Table of Contents

Sim Mannequin ..................................................................................................... 2

Simman Structure (Conscious) ......................................................................................... 2
Simman Structure (Unconscious) ..................................................................................... 3
Asthma ....................................................................................................................................... 5
COPD .......................................................................................................................................... 7
Heart Failure ................................................................................................................................ 9
Opioid OD - Morphine ................................................................................................................. 11
Pulmonary Embolism .................................................................................................................. 13
Anaphylaxis ............................................................................................................................... 14
Post UTI Sepsis Shock .................................................................................................................. 17
Post CAP Sepsis .......................................................................................................................... 19
Post-Partum Haemorrhage .......................................................................................................... 20
Upper GI Bleed – Post Endoscopy ................................................................................................. 23
PR Bleed (Bloody Diarrhoea) ........................................................................................................ 25
Hypovolaemic Shock – Post Hysterectomy ..................................................................................... 25
Hypoglycaemia – Unconscious ..................................................................................................... 27
Hypoglycaemia – Confused/ Semi-Unconscious .............................................................................. 29
Acute Limb Ischaemia ................................................................................................................. 31
Post CS – Pain Management......................................................................................................... 33
UTI after TURP ........................................................................................................................... 34
Dizzy Spells ................................................................................................................................ 37
Upper GI Bleed........................................................................................................................... 39
DNAR ........................................................................................................................................ 42
Sim Mannequin

Simman Structure (Conscious)

IntroducQon
PC + Onset QuesQons
Any other symptoms?
Vitals - unstable (Tachypnoea, Low SATs, Tachycardia, Low BP, Hight Temp)
PMHx – Any medical condiQons? MedicaQons? Allergies?

ABCDE Assessment Management Investigation

Airway Patient is talking. Start High flow O2. Cervical Spine X-Ray (If
His airway is patent. 15L/min Trauma)
Via Non-Rebreather Mask

Triple Immobilisation (If

Trauma)
Breathing Trachea Trachea deviated – Urgent CXR
Chest Examination Needle Decompression. ABG
RR Peak Flow (If Asthma)
SATs Wheeze – Nebulisers (See next
page)

Creps – Diuretics (If Fluid

overload)

Low RR – Naloxone

Circulation Pulse Insert 2 large bore IV cannulas. Routine Bloods (FBC,

Pallor Start fluid resuscitation with CRP, U&Es, LFTs)
Cap Refill bolus of warm crystalloids (See
Cyanosis next page). Blood Culture (Sepsis)
Cold Peripheries ABG – Lactate
Active Bleeding sites Massive Haemorrhage –
HR Massive haemorrhage protocol Group & Cross Match
BP (See next page)
Bleeding/Clotting
Arrange Blood Transfusion
Profile (Haemorrhage
Stop the bleeding (Uterine cases)
massage, Urgent endoscopy,
etc)

Disability Blood Sugars Blood Sugars – Normal

GCS GCS – 15/15
Exposure Head to Toe Inspection IV PCM if high temperature X-Rays
Scans
Simman Structure (Unconscious)

IntroducQon
Response + Breathing (Look/Listen/Feel) à No Response but Pt is breathing (Simman chest is moving with
respiraQon)
Vitals – Stable
PMHx – I would like to check for Any medical condiQons? MedicaQons? Allergies? From Pts medical
records/collateral history, etc. They will tell you if there is anything posiQve.
I would like to check for ambulance note as well.

ABCDE Assessment Management Investigation

Airway Patient is breathing and I Start High flow O2. Cervical Spine X-Ray (If
cannot hear any added 15L/min Trauma)
sounds. Via Non-Rebreather Mask
His airway is patent.
Triple Immobilisation (If
Trauma)
Breathing Trachea All normal CXR
Chest Examination
RR
SATs
Circulation Pulse All normal Routine Bloods (FBC,
Pallor CRP, U&Es, LFTs)
Cap Refill
Cyanosis Blood Culture (Sepsis)
Cold Peripheries ABG – Lactate
Active Bleeding sites
HR Group & Cross Match
BP
Bleeding/Clotting

Profile (If Trauma)

Disability Blood Sugars IM Glucagon CT Head (If Head

GCS IV Dextrose (See next page) Trauma)
Pupillary Reflexes
Alert Anaesthetics
Exposure Head to Toe Inspection IV PCM if high temperature X-Rays
Scans

Reassess the paQent a_er compleQng ABCDE à checks the vitals, ask the paQent (how is he doing now), check
if the bleeding has stopped (in haemorrhage cases), repeat blood sugars (in hypoglycaemia case) etc.

Summarise to the paQent now:

Summarise your ACBDE assessment and tell him the diagnosis and give the definiQve immediate management.
Now, talk about any further management plan (involving senior, referring to different specialiQes, invesQgaQon,
etc).
Take relevant history related to the current episode only if Qme permits.

Summary:
IntroducQon and presenQng complaint, onset quesQons, vitals, past medical history à ABCDE à reassess –
diagnose, summary and definiQve immediate management à further management à addiQonal history if
Qme permits.
Complete Management Plans
Airway:
The paQent's airway is patent. I would like to start high-flow oxygen (15 L/min) via non-rebreather mask.

Breathing:
Wheeze: Salbutamol and ipratropium nebulisers via nebuliser mask back-to-back, preferably every 15-20
minutes for the first hour, driven by oxygen saturaQon (for asthma) or respiratory acidosis (for COPD). Reassess
a_er 1 hour.
Crackles: Furosemide stat dose and reassess (if HF).
Respiratory depression: Naloxone IV (200-400 micrograms).

CirculaAon:
I would like to insert two large-bore IV cannulas and start resuscitaQng by giving warm crystalloids. I would like
to start with 1 L of normal saline (if shock) or 500 mL of normal saline (if hypotensive) and then reassess. If the
paQent needs more fluids, I will give boluses of 500 mL unQl a maximum of 2 L in the first hour.
Always give choice of fluid, rate of infusion and how much fluids to give.
Normal Saline is the choice of fluid for all emergencies except Sepsis where we give Ringer’s Lactate.

Massive Haemorrhage:
As the paQent has lost more than 40% of their blood volume in under 3 hours, I would like to iniQate massive
haemorrhage protocol and call the lab to arrange for O-negaQve blood and transfuse as soon as possible. I
would like to send for group and cross match, bleeding/clojng profile, and give cross-matched blood when it
is ready. I would like to arrange for 5-6 units of RBCs and 4 units of FFPs and wait for the blood results to come
back and arrange for platelets and fibrinogen as required. I would like to stop the bleeding by doing [___]
(uterine massage, urgent endoscopy, etc).

Hypoglycaemia:
Once I have gained IV access, I would like to give IM glucagon followed by IV dextrose 20% in 100 mL of normal
saline as a bolus. I would like to check the blood sugars every 10-15 minutes and give boluses of dextrose as
required.

Low GCS:
If the paQent's GCS drops to 8 or below 8, I will alert the anaestheQst as they may need to be intubated.

Abdominal Examination Done in Circulation if Lower Limb Acute Limb Ischaemia

suspected bleeding, if Examination
not in exposure.
Inspection General inspection and Inspection General inspection and
comment about the scar comment about
if present. swelling, redness, skin
(Clean/Swelling, changes, ulcers,
Redness, Discharge, gangrenous changes,
Bleeding, etc). missing toes, etc.
Palpation Superficial Palpation Temperature,
Tenderness, Pulses
(Dorsalis Pedis (if pulses
absent, go in ascending
order), Capillary refill
time.
Auscultation Sensory Cotton wisp or rub your
finger on feet.
Motor Wriggle your toes.
Asthma

You are FY2 in A&E. James Rodriguez, aged 40, came with acute shortness of breath. Please talk to the
patient, assess his condition, examine him and discuss the initial plan of management with the examiner.

D: What brought you to the hospital? P: I can’t breathe, my asthma is killing me.
D: When did it start? P: It started 2 hours ago
D: How did it start? P: I was sitting at home, and it started suddenly.
D: Has it changed since it started? P: It got worse, and I called the ambulance
D: Do you have any other symptoms? P: No

Reassure
D: Let me quickly have a look at your vitals

Note: Saturations are decreased, and Respiratory rate is increased

As my paQent vitals are unstable, I would like to proceed with ABCDE assessment.

Start ABCDE approach immediately.

A - Airway Patient is talking to me. His airway is patent.

I would like to start my patient on high flow O2 – 15L/min via non-
rebreather mask.
B - Breathing Trachea and Chest Examination
Examination:
- Trachea is central and there is bilateral wheeze on chest
Examination
Management:
- I would like to give salbutamol and ipratropium bromide
nebulisers to my patient, preferably every 15-20 mins driven by
O2.
C - Circulation Peripheral signs of perfusion:
- Pulse,
- Cold peripheries,
- Cap refill,
- Cyanosis,
- Pallor,
- Active bleeding site.
Management:
- HR & BP stable. Insert one IV cannula and draw some bloods at the
same time for routine investigations including blood sugars.
D - Disability Patients GCS seems to be 15/15.
E - Exposure Expose the patient fully for Head-to-Toe examination. Look for any
redness, rashes, swelling, temperature.

Reassess à Vitals are improving, and paQent says he is feeling beper.

(Look at the monitor and check if vitals have improved. Ask the paQent if he feels any beper).

• Summarise your initial assessment: ABCDE – O2 and nebulisers.

• Give the diagnosis and definitive management for the diagnosis: Asthma exacerbation and I would like to
give steroids. (You must give steroids even if the patient is getting better with nebulisers).

Start taking history NOW, if the patient’s vitals are stable.

Note: If the patient deteriorates while you are taking history, reassess the patient using ABCDE approach and call
your senior to review and consider further plan of management – IV Magnesium, IV Salbutamol or IV
Aminophylline.

Inform ITU if you suspect life threatening or near fatal asthma.

You can ask the below Qs:

D: Do you have any cough? P: No

D: Do you have any chest Qghtness? P: No
D: Do you have any wheeze? P: I don’t know.
D: Have you experienced any heavy pain in your chest? P: No (ACS)
D: Do you have any pain, redness, hotness or swelling in your legs? P: No (P.E)
D: Do you have any fever, flu like symptoms? P: No (Pneumonia)

D: Has it happened before? P: Yes/No

D: When were you diagnosed with asthma? P: Since childhood.

D: How was it managed? P: I was taking blue and brown inhalers.
D: Did you use your inhaler to relieve your shortness of breath today? P: I did, but it did not work.

