including if the patient says anything not directed at you. Speak directly to the patient, not to the interpreter ("Mrs Al-Rashid, the CT scan has shown...").
Consent process (Montgomery standard — UK): Diagnosis clearly explained. Proposed treatment explained — what the operation involves (laparoscopic or open appendicectomy, GA, removal of appendix). Why it is needed — risk of perforation, peritonitis, death if untreated. Alternatives — antibiotic treatment (conservative management — explain success rate ~70%, but higher failure rate in severe cases, only appropriate in uncomplicated appendicitis; CT confirmed surgical case here). Risk of not having the operation explained.
Specific risks (appendicectomy): Common: wound infection (5–10%), nausea and vomiting post-GA, shoulder tip pain (laparoscopic gas). Uncommon: bleeding, ileus. Rare: conversion to open surgery (explain this proactively — do not let patient be surprised if laparoscopic not possible), bowel injury, hernia at port site, anastomotic leak, deep vein thrombosis, pulmonary embolism. Anaesthetic risks including mortality (very low — 1:100,000).
Capacity assessment under MCA 2005: Four functional tests: (1) Understand the information — check by asking her to repeat back key points. (2) Retain the information. (3) Weigh up pros and cons — can she reason? (4) Communicate decision — can she indicate yes or no? Must assume capacity unless evidence to contrary. If lacking capacity → best interests decision with most senior available staff and document thoroughly.
Checking understanding: Ask: "Can you tell me in your own words what the operation involves?" via interpreter. Ask if she has any questions. Do not rush through risks — pause after each section for interpretation. Short sentences — pause after each statement.
Documentation: Record interpreter name, ID number, service used, language, time. Document risks discussed. Document patient confirmed understanding. Document capacity assessment. Consent form signed by patient and witnessed.
Handling patient fear: Address anxieties empathically. Do not dismiss fear. Acknowledge the situation is frightening. Explain the team is experienced. Reassure without making guarantees.
⚠️ Examiner / Role-player Instructions — Not for Candidate
Play Mrs Fatima Al-Rashid — respond as if the candidate's words are being interpreted. She has capacity. She is frightened and asks: "Is this operation dangerous? Could I die?" She also asks: "Can I not just have antibiotics instead?" At 5 minutes, if the candidate has not checked understanding, ask: "So — just tell me again what is wrong with me and what you are going to do." If the candidate uses their phone as a translation tool without arranging a professional interpreter first, say: "Are you sure that's the right way to do this?"
🔔 Examiner Cues ▼
If candidate tries to use family member or Google Translate as interpreter: "Mrs Al-Rashid's nephew has just arrived and offers to translate — what do you do?"
If candidate does not explain risks: "Mrs Al-Rashid asks: 'What could go wrong?' — how do you respond?"
If candidate rushes through without pausing for interpretation: "The interpreter asks you to slow down — she cannot keep up."
At 7 minutes: "What documentation must you complete after this consent discussion?"
Criterion
Marks
Interpreter Setup
Professional telephone interpreter arranged — explicitly rejects family member and digital translation apps
2
All three parties introduced — patient, doctor, interpreter; speaks directly to patient (not interpreter)
1
Diagnosis and Procedure
Diagnosis explained clearly — appendicitis, risk of perforation/peritonitis without surgery
2
Operation explained — laparoscopic/open appendicectomy, general anaesthetic, what happens
Antibiotic alternative explained — notes this CT-confirmed case is not suitable for conservative management alone
1
Capacity and Understanding
Capacity assessed — patient asked to repeat back key points; decision-making ability confirmed
2
Handles patient's fear sensitively — "Could I die?" addressed honestly and empathically
2
Documentation and Communication Process
Interpreter name, ID and service to be documented — states this
1
Short sentences with pauses for interpretation throughout — clear evidence of paced delivery
2
Patient given opportunity to ask questions before signing; consent form completed
1
Total
20
💬
Disclosure to Police — Knife Wound Without Consent
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 doctor. Mr Ryan Clarke, 22 years old, was admitted following an emergency laparotomy for a stab wound to the abdomen. He is now on the surgical ward, clinically stable, day 2 post-op. The police have requested information regarding his admission.
