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Table of Contents

Subject Page

Induction and general approach 2

Acute exacerbation of asthma 12

COPD exacerbation 15

Chronic Bronchitis 18

Anaphylaxis 21

Heart failure 25

Haematemesis 30

Post partum haemorrhage 32

Post hysterectomy hypotension 37

Bleeding on warfarin 39

Acute limb ischaemia 43

Post operative pain 45

Hypoglycaemia 47

Hospital acquired pneumonia 58

Community acquired pneumonia 62

IECOPD 64

Catheter associated UTI 66

Urosepsis 68

Sepsis on Unknown cause 71

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Morphine Toxicity 73
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General Approach
4-4 before role
- 4:
- Introduce yourself to the examiner by name and GMC number.
- Assume you have taken universal precautions.
- Introduce yourself and your setting for your patient.
- Con rm patient ID (check bracelet if unconscious).
- 4:
- Scan the room
- Reassure the patient and acknowledge that the patient is attached to the
monitor.
- Focused History; if possible:
- Analysis of concern
- Associated symptoms
- Differential diagnosis
- MMA
- Consent and chaperone: “Mr X, I’m going to check your chest,
abdomen, and limbs. This will involve exposing different areas of your
body, including the more private parts. I’ll make sure a chaperone is
present, and I’ll do everything I can to respect your privacy throughout.
Is it alright for me to go ahead?”

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ASSESSMENT: ABCDE approach

- Start by acknowledging that the patient is in semi-sitting position.

A: AIRWAY
- Patient: Check the airway for signs of airway obstruction by asking the
patient to open their mouth.
- Monitor: Check SpO2 on the monitor.
- Intervention:
- Patient’ with no history of COPD: Offer NRM 100% oxygen 15L/min
- Patients with COPD: Offer Venturi mask 24% 4L/min.
- Goal: Aim to maintain an oxygen saturation of 94–98%, except in patients
with COPD as we aim for 88-92%.
- Treat: Proceed once the airway is clear.

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B: BREATHING
- Patient: Chest examination:
1. Inspection: Note any chest deformity.
2. Palpation: palpate the trachea position and chest expansion.
3. Percussion: Percuss the chest.
4. Auscultation: Auscultate the chest for heart and lungs together, don't
forget the base of the lung.

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- Monitor: Look at the monitor for the respiratory rate. Normal RR is 12-20
breaths/min.
- Intervention:
1. Request CXR “ I will be requesting a CXR to ensure that there are
no abnormalities in your lungs”.
2. Perform ABG by bringing the ABG needle from the trolley “I will be
assessing the oxygen level in your blood through a sample from
your wrist, sharp scratch is coming”.
- Goal: Maintain effective breathing.
- Treat: Naloxone, nebulisers (air driven or oxygen driven), furosemide or
antibiotics depending on the case

C: CIRCULATION
- Patient:
1. Measure the capillary re ll time (CRT) by applying pressure on a
ngertip held at the level of the heart or slightly above for 5 seconds.
Normal CRT is <2 seconds.
2. Assess the carotid pulse on one side.
3. Assess the radial pulses bilaterally.
4. Assess the dorsals pedis pulses bilaterally.
5. Expose area of bleeding or surgical site.
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- Monitor: Look at the monitor for the heart rate, blood pressure and lead II.
- Intervention:
- Insert 1 or 2 large intravenous cannulas depending on individual cases.
- Request routine bloods and additional bloods depending on the case by
brining the blood tubes from the trolley.
- Request an ECG.
- Goal: Maintain blood pressure >100 systolic.
- Treat: consider uids, blood transfusion or speci c medications depending on
the case.

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D: DISABILITY
- Patient:
1. Examine the pupils using a pen torch.
2. Make a rapid assessment of the patient’s consciousness level using the
AVPU score (Alert, responds to Verbal command, responds to Pain,
unresponsive).
- Monitor: Check the monitor for the patient’s temperature.
- Intervention: Measure the blood glucose using the glucometer, lancet and
strips.
- Goal: Ensure intact neurological status
- Treat: Give paracetamol if the patient is pyrexial. Give IV dextrose (10% or
20%) in hypoglycaemia case.

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E: EXPOSURE
- Patient:
- Expose the patient’s abdomen and palpate it for tenderness.
- Expose the patient’s private part to check for any bleeding.
- Expose the legs and examine them for rash or oedema.
- Intervention: Consider inserting a catheter if needed.

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Example of 2 mins SBAR handover

Situation:
I am Dr (—), I managed a 35-year-old male patient named Tory Jones, who
presented to the Emergency Department with (———).
Background:
Tory has a long-standing history of asthma with multiple exacerbations. He
mentioned that he was recently exposed to cat fur at a friend's house, which he
knows triggers his asthma.
Assessment:
On initial assessment, his vital signs were unstable and O2 saturation was low.
He had generalised wheezing on auscultation. Therefore, I suspected the patient
was having an acute exacerbation of asthma. I started him on high- ow oxygen
and administered nebulized salbutamol 5mg, ipratropium bromide nebuliser and
IV hydrocortisone.
Recommendation:
After the initial treatment, his oxygen saturation improved to 94%. My
recommendation is to continue monitoring his respiratory status closely and
provide repeat nebulizer treatments as needed. He should be reassessed
frequently to ensure continued improvement. Upon stabilisation, he will need
discharge planning including ensuring he has an adequate supply of his
maintenance medications, education on avoiding known triggers like cat fur,
and follow-up with the asthma clinic once discharged.

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How To Pass The Station

1. Treat the SimMan as you would treat a real patient (maintain eye contact,
explain in simple words what’s happening, offer reassurance, have a 2 way
conversation).
2. Don’t touch the patient until you signpost examination, privacy and
chaperone.
3. Don’t talk abt the patient in a 3rd person.
4. Cover the patient as soon as you nish chest and abdominal examination.
5. Make it clear that you are following the ABCDE approach.
6. Reassess your patient when moving from one step to another. It can take a
few minutes for treatments to take effect, so wait a short while before
reassessing the patient following an intervention.
7. Treat life-threatening problems before moving to the next part of the
assessment.
8. The initial course of treatment is to maintain the patient's life and
accomplish a few clinical enhancements.
9. Do not assume anything.
10. Do not look at, speak to, or engage with the examiner in any way.
11. Always verbalise the concentration and ow rate of oxygen.
12. Always verbalise the dose and route of medications.

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Acute Exacerbation Of Bronchial Asthma

Where you are:
You are the resident doctor working in the A&E.
Who the patient is:
Mr. Tory Jones a 35-year-old male came with acute shortness of breath.
What you must do:
Talk to the patient, assess his condition, examine him and manage him
accordingly.

Monitor:
SpO2%: 86%, H.R 115, RR: 26, BP 100/70, Temp 36.5℃.

Setting:
- Blue and brown inhalers with the patient.

History:
Patient can answer questions with full sentences:
- Analyse shortness of breath through ODIPARA.
- Associated symptoms and differentials: cough, fever, chest pain, calf pain.
- MMA: regular medications, medical conditions and allergies: asthma for 5
years and takes blue and brown inhalers.
- Risk factors: exercise, smoking, pets.
- Acknowledge that the patient is in a semi-sitting position.
Patient can’t talk in full sentence:
- Postpone history and start your ABCDE assessment.
- Acknowledge that the patient is in a semi-sitting position.