D: Do you use inhalers regularly as prescribed? P: Yes

D: How o_en do you use blue inhaler? P: Once / twice a day recently.

D: Did you noQce any trigger factors? P: No

Management:
Severe Asthma if any of:

1. PEFR 33% - 50%.

2. Respiratory rate > 25
3. PR >110
4. Unable to complete sentence in one breath.
5. Using accessory muscles.

Management:
1. High flow oxygen:
40% - 60% (6 L/min) up to 100% (15 L/min) to maintain saturaQon of 94% - 98%.
2. Nebulized salbutamol 2.5 – 5mg every 5 – 15 minutes, driven by O2.
3. Ipratropium bromide (Atrovent) 500 microgram.
4. CorQcosteroids:
Prednisolone 40 mg PO or HydrocorQsone 100-200 mg IV.

Involve Senior:
1. Magnesium 2 gm IV over 20 minutes
2. Salbutamol 250 microgram IV bolus.
3. Salbutamol infusion 5 – 20 microgram / min.

AlternaQve:
1. Aminophylline 5mg/kg iv over 20 minutes loading (unless on oral therapy)
2. Aminophylline 0.5 – 0.7 mg/kg/hour
If paQent on oral aminophylline or theophylline, check blood levels on admission and daily if infusion started.
COPD

You are F2 in A&E. Mr James Bond, aged, 70, came with acute shortness of breath. Please talk to the paAent,
assess his condiAon, examine him, and discuss about iniAal plan of management with the paAent.

Talk to the paQent. PaQent is conscious and oriented.

D: What brought you to the hospital? P: I can’t breathe

D: When did it start? P: It started 2 hours ago
D: How did it start? P: Started suddenly.
D: What were you doing? P: Nothing specific
D: Has it changed since it started? P: It got worse, and I called the ambulance
D: Do you have any other symptoms? P: No

Reassure

D: Let me quickly have a look at your vitals

Note: SaturaQons are decreased, and Respiratory rate is increased

As my paQents’ vitals are unstable, I would like to proceed with ABCDE assessment.

Ask PMHx (paQent has COPD) and start ABCDE approach immediately.

A:
- PaQent is talking to me. His airway is patent.
- I would like to start my paQent on high flow O2 – 15L/min via non-rebreather mask as my Pts saturaQons
are 79%.
- I would like to switch to Venturi once his saturaQon improve and maintain my Pts saturaQons between 88-
92% as he has COPD.

B:
- Trachea and Chest Ex
- Trachea is central and there is bilateral wheeze on chest Ex.
- Mx: I would like to give salbutamol and ipratropium bromide nebulisers to my paQent, preferably every 15-
20 mins driven by RA for the first one Hr and reassess.

C:
- Peripheral signs of perfusion - Pulse, Cold peripheries, Cap refill, Cyanosis, Pallor, AcQve bleeding site.
- Mx: HR & BP stable. Insert one IV cannula and draw some bloods at the same Qme for rouQne
invesQgaQons including blood sugars.

D:
- As my paQent is Alert, Conscious, talking to me and is obeying commands, his GCS seems to be 15/15.

E:
- Expose the paQent fully for Head-to-Toe examinaQon. Look for any redness, rashes, swelling, temperature.

Reassess - Vitals are improving, and Pt says he is feeling beper.

(Look at the monitor and check if vitals have improved. Ask the paQent if he feels any beper).

Summarise your iniQal assessment: ABCDE – O2 and nebulisers.

Give the diagnosis and definiQve management for the diagnosis: COPD exacerbaQon and I would like to give
steroids.
I have sent for some blood invesQgaQons and a CXR. If we find any signs of infecQon, we will start you on
AnQbioQc.

Start taking relevant history NOW, if the paQent’s vitals are stable.

If the paQent deteriorates while you are taking relevant history, reassess the paQent using ABCDE approach and
call your senior to review and consider further plan of management.

You can ask the below Qs:

D: Do you have any cough? P: No

D: Do you have any chest Qghtness? P: No
D: Do you have any wheeze? P: I don’t know.
D: Have you experienced any heavy pain in your chest? P: No (ACS)
D: Do you have any pain, redness, hotness or swelling in your legs? P: No (P.E)
D: Do you have any fever, flu like symptoms? P: No (Pneumonia/Viral)

D: Has it happened before? P: Yes/No

D: When were you diagnosed with COPD? P: 5 years.

D: How was it managed? P: I was taking blue and brown inhalers.
D: Did you use your inhaler to relieve your shortness of breath today? P: I did, but it did not work.

D: Do you use inhalers regularly as prescribed? P: Yes

D: How o_en do you use blue inhaler? P: Once / twice a day recently.
D: Do you think your COPD is under control? P: Yes/No
Heart Failure

You are FY2 in A&E. Mrs Michelle Turner, aged 75, has come to the A&E with shortness of breath and
palpitations. Please talk to her, assess her, manage her, and discuss the management plan with the her.

Talk to the paAent. PaAent is CONSCIOUS and oriented.

D: What brought you to the hospital? P: I can’t breathe.

D: When did it start? P: It started yesterday.
D: How did it start? P: Just started.
D: What were you doing? P: Nothing specific
D: Is it conQnuous or on & off? P: ConQnuous
D: Has it changed since it started? P: It got worse, and I called the ambulance
D: Do you have any other symptoms? P: No

Reassure…
D: Let me quickly have a look at your vitals

Note: SaturaQons are decreased. (You may also find AF on ECG).

As my Pts vitals are unstable, I would like to proceed with ABCDE assessment.

Ask PMHx (Pt has HTN and is on Ramipril) and

Start ABCDE approach immediately.

A:
- PaQent is talking to me. Her airway is patent.
- I would like to start my paQent on high flow O2 – 15L/min via non-rebreather mask.

B:
- Trachea and Chest Ex
- Trachea is central and there are bilateral crackles on chest Ex.
- I would like to do a CXR and ABG.
(Examiner will give you CXR which shows Cardiomegaly).

- As my Pt seems to be having Fluid overload due to HF, I would like to give stat dose of Furosemide and Reassess.

C:
- Peripheral signs of perfusion - Pulse, Cold peripheries, Cap refill, Cyanosis, Pallor, AcQve bleeding site.
- Mx: HR & BP stable. Insert one IV cannula and draw some bloods at the same Qme for rouQne invesQgaQons
including blood sugars.

D:
- As my paQent is Alert, Conscious, talking to me and is obeying commands her GCS seems to be 15/15.

E:
- Expose the paQent fully for Head-to-Toe examinaQon. Look for any redness, rashes, swelling, temperature, pedal
oedema. (Note: Examiner might say NO pedal oedema or pedal oedema is present).

REASSESS - Vitals are improving, and Pt says he is feeling beper.

(Look at the monitor and check if vitals have improved. Ask the paQent if he feels any beper).

Summarise your iniQal assessment: ABCDE – O2.

Verbalise about further invesQgaQons: ECG, CXR and BNP. (Note: Examiner will give you an ECG with AF and a CXR with
findings of Heart Failure {Cardiomegaly and Pulmonary oedema or Bilateral pleural effusions}).
Give the diagnosis and definiQve management for the diagnosis: My paQent seems to be having Heart Failure, and I would like
to give DiureQcs to my paQent. I will ask my senior to review my paQent.

I will admit my Pt and arrange for an in-paQent Echo to confirm the diagnosis and refer to a cardiologist.
I will also monitor my paQent’s Renal funcQon regularly.
I will insert a catheter to monitor 24 Hr fluid input and output.

Start taking history NOW, if the paQent’s vitals are stable.

History to take:

D: Do you have any cough? P: No

D: Do you have any faQgue? P: Yes/No
D: Have you experienced any heavy pain in your chest? P: No

D: Has it happened before? P: Yes/No

D: You menQoned about HTN? P: Yes

D: When was it diagnosed? P: 7 years
D: How is it managed? P: Ramipril
D: Is it well controlled? P: Yes
D: Are you taking any other medicaQons other than Ramipril? P: No
D: Have you been hospitalized before? P: No
D: Have you had any surgeries in the past? P: No

D: Has any member of your family ever been diagnosed with any medical condiQons? P: No

D: Do you smoke? P: Yes/No

D: Are you physically acQve? P: I am not quite acQve.
D: What do you do for a living? P: I am reQred.
D: Have you travelled recently? P: No.

D: How is your living status? P: It’s fine

Opioid OD - Morphine

You are F2 in A&E. Mr, James Bond aged 70, came with acute shortness of breath. He is recently diagnosed
with hip fracture and had hip surgery. He is on Calcium, Vit D, Morphine for pain management. Please talk to
the paAent, assess his condiAon, examine him, and discuss about iniAal plan of management with the
paAent.

Talk to the paQent. PaQent is conscious and oriented.

D: What brought you to the hospital? P: I can’t breathe

D: When did it start? P: It started 2 hours ago
D: How did it start? P: Just started.
D: What were you doing? P: Nothing specific
D: Has it changed since it started? P: It got worse, and I called the ambulance
D: Do you have any other symptoms? P: No

Reassure
D: Let me quickly have a look at your vitals
Note: SaturaQons are decreased, and Respiratory rate is DEPRESSED. RR - 5

As my paQents’ vitals are unstable, I would like to proceed with ABCDE assessment.

Ask PMHx (paQent had Hip Fracture and is on Morphine now).

Check compliance:
Are you taking your medicaQon regularly? As prescribed?
Yes Dr. Today I had severe pain and took couple of extra PKs.

Start ABCDE approach immediately.

A:
- PaQent is talking to me. His airway is patent.
- I would like to start my paQent on high flow O2 – 15L/min via non-rebreather mask.

B:
- Trachea and Chest Ex
- Trachea is central and chest is clear. RR – 5
- Mx: As my Pt’s RR is depressed probably due to Morphine, I would like to check his pupils. (Pupils will be
pin pointed).
- I would like to insert a cannula and give IV Naloxone 200-400 micrograms and reassess. At the same Qme, I
would like to draw some bloods for rouQne invesQgaQons including blood sugars.

C:
- Peripheral signs of perfusion - Pulse, Cold peripheries, Cap refill, Cyanosis, Pallor, AcQve bleeding site.
- Mx: HR & BP stable.

D:
- As my paQent is Alert, Conscious, talking to me and is obeying commands, his GCS seems to be 15/15.

E:
- Expose the paQent fully for Head-to-Toe examinaQon. Look for any redness, rashes, swelling, temperature.