Mr Clarke explicitly asked you not to contact police: "It was an accident — my mate tripped and the knife caught me. Please don't call the police, I don't want any trouble."
Please speak to Mr Clarke about your duty to disclose information to the police. You have 8 minutes.
💡 Framework — Confidentiality, Public Interest Disclosure, GMC Guidance ▼
Core legal framework — common law: Confidentiality is a fundamental duty in medicine. However, disclosure without consent is justified when the public interest in disclosure outweighs the public interest in protecting confidentiality. A stabbing involves a serious criminal offence, use of a weapon, risk of harm to others — the public interest threshold is met.
GMC Confidentiality Guidance (2017): Doctors may disclose confidential information without consent if: disclosure is necessary to prevent a serious crime; the benefits of disclosure outweigh the risks; disclosure is of minimum necessary information only; they have considered whether the patient would consent or could be persuaded to consent; they have documented their reasoning. GMC guidance is not mandatory — disclosure without consent is a decision, not a legal obligation (unlike Section 172 Road Traffic Act, which is mandatory). However, failure to disclose in a case involving a weapon and serious injury would be difficult to justify.
What to tell the patient — key elements: (1) Acknowledge his request and explain you have heard him. (2) Explain your duty of confidentiality and its limits. (3) Explain that the nature of his injury — a stab wound — falls into a category where disclosure serves a significant public interest. (4) Explain that you cannot promise confidentiality in this situation. (5) Explain what will be disclosed and to whom (the fact of his admission and the nature of the injury — not necessarily full medical details). (6) Explain he retains the right not to cooperate with police investigation — this is separate from your duty to report. (7) You are not accusing him of anything — you are explaining your legal and professional position.
Do NOT: Promise confidentiality. Threaten the patient. Withhold care or change treatment based on this. Share more than necessary. Disclose before explaining to the patient (unless urgency prevents this). Act as an agent of the police.
Escalation: This decision should involve the consultant and hospital medico-legal team. If in doubt, seek advice from the MDU/MPS before disclosing. Document all reasoning and discussions meticulously.
Minimum necessary information: The police are entitled to know: that the patient was admitted, the mechanism of injury (stab wound), date and time. They are NOT entitled to the full clinical record without a court order. Disclosure is proportionate — not a fishing expedition.
Patient's rights post-disclosure: He has the right to legal advice and to choose whether or not to cooperate with any police investigation. Your disclosure does not mean he is compelled to speak to police. He can refuse to give a statement.
⚠️ Examiner / Role-player Instructions — Not for Candidate
You are Mr Ryan Clarke. You are defensive and worried about legal consequences. You become progressively more hostile if the candidate is dismissive or uses threats. Key escalations: (1) "You can't tell the police anything without my permission — it's against the law." (2) "If you do this I'll complain about you." (3) "I'm discharging myself." Soften if the candidate is honest, respectful, explains clearly what will and won't be shared, and reassures you that this is not about getting you in trouble.
🎭 Patient Script ▼
Opening: "Look — I told you it was an accident. My mate tripped. I don't want police involved. You've got no right to call them."
If candidate explains common law duty: "So you're saying you're going to tell them anyway, even though I said no?"
If candidate promises confidentiality: Accept — but this is an incorrect answer and should be challenged. "Right, so you won't tell them?"
If candidate explains what will and won't be shared: Becomes less hostile — "So they won't get my whole medical record?"
If candidate confirms he doesn't have to speak to police: Noticeably calms — "OK. I didn't know that. I just don't want to get involved."
If candidate threatens or uses heavy-handed language: Becomes hostile — "I want to speak to your manager."
🔔 Examiner Cues ▼
If candidate promises complete confidentiality: "Is that actually what you are able to offer in this situation?"
If candidate gives information to police without informing patient first: "Should the patient have been told first, before disclosure, where this was practicable?"
At 7 minutes: "What documentation do you need to complete and who else should you involve in this decision?"