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Assessment:
A- Airway:
- Check for any obstruction. If the patient is talking, the air way is patent.
- Give 100% O2 15L/min via non rebreather mask
B- Breathing:
- Examine the chest in order: Inspection, palpation, percussion, auscultation.
- If you hear wheezing then give nebulised Salbutamol 5mg via an oxygen-
driven nebulizer mask with the ow rate of 6L/ min and repeat every 15
minutes till under control.
- Order Chest X-ray. Perform ABG.
- Reassess oxygen Sats
C- Circulation:
- Check: Capillary Re ll + Pulse + BP + Insert 1 Cannula.
- Request routine bloods, in ammatory and infection markers and ECG.
- Re-asses chest :
- If Improved: continue your assessment.
- Still wheezy: add Ipratropium bromide 0.5mg
D- Disability
- Check: Blood Sugar + Temperature + Pupils
- Re-assess chest:
- If improved: continue your assessment.
- Still wheezy: Give Hydrocortisone 100mg I.V. or Methylprednisolone 160
mg I.M.
E - Exposure
- Examine the abdomen, legs and private area.

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Management:
- Admit.
- Consider IV magnesium if no improvement
- Involve senior and give Aminophylline if patient isn’t improving.
- Further investigations: PEFR.
- Advice regarding attacks, triggers, inhalers.
- Refer to Asthma Clinic.
- Safety netting.

Summary of treatment
1. Nebulised Salbutamol
2. If poor response: add Ipratropium bromide
3. If poor response: add IV hydrocortisone

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COPD Exacerbation
Where you are:
You are resident doctor working in the A&E.
Who the patient is:
Mr. Smith Jones a 55-year-old male came with acute shortness of breath. He
has been diagnosed with COPD and takes inhalers. The nurses asked you to
complete the NEWS chart in the cubicle.
What you must do:
Talk to the patient, assess his condition, examine him and manage him
accordingly.

Monitor:
SpO2%: 79%, H.R: 95 b/min, RR: 23, BP: 120/80, Temp 37.5.

History:
Patient can answer questions with full sentences:
- Analyse shortness of breath.
- Associated symptoms and differentials: cough, sputum volume and colour,
fever, chest pain, leg pain or swelling.
- MMA: regular medications, medical conditions and allergies.
- Risk Factors: smoking.
-Acknowledge that the patient is in a semi-sitting position.
Patient can’t talk in full sentence:
- Postpone history and start your assessment.
- Acknowledge that the patient is in a semi-sitting position.

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Assessment:
A- Airway:
- Check for any obstruction.
- Give oxygen via a Venturi mask to maintain sats 88-92%
B- Breathing:
- Examine the chest in order: Inspection, palpation, percussion, auscultation.
- If you hear wheezes, give nebulised Salbutamol 5mg and ipratropium bromide
500mcg via an air-driven nebulizer mask.
- Order Chest X-ray.

- Perform ABG.

C- Circulation:
- Check: Capillary Re ll + Pulse + BP + Insert 1 Cannula.
- Request routine bloods, in ammatory and infection markers and ECG.
D- Disability
- Check: Blood Sugar + Temperature + Pupils

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E - Exposure
- Examine the abdomen, legs and private area.

Management:
- Admit.
- Involve Senior.
- Consider antibiotics if there are any signs of infection (pyrexia, increase in the
volume of sputum, change in the colour of sputum, raised in ammatory
markers, abnormal CXR).
- Oral steroids 30mg for 5 days.
- Safety netting.

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Chronic Bronchitis

Where you are :

You are an FY2 in emergency department.
Who the patient is :
A 45-year old man has presented with breathlessness (SOB).
Your task :
Take focused history and manage the patient.
Monitor:
SpO2- 98%, BP- 120/70 mmHg, RR- 15 breaths/min, PR- 80, Temp 37C.

History :
-He has been diagnosed with chronic bronchitis previously.
-Taking blue inhaler
-He hasn’t been taking his inhalers for the past few days.
-Cough (+)
-No known allergy
-No smoking
(Patient can speak in full sentences without any breathlessness)

Data Gathering :
-Ask about SOB
-Any associated symptoms (Fever, Phlegm, chest pain, noisy breathing)
DDx (Asthma, COPD,PE,HF)

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Assessment :
A- Airway :
-Check for any obstruction and Spo2.

B- Breathing :
-Examine the chest in order : Inspection, palpation, percussion and
auscultation.
-As the patient said he is dyspneic and has a history of chronic bronchitis,
give nebulised Salbutamol 5mg.
-Order Chest X-ray and ABG.

C- Circulation :
Check : Capillary Re ill + Pulse + BP + Insert 1 cannula.
Request routine bloods, in lammatory and infection markers and ECG.

D- Disability :
Check : Blood sugar + Temperature + Pupils

E- Exposure :
Examine the abdomen, legs and private area.

Management :
- Admit
- Involve seniors.
- Consider antibiotics if there are signs of infection (Pyrexia, increase in
volume of sputum, change in colour of sputum, raised in lammatory
markers, abnormal CXR)
- ADVICE
-Regular use of inhalers
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-Maintain a Trigger diary , Avoid secondary smoking
-Safety netting.

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Anaphylaxis
Where are you:
You are resident doctor in the Emergency Department.
Who the patient is:
Mr. Alex Fay, 60 years old, was admitted to the hospital for abdominal surgery.
He was transferred to the post operative room. The nurse asked you to assess
the patient as he is now having some dif culty in breathing. He was given his
pain medications, uids and transfused 1 unit of blood 15 minutes ago.
What you must do:
Take focused history, do relevant examination and manage him accordingly.

Monitor:
SpO2%: 86%, BP: 90/50 H.R.: 105 bpm, Temp 37, RR 13, Lead II SR.

History:
Patient can answer questions with full sentences:
- Analyse shortness of breath using ODIPARA.
- Associated symptoms and differentials: cough, fever, chest pain, calf pain.
- MMA: regular medications, medical conditions and allergies.
-If the patient has a urinary catheter ask about when it was inserted.
-Acknowledge that the patient is in a semi-sitting position.
Patient can’t talk in full sentence:
- Postpone history and start your assessment.
- Acknowledge that the patient is in a semi-sitting position.

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Assessment:
A- Airway:
- Check for any obstruction, any tongue and lips swelling.
- Explain to the patient that you are suspecting a severe allergic reaction. Check
the BP to con rm anaphylactic shock.
- Call for help.
- Discontinue any medications the patient is receiving and remove all foreign
objects attached to the patient, such as a urinary catheter or a blood transfusion
line, but do not remove the cannula.
- Give IM Adrenaline 0.5ml 1:1000.
- Give 100% oxygen 15L/min via non-rebreather mask.
B- Breathing:
- Examine the chest in order: Inspection, palpation, percussion, auscultation.
- If you hear wheezes give nebulised Salbutamol 5mg through oxygen-driven
nebulizer mask 6L/min.
- Request chest X-ray and perform ABG.
- Reassess patient: if the tongue is still swollen then verbalise that 5 minutes
have passed and repeat IM Adrenaline.
C- Circulation:
- Check: Capillary Re ll + Pulse + BP + Insert 2 Cannulas.
- If the patient’s blood pressure is still low, verbalise positioning the patient in
supine position with or without leg elevation and give 500ml of N. saline over
15mins.
- Request routine bloods, tryptase and ECG.
D- Disability
- Check: Blood Sugar + Temperature + Pupils
- Reassess the patient’s blood pressure; if still low give another 500ml of
[Link] over 15mins.
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E - Exposure
- Examine the abdomen, legs and private area. If the patient has a rash then give
Chlorpheniramine 10-20mg IV.