REASSESS Vitals are improving, and pt says he is feeling beper.

(Look at the monitor and check if vitals have improved. Ask the paQent if he feels any beper).
If the paQent’s RR is sQll under 10, verbalised that you would like to repeat Naloxone and call your senior
immediately to review the paQent.

• Summarise your iniQal assessment: ABCDE – O2 and Naloxone.

• Give the diagnosis and definiQve management for the diagnosis: Morphine OD and naloxone as
anQdote.
• I have sent for some blood invesQgaQons and a CXR.
• I will admit you and monitor you closely and ask my senior to come and review you.

Start taking relevant history NOW, if the paQent’s vitals are stable.

You can ask the below qs:

- When was the operaQon done?
- Is everything oaky during and a_er the operaQon?
- Is your pain under control?
Are you managing well at home?
Pulmonary Embolism

Mrs Tracy White aged 65 was admiped to the hospital for hysterectomy. She had the procedure 3 hours ago
and is now complaining of SOB. Please talk to the Pt, do the iniQal assessment, and manage the Pt.

D: I would like to check my paQents’ vitals. (Look at the monitor)

- RR 24
- SpO2 88
- Pulse 100
- BP 120/80
- Temp 37.0
-
Note: PaQent has Hypoxic and raised RR.
Anaphylaxis

You are FY2 in surgery. Mr Kane West, aged 55, had undergone surgery on the abdomen for burst appendix.
Surgery team decided to give two units of blood. He was given one unit of blood already. While he was
receiving a second unit of blood, he experienced shortness of breath. Your nurse colleague was concerned
about the patient and asked you to talk to the patient. Please talk to the patient, assess him and do relevant
management.

Inside the cubicle, sim-man is lying down on a couch wearing a gown. You can see blood attached to it. There
are 2 masks, one with a bag attached and one with a tubing. Sim-man is catheterised as well. There is a bag of
blood that is connected, and transfusion is taking place at the moment. There is also a bag of IV fluid,
adrenaline, and colloid on the table nearby. Sometimes you may find a wrist band showing penicillin allergy.

Talk to the paQent. PaQent is conscious and oriented.

D: How can I help you?

P: Help me Dr, I can’t breathe. (Breathing heavily).
D: Tell me what exactly happened?
P: I had a surgery for my appendix, and I was receiving blood a_er that. Suddenly my lips and tongue have
swollen up. My hands got itchy, and I developed breathing difficulty.
D: Since when are you having this problem? P: From last 20 minutes.
D: Has it changed ever since it started? P: It is gejng worse.
D: Any other symptoms P: Yes, I feel my tummy is bloated.
D: Since when? P: Same Qme

D: Examiner I would like to stop the blood transfusion as I suspect my paQent has some reacQon to it.
Examiner: Ok stop it.

Reassure the paQenp and look at the monitor.

- Monitor findings:
- ECG-normal
- Oxygen- 85-88%
- Pulse-92
- BP- 90/50
- RR->25
Note: PaQent is hypotensive, tachycardic and tachypnoeic.

D: My Pt seems to be having Anaphylaxis reacQon to the blood he was receiving; I would like to call for help
and ask my colleague to arrange for adrenaline immediately while I proceed with ABCDE assessment.

Examiner: Whatever you need is in the trolley.

D: Pick up the correct dose Adrenaline and give it on Pts thigh.

D: As my Pts vitals are unstable, I would like to proceed with ABCDE Assessment.

Ask PMHx and Start ABCDE approach immediately.

A:
- PaQent is talking to me. Airway is patent.
- I would like to start my paQent on high flow O2 – 15L/min via non-rebreather mask.
- Pick the oxygen mask with a reservoir bag apached. (SaturaQon will improve)

B:
- Trachea and Chest Ex
- Trachea is central and Chest Ex is Normal.
 - Chest was also undressed showing rash which was basically red.

C:
- Peripheral signs of perfusion - Pulse, Cold peripheries, Cap refill, Cyanosis, Pallor, AcQve bleeding site.
- Mx: HR & BP unstable. I would like to Insert TWO large bore IV cannulas (Grey colour) and start
resuscitaQng my paQent by giving IV Fluids. I would also like to draw some bloods at the same Qme for
rouQne invesQgaQons including cross match with the blood she was receiving.
- Fluid Challenge: Adults - 500 mL of warmed crystalloid soluQon (0.9% saline) in 5-10 minutes if the
paQent is hypotensive or 1 L if the paQent is in shock).
- I would like to reassess a_er the bolus and give further boluses of 500 ml fluids unQl a maximum of 2L
in the first one hour.

D:
- As my paQent is alert, conscious, talking to me and is obeying commands her GCS seems to be 15/15.

E:
- Expose the paQent fully for Head-to-Toe examinaQon. Look for any redness, rashes, swelling,
temperature (Might see a band on paQent’s wrist saying allergic to Penicillin – In that case ask if the
paQent has received any Abx)
- I would like to examine your tummy as well. P: Okay Dr.

Abdomen shows three bandages as paQent had laparotomy.

There was nothing found on palpaQon.

REASSESS Vitals are improving and Pt says he is feeling beper.

(Look at the monitor and check if vitals have improved. Ask the paQent if he feels any beper).

Summarise your iniQal assessment: ABCDE – O2 and IV Fluids.

Give the diagnosis and definiQve management for the diagnosis: You seem to be having an AnaphylacQc
reacQon which is an allergic reacQon to the blood which you are receiving. I have stopped the blood and given
you O2 and IV Fluids.

I have given you adrenaline (0.5ml IM (500 micrograms) 1:1000 QtraQon) and will monitor you closely and may
give another dose of adrenaline if needed.

(I would like to reassess my Pt and give another dose of adrenaline if she doesn’t improve).

I would like to send the blood you are receiving to the lab to cross match and see if you are receiving the
correct blood or not. If it is not the correct blood, then I will have to fill an incident form.

D: Are you feeling beper

P: Yes, Dr much beper.
(If paQent is not feeling beper, we need to auscultate the chest and further treatment with a bronchodilator,
such as salbutamol (inhaled or IV), ipratropium (inhaled), aminophylline (IV) or magnesium sulfate (IV -
unlicensed indicaQon). Magnesium is a vasodilator and can compound hypotension and shock)

D: We are suspecQng that you had a condiQon called anaphylaxis reacQon. It is an allergic reacQon that
happens when a foreign object enters the body and our body’s defence system release a substance to fight
against it.

We will send Blood to the lab for further invesQgaQon, for Blood grouping and incompaQbility, FBC, LFT, U&Es,
CreaQnine, ABG, bleeding and Clojng screen. We will do an ECG and keep an eye on the vitals.

I will check your notes as to see what kind of anQbioQcs were given to you a_er the surgery. If it belongs to the
penicillin group, then that could explain the symptoms. However, I need to check if there has been any
mismatch of blood as well.
I sincerely apologise for all you have been going through.

We have a system in our hospital in such situaQons, I will document this incident in your notes, I will inform my
consultant, and I will fill in an adverse report form (Incident form) to let the hospital authoriQes know about
the incident. In this way, the hospital authoriQes can act promptly to reduce the risk of further incidents and
improve the service we provide in the NHS. These incidents are reported naQonally as well to prevent them
happening.

Start taking other relevant history NOW, if the paQent’s vitals are stable.

D: When did you noQce this allergy to penicillin?

D: What happens when you take Penicillin?
D: Has anything like this happened before?
Post UTI Sepsis Shock

You are an FY2 in the Medicine Dept. Mrs Rachel Thompson, aged 73, was admitted to the hospital with UTI
3 days ago. Nurse has called you and says that the patient is feeling poorly. She says that you are the only
doctor available to see her. Talk to the patient, assess her and manage her situation appropriately.

Talk to the patient. Patient is concious and oriented.

D: Hello, Mrs. Thomson, how are you doing today. (Introduce yourself)
P: I Cannot breathe doctor

D: May I know since when? P: 2 hours

D: How did it start? P: It just started Dr.
D: Is it continuous? P: Yes
D: Anything specific happened before? P: No
D: Any other symptoms? P: No

D: I am sorry to hear that Mrs. Smith, but don’t worry, let me quickly examine you and see what’s going on.
P: Okay Dr.

D: I would like to check my patients’ vitals. (Look at the monitor)

- RR 24
- SpO2 88
- Pulse 110
- BP 90/60
- Temp 39.0
Note: Patient is hypotensive and tachycardic. Her temperature is raised.

D: As my Pts vitals are unstable, I would like to proceed with ABCDE Assessment.

Ask PMHx and Start ABCDE approach immediately.

A:
- Patient is talking to me. Her airway is patent.
- I would like to start my patient on high flow O2 – 15L/min via non-rebreather mask.

B:
- Trachea and Chest Ex
- Trachea is central and Chest Ex is Normal. (You may find crackles sometimes).

C:
- Peripheral signs of perfusion - Pulse, Cold peripheries, Cap refill, Cyanosis, Pallor, Active bleeding.
- Mx: HR & BP unstable. I would like to Insert TWO large bore IV cannulas and start resuscitating my
patient by giving IV Fluids. I would also like to draw some bloods at the same time for routine
investigations including blood cultures, lactate, and blood sugars.
- Fluid Challenge: Adults - 500 mL of warmed crystalloid solution (Ringers Lactate) in 5-10 minutes if the
patient is Hypotensive or 1 L if the patient is in shock).
- I would like to reassess after the bolus and give further boluses of 500 ml fluids until a maximum of 2L
in the first one hour.

D:
- As my patient is Alert, Conscious, talking to me and is obeying commands her GCS seems to be 15/15.

E:
- Expose the patient fully for Head-to-Toe examination. Look for any redness, rashes, swelling,
temperature - 39. Start patient on IV paracetamol.
I would like to examine your tummy as well. P: Okay Dr.

Abdominal Ex - Normal

REASSESS - Vitals are improving, and Pt says she is feeling better.

(Look at the monitor and check if vitals have improved. Ask the patient if she feels any better).
Summarise your initial assessment: ABCDE – O2 and IV Fluids.

Give the diagnosis and definitive management for the diagnosis: Sepsis on background of UTI which is a
common complication.

D: From my assessment, I think you have a condition called Sepsis. This means you have an infection that has
spread all over your body through your blood. The source of infection looks like to be from your UTI.