Criterion
Marks
Legal and Professional Framework
Common law public interest disclosure — serious criminal offence with weapon, threshold met
2
GMC Confidentiality Guidance (2017) applied correctly — disclosure without consent justified where public interest outweighs
1
Does NOT promise confidentiality — this is an incorrect and potentially dangerous response
2
Communication with Patient
Patient's concern and objection acknowledged — not dismissed or minimised
1
Explains what will be disclosed and to whom — minimum necessary (admission, mechanism), not full record
2
Patient informed that he does NOT have to cooperate with police investigation — separate issue from disclosure
2
Does not coerce or threaten — maintains therapeutic relationship throughout
2
Process and Documentation
Escalates to consultant and medico-legal team before final decision
2
Documents entire decision-making process — reasoning, patient's objection, information disclosed, who was informed
2
Honest, non-confrontational, empathic — explains position clearly without being punitive
2
Total
20
📊 Data Interpretation
📊
ECG Interpretation — Long QT and Torsades de Pointes
Data · 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 doctor. A 34-year-old woman collapsed during her aerobics class. She was briefly unresponsive and self-terminated. She is now awake and distressed. She has no known cardiac history. Her sister had a sudden cardiac death at age 28.
The examiner will read you the ECG findings. Please interpret the ECG systematically, state your diagnosis, and outline immediate management and the underlying causes. You have 8 minutes.
💡 Long QT, Torsades de Pointes — Diagnosis and Management ▼
QTc measurement: QT interval corrected for heart rate using Bazett's formula: QTc = QT ÷ √(RR interval in seconds). Normal QTc: males <440ms, females <460ms (some guidelines use <440ms for both). This patient's QTc = 560ms — markedly prolonged.
Torsades de Pointes (TdP) — ECG features: Polymorphic ventricular tachycardia. The QRS axis rotates around the isoelectric baseline in a twisting or spiralling pattern ("twisting of the points" — the French name). Rate typically 200–250 bpm. Episodes typically self-terminate but can degenerate into VF. Always occurs in the context of a long QT.
Differentiate from monomorphic VT: Monomorphic VT — uniform QRS morphology, fixed axis, usually associated with structural heart disease (post-MI scar), responds to amiodarone. TdP — polymorphic (varying QRS), associated with long QT, does NOT respond to (and may be worsened by) class Ia/Ic antiarrhythmics or amiodarone (these further prolong QT).
Immediate management: (1) If haemodynamically unstable/not self-terminating — synchronised DC cardioversion (defibrillation if no organised rhythm). (2) IV magnesium sulphate 2g (8 mmol) in 100ml 0.9% NaCl over 10–15 minutes — first-line regardless of serum magnesium level. Magnesium raises the fibrillation threshold. (3) Correct electrolytes: target K⁺ >4.5 mmol/L, Mg²⁺ >1.0 mmol/L, Ca²⁺ normal. (4) Remove any causative drugs immediately. (5) Continuous cardiac monitoring, defibrillator at bedside.
Acquired causes of long QT (drugs — learn by class): Antiarrhythmics: amiodarone, sotalol, quinidine, flecainide, disopyramide. Antipsychotics: haloperidol, quetiapine, chlorpromazine, droperidol. Antidepressants: TCAs (amitriptyline), SSRIs (citalopram at high doses). Antibiotics: azithromycin, erythromycin, clarithromycin, moxifloxacin, ciprofloxacin (less). Antiemetics: ondansetron, domperidone, metoclopramide. Antifungals: fluconazole. Methadone. Chloroquine/hydroxychloroquine.
Acquired metabolic causes: Hypokalaemia (most common — K⁺ below 3.5; significantly prolongs QT), hypomagnesaemia, hypocalcaemia, hypothyroidism, hypothermia, severe bradycardia.
Congenital long QT syndrome (LQTS): Romano-Ward syndrome — autosomal dominant, no deafness, most common form. Mutations in cardiac ion channels: KCNQ1 (LQT1 — triggered by exercise/swimming), KCNH2 (LQT2 — triggered by sudden auditory stimuli/alarm), SCN5A (LQT3 — bradycardia at rest/sleep). Jervell and Lange-Nielsen syndrome — autosomal recessive, associated with congenital sensorineural deafness (KCNQ1/KCNE1 mutations). Family history of sudden cardiac death in young relative should prompt genetic testing. This patient — sister died young = congenital LQTS likely.