Management:
- Explain to the patient that they had an allergic reaction to the blood they are
receiving or the urinary catheter.
-Involve Senior.
- Document in the patient’s notes what happened.
- Send the blood to the lab to be cross-matched.
- Fill out an incident form.
- Use a latex free catheter if the allergic reaction was due to the catheter.

ADRENALINE SHOULD BE GIVEN IN A AND NOT DELAYED UDNER

ANY CIRCUMSTANCES!

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Heart Failure
Scenario 1:
Where you are:
You are resident doctor in A&E.
Who the patient is:
Mr. Barry Allen, aged 65, has come to the A&E with dizziness, heart racing and
shortness of breath that started a while ago.
What is your task:
Please talk to him, assess him, and discuss the management plan with him.

Monitor:
SpO2% 86%, BP 110/65 H.R 120 bpm, RR 20, Temp 36, Lead II AF.

History:
Patient can answer questions with full sentences:
- Analyse dizziness, shortness of breath and palpitations using ODIPARA.
- Associated symptoms: fainting attacks, orthopnea, leg swelling, PND, chest
pain, calf pain.
- MMA: regular medications, medical conditions and allergies: HTN
- Acknowledge that the patient is in a semi-sitting position.

Assessment:
A- Airway:
-Check for any obstruction.
-Give oxygen via non-rebreather mask 100% oxygen 15L/min.

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B- Breathing:
- Examine the chest in order: Inspection, palpation, percussion, auscultation.
- Once you hear bi-basal crackles, insert a cannula and start the patient on IV
furosemide (diuretic) 40mg.
- Order chest X-ray and perform ABG.
- Chest X-ray will show pulmonary oedema.
- If the patient is distressed, offer a small dose of morphine such as 2.5mg

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C- Circulation:
- Check: Capillary Re ll + Pulse + BP.
- Check Lead II: AF.
- Request routine bloods, BNP, troponin, D-dimer.
- Request ECG.
D- Disability
- Check: Blood Sugar + Temperature + Pupils
E - Exposure
- Examine the abdomen, legs and private area.
- Insert a urinary catheter.

Management:
- Admit.
- Discuss with cardiology starting the patient on Digoxin.
- Request Echo.
- Explain will likely need anti coagulation and medications to control the heart
rate.

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Scenario 2:
Where you are:
You are the resident doctor in A&E.
Who the patient is:
Mr. Barry Allen, aged 65, has been referred by his GP due to shortness of
breath.
What is your task:
Please talk to him, assess him, and discuss the management plan with him.

Monitor:
SpO2% 98%, BP 130/65 H.R 90 bpm, RR 14, Temp 36, Lead II AF.

History:
Patient can answer questions with full sentences:
- Analyse SOB using ODIPARA: on and off for months, worse on climbing the
stairs and lying at.
-Associated symptoms: leg swelling.
-MMA: Rheumatic heart disease.
-Acknowledge that the patient is in a semi-sitting position.

Assessment:
A- Airway:
- Check for any obstruction.
B- Breathing:
- Examine the chest in order: Inspection, palpation, percussion, auscultation.
- You might be able to hear a murmur.

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- Once you hear bi-basal crackles, insert a cannula and start the patient on IV
furosemide (diuretic) 40mg.
- Order Chest X-ray and perform ABG.
C- Circulation:
- Check: Capillary Re ll + Pulse + BP + Lead II.
- Request routine bloods, BNP, troponin, D-dimer and ECG.
D- Disability
- Check: Blood Sugar + Temperature + Pupils
E - Exposure
- Examine the abdomen, legs and private area.
- Insert a urinary catheter.

Management:
- Admit.
- Explain diagnosis of heart failure secondary to rheumatic heart disease.
- Request Echo.
- Involve senior.

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Haematemesis
Where you Are:
You are the resident doctor in the Gastroenterology Department.
Who the patient is:
Peter Drink, a 50-year-old gentleman, presented with vomiting of blood.
Other Information:
An upper GI Endoscopy was done on him 2 days ago.
Your Task:
Take a focused history, assess his condition and manage him.

Monitor:
SpO2: 90%, BP: 80/55, H.R: 120, RR 30, Temp 37, Lead II SR.

Settings:
- A kidney dish full of blood next to the patient.

History:
Patient can answer questions with full sentences:
- Analyse haematemesis using ODIPARA and TRAC.
- Associated symptoms: abdominal pain, bleeding from anywhere else.
- Ask about endoscopy: why was it performed? What was found?
- MMA: regular medications including blood thinners, medical conditions and
allergies.
-Acknowledge that the patient is in a semi-sitting position.

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Assessment:
A- Airway:
- Check for airway obstruction and blood clots in mouth.
- Give oxygen via nasal cannula.
B- Breathing:
- Examine the chest in order: Inspection, palpation, percussion, auscultation.
- Request chest X-ray and perform ABG.
C- Circulation:
- Check: Capillary Re ll + Pulse + BP + lead II
- Activate major haemorrhage protocol: order 4 units of O-negative blood.
- Insert 2 large bore cannulas and request routine bloods, group and save and
coagulation pro le.
- Give 500ml of IV uids over 15 minutes.
- Give O-negative blood as soon as you receive it with the rate of 1 unit every
10 minutes.
- Request 12 leads ECG
D- Disability
- Check: Blood Sugar + Temperature + Pupils
- Reassess blood pressure: if still low give another 500ml of IV uids over
15mins.
E - Exposure
- Examine the abdomen, legs and private area.
- Insert a urinary catheter.

Management:
- Admit.
- Discuss with gastroenterology for an urgent endoscopy.
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Postpartum Haemorrhage
Where you are:
You are the resident doctor working in the Obstetrics and Gynecology
Department.
Who the patient is:
Mrs. Jefferson aged 35, multigravida, had her 5th delivery an hour ago via
vaginal delivery.
Other Information:
The patient has lost 1.5L during delivery. She doesn’t have any medical
conditions and the placenta has been delivered.
What you must do:
The nurse has called you because Mrs. Jefferson is having vaginal bleeding.
Please assess the patient and address her concerns.

Monitor:
SpO2: 88%, BP: 77/50, H.R: 120, RR: 30, Temp: 37, Lead II: SR.

Setting:
- Patient covered with a pad soaked with blood.