D: I have given you O2 as your oxygen levels are low in your blood. I have given you fluids and paracetamol
through your vein as your BP is low and you have a high temp.
I will arrange for some blood and urine tests and a Chest X-Ray.

D: I will have to give you stronger antibiotics through your veins for your condition. Is that okay with you.
P: Yes doctor.

D: I will inform my senior and Intensive Care team to come and review you.

I would like to start SEPSIS 6 immediately.

Give 3 and Take 3. I have already given high flow O2 and fluids. I would like to give broad spectrum IV
antibiotics to my patient according to hospital protocol and change the Abx according to culture and sensitivity
report.

I have already sent for lactate and blood cultures. I would like to insert a urinary catheter to monitor hourly
urine output.
I would also send urine for culture and sensitivity and order a CXR to look for other sources of sepsis.

Start taking history NOW, if the patient’s vitals are stable.

D: You were admitted with UTI, is it right? P: Yes

D: Do you have any other symptoms? P: No
D: Any cough? P: No
D: Any tummy pain? P: No
D: Any flank or back pain? P: No
D: Are you able to pass urine? P: Yes
D: Any pain while passing urine? P: No
D: Any burning sensation while passing urine? P: No

SEPSIS SCREEN: (Find out source of sepsis)

• Bloods for FBC, CRP, Renal and Liver function tests
• Blood Culture
• Urine Dip and Culture
• CXR
• Sputum culture (If cough + phlegm present)

SEPSIS SIX:
GIVE: TAKE:
1. Oxygen 1. Blood cultures
2. IV Fluids 2. Lactate
3. IV Antibiotics 3. Urine Output
Post CAP Sepsis

You are an F2 in the Medicine Dept. Mr John Smith, aged 73, was admitted to the hospital with Pneumonia 3
days ago. The nurse has called you and says that the patient is feeling poorly. She says that you are the only
doctor available to see her. Talk to the patient, assess her, and manage her situation appropriately.

D: I would like to check my patients’ vitals. (Look at the monitor)

- RR 24
- SpO2 88
- Pulse 110
- BP 90/60
- Temp 39.0
Note: PaQent is hypotensive and tachycardic. Her temperature is raised.
Post-Partum Haemorrhage

You are an FY2 in O&G. Mrs Samantha Jefferson, aged 36, multigravida, had her 6th delivery an hour ago. She
is bleeding. Nurse called you. Assess the patient and do the initial management. There is a nurse in the cubicle.

Talk to the paQent. PaQent is CONSCIOUS and oriented.

(Introduce yourself to the paQent)

D: How can I help you?
P: I just delivered a baby, and I am bleeding heavily and now I can’t breathe. (Or say hmm)
D: When did the bleeding start? P: Just now
D: How much blood is lost so far? P: Around bucket full
(SomeQmes, Pt shows a bucket filled with blood)
D: How did the delivery go? P: It was fine
D: Did they tell you about any complicaQons during the delivery? P: No

I would like to have a look at the Pts delivery notes.

Reassure the paQent and look at the monitor.

- SpO2: 91
- RR: 26
- BP: 85/55
- Pulse: 117
- Temp: Afebrile
Note: PaQent is hypotensive, tachycardic and hypoxic.

D: As my paQents vitals are unstable, I would like to proceed with ABCDE Assessment.

Ask PMHx and Start ABCDE approach immediately.

A:
- PaQent is talking to me. Her airway is patent.
- I would like to start my paQent on high flow O2 – 15L/min via non-rebreather mask.
- Pick the oxygen mask with a reservoir bag apached. (SaturaQon will improve)

B:
- Trachea and Chest Ex.
- Trachea is central and Chest Ex is Normal.
- Let me examine you quickly. For the purpose of examinaQon, I would like you to undress above your
waist, and I will keep a chaperone with me to ensure your privacy.

C:
- Peripheral signs of perfusion - Pulse, Cold peripheries, Cap refill, Cyanosis, Pallor, AcQve bleeding site
(Examine Vagina and Abdomen).

D: I can see bleeding from her vagina.

I would also check if placental delivery complete (Tissue)? any vaginal tear during delivery (Trauma)?
I would like to examine your tummy as well to see if there is any uncontracted uterus (Tone). P: Okay Dr.

- Mx: HR & BP unstable. I would like to Insert TWO large bore IV cannulas and start resuscitaQng my
paQent by giving IV Fluids. I would also like to draw some bloods at the same Qme for rouQne
invesQgaQons including group and cross match for blood transfusion.
- Fluid Challenge: Adults - 500 mL of warmed crystalloid soluQon (0.9% Normal Saline) in 5-10 minutes if
the paQent is Hypotensive or 1 L if the paQent is in shock).
 - I would like to reassess a_er the bolus and give further boluses of 500 ml fluids unQl a maximum of 2L
in the first one hour.
- We need to transfuse blood immediately. As my Pt had massive blood loss, I would like to start
massive haemorrhage protocol and arrange O-Neg blood (2 Units) and 4 Units FFPs immediately and
transfuse. I would also like to take bloods for FBC, U&E’s, clojng profile and for Grouping and Cross
matching and arrange 4 Units of Blood. I will wait for the blood results to come back and arrange for
platelets and fibrinogen as required. To stop the bleeding, I would like to insert a catheter and start
uterine massage for my paQent as I suspect uterine atony to be the cause for bleeding. I would like to
ask my colleague to take over and conQnue with my assessment.
- I would like to add IV Oxytocin if the bleeding doesn’t stop and ask my senior to review and consider
surgical opQons if needed.

D:
- As my paQent is Alert, Conscious, talking to me and is obeying commands her GCS seems to be 15/15.

E:
- Expose the paQent fully for Head-to-Toe examinaQon. Look for any redness, rashes, swelling,
temperature.

REASSESS - Vitals are improving, and Pt says he is feeling beper.

(Look at the monitor and check if vitals have improved. Ask the paQent if he feels any beper).
I would like to check if the bleeding has stopped. If not, I would like to add IV Oxytocin if the bleeding doesn’t
stop and ask my senior to review and consider surgical opQons if needed.

Summarise your iniQal assessment: ABCDE – O2 and IV Fluids.

Give the diagnosis and definiQve management for the diagnosis: You seem to be having bleeding from your
front passage. This is called post-partum haemorrhage (PPH). That is why you are having all these symptoms.
This is an emergency. I will involve my senior. I need to do a manoeuvre called uterine massage to control the
bleeding. If that doesn’t help, then we will give you some medicaQon to control your bleeding called Oxytocin.
Lastly, we might have to do surgical intervenQon to control the bleeding.

Start taking history NOW, if the paQent’s vitals are stable.

D: Any pain? P: No Dr

D: How has your pregnancy been? P: Fine

D: Any problems during your pregnancy? P: No
D: Any problems with your previous pregnancies or deliveries? P: No
D: Any bleeding like this in previous deliveries? P: No

Talk to the Examiner or Present case to Registrar – SBAR (ONLY if Ex says I am the senior or trauma team is
here).
Ex: What happened?
Ex: What have you done so far?
Ex: Causes of PPH?
Ex: What else can be done to Control bleeding?

Postpartum haemorrhage (PPH) is a rare complicaQon where you bleed heavily from the
vagina a_er baby’s birth.
There are two types of PPH, depending on when the bleeding takes place:
- primary or immediate – bleeding that happens within 24 hours of birth.
- secondary or delayed – bleeding that happens a_er the first 24 hours and up to six weeks a_er the birth.

SomeQmes PPH happens because your womb doesn't contract strongly enough a_er the
birth. It can also happen because part of the placenta has been le_ in your womb or you
get an infecQon in the lining of the womb (endometriQs). It can also happen in bleeding disorders or trauma
during delivery.

To help prevent PPH, you will be offered an injecQon of oxytocin (10 IU IM) as your baby is being born. This
sQmulates contracQons and helps to push the placenta out.

PPH Management:
Give immediate clinical treatment:
• emptying of the bladder and
• uterine massage and
• uterotonic drugs and
• intravenous fluids and
• controlled cord tracQon if the placenta has not yet been delivered.

First-line treatment (can repeat another bolus)

Administer a bolus of one of the following as first-line treatment for postpartum haemorrhage (uterotonic
drugs):
• oxytocin (10 IU intravenous) or
• ergometrine (0.5 mg intramuscular) or
• combined oxytocin and ergometrine (5 IU/0.5 mg intramuscular).
If haemorrhage conQnues:
Consider oxytocin infusion or tranexamic acid

If the haemorrhage conQnues:

• perform examinaQon under anestheQc
• ensure that the uterus is empty and repair any trauma
• consider balloon tamponade before surgical opQons.

Surgical opQons: May include uterine artery ligaQon, ovarian artery ligaQon, internal iliac artery ligaQon,
selecQve arterial embolisaQon, B-lynch suture, dilataQon and curepage and hysterectomy.

Post resuscitaQon care:

It isn't a good idea to use tampons unQl a_er your 6-week postnatal check because they
could increase your chance of gejng an infecQon.
You may noQce the bleeding is red and heavy when you breas~eed. This happens because breas~eeding makes
your womb contract. You may also feel cramps like period pains. The bleeding will carry on for a few weeks. It
will gradually turn brownish in colour and decrease unQl it finally stops.
If you're losing blood in large clots, tell your midwife. You may need some treatment.

SBAR Approach for presenQng the case to your senior (registrar), referral or hand over:
SituaQon: Mrs Smith, 35 years old on O&G ward has massive vaginal bleeding a_er giving birth to a healthy
baby.
Background: She had her 5th baby delivered an hour ago. She has no medical problems from before and she is
not on any blood thinners. There are no complicaQons during her previous deliveries.
Assessment: Mrs Smith was stable since admission for her delivery but suddenly she started bleeding from her
vigina and her vitals deteriorated to SpO2: 91, RR: 26, BP: 90/60, Pulse: >100.
She is going into circulatory shock.
I have resuscitated her by giving high flow O2, inserted 2 large bore IV cannulas and started her on warm
crystalloids. I have started her on Massive Haemorrhage Protocol and arranged for O-Neg blood to be
transfused immediately. I have sent her bloods for clojng and for grouping and cross match. (Explain Massive
Haemorrhage Protocol and Uterine Massage).
RecommendaQon: I suspect my Pt is having PPH most probably due to uterine atony. I would like you to review
Mrs Smith and consider Oxytocin 10 IU IV and balloon tamponade or surgical intervenQon if needed.
Upper GI Bleed – Post Endoscopy

You are FY2 in Gastroenterology. Mr Ma^ Bloomfield, aged 50, was admi^ed to the hospital yesterday for
Endoscopy for UGI Bleed. He underwent the procedure yesterday and is now complaining of hematemesis.
Please talk to him, assess him, and give the management plan to the Pt.