Temporary pacing: For recurrent or pause-dependent TdP (TdP triggered by post-ectopic pauses — bradycardia-dependent). Temporary transvenous pacing at rate 90–110 bpm shortens QT by increasing heart rate (QTc improves). Isoproterenol (isoprenaline) infusion as alternative.
Long-term management: Cardiology/electrophysiology referral. Beta-blockers (nadolol/propranolol — first-line in congenital LQTS, especially LQT1 and LQT2). ICD in high-risk patients (prior cardiac arrest, syncope despite beta-blockers, LQT3). Avoid QT-prolonging drugs. Genetic testing + family screening.
⚠️ Examiner Instructions — Not for Candidate
Read out: "ECG shows: rate 96, sinus rhythm now. QT interval measured 480ms at this heart rate. Corrected QTc = 560ms. During the collapse, a rhythm strip shows polymorphic ventricular tachycardia with the QRS axis twisting around the baseline — alternating between positive and negative deflections in a regular sinusoidal pattern." Ask: "A nurse suggests giving amiodarone — what do you say?" (Expected: contraindicated — amiodarone prolongs QT and worsens TdP.) Ask: "What does the family history suggest?" (Expected: congenital LQTS — Romano-Ward or Jervell-Lange-Nielsen.)
🔔 Examiner Cues ▼
If candidate states amiodarone: "Is that appropriate for Torsades? What effect does amiodarone have on the QT interval?"
If candidate gives only one drug cause class: "Can you name causes from at least three different drug classes?"
If candidate doesn't mention temporary pacing: "The patient has had three further brief episodes of TdP — what other intervention can you use?"
At 7 minutes: "The patient asks whether her two teenage children need to be checked. What do you advise?"
Coagulation Screen — Warfarin Toxicity and Reversal
Data · 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
You are the ED doctor. Mr Arthur Wells, 78 years old, is on warfarin for permanent atrial fibrillation (CHA₂DS₂-VASc score 5). He presents with haematuria noted for 2 days. He is haemodynamically stable.
Obs: HR 74 (AF), BP 138/80, SpO₂ 97%. Alert, no active bleeding elsewhere. No head injury, no GI bleeding, no haemoptysis.
The examiner will read you his blood results. Please interpret the coagulation screen systematically, explain the cause, and outline management according to current BCSH guidelines. You have 8 minutes.
PT/INR (prothrombin time / international normalised ratio): measures extrinsic and common pathway (factors VII, X, V, II, fibrinogen). Prolonged by: warfarin (inhibits factors II, VII, IX, X + proteins C and S), liver disease, vitamin K deficiency, factor VII deficiency. Normal INR 0.9–1.2. Therapeutic warfarin for AF: 2.0–3.0.
APTT (activated partial thromboplastin time): measures intrinsic and common pathway (factors XII, XI, IX, VIII, X, V, II, fibrinogen). Prolonged by: heparin (UFH most; LMWH minimal effect), haemophilia A (VIII), haemophilia B (IX), Von Willebrand disease (via low VIII), DIC, liver disease, lupus anticoagulant. Normal 25–35 seconds.
TT (thrombin time): measures conversion of fibrinogen to fibrin by thrombin. Prolonged by: heparin (very sensitive), fibrin degradation products, low or dysfunctional fibrinogen (DIC, liver failure). Normal 10–15 seconds.
Fibrinogen: Normal 2–4 g/L. Low in DIC (consumption), liver failure, fibrinolysis, massive transfusion.
Warfarin toxicity — pattern on coag screen: Markedly elevated INR (PT prolonged). Mildly prolonged APTT (warfarin affects common pathway). Normal TT. Normal fibrinogen. Normal platelets. This pattern = isolated factor II, VII, IX, X deficiency from warfarin — confirms supratherapeutic warfarin.
BCSH (British Committee for Standards in Haematology) Warfarin Reversal Guidelines — INR and bleeding:
INR >8.0, no bleeding or minor bleeding: Stop warfarin. Give oral vitamin K 1–5mg (or IV 0.5–1mg slow infusion if NPO). Recheck INR in 24 hours. Do not give PCC routinely. Monitor.