History:
Patient can answer questions with full sentences:
- Analyse bleeding using ODIAPTA and TRAC.
- Ask the 4 T questions: Trauma (instrumentation, injuries), Tone (prolonged
labour, no of babies delivered), Tissue (placenta delivered), Thrombophilia
(MMA)

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Assessment:
A- Airway:
- Check for any obstruction.
- Give 100% oxygen 15 L/min via non-rebreather mask.
B- Breathing:
- Examine the chest in order: Inspection, palpation, percussion, auscultation.
- Order Chest X-ray and perform ABG.
C- Circulation:
- Check: Capillary Re ll + Pulse + BP + lead II
- Activate major haemorrhage protocol: order 4 units of O-negative blood.
- Insert 2 large bore cannulas, and request routine bloods, group and save and
coagulation pro le.
- Explore the site of bleeding and con rm vaginal bleeding.
- Asses for uterine tone to con rm the aetiology of PPH. If low tone then give
IV oxytocin 5-10units slowly and perform uterine massage.
- Start the patient on IV Tranexamic acid 1g over 10 mins followed by an
infusion of 1g over 8 hours.
- Give 500ml of IV uids over 15 minutes.
- Give O-negative blood as soon as you receive it with the rate of 1 unit every
10 minutes.
- Request 12 leads ECG
D - Disability
- Check: Blood Sugar + Temperature + Pupils.
- Reassess blood pressure: if still low give another 500ml of uids over 15mins.
E - Exposure
- Examine the abdomen and legs
- Insert a urinary catheter.

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Management:
- Discuss with obstetrics team further management.

Complications of PPH:
- Hypovolaemic shock
- DIC
- Sheehan’s syndrome
- Multi organ failure
- Death

2 mins SBAR handover (only if the examiner asks you to):

Situation:
I am Dr (---). I managed a 35-year-old patient, Layla Jafferson, who was
bleeding from her vagina.
Background:
Layla had her 5th delivery an hour back. She reported no allergies.
Assessment:
On initial assessment, her vital signs were: BP 80/55 mmHg, HR 110 beats per
minute, respiratory rate 22 breaths per minute, and SpO2 90% on room air. I
gave her 100%O2 15L/min via a non-rebreather mask. On abdominal
examination, the uterus was enlarged and boggy. So, I suspected the patient is
having PPH. So, I gave her IV uid (---)ml and activated the major
haemorrhage protocol. I gave her oxytocin (5 units) and Tranexamic acid 1g
and did a uterine massage to stimulate uterine contraction and reduce bleeding.
I requested blood group and cross-matching to order blood.
Recommendation:

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My recommendation is to continue monitoring her vital signs and response to

the treatment closely. After getting the blood cross-matching result, I will order
the blood according to her blood group. I will involve my senior as the patient
may need an ultrasound scan to check if there are any retained products in the
uterus. If the bleeding does not stop, we may need to consider other measures
like bimanual compression, balloon tamponade or bilateral ligation of uterine
arteries.

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Post Hysterectomy Hypotension

Where you are:
You are the resident doctor working in the Obstetrics and Gynaecology.
Who the patient is:
Mrs. Julie Perry aged 58 had a hysterectomy done an hour ago. The nurse has
called you to asses her as she has became hypotensive and her oxygen
saturation has dropped.
What you must do:
Assess the patient and manage her accordingly.

Monitor:
SpO2: 90%, BP = 80/55, H.R. = 120, RR 30, Temp 36, Lead II: SR.

History:
Patient can answer questions with full sentences:
- Ask about abdominal pain, bleeding, shortness of breath, cough, chest pain,
leg swelling.
-MMA: regular medications including blood thinners, medical conditions and
allergies.

Assessment:
A- Airway:
- Check for any obstruction.
- Give 100% oxygen 15L/min via non-rebreather mask.
B- Breathing:
- Examine the chest in order: Inspection, palpation, percussion, auscultation.
- Order Chest X-ray and perform ABG.

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C- Circulation:
- Check: Capillary Re ll + Pulse + BP+ lead II
- Activate major haemorrhage protocol: order 4 units of O-negative blood.
- Insert 2 large bore cannulas, and request routine bloods, group and save and
coagulation pro le.
- Explore the surgery site for bleeding or discharge.
- Give 500ml of IV uids over 15 minutes.
- Give O-negative blood as soon as you receive it with the rate of 1 unit every
10 minutes.
- Request 12 leads ECG.
D - Disability
- Check: Blood Sugar + Temperature + Pupils
- Reassess blood pressure: if still low give another 500ml of IV uids over
15mins.
E - Exposure
- Examine the legs and private area.

Management:
- Discuss with obstetrics team further management: exploratory surgery.
- Closely monitor the patient.

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Bleeding On Warfarin
Where you Are:
You are the resident doctor in the emergency department.
Who the patient is:
Mr. Peter Drink, a 32-year-old gentleman presented with PR bleed.
Your Task:
Take a focused history, assess his condition and manage him.

Monitor:
SpO2: 89%, BP: 80/55, H.R.: 110, RR: 30, Temp 36, Lead II: AF.

Settings:
-Patient covered with a pad soaked with blood.

History:
Patient can answer questions with full sentences
- Analyse bleeding using ODIPARA and TRAC.
- Associated symptoms: abdominal pain, bleeding from anywhere else
- MMA: regular medications including blood thinners, medical conditions and
allergies.
- History of colonoscopy 2 weeks ago which showed diverticular disease.

Assessment:
A- Airway:
- Check for any obstruction.
- Give 100% oxygen 15 L/min via non-rebreather mask.

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B- Breathing:
- Examine the chest in order: Inspection, palpation, percussion, auscultation.
- Order Chest X-ray and perform ABG.
C- Circulation:
- Check: Capillary Re ll + Pulse + BP+ lead II
- Activate major haemorrhage protocol: order 4 units of O-negative blood.
- Insert 2 large bore cannulas, and request routine bloods, group and save and
coagulation pro le.
- Explore the site of bleeding.
- Give 500ml of IV uids over 15 minutes.
- Give O-negative blood as soon as you receive it with the rate of 1 unit every
10 minutes.
- Give Vit K 5mg IV and PCC 50units/kg.
- Request 12 leads ECG.
D- Disability
- Check: Blood Sugar + Temperature + Pupils
- Reassess blood pressure: if still low give another 500ml of IV uids over
15mins.
E - Exposure
- Examine the abdomen, legs and private area.
- Insert a urinary catheter.

Management:
- Recheck coagulation pro le after 15mins of treatment with PCC and vit-K.
-Discuss with the surgical team and haematology further management.
- Stop Warfarin

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Acute Limb Ischaemia

Where you Are:
You are the resident doctor in A&E.
Who the patient is:
A 55 year old male, Mr. Walker, presented with a history of severe pain in his
right leg since the morning.
Your Task:
Take a focused history, assess his condition and manage him.

Monitor:
SpO2: 99%, BP: 120/80, H.R: 110, RR 24, Temp 36, Lead II: AF.

History:
Patient can answer questions with full sentences:
- Analyse leg pain using SOCRATES.
- Associated symptoms and differentials: bruising, swelling, trauma, travel,
mobility.
- MMA: regular medications, medical conditions and allergies.
- Smoking

Assessment:
A- Airway:
- Check for any obstruction.
- Acknowledge the normal SpO2 level.
B- Breathing:
- Do quick chest examination.