Talk to the paQent. PaQent is CONSCIOUS and oriented.

(Introduce yourself to the paQent)

D: How can I help you? P: I am vomiQng Blood.
D: When did the bleeding start? P: 1 Hr
D: How much blood is lost so far? P: Around bucket full
(SomeQmes, Pt shows a bucket filled with blood)
D: Do you have any other symptoms? P: No

Reassure the Pt and look at the monitor.

- SpO2: 91
- RR: 26
- BP: 85/55
- Pulse: 117
- Temp: Afebrile
Note: PaQent is hypotensive, tachycardic and hypoxic.

D: As my Pts vitals are unstable, I would like to proceed with ABCDE Assessment.

Ask PMHx and Start ABCDE approach immediately.

D: I understand that you had an Endoscopy yesterday. P: Yes
D: May I know why did you have it? P: For same problem
D: How did the procedure go? P: It was okay
D: Any complicaQons? P: No

I would like to check the Endoscopy report from yesterday.

A:
- PaQent is talking to me. His airway is patent.
- I would like to start my paQent on O2 using Nasal Cannula as my Pt is vomiQng.

B:
- Trachea and Chest Ex
- Trachea is central and Chest Ex is Normal.

C:
- Peripheral signs of perfusion - Pulse, Cold peripheries, Cap refill, Cyanosis, Pallor, AcQve bleeding site.
- Mx: HR & BP unstable. I would like to Insert TWO large bore IV cannulas and start resuscitaQng my
paQent by giving IV Fluids. I would also like to draw some bloods at the same Qme for rouQne
invesQgaQons including group and cross match for blood transfusion.
- Fluid Challenge: Adults - 500 mL of warmed crystalloid soluQon (0.9% Normal Saline) in 5-10 minutes if
the paQent is Hypotensive or 1 L if the paQent is in shock).
- I would like to reassess a_er the bolus and give further boluses of 500 ml fluids unQl a maximum of 2L
in the first one hour.
- We need to transfuse blood immediately. As my Pt had massive blood loss, I would like to start
massive haemorrhage protocol and arrange O-Neg blood (2 Units) and 4 Units FFPs immediately and
transfuse. I would also like to take bloods for FBC, U&E’s, clojng profile and for Grouping and Cross
matching and arrange 4 Units of Blood. I will wait for the blood results to come back and arrange for
platelets and fibrinogen as required. I would like to stop the bleeding by referring the Pt to Gastro
team for an Urgent Endoscopy.
 - I would like to examine your tummy as well. P: Okay Dr.

Abdominal Ex - Normal

D:
- As my paQent is Alert, Conscious talking to me and is obeying commands his GCS seems to be 15/15.

E:
- Expose the paQent fully for Head-to-Toe examinaQon. Look for any redness, rashes, swelling,
temperature.

REASSESS - Vitals are improving, and Pt says he is feeling beper.

(Look at the monitor and check if vitals have improved. Ask the paQent if he feels any beper).

Summarise your iniQal assessment: ABCDE – O2 and IV Fluids.

Give the diagnosis and definiQve management for the diagnosis: You seem to be having bleeding from your gut.
That is why you are having these symptoms. This is called Upper GI Bleed. This is an emergency. I need to refer
you to a specialist urgently. We will keep you Nil by Mouth and conQnue fluids for now. We need to give some
blood as you have lost blood.

P: Okay doctor.

D: The specialist will do the endoscopy again and try to find out the source of bleeding and stop it.

D: I will review you regularly unQl you are seen by the specialist and get the procedure done.
P: Okay doctor.

Start taking history NOW, if the paQent’s vitals are stable.

D: Any pain? P: No Dr
D: Why did you under the procedure yesterday?
P: I was vomiQng blood for the last 3 weeks.
D: Did they tell you what happened?
P: Yes/No
PR Bleed (Bloody Diarrhoea)

You are an FY2 in A&E. Mrs Mary, aged 61, was brought into the hospital by her partner as she was feeling
dizzy and out of breath. She had 7 episodes of bloody stools from the past 2 days, and she is a known paAent
of diverAculiAs disease. She has AF and is on warfarin. Please talk to her, assess her and discuss the
management plan with her.

PC from PT: SOB, light-headedness, and bloody diarrhoea (Elaborate Quickly)

Reassure the Pt and look at the monitor.
- SpO2: 91
- RR: 26
- BP: 85/55
- Pulse: 117
- Temp: Afebrile
Note: PaQent is hypotensive, tachycardic and hypoxic.

D: As my Pts vitals are unstable, I would like to proceed with ABCDE Assessment.

Ask PMHx and Start ABCDE approach immediately.

CirculaQon: Manage as other Haemorrhage StaQons. Give Vit K IV as per the hospital policy and refer the Pt to
Lower GI surgeons for urgent Colonoscopy.

5 Steps for CirculaQon Management in Haemorrhage cases:

- Examine Peripheral signs of Perfusion

- Fluid ResuscitaQon
- Examine Bleeding Sites
- Massive Haemorrhage Protocol
- Stop the Bleeding
Hypovolaemic Shock – Post Hysterectomy

You are an FY2 in hospital.

Mrs Tracy Yellow, aged 65, was admiped to the hospital for abdominal hysterectomy. She had the procedure 2
hours ago and is now complaining of SOB. Please talk to the Pt, do the iniQal assessment, and manage the Pt.

D: I would like to check my paQents’ vitals. (Look at the monitor)

- RR 24
- SpO2 92
- Pulse 110
- BP 90/60
- Temp 37.0
Note: PaQent is hypotensive and tachycardic.
Hypoglycaemia – Unconscious

You are F2 in A&E. A 50-year-old patient was brought into the hospital by ambulance as he was found
unconscious. Please talk to the patient, assess the patient, and do the initial management.

D: Try and TALK to the patient: Patient is not talking back.

Tap on the shoulders: Patient is not responding again.

Patient is UNCONSCIOUS/UNRESPONSIVE.

D: Now check whether the patient is breathing or not?

D: Look/ Listen/ Feel: Patient is breathing

Patient is BREATHING.

RESPONSE + BREATHING (Look/Listen/Feel) No Response but Pt is breathing (SimMan chest is moving with
respiration)

D: I would like to connect my Pt to the monitor and check the Vitals.

NOTE: Vitals are Stable.
I would like to check for ambulance note as well.
As the presentation of the Pt is is unavailable, I would like to secure his cervical spine by Triple Immobilisation
and also request for a Cervical spine X-Ray.

(As the patient is Unconscious and Breathing. Continue with ABCDE approach and keep an eye on the vitals).

PMHx – I would like to check for Any medical conditions? Medications? Allergies? From Pts medical
records/collateral Hx, etc. They will tell you if there is anything positive.

D: Start ABCDE approach immediately.

D: I would like to arrange for blood sugars as my patient is unconscious in the mean while I would like to
proceed with ABCDE.

A:
- Patient is breathing. There are no added sounds. His airway is patent.
- I would like to start my patient on high flow O2 – 15L/min via non-rebreather mask.
- (As my patient is unconscious and breathing with no added sounds, I assume my Pt’s airway is patent.
I would like to start my Pt on O2 and look at the vitals. I would also like to call for help and ask one of
my colleagues to do a bed side RBS).

B:
- Trachea and Chest Ex
- Trachea is central and Chest Ex is Normal.

C:
- Peripheral signs of perfusion - Pulse, Cold peripheries, Cap refill, Cyanosis, Pallor, Active bleeding site.
- Mx: HR & BP stable.

D:
- Blood Glucose = 1.8. My patient has Hypoglycaemia, and I would like to give IM Glucagon as my
patient is unconscious and start him on IV Dextrose 20% in 100 mls NS bolus. I would like to check his
blood sugars every 10-15 minutes and repeat boluses of Dextrose as required. I would like to draw
some bloods at the same time for routine investigations including blood sugars.
 - I would like to check my patient’s GCS. Examiner will give you the findings.

- My Pt’s GCS is low. I would like to alert the anaesthetics just in case my Pt’s GCS drops to 8 or below
8, he might need intubation. I am suspecting this is because of Hypoglycaemia. I would like to correct
his blood sugars and reassess his GCS.

E:
- Expose the patient fully for Head-to-Toe examination. Look for any redness, rashes, swelling, injuries,
bruises, head trauma, temperature.

REASSESS - Vitals are stable, and Pt is not responding. Repeat Blood sugars 3.1 (Improving).
(Look at the monitor, check if the Pt is responding and repeat Blood sugars).

Summarise your initial assessment: ABCDE – O2 and Low Blood Sugars.

Give the diagnosis and definitive management for the diagnosis: Hypoglycaemia and I have already given IM
Glucagon as my patient is unconscious and started him on IV Dextrose 20% in 100 mls NS.

My patient’s blood sugars are improving. I would like to Admit my Pt, keep an eye on his vitals and continue
with the same treatment and give another bolus of 20% Dextrose, I will involve my seniors to come and review
my Pt.

a. Start talking to the patient and take history if the patient gains Consciousness.

b. If the patient is not regaining his consciousness, start verbalizing that I would like to continue the
same management plan after involving my seniors and keep checking his blood sugars every 10-15 mins. Once
the blood sugars are above 4 and Pt regains his consciousness, I would like to give him a full meal and check his
blood sugars until they are normal.

Then I would like to take a full detailed Hx (See below) of the event and PMHx and refer him to Endocrinology.
I would like to counsel him about management of Diabetes before discharge.

On the other hand, if the Pt doesn’t regain his consciousness even after his blood sugars are improved, I would
like to discuss with my senior and investigate for other causes of unconsciousness (CT Head, Toxicology screen,
etc).

I would like to check:

-What was he doing and where was he before the incident.
-When was his last meal timings?
-What happened after he went unconscious?
-If he is diabetic, when was his last meal?
-How is his diabetic control?
-Any previous Hypoglycaemic episodes?
Hypoglycaemia – Confused/ Semi-Unconscious

You are an FY2 in Medicine. Mr John Lords, aged 40, was admi^ed to the hospital for CAP. He had a fall on
the way to the X-ray department. He has PMHx of Diabetes and is on Insulin. Assess the paAent and manage
him. NOTE: Pt is lying in the couch and moaning throughout the staAon. He is not answering any of your
quesAons.