INR >8.0, minor bleeding (e.g. haematuria, epistaxis, bruising): Same as above — oral/IV vitamin K 1–5mg. Consider whether bleeding requires specific treatment (e.g. urological investigation). Repeat INR.
INR any level, major or life-threatening bleeding (intracranial, GI with haemodynamic compromise, major surgery): 4-factor PCC (Beriplex® or Octaplex®) 25–50 IU/kg IV PLUS IV vitamin K 5mg. Repeat INR 15 minutes post-PCC. Do not use FFP as first-line — large volumes required (1–2L), slow correction, transfusion reactions.
Why NOT FFP first-line for warfarin reversal? Fresh Frozen Plasma (FFP) — requires large volumes (1–2L = 4–8 units) to correct INR substantially. Slow thaw (20–30 min). Risk of transfusion-associated circulatory overload (TACO), TRALI, allergic reactions, infection. PCC provides concentrated factors II, VII, IX, X in a small volume (20–40mL) — immediate correction within minutes. FFP may be used if PCC unavailable.
Vitamin K mechanism and timing: Warfarin inhibits vitamin K epoxide reductase → cannot activate factors II, VII, IX, X. Vitamin K bypasses this. Oral/IV vitamin K → INR normalises in 6–24 hours (not immediate). IV vitamin K faster than oral but rare risk of anaphylaxis (administer slowly). Vitamin K also prevents rebound after PCC.
Post-reversal anticoagulation: After reversal, reassess whether warfarin should be restarted. CHA₂DS₂-VASc 5 = high stroke risk — anticoagulation should be restarted when safe, with rheumatology/haematology/stroke team advice. DOAC may be considered (no reversal needed). Anticoagulation review with haematology.
⚠️ Examiner Instructions — Not for Candidate
Read results: "INR 9.2 (therapeutic target 2.0–3.0). PT markedly prolonged. APTT mildly prolonged. TT normal. Fibrinogen 3.1 g/L (normal). Platelets 198 ×10⁹/L (normal). Hb 101 g/L (mild anaemia). U&Es normal. No signs of major bleeding — haematuria only." Ask: "A junior doctor suggests 4 units of FFP — what is your response?" (Expected: FFP is not first-line for warfarin reversal — large volume, slow to work, risk of TACO/TRALI. Vitamin K ± PCC is correct.) Ask: "After reversal, the patient asks if he'll need to go back on warfarin — what do you say?"
🔔 Examiner Cues ▼
If candidate gives PCC for minor bleeding with no haemodynamic compromise: "Is 4-factor PCC indicated here, or is this minor bleeding? What does the BCSH guideline say for INR >8 with minor bleeding?"
If candidate selects FFP as first-line: "What are the advantages of PCC over FFP in this scenario?"
If candidate doesn't mention vitamin K: "What happens to the INR 6 hours after giving PCC alone without vitamin K?"
At 7 minutes: "What is the risk of simply stopping warfarin in a patient with CHA₂DS₂-VASc 5?"
Criterion
Marks
Coagulation Screen Interpretation
Systematic interpretation — PT/INR, APTT, TT, fibrinogen, platelets addressed in order
2
Pattern correctly identified — isolated PT/INR elevation, normal TT and fibrinogen = warfarin effect (not DIC or liver failure)
2
Supratherapeutic warfarin confirmed as cause — INR 9.2 vs therapeutic target 2.0–3.0
1
Haematuria Classification
Classifies as minor bleeding — haematuria, haemodynamically stable — NOT major/life-threatening
2
Management — BCSH Guidelines
Stop warfarin — stated
1
Oral or IV vitamin K 1–5mg — correct dose and route for minor bleeding
2
Recheck INR in 24 hours — monitoring plan
1
4-factor PCC (Beriplex) indicated for major bleeding only — correctly withheld here with rationale
2
FFP rejected as first-line — states inferior to PCC: volume, speed, risk of TACO/TRALI
2
Anticoagulation Review
Post-reversal anticoagulation plan — CHA₂DS₂-VASc 5 means high stroke risk, anticoagulation should be restarted when safe; haematology/stroke review
2
Urological cause of haematuria to be investigated independently of warfarin toxicity
1
Total
20
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