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- Order chest X-ray and perform ABG

C- Circulation:
- Check: Capillary Re ll + Pulse + BP+ lead II
- Absent dorsalis pedis pulse on affected side. Then go up proximally until you
feel the pulse.
- Check other features of 6 Ps: pallor, paralysis (ask the patient to wiggle his
toes), parasethesia (ask the patient if he has numbness), perishing cold
(compare the temperature of both legs using the back of your hand).
- Explain the diagnosis of ALI.
- Insert IV cannula and request routine bloods, coagulation pro les.
- Start the patient on unfractionated heparin 5000units IV.
- Start the patient on 15L 100% oxygen even if the oxygen saturation is
normal.
- Give IV morphine 5mg.
- Involve vascular surgeons immediately
- Request 12 leads ECG.
D- Disability
- Check: Blood Sugar + Temperature + Pupils
E - Exposure
- Examine the abdomen and private area.
Management:
- Specialist will perform arterial and venous doppler signal.
- Address the patient’s concern: Will my leg be saved or not?
***In some cases the patient won’t have AF but will be a heavy
smoker***

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Post Operative Pain Management

Where you Are:
You are the resident doctor in the Obstetric department.
Who the patient is:
Mrs Elena Wilson, a 35-year old lady, had a cesarean section 8 hours back. The
nurse asked you to see the patient.
Your Task:
Take a focused history, assess her condition and manage her concerns.

Setting inside the cubicle:

Surgical notes:
- Surgery was done 8 hours ago.
- Surgery was uneventful with delivery of twins.
- Placenta was completely removed with blood loss of 250ml.
- Surgery was done under spinal anaesthesia using diamorphine.

Monitor:
SpO2: 99%, BP: 130/70, H.R: 95, RR: 18, Temp: 37.4, Lead II: SR.

History:
Patient can answer questions with full sentences:
- Analyse abdominal pain using SOCRATES
- Associated symptoms and differentials: fever, bowel movement, dysuria,
bleeding, discharge from wound.
-Ask about any complications during delivery and breast feeding.
- MMA: regular medications, medical conditions and allergies.

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Assessment:
A- Airway:
- Check for any obstruction.
B- Breathing:
- Examine the chest in order: Inspection, palpation, percussion, auscultation.
- Order Chest X-ray and perform ABG.
C- Circulation:
- Check: pulse + CRT + BP + lead II
- Insert 1 cannula.
- Request routine bloods and infection markers.
-Request ECG.
D- Disability
- Check: Blood Sugar + Temperature + Pupils
E - Exposure
- Examine the legs and private area.
- Examine the abdomen for tenderness.
- Check the wound for bleeding, swelling or discharge.

Management:
- Start the patient on IV paracetamol explaining that this is the most suitable
analgesia in her condition.
- Explain that she received strong painkillers during the procedure and further
use of strong pain killers can lead to life threatening complications.
- Reassure her that she will be getting better soon.
- If the patient still insists on more potent painkillers, she can have morphine
but this will need senior involvement due to the risk of respiratory depression.

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Hypoglycaemia
Scenario 1:
Where you Are:
You are the resident doctor in the A&E.
Who the patient is:
Mr Jack Adams, a 28 year old male, was brought unconscious by the ambulance
after fainting at work.
Your Task:
Assess the patient’s condition and manage him accordingly.

Monitor:
SpO2 98%, BP 120/80, H.R 80, RR 16, Temp 36.5

History:
- Postpone history and start your assessment.

Assessment:
A- Airway:
- Check for any obstruction.
- Acknowledge that SpO2 is within the normal range.
B- Breathing:
- Examine the chest in order: Inspection, palpation, percussion, auscultation.
- Order Chest X-ray and perform ABG.
C- Circulation:
- Check: Capillary Re ll + Pulse + BP + Lead II
- Insert 1 cannula.

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- Perform routine bloods.

- Request ECG.
D - Disability
- Check: Blood Sugar + Temperature + Pupils
- Blood sugar less than 4 mmol: give IV 200ml of 10% glucose or 100ml of
20% glucose over 15 minutes.
E - Exposure
- Examine the abdomen, legs and private area.
- Reassess blood sugar after 15 minutes, if still less than 4 mmol and
unconscious then give another 10% or 20% glucose of same amount as before
over 15 minutes.
- If the blood glucose level remains below 4 mmol/L, but the patient is
conscious and able to swallow, they should be treated with a fast-acting
carbohydrate (oral glucose gel) administered orally.
- A long-acting carbohydrate should be given as soon as possible once the
patient has recovered and their blood-glucose concentration is above 4 mmol/
litre (e.g. two biscuits, one slice of bread, 200–300 mL of milk)

Management:
- Take a focused history as soon as the patient becomes conscious and able to
talk.
- Admit.
- Diabetes team review.
- HbA1c

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Scenario 2:
Where you Are:
You are the resident doctor in the A&E.
Who the patient is:
Mr Jack Adams, a 28 year old male, was brought unconscious by the ambulance
after fainting at work. The nurse has seen the patient and a blood sample was
done.
Your Task:
Assess the patient’s condition and manage him accordingly. At the 2 minute bell
discuss the case with the examiner.

Monitor:
SpO2 98%, BP 120/80, H.R 80, RR 16, Temp 36.

Setting inside the cubicle:

- ABG result inside the cubicle showing low blood glucose.
- Cannula inserted.

History:
- Postpone history and start your assessment.
- Start by giving the patient IV 200 ml of 10% glucose or 100 ml of 20%
glucose over 15 minutes.

Assessment:
A- Airway:
- Check for any obstruction.
-Acknowledge that SpO2 is within the normal range.

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B- Breathing:
- Examine the chest in order: Inspection, palpation, percussion, auscultation.
- Order Chest X-ray and perform ABG.
C- Circulation:
- Check: Capillary Re ll + Pulse + BP + lead II
- Perform routine bloods.
- Request 12 leads ECG.
D - Disability
- Check: Temperature + Pupils
- Verbalise that 15 mins have passed and recheck blood glucose, if still less than
4 mmol and unconscious then give another 10% or 20% glucose of same
amount as before over 15 minutes.
- If the blood glucose level remains below 4 mmol/L, but the patient is
conscious and able to swallow, they should be treated with a fast-acting
carbohydrate administered orally.
E - Exposure
- Examine the abdomen, legs and private area.
- Recheck blood glucose if the previous result is less than 4 mmol.
- A long-acting carbohydrate should be given as soon as possible once the
patient has recovered and their blood-glucose concentration is above 4 mmol/
litre (e.g. two biscuits, one slice of bread, 200–300 mL of milk) Diabetes team
review.

Management:
- Admit.
- HbA1c

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Scenario 3:
Where you Are:
You are the resident doctor in the A&E.
Who the patient is:
Mrs Lilian Strafford, 35 year old lady presented to the emergency department
feeling unwell. She is well know to the department as she frequently presents
with alcohol excess.
Your Task:
Assess the patient’s condition and manage her accordingly.
Monitor:
SpO2 98%, BP 120/80, H.R 80, RR 16, Temp 36.

History:
- Feeling generally unwell since the morning.
- Had too much to drink last night and this morning.
- Didn’t eat well.
- Patient then becomes unconscious.