D: My Pt looks confused, and he is not answering to my quesQons.

Check the vitals Directly.
D: I would like to connect my Pt to the monitor and check the Vitals.
NOTE: Vitals are Stable.
D: As my Pt is confused, I would like to start ABCDE immediately to stabilise my Pt.

A:
- As my Pt is making incomprehensive sounds and I do not hear any stridor, I assume my Pt’s airway is
patent. I would like to start my paQent on high flow O2 – 15L/min via non-rebreather mask.

B:
- Trachea and Chest Ex
- Trachea is central and Chest Ex is Normal.

C:
- Peripheral signs of perfusion - Pulse, Cold peripheries, Cap refill, Cyanosis, Pallor, AcQve bleeding site.
- Mx: HR & BP stable.

D:
- Blood Glucose = 1.8. My paQent has Hypoglycaemia, and I would like to give IM Glucagon as my
paQent is confused and start him on IV Dextrose 20% in 100 mls NS bolus. I would like to check his
blood sugars every 10-15 minutes and repeat boluses of Dextrose as required. I would like to draw
some bloods at the same Qme for rouQne invesQgaQons including blood sugars.

- I would like to check my paQent’s GCS. Examiner will give you the findings.

- My Pt’s GCS is low. I would like to alert the anaestheQcs just in case my Pt’s GCS drops to 8 or below 8,
he might need intubaQon. I am suspecQng this is because of Hypoglycaemia. I would like to correct his
blood sugars and reassess his GCS.

E:
- Expose the paQent fully for Head-to-Toe examinaQon. Look for any redness, rashes, swelling, injuries,
bruises, head trauma, temperature.

REASSESS - Vitals are stable, and Pt is not responding. Repeat Blood sugars 3.1 (Improving).
(Look at the monitor, check if the Pt is responding and repeat Blood sugars).

Summarise your iniQal assessment: ABCDE – O2 and Low Blood Sugars.

Give the diagnosis and definiQve management for the diagnosis: Hypoglycaemia and I have already given IM
Glucagon as my paQent is unconscious and started him on IV Dextrose 20% in 100 mls NS.

My paQent’s blood sugars are improving. I would like to Admit my Pt, keep an eye on his vitals and conQnue
with the same treatment and give another bolus of 20% Dextrose, I will involve my seniors to come and review
my Pt.

a. Start talking to the paQent and take history if the paQent gains Consciousness.
b. If the paQent is not regaining his consciousness, start verbalizing that I would like to conQnue the
same management plan a_er involving my seniors and keep checking his blood sugars every 10-15 mins. Once
the blood sugars are above 4 and Pt regains his consciousness, I would like to give him a full meal and check his
blood sugars unQl they are normal.

Then I would like to take a full detailed Hx (See below) of the event and PMHx and refer him to Endocrinology. I
would like to counsel him about management of Diabetes before discharge.

On the other hand, if the Pt doesn’t regain his consciousness even a_er his blood sugars are improved, I would
like to discuss with my senior and invesQgate for other causes of unconsciousness (CT Head, Toxicology screen,
etc).

I would like to check:

-What was he doing and where was he before the incident.
-When was his last meal Qmings?
-What happened a_er he went unconscious?
-If he is diabeQc, when was his last meal?
-How is his diabeQc control?
-Any previous Hypoglycaemic episodes?
Acute Limb Ischaemia

You are an FY2 in A&E. Mrs Alexandra Stuey, 60-year-old, presented with a history of severe pain in her right
leg since this morning. Talk to her, take history, assess the patient, do relevant examination and discuss the
management.

D: What brought you to the hospital?

P: I have had severe pain in my right leg since this morning.

D: I am sorry to hear that, are you comfortable to talk? P: Yes Dr.

D: Let me quickly have a look at your vitals

Note: Patient has AF, HR is increased, and other vitals are normal. So, continue with History. Keep monitoring
the vitals while you are taking History.

D: Could you please elaborate this pain for me? P: What do you want to know?
D: Where exactly is the pain? P: It’s all over my leg.
D: How did the pain start? P: It just started suddenly .
D: What were you doing when the pain started? P: I was at home, not doing anything.
D: Is it continuous or intermittent? P: It is continuous.
D: Is it getting worse? P: Yes
D: Could you please describe this pain for me? P: It is very painful.
D: Does the pain go anywhere else? P: Just my leg.
D: Does the pain start at your back and travel down your legs? P: No.
D: Does anything make the pain worse? P: It is getting worse by itself.
D: Does anything make the pain better? P: No.
D: Could you please score the pain for me on a scale of 1-10, 1 being the lowest and 10 being the most severe
pain you have ever experienced? P: 6/7/8

D: Do you have any other problems? P: No.

D: Is this the first time you are experiencing this kind of pain? P: Yes.
D: Have you experienced any pain in your legs recently after walking a certain distance? P: No.
D: Do you have any fever or flu like symptoms? P: No.
D: Any swelling of the legs? P: No.
D: Any redness/swelling/hotness around the calf? P: No.
D: Any weakness in your legs? P: Yes Dr, I feel my right leg is weak.
D: When did this start? P: This morning.
D: Is it getting worse? P: Yes
D: Any tingling or numbness or loss of sensation in your legs? P: No.
D: Have you noticed any change in skin colour or ulcers in your legs? P: No.
D: Have you hurt your leg recently? P: No.
D: Do you have any chest pain or heart racing?
P: Dr I had a chest pain and my heart was racing 2 weeks back, but I am fine now.

D: Did you have any more episodes like that? P: No.

D: Have you ever been diagnosed with any medical conditions? P: No.
D: Any heart problems or diabetes or high blood pressure or high cholesterol? P: No.
D: Any regular medications or OTC drugs? P: No.
D: Any allergies to any food or drugs? P: No.
D: Any hospital admissions or surgeries recently? P: No.
D: Any family members diagnosed with any medical conditions? P: No.

D: Do you smoke? P: Yes.

D: How much and how often?
P: I have smoked 30 cigarettes a day from the last 30 years.
D: Do you drink alcohol? P: Yes
D: How much and how often? P: I drink occasionally.
D: Could you please tell me about your diet? P: I eat everything.
D: Are you physically active? P: I am not that active.
D: Do you have any stress in life? P: Yes/No
D: What do you do for a living? P: I have an office job.
D: Have you travelled anywhere recently? P: No.
D: Whom do you live with? P: I live alone.

D: I need to examine you, check your vitals, GPE and examine your legs.

Findings:
Right Limb: Pale/Bluish discolouration, cold compared to other leg, Extremely tender, No dorsalis pedis pulse
felt, Prolonged Cap Refill time.
Left Limb: Normal

D: I would like to examine your heart.

Tachycardic
S1 S2 heard
Murmur: Yes/no

D: From my assessment, I suspect that you have a condition called acute limb ischemia. This is a condition in
which there is disruption in blood supply due to blockage of one of your arteries.

P: Why do I have this condition?

D: I think this is because of your heart beating very fast. We call this condition atrial fibrillation. We have done
tracing of your heart called ECG and it shows AF.

D: Sometimes when your heart is beating too fast, there might be some blood clot formation which may
dislodge into the circulation. When these clots get stuck in smaller arteries, they obstruct the blood flow.

P: What are you going to do next Dr?

D: This is a serious condition, so we need to admit and treat you immediately. I am going to arrange for some
blood tests and an US scan of the arteries in your legs. I am going to refer you to specialists called vascular
surgeons. Depending upon your ultrasound scan result, they might have to give you some medication to
dissolve the clot or do a procedure to remove the clot. Sometimes, they might have to do a bypass operation
to restore the blood flow to your legs. Is it OK with you?

P: Yes.

Management of Acute Limb Ischaemia:

- Oxygen
- Morphine
- Heparin
- US Doppler
- Referral to Vascular Surgeons.
Post CS – Pain Management

You are on FY2 in OBG. Mrs Mary Poppins had CS and had delivered twins 8 hours ago. Both the babies are
fine safe with the father in the other room. Talk to her and address her concerns.

Addi%onal informa%on:

Surgery was done 8 hours ago.

Surgery was uneven9ul with delivery of twins.
Placenta was completely removed with blood loss of 250ml.
Surgery was done under spinal using diamorphine.

Vital Chart:
HR: 95, SP02: 99, RR: 19, BP: 130/70, T:37.4C, ECG: Sinus Rhythm

D: How can I help you?

P: I have pain at the surgical area.

Elaborate PAIN

Explore if she is breast feeding.

Exclude:
1. Urinary retenQon (See if the paQents Bladder is full or is catheterised)
2. ConsQpaQon/Passed wind or not
3. Sepsis/InfecQons (Check the wound site and vitals)
4. Haemorrhage (Check the wound site and vitals for internal bleeding)

As the paQent has received Diamorphine during the inducQon of anaesthesia, you can give paracetamol and
NSAIDS unless contraindicated. Counsel the paQent for the pain as the pain killer takes some Qme to show its
affects. Offer oral morphine sulphate to women who have received spinal or epidural anaesthesia for Caesarian
birth. If oral is not tolerated, offer subcutaneous, IV, IM morphine. In breast feeding women, you can use
morphine, dihydrocodiene, tramadol or oxycodone. At the lowest effecQve dose for the short duraQon and not
more than 3 days without close supervision. Consider laxaQves and anQ-emeQcs for women taking opioids for
the prevenQon of consQpaQon and nausea/vomiQng respecQvely.

Remember:

1) You can give co-dydramol (paracetamol and dihydrocodiene).

2) Do not offer co-codamol to women who are currently breasPeeding because it can lead to serious
neonatal sedaQon and respiratory depression.
3) When the paQent is using paracetamol, NSAIDS, co-dydramol, prescribe them to be taken regularly
and not when needed for pain relief.
UTI after TURP

You are FY2 in A&E. Mr Rodrey Pink, aged 75, was brought in the hospital by his wife as he was feeling sick.
Please talk to the patient and address his concerns.

Urinary catheter was apached to the Simman, and he was apached to the monitor.

Monitor:
- ECG - Normal
- Pulse - 110/min
- Blood Pressure - 100/70 mm hg,
- SPO2 - 97%,
- Temperature - 38 C

NOTE:
1. If vitals are stable, go with History. Diagnose as UTI and admit and give management plan for UTI.
2. If the vitals are unstable and you suspect sepsis as paQent’s temperature is high, go with ABCDE approach.