Assessment:
A- Airway:
- Check for any obstruction.
- Acknowledge that SpO2 is within the normal range.
B- Breathing:
- Examine the chest in order: Inspection, palpation, percussion, auscultation.
- Order Chest X-ray and perform ABG.
C- Circulation:
- Check: Capillary Re ll + Pulse + BP + Lead II
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- Insert 1 cannula.
- Perform routine bloods.
- Request ECG.
D - Disability
- Check: Blood Sugar + Temperature + Pupils
- Blood sugar less than 4 mmol: give IV 200ml of 10% glucose or 100ml of
20% glucose over 15 minutes.
- In alcoholic patients, thiamine (2 vials of IV pabrinex) should be given
with, or following, the administration of IV glucose to minimise the risk of
Wernicke's encephalopathy.
E - Exposure
- Examine the abdomen, legs and private area.
- Reassess blood sugar after 15 minutes, if still less than 4 mmol and
unconscious then give another 10% or 20% glucose of same amount as before
over 15 minutes.
- If the blood glucose level remains below 4 mmol/L, but the patient is
conscious and able to swallow, they should be treated with a fast-acting
carbohydrate (oral glucose gel) administered orally.
- A long-acting carbohydrate should be given as soon as possible once the
patient has recovered and their blood-glucose concentration is above 4 mmol/
litre (e.g. two biscuits, one slice of bread, 200–300 mL of milk).

Management:
- Admit.
- Monitor blood sugar
- Alcohol liaison team
- Advice on hypoglycaemia symptoms

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Scenario 4:
Where you Are:
You are the resident doctor in the A&E.
Who the patient is:
Jack Power, 65 year old gentleman was in the hospital for a chest X-ray. You
were called as he lost consciousness in the radiology department.
Your Task:
Assess the patient’s condition and manage him accordingly.

Setting inside the cubicle:

Clinical notes:
- Name: Jack Power
- Age: 65 years old
- Reason for referral: chronic cough
- Past medical history: Diabetes on Insulin

Monitor:
SpO2 98%, BP 120/80, H.R 80, RR 16, Temp 36.5

History:
- Postpone history and start your assessment.

Assessment:
A- Airway:
- Check for any obstruction.
- Acknowledge that SpO2 is within the normal range.

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B- Breathing:
- Examine the chest in order: Inspection, palpation, percussion, auscultation.
- Order Chest X-ray and perform ABG.
C- Circulation:
- Check: Capillary Re ll + Pulse + BP + Lead II
- Insert 1 cannula.
- Perform routine bloods.
- Request ECG.
D - Disability
- Check: Blood Sugar + Temperature + Pupils
- Blood sugar less than 4 mmol: give IV 200ml of 10% glucose or 100ml of
20% glucose over 15 minutes.
E - Exposure
- Examine the abdomen, legs and private area.
- Reassess blood sugar after 15 minutes, if still less than 4 mmol and
unconscious then give another 10% or 20% glucose of same amount as before
over 15 minutes.
- If the blood sugar is more than 4mmol and the patient is unsafe to swallow
due to confusion then start the patient on 10% dextrose at a rate of 100ml/hr.

Management:
- Admit.
- Diabetes team review.
- HbA1c

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Scenario 5:
Where you Are:
You are the resident doctor in the A&E.
Who the patient is:
Mrs Lilian Strafford, 65 year old lady is brought to A&E. She was recently
discharged from hospital following a fall and was in a physiotherapy session.
She felt drowsy during the sessions and lost consciousness during the session.
Your Task:
Assess the patient’s condition and manage her accordingly. At the 2 minute bell
discuss the case with the examiner.

Monitor:
SpO2 98%, BP 120/80, H.R 80, RR 16, Temp 36.

History:
- Postpone history and start your assessment.

Assessment:
A- Airway:
- Check for any obstruction.
- Acknowledge that SpO2 is within the normal range.
B- Breathing:
- Examine the chest in order: Inspection, palpation, percussion, auscultation.
- Order Chest X-ray and perform ABG
C- Circulation:
- Check: Capillary Re ll + Pulse + BP + lead II

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- Insert 1 cannula.
- Perform routine bloods.
- Request ECG.
D - Disability
- Check: Blood Sugar + Temperature + Pupils
- Blood sugar less than 4 mmol: give IV 200ml of 10% glucose or 100ml of
20% glucose over 15 minutes. If you don’t nd glucose then give Glucagon
1mg IM.
E - Exposure
- Examine the abdomen, legs and private area.
- A long-acting carbohydrate should be given as soon as possible once the
patient has recovered and their blood-glucose concentration is above 4 mmol/
litre (e.g. two biscuits, one slice of bread, 200–300 mL of milk)

Management:
- Admit.
- Advice regarding hypoglycaemia signs.
- Diabetes team review.
- HbA1c

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Hospital Acquired Pneumonia

Scenario 1:
Where you Are:
You are the resident doctor in the acute medical unit.
Who the patient is:
Mr. Lincoln Peterson, a 67-year old gentleman has been admitted to the hospital
3 days back from care home with a UTI. He was treated well and was ready to
be discharged. The nurse has called you to review him as he is feeling unwell.
Your Task:
Take a focused history, assess his condition and manage him accordingly.

Monitor:
SpO2: 87%, BP: 88/50, H.R: 120, RR 24, Temp 39.

History:
Patient is confused and can’t give history:
- Postpone history and start your assessment.

Assessment:
A- Airway:
-Check for any obstruction.
- Give oxygen via non-rebreather mask 100% oxygen 15L/min.
B- Breathing:
- Examine the chest in order: Inspection, palpation, percussion, auscultation.
- Auscultation: unilateral coarse crackles.
- Order Chest X-ray.

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- Perform ABG: Lactate will be more than 2. (Sometimes lactate result will not
be provided)
C- Circulation:
- Check: pulse + CRT + BP + lead II
- Since the patient looks really sick with signs of infection in lung and low BP,
start Sepsis 6 pathway:
1. Insert 2 cannulas and perform routine bloods, infection markers, blood
cultures and sensitivity.
2. Give IV broad spectrum antibiotics
3. Give IV uid (normal saline) 500ml over 15 minutes
4. Insert a urinary catheter and send urine for culture
- Request ECG.
D- Disability
- Check: Blood Sugar + Temperature + Pupils.
- Temp 39: give paracetamol 1 g IV
- Re-assess blood pressure and if still low give additional 500ml of uids over
15 minutes up to 2L in the 1st hour
E - Exposure
- Examine the abdomen, legs and private area.
- Start your discussion with the patient.

Management:
- Involve your senior.
- Monitor the urine out put
- Change antibiotics to speci c antibiotics following results of cultures.
- Discuss with ITU reviewing the patient.

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Scenario 2:
Where you Are:
You are the resident doctor in the rehabilitation unit.
Who the patient is:
Mr. Lincoln Peterson, a 67-year old gentleman has been admitted to the hospital
following a hip fracture. The nurses have called you to review him as he is
hypoxic and hypotensive.
Your Task:
Take a focused history, assess his condition and manage him accordingly.

Monitor:
SpO2: 87%, BP: 88/50, H.R: 120, RR 24, Temp 39.

History:
Patient is confused and can’t give history:
- Postpone history and start your assessment.