SCENARIO 1: PaQent NOT in shock

D: How can I help you? P: I am not feeling well.
D: Could you please tell me more? P: I am feeling very Qred. I haven’t passed urine,
and it was very uncomfortable.
D: For how long are you having this problem? P: Since yesterday

D: Do you have any other symptoms? P: Yes, I feel feverish from last few days.
D: Did you take anything for that? P: I tried PCM it helped a bit.
D: How much did you take? P: I took 2 tablets yesterday.

D: Do you have any other symptoms? P: No

D: Let me quickly have a look at your vitals

Note: PaQent’s vitals are stable.

D: Did you have tummy pain? P: Yes doctor.

D: Was it conQnuous or comes and goes? P: It is conQnuous.
D: Was it sudden or gradual? P: it is gradual & gejng worse
D: What type of pain is it? P: It is dull pain.
D: Does the pain go anywhere? P: No
D: Is there anything that makes the pain worse? P: It is gejng worse.
D: Could you please score the pain on a scale of 1 to 10, where 1 being no pain and 10 being the most severe
pain you have ever experienced? P: around 5
D: Any changes in your urine color or smell? P: Yes, it is smelly and cloudy
D: Any blood in it? P: No
D: Any nausea and vomiQng? P: Yes, but I didn’t vomit.
D: Any cough? P: No
D: Any problem with the bowel? P: No
D: Any Qredness or SOB? P: No.
D: Someone your friends or family told you are losing weight? P: No

D: Do you have to go to the loo more o_en these days?

P: I was going to the loo more since last few weeks. I had operaQon TURP 4 days ago for my prostate.
D: How did the operaQon go?
P: It went well, I was in the hospital for two days and then I was sent home.
D: Any complicaQons during the surgery? P: No

D: Have you been diagnosed with any other medical condiQon in the past? P: No
D: Any diabetes, high blood pressure, high cholesterol, kidney or heart disease P: No.
D: Are you taking any medicaQons including OTC or supplements? P: No
D: Any long-term anQbioQcs or steroids? P: No
D: Any allergies from any food or medicaQons? P: No
D: Has anyone in the family been diagnosed with any medical condiQon? P: No

D: Do you smoke? P: Yes/ No

D: Do you drink alcohol? P: Occasionally
D: Whom do you live with? P: I live with my wife.

D: I would like to check your vitals, examine your tummy. I will be having a chaperone with me to ensure your
privacy.

Examiner: Do it doctor.

Remove the hospital gown and the shorts. (Don’t forget to cover in the end)

Urine catheter apached to the urine bag showing yellowish turbid urine with pus collecQon +/- Blood.

Abdomen: Tenderness over suprapubic area.

Examiner: Dr. What do you think is going on with the paQent?

D: I am suspecQng my paQent is having urinary tract infecQon probably a_er TURP as it is one of the most
common complicaQons of this surgery.
Examiner: What would you like to do for the paQent?
D: I would like to send for some iniQal invesQgaQons rouQne blood test including kidney funcQon test, urine dip.
We would like to take urine sample and send for culture and sensiQvity.

We will do ABG as well.

Examiner: Here is your ABG

ABG shows metabolic acidosis.
PH - low,
HCO3 - low
CO2 – Normal

Management:
(Follow SEPSIS 6 if paQent is in sepsis)
We will give him some broad-spectrum anQbioQcs as per the hospital policy. We may also change anQbioQcs
according to the bug that is causing the infecQon.
We will give PCM and painkiller for the temperature and pain
We will give anQ-sickness medicaQon for nausea.
We will consider giving him IV fluids.
We will inform my seniors, and I will arrange for USG of abdomen and prostate.
General advice:
Place a hot water bople on your tummy, back or between your thighs
Rest and drink plenty of fluids – this helps your body to flush out the bacteria

NOTE:
SomeQmes this paQent is planned for the surgery and is having urine retenQon. The paQent was catheterized
and posted for the surgery.

SCENARIO 2: PaQent is IN shock.

D: How can I help you? P: I am not feeling well.

D: Could you please tell me more? P: I am feeling very Qred. I haven’t passed urine,
and it was very uncomfortable.
D: For how long are you having this problem? P: Since yesterday

Reassure
D: Let me quickly have a look at your vitals
Note: PaQent is hypotensive and tachycardic. His temperature is raised.

D: Start ABCDE approach immediately

A:
- PaQent is talking to me. His airway is patent.
- I would like to start my paQent on high flow O2 – 15L/min via non-rebreather mask.

B:
- Trachea and Chest Ex
- Trachea is central and Chest Ex is normal.

C:
- Peripheral signs of perfusion - Pulse, Cold peripheries, Cap refill, Cyanosis, Pallor, AcQve bleeding site.
- Mx: HR & BP unstable. I would like to Insert TWO large bore IV cannulas and start resuscitaQng my
paQent by giving IV Fluids. I would also like to draw some bloods at the same Qme for rouQne
invesQgaQons including blood cultures, lactate, and blood sugars.
- Fluid Challenge: Adults - 500 mL of warmed crystalloid soluQon (0.9% Normal Saline) in 5-10 minutes if
the paQent is Hypotensive or 1 L if the paQent is in shock).
- I would like to reassess a_er the bolus and give further boluses of 500 ml fluids unQl a maximum of 2L
in the first one hour.

D:
- As my paQent is talking to me and is obeying commands his GCS seems to be 15/15.

E:
- Expose the paQent fully for Head-to-Toe examinaQon. Look for any redness, rashes, swelling,
temperature – 38.9. I would like to start IV paracetamol.

Summarise your iniQal assessment: ABCDE – O2 and IV Fluids. Ask the paQent if he feels any beper.
Give the diagnosis and definiQve management for the diagnosis: Sepsis on background of UTI which is a
common complicaQon a_er TURP procedure. I would like to start SEPSIS 6 immediately.
Give 3 and Take 3. I would like to give broad spectrum anQbioQcs to my paQent according to hospital protocol
and change the Abx according to culture and sensiQvity report. I would also like to monitor urine output and
send urine for culture.

SEPSIS SCREEN: (Find out source of sepsis)

• Bloods for FBC, CRP, Renal and Liver funcQon tests
• Blood Culture
• Urine Dip and Culture
• CXR
• Sputum culture (If cough + phlegm present)

SEPSIS SIX:
GIVE: TAKE:
1. Oxygen 1. Blood cultures
2. IV Fluids 2. Lactate
3. IV Antibiotics 3. Urine Output

Start taking history NOW, if the paQent’s vitals are stable.

Dizzy Spells

You are F2 in A&E. Mr John Smith aged, 57 came with dizziness. Please talk to the patient, assess his
condition, examine him and discuss about initial plan of management with the examiner. After 6 mins
discuss plan of management with the patient.

D: What brought you to the hospital? P: I have been feeling dizzy.

D: What you mean by dizzy? P: I feel like I am about to fall. But I don’t fall.
D: When did it start? P: It started few weeks ago.
D. How did it start? P: Just started
D: What were you doing when it started? P: I don’t know. I wasn’t doing anything special.
D: Is it there all the time or does it come and go? P: I have this feeling time to time.
D: How often do you get this feeling? P: I had 4 episodes so far.
D: How long does each episode last? P: It lasts for a few seconds / minutes.
D: Is there anything which triggers your symptom? P: No, I can’t think of anything.
D: Is there anything which makes it better? P: Not really.
D: Has it changed since it started? P: What do you mean by that?
D: Are you experiencing it more often these days? P: I don’t think so.
D: Does each episode last longer than before? P: Not really.
D: Apart from what you told me, is there anything else you are experiencing? P: I feel tired these days.
D: When did it start? P: It started about the same time as dizziness.
D: Has it changed since it started? P: I am getting more tired now.
D: Are you experiencing anything else? P: No

Reassure
D: Let me quickly have a look at your vitals
Monitor:
- BP: 110 / 70mmHg
- HR: 70 – 110 bpm (Fluctuating)
- RR: 18
- ECG: AF.
Note: Patient has AF, HR is increased, and other vitals are normal.
(So, continue with History. Keep monitoring the vitals while you are taking History).

D: Any heart racing? P: I am not sure.

D: Are you feeling lightheaded? P: No
D. Are you short of breath?
P: Yes Doc. It started with dizziness. Whenever I feel dizzy, I have this shortness of breath.
D: Do you have any chest pain or chest discomfort? P: No (ACS)
D: Did you faint by any chance? P: No
D: Is there anything else you are experiencing? P: No

D: Has it happened before? P: No

D: Any fever or flu-like symptoms? P: No
D: Any pain, swelling, redness or hotness in your legs? P: No
D: Any headaches recently? P: No.
D: By any chance, do you have any sweating? P: No
D: Do you feel hot when everyone around you is fine? P: No
D: Have you been losing weight? (Thyroid) P: No
D: Have you been diagnosed with any medical condition? P: No
D: Are you taking any medications regularly? P: No
D: Do you have any allergies? P: No
D: Has anyone in your family been diagnosed with any heart problems? P: No

D: Do you smoke? P: No
D: Do you drink alcohol? P: I am an occasional / social drinker.
D: How is your diet? P: I pretty much eat healthy food.
D: Do you drink coffee or tea? P: Yes, 1 or 2 cups per day.
D: Are you physically active? P: I am quite active.
D: Do you have any stress in life? P: No
D: Do you use any recreational drugs? P: No

D: What do you do for a living? P: I work as a clerk / estate agent.

In this station,
1. Look at the monitor carefully.
2. Check the patient’s pulse for irregularly irregular pulse.
3. Auscultate the heart for murmur.

Management
Note: At 6 mins bell, examiner will ask you:

E: What is wrong with this patient?

D: Based on the history and examination, patient has got AF.

E: Please summarise your findings of examination:

D:
1. Patient’s pulse is irregularly irregular.
2. On monitor – Verbalise all the vitals.

- ECG shows narrow complex and absent P waves.

- The pulse rate is fluctuating.
- Blood pressure is …..
- Temp is …..
- Respiratory rate is ……

On Auscultation there is murmur. I would like to confirm with my senior.

E: What are you going to do for this patient?

D: I will do some investigations
I would like to do some blood tests (FBC, VBG, U&E, TFT, LFT, Troponin)
I would like to do a 12 lead ECG.
I would like to order a chest x-ray to identify any lung problem that may be causing AF.

E: How will you manage this patient?