Assessment:
A- Airway:
-Check for any obstruction.
- Give oxygen via non-rebreather mask 100% oxygen 15L/min.
B- Breathing:
- Examine the chest in order: Inspection, palpation, percussion, auscultation.
- Auscultation: unilateral coarse crackles.
- Order Chest X-ray.
- Perform ABG: Lactate will be more than 2. (Sometimes lactate result will not
be provided)
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C- Circulation:
- Check: pulse + CRT + BP + lead II
- Since the patient looks really sick with signs of infection in lung and low BP,
start Sepsis 6 pathway:
1. Insert 2 cannulas and perform routine bloods, infection markers, blood
cultures and sensitivity.
2. Give IV broad spectrum antibiotics
3. Give IV uid (normal saline) 500ml over 15 minutes
4. Insert a urinary catheter and send urine for culture
- Request ECG.
D- Disability
- Check: Blood Sugar + Temperature + Pupils.
- Temp 39: give paracetamol 1 g IV
- Re-assess blood pressure and if still low give additional 500ml of uids over
15 minutes up to 2L in the 1st hour
E - Exposure
- Examine the abdomen, legs and private area.
- Start your discussion with the patient.

Management:
- Involve your senior.
- Monitor the urine out put
- Change antibiotics to speci c antibiotics following results of cultures.
- Discuss with ITU reviewing the patient.

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Community Acquired Pneumonia

Where you Are:
You are the resident doctor in the A&E.
Who the patient is:
John smith, 18 year old student was brought to hospital by his friend due to
fever and confusion.
Your Task:
Take a focused history, assess his condition and manage him accordingly.

Monitor:
SpO2: 94%, BP: 100/60, H.R: 120, RR 24, Temp 39, Lead II: SR.

History:
Patient is NOT confused and can give history:
- Feels feverish since the morning.
- No shortness of breath, cough or chest pain.
-No dysuria or frequency.
- No past medical history or regular medications.

Assessment:
A- Airway:
-Check for any obstruction.
- Give oxygen via non-rebreather mask 100% oxygen 15L/min to maintain
oxygen sats above 94%.
B- Breathing:
- Examine the chest in order: Inspection, palpation, percussion, auscultation.

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- Auscultation: unilateral coarse crackles.

- Order Chest X-ray.
- Perform ABG: Lactate will be more than 2. (Sometimes lactate result will not
be provided)
C- Circulation:
- Check: pulse + CRT + BP + lead II
- Since the patient looks really sick with signs of infection in lung and low BP,
start Sepsis 6 pathway:
1. Insert 2 cannulas and perform routine bloods, infection markers, blood
cultures and sensitivity.
2. Give IV broad spectrum antibiotics
3. Give IV uid (normal saline) 500ml over 15 minutes
4. Insert a urinary catheter and send urine for culture
- Request ECG.
D- Disability
- Check: Blood Sugar + Temperature + Pupils.
- Temp 39: give paracetamol 1 g IV
- Re-assess blood pressure and if still low give additional 500ml of uids over
15 minutes up to 2L in the 1st hour
E - Exposure
- Examine the abdomen, legs and private area.

Management:
- Involve your senior.
- Monitor the urine out put
- Change antibiotics to speci c antibiotics following results of cultures.
- Discuss with ITU reviewing the patient.

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Infective Exacerbation of COPD

Where you Are:
You are the resident doctor in the A&E.
Who the patient is:
Jaden Allen, 50 year old student presented to hospital feeling unwell.
Your Task:
Take a focused history, assess his condition and manage him accordingly.

Monitor:
SpO2: 85%, BP: 100/60, H.R: 120, RR 24, Temp 39, Lead II: SR.

History:
- Dif culty breathing and fever.
- No associated symptoms
-History of COPD on inhalers

Assessment:
A- Airway:
-Check for any obstruction.
- Give oxygen via Venturi mask to maintain oxygen saturation between 88% to
92%
B- Breathing:
- Examine the chest in order: Inspection, palpation, percussion, auscultation.
- Auscultation: wheezes and unilateral coarse crackles.
- Start the patient on Salbutamol 5mg and ipratropium bromide 0.5 mg via air
driven nebuliser mask.

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- Order Chest X-ray.

- Perform ABG: Lactate will be more than 2. (Sometimes lactate result will not
be provided)
C- Circulation:
- Check: pulse + CRT + BP + lead II
- Since the patient looks really sick with signs of infection in lung and low BP,
start Sepsis 6 pathway:
1. Insert 2 cannulas and perform routine bloods, infection markers, blood
cultures and sensitivity.
2. Give IV broad spectrum antibiotics
3. Give IV uid (normal saline) 500ml over 15 minutes
4. Insert a urinary catheter and send urine for culture
- Request ECG.
D- Disability
- Check: Blood Sugar + Temperature + Pupils.
- Temp 39: give paracetamol 1 g IV
- Re-assess blood pressure and if still low give additional 500ml of uids over
15 minutes up to 2L in the 1st hour
E - Exposure
- Examine the abdomen, legs and private area.

Management:
- Involve your senior.
- Monitor the urine out put
- Change antibiotics to speci c antibiotics following results of cultures.
- Discuss with ITU reviewing the patient.

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Catheter Associated UTI

Where you Are:
You are the resident doctor in the A&E.
Who the patient is:
Mr. Lincoln Peterson, a 60-year old gentleman presented with confusion. His
wife reports that he has been having burning sensation while passing urine and
has a high temperature for the last 2 days. He has a history of prostate surgery 1
week back and has a catheter inserted since then.
Your Task:
Take a focused history, assess his condition and manage him accordingly.

Monitor:
SpO2: 90%, BP: 100/60, H.R: 120, RR 24, Temp 39, Lead II: SR.

History:
Patient is confused and can’t give history:
- Postpone history and start your assessment.

Assessment:
A- Airway:
- Check for any obstruction.
- Give oxygen via non-rebreather mask 100% oxygen 15L/min.
B- Breathing:
- Examine the chest in order: Inspection, palpation, percussion, auscultation.
- Order Chest X-ray.

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- Perform ABG: Lactate will be more than 2. (Sometimes lactate result will not
be provided)
C- Circulation:
- Check: pulse + CRT + BP + lead II.
- Since the patient looks really sick with possible infection via urinary catheter
and low SBP, start Sepsis 6 pathway:
1. Insert 2 cannulas and perform routine bloods, infection markers, blood
cultures and sensitivity
2. Give IV broad spectrum antibiotics
3. Give IV uid (normal saline) 500ml over 15 minutes
4. Remove the old catheter and insert a new one. Take a urine sample for
culture.
- Request ECG.
D- Disability
- Check: Blood Sugar + Temperature + Pupils
- Temp 39: give paracetamol 1 g IV
- Re-assess blood pressure and if still low give additional 500ml of uids over
15 minutes up to 2L in the 1st hour
E - Exposure
- Examine the abdomen, legs and private area.

Management:
- Involve your senior.
- Change antibiotics to speci c antibiotics following results of cultures.
- Discuss with ITU reviewing the patient.

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Urosepsis
Where you Are:
You are the resident doctor in the Medical Ward.
Who the patient is:
The nurse asked you to come assess Mr. Peter Lincoln, an 80 year old man who
was admitted with a UTI.
Special notes:
Use the appropriate equipment from the trolley provided.
Your Task:
Take a focused history, assess his condition and manage him accordingly.

Monitor:

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SpO2: 88%, BP: 85/50, H.R: 120, RR 24, Temp 39, Lead II: AF.
Setting:
Medical notes: patient was admitted with UTI yesterday and is on antibiotics.
He doesn’t have any past medical history.

History:
Patient is confused and can’t give history:
- Postpone history and start your assessment.

Assessment:
A- Airway:
- Check for any obstruction.
- Give oxygen via non-rebreather mask 100% oxygen 15L/min.

B- Breathing:
- Examine the chest in order: Inspection, palpation, percussion, auscultation.
- Order Chest X-ray.
- Perform ABG: Lactate will be more than 2.
C- Circulation:
- Check: pulse + CRT + BP + lead II.
- Since the patient looks really sick with possible UTI and low BP, start Sepsis
6 pathway:
1. Insert 2 cannulas and perform routine bloods, infection markers, blood
cultures and sensitivity
2. Give IV broad spectrum antibiotics
3. Give IV uid (normal saline) 500ml over 15 minutes
4. Insert a urinary catheter and send a urine sample for catheter
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- Request ECG.
D- Disability
- Check: Blood Sugar + Temperature + Pupils
- Temp 39: give paracetamol 1 g IV
- Re-assess blood pressure and if still low give additional 500ml of uids over
15 minutes up to 2L in the 1st hour
E - Exposure
- Examine the abdomen, legs and private area.

Management:
- Involve your senior.
- Change antibiotics to speci c antibiotics following results of cultures.
- Discuss with ITU reviewing the patient.

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Sepsis of unknown source

Where you are :
You are an FY2 doctor in the A&E.
Who the patient is :
A 30-year-old man had a fever last night, and so his at mate called an
ambulance.
Your Task :
Take a focused history, access his conditions and manage him accordingly.
Monitor:
SpO2- 94% on air, RR- 26/min, BP- 80/55 mmHg, PR- 120/min, Temp - 38.9C

Data Gathering -
Explore about fever (ODIPARA)
Explore about associated symptoms- rash, cough, runny nose, sore throat, SOB,
abdominal pain , nausea, vomiting, urinary symptoms, bowel problems,
Explore Red Flags- neck stiffness, photophobia.
Assessment :
A- Airway :
- check for any obstruction
- Sp02 Low- Give Oxygen via non-rebreather mask 100% Oxygen 15 L/min.
- B - Breathing :
- Examine the chest in order, inspection , palpation, percussion and auscultation.
- On auscultation - Crackles in both lower zones
- Order Chest X ray , ECG and ABG
- C - circulation :
- Check - pulse+ CRT+ BP + Lead II .

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- Since the patient looks really sick with possible chest infection and low BP,
- Start SPESIS 6 PATHWAY :
- 1. Insert two cannulas and perform routine bloods, infection markers, blood
cultures and sensitivity.
- 2. Give IV broad spectrum antibiotics
- 3. Give IV uid (Normal Saline) 500ml over 15 minutes.
- 4. Insert a urinary catheter.
- D- Disability :
- Check Blood sugar + Temperature + Pupils
- Temperature _ 38.9 C , Give Paracetamol 1g IV.
- Re-access Blood pressure and if still low, give additional 500 ml of uids over
15 minutes up to 2L in the rst hour.
- E - Exposure :
- Examine the abdomen, legs and private area.

Management :
- Involve your seniors.
- Complete “Take 3, Give 3”
- Change antibiotics to speci c antibiotics following the results of cultures.
- Discuss with ITU reviewing the patient.

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Morphine Toxicity
Scenario 1:
Where you Are:
You are the resident doctor in the emergency department.
Who the patient is:
Mr. Gary Penman is a 75 year old male, presented with dizziness and
sleepiness. He has a past medical history of CKD 4. He came a week ago with
back pain following a fall and was prescribed morphine.
Your Task:
Take a focused history, assess his condition and manage him accordingly.

Monitor:
SpO2: 88%, BP: 90/60, H.R: 94, RR 6, Lead II: SR.

History:
Patient is drowsy and can’t talk in full sentence:
- Postpone history and start your assessment.

Assessment:
A- Airway:
- Check for any obstruction.
- Give 100% oxygen 15L/min via non-rebreather mask.
B- Breathing:
- Examine the chest in order: Inspection, palpation, percussion, auscultation.
- RR will be low.

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- Verbalise that you suspect morphine toxicity and check the pupils which will
be pinpoint.
- Give IV Naloxone 0.4mg.
- Request chest X-ray and perform ABG.
C- Circulation:
- Check: Capillary Re ll + Pulse + BP + Lead II
- Insert 1 cannula.
- Perform routine bloods.
- Request ECG.
- Re-assess the patient: if still unconscious then give IV Naloxone 0.8mg.
D- Disability
- Check blood sugar and temperature.
- Re-assess the patient: if still unconscious then give another IV Naloxone
0.8mg.
E - Exposure
- Examine the abdomen, legs and private area.
- Re-assess the patient: if still unconscious then give IV Naloxone 2mg.
- Re-assess the patient after 1 minute: if still unconscious then give 4mg of IV
Naloxone.
- Start your discussion with the patient.

Management:
- Review the Morphine dose and discuss reducing it to avoid toxicity.
- Offer simple analgesia
- Involve senior
- Monitor the patient conditions closely.

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Scenario 2:
Where you Are:
You are the resident doctor in the emergency department.
Who the patient is:
Mr. Gary Penman is a 75 year old male, presented with dizziness and
sleepiness. He was recently discharged from hospital following a fall.
Your Task:
Take a focused history, assess his condition and manage him accordingly.

Setting inside the cubicle:

Clinical notes:
- Name: Gary Penman
- Age: 75 years old
- Previous admission history: Presented with hip pain. Hip xray didn’t show
any fractures.
- Discharge medications: Morphine 10mg MR twice/day, Morphine 5mg as
required maximum 4 times/day.
Monitor:
SpO2: 88%, BP: 90/60, H.R: 94, RR 6, Lead II: SR.

History:
Patient is drowsy and can’t talk in full sentence:
- Postpone history and start your assessment.

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Assessment:
A- Airway:
- Check for any obstruction.
- Give 100% oxygen 15L/min via non-rebreather mask.
B- Breathing:
- Examine the chest in order: Inspection, palpation, percussion, auscultation.
- RR will be low.
- Verbalise that you suspect morphine toxicity and check the pupils which will
be pinpoint.
- Give IV Naloxone 0.4mg.
- Request chest X-ray and perform ABG.
C- Circulation:
- Check: Capillary Re ll + Pulse + BP + Lead II
- Insert 1 cannula.
- Perform routine bloods.
- Request ECG.
- Re-assess the patient: if still unconscious then give IV Naloxone 0.8mg.
D- Disability
- Check blood sugar and temperature.
- Re-assess the patient: if still unconscious then give another IV Naloxone
0.8mg.
E - Exposure
- Examine the abdomen, legs and private area.
- Re-assess the patient: if still unconscious then give IV Naloxone 2mg.
- Re-assess the patient after 1 minute: if still unconscious then give 4mg of IV
Naloxone.

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Management:
- Review the Morphine dose and discuss reducing it to avoid toxicity.
- Offer simple analgesia
- Involve senior
- Monitor the patient condition closely.

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