D: I will discuss this case with my senior.
I would like to give my patient a medication to control the rate of heartbeat as the first line management such
as beta blocker (metoprolol) or a calcium channel blocker (verapamil or digoxin)
If symptoms continue after heart rate has been controlled or if the rate control strategy has not been
successful, rhythm control should be considered to restore a normal heart rhythm:
(A) medication such as flecainide
(B) cardioversion.

Since my patient has not got any risk of stroke (based on CHADVAS and HAS-BLED scoring system) there is no
need of prescribing anti-coagulant.

I will discharge the patient after discussing with the senior.

I will do cardiology OPD referral urgently for further investigations.

E: Which investigation?
D: 1. Holter Monitor ECG (24 – 48 hrs), 2. Echocardiograph.
Upper GI Bleed

You are an FY2 in A&E. Mr. John Taylor, aged 68, was brought into the A&E by his wife, as he is feeling
dizzy and faint. Talk to the patient, assess him, and discuss the initial plan of management with him.

Both Sim-Man and Nurse are present inside the cubicle.

D: Who do we have in here? (Introduce yourself to the nurse)

Nurse: We have Mr. John here, who was brought in by his wife.

D: Do we know anything about why his wife brought him here today?
Nurse: No doctor.

D: Have you done anything so far?

Nurse: Yes, I have connected him to the monitor. Please have a look at the patient doctor.

D: That’s fine, let me talk to the patient first and assess him to see what’s going on.
Nurse: Okay doctor.

D: Hello Mr. John, what brought you to the hospital today?

P: I was feeling dizzy and faint doctor.

D: I am sorry to hear that Mr. John, Could you tell me when did this start? P: 2-3 days
D: How did it start? P: Just started
D: What were you doing? P: Nothing in particular

Let me quickly have a look at your vitals and then I will get back to you.

(Look at the monitor for vitals)

Vitals are stable.
If vitals deranged – Stabilise the patient first by ABCDE approach.

D: Nurse, could you please keep an eye on the vitals and let me know if they are unstable.
Nurse: Okay.

D: Your vitals are stable Mr. John. Could you please tell me more about your dizziness and fainting?
P: What do you want to know doctor?

D: What do you mean by dizziness? P: I feel lightheaded and loose balance.

D: Do you have this all the time? P: No, only when I walk for some time.
D: How many episodes did you have? P: 4-5
D: How long does each episode last? P: Few minutes
D: Is it getting worse? P: Yes
D: Does anything make it worse? P: When I do some activity.
D: Does anything make it better? P: When I rest

D: You told me that you this have feeling of fainting? Could you please tell me more about it?
P: What do you want to know?

D: What do you mean by feeling faint?

P: I feel like I am about to fall and lose consciousness, but I don’t.

D: Did you lose consciousness anytime? P: No

D: Did you have a fall anytime? P: No
D: When did this start? P: Same time, 2-3 days
D: Is it getting worse? P: Yes
D: Do you have any other symptoms along with these? P: No

D: Any fever/flu like symptoms? P: No

D: Any nausea/vomiting? P: No
D: Any SOB? P: Yes/No
D: Any chest pain or discomfort? P: Yes, I feel some discomfort in my chest.
D: Can you tell me more about it? P: It started with my symptoms & it’s all over my chest.
D: Any heart racing? P: Yes/No
D: Any ear pain or hearing problems? P: No
D: Any ringing sensation in your ear? P: No
D: Any headache? P: No
D: Any weakness in any part of your body? P: No
D: Any speech or vision problems? P: No
D: Any problems with your bowel or bladder? P: No
D: Any loose stools? (dehydration)? P: No
D: Any tummy pain or discomfort? P: No
D: Any bleeding from anywhere in your body? P: No
D: Any change in colour of your stool/any dark-coloured stools?
P: Yes/No, I didn’t look at my stools recently.

D: Is this the first time you have these symptoms? P: Yes

D: Have you been diagnosed with any medical condition in the past?
P: Yes, I have Osteoarthritis of my Knee.
D: How is it managed? P: I take pain killers for that.
D: Which pain killer and for how long? P: Diclofenac. Since few months.

D: Are you on any other medications apart from this? Any PPI’s (Gastric Tablets), steroids or blood
thinners? P: No

D: Are you diagnosed with any other medical problems? Any heart problems or blood disorders?
P: No

D: Do you have any allergy to any food or drug? P: No

D: Any medical conditions in the family? P: No

P: Sim-Man says doctor I have soiled myself now and I feel short of breath.
D: Don’t worry Mr John, let me quickly have a look.

D: Let me quickly have a look at your stool. DARK STOOL – MALEANA.

D: I think you have some bleeding from your gut. Let me quickly look at your vitals and examine you.

Reassure and LOOK at the monitor for vitals:

RR 26
SpO2 90
HR 98
BP 90/60
Temp 37.5
Note: Patient is hypotensive and tachycardic.

D: As my Pts vitals are unstable, I would like to proceed with ABCDE Assessment.

Ask PMHx and Start ABCDE approach immediately.

A:
- Patient is talking to me. His airway is patent.
- I would like to start my patient on high flow O2 – 15L/min via non-rebreather mask.
 - Pick the oxygen mask with a reservoir bag attached. (Saturation will improve)

B:
- Trachea and Chest Ex
- Trachea is central and Chest Ex is Normal.

C:
- Peripheral signs of perfusion - Pulse, Cold peripheries, Cap refill, Cyanosis, Pallor, Active bleeding
site.
- Mx: HR & BP unstable. I would like to Insert TWO large bore IV cannulas and start resuscitating my
patient by giving IV Fluids. I would also like to draw some bloods at the same time for routine
investigations including group and cross match and arrange for blood transfusion.
- Fluid Challenge: Adults - 500 mL of warmed crystalloid solution (0.9% Normal Saline) in 5-10
minutes if the patient is Hypotensive or 1 L if the patient is in shock).
- I would like to reassess after the bolus and give further boluses of 500 ml fluids until a maximum
of 2L in the first one hour.
- Inspect the bleeding - Undress his diaper and you can see dark coloured stools. Abdominal Ex.
- I would like to call the Gastro team for urgent Endoscopy.

D:
- As my patient is talking to me and is obeying commands his GCS seems to be 15/15.

E:
- Expose the patient fully for Head-to-Toe examination. Look for any redness, rashes, swelling,
temperature.

REASSESS - Vitals are improving, and Pt says he is feeling better.

(Look at the monitor and check if vitals have improved. Ask the patient if he feels any better).

Summarise your initial assessment: ABCDE – O2 and IV Fluids. Ask the patient if he feels any better.
Give the diagnosis and definitive management for the diagnosis: You seem to be having bleeding from your
gut. That is why you are having these symptoms. This is called Upper GI Bleed. This is an emergency. I need
to refer you to a specialist. We will keep you Nil by Mouth and continue fluids for now. We need to give
some blood as you have lost blood.

This seems to be because of the pain killers which you are taking for your Osteoarthritis.

D: I will ask a specialist (gastroenterologist) to review you.

P: Okay doctor.

D: The specialist will do a procedure called endoscopy (explain endoscopy) and try to find out the source of
bleeding and stop it.

D: I will review you regularly until you are seen by the specialist and get the procedure done.
P: Okay doctor.
DNAR

You are F2 Medicine. Mr. John Smith aged 90 has been admitted in the hospital with lung cancer. He has
been receiving treatment for it. Nurse wants to talk to you about Mr. Smith. Talk to the nurse, assess the
patient, and write medical notes.

D: How can I help you?

Nurse: Mr. Smith is admitted in the hospital for past few weeks. He is receiving chemotherapy for lung cancer.
He is not well for last one week and now his condition is deteriorating. He is not responding now.

D: Hello, Hello. Tap on his shoulder.

Assess RESPONSE (Shout and tap on shoulder) and BREATHING (Look, Listen & Feel).
(Patient has NO Response and is not breathing.)

D: He is in cardiac arrest. Please help me connect the monitor to confirm.

Nurse: Sorry doctor, there are no monitors here.

D: Ok then we must start CPR immediately. Could you please call for help, activate cardiac arrest call and check
the patient’s notes for DNAR.

Nurse: Yes doctor, Mr. Smith has a DNAR form. Here I have the form if you want to have a look at it. (She will
show you the form)

D: Mr. Smith has a DNAR form and is signed by the consultant. Unfortunately, I cannot proceed with the CPR.
I would like to examine for signs of life and confirm patient’s death.
Patient is lying in bed with eyes closed.

Note: You will get Neuro-pin, Pen Torch & Stethoscope

Death Confirmation:
1. Confirm the identity of the patient – check the wrist band
2. General inspection – skin colour / any obvious signs of life
3. Look for signs of respiratory effort
4. Does the patient respond to verbal stimuli? – Hello Mr Smith, can you hear me?
5. Does the patient respond to pain? – press on fingernail / trapezius squeeze / supraorbital/sternal
pressure
6. Assess pupils using pen torch – after death they become fixed and dilated
7. Feel for central & peripheral pulses – No carotid & radial pulses felt
8. Auscultation:
- Listen for heart sounds for at least 2 minutes
- Listen for respiratory sounds for at least 3 minutes
(It might differ according to the hospital policies)
9. Cold Peripheries
10. Rigor Mortis

Patient declared as deceased at (Date and time).

a. Inform nursing staff that you have confirmed the death: They will then inform next of kin, if not
already present. They will also contact the porters to arrange the transfer of the body to the morgue.
b. Write the above findings and death confirmation in patient’s notes. Write the date and time of your
examination.
c. Discuss with the senior regarding cause of death before signing the death certificate (If they ask you
to fill a death certificate).

NOTE: Death Notes and Death Certificate are different (Death Notes is what you write in Pt Notes after you’re
your assessment and Death Certificate is where you write the cause of Death).
Consider if this death needs a referral to the coroner, as if this is the case, a death certificate cannot be issued
– this will require discussion with the consultant responsible for the patient.

Name:
Age:
Gender:
Date of Birth
NHS Number:

Date:

Death Confirmation Assessment:

Identity confirmed as John Smith from wrist band.

Patient in bed, eyes closed, no signs of life.
No respiratory effort noted.
No response to verbal stimuli
No response to painful stimuli
No central or peripheral pulse palpable
Pupils fixed and dilated bilaterally.
No heart sounds noted during 2 minutes of auscultation.
No breathing sounds noted after 3 minutes of auscultation.
Peripheries are cold.

Death Confirmed at __/__/__ at 09.30

Signed