Guidelines Station 5 Scenarios

MRCP(UK) Guidelines for
Station 5 scenarios
A guide to writing and vetting

PACES Station 5 scenarios
Contents
GUIDELINES FOR WRITING STATION 5 SCENARIOS
BACKGROUND
SELECTION OF CASES
WRITING SCENARIOS
RE-USE OF SCENARIOS
GUIDANCE ON THE USE OF SURROGATES
SUBMISSION OF SCENARIOS FOR VETTING
GUIDELINES FOR VETTING STATION 5 SCENARIOS
INTRODUCTION
GENERAL GUIDANCE – SCENARIO CONTENT
SPECIFIC GUIDANCE
APPENDIX 1: SCENARIO TEMPLATE
APPENDIX 2: CMT CURRICULUM
APPENDIX 3: EXAMPLES OF SUITABLE SCENARIOS

Guidelines for writing Station 5 scenarios
Background
The information in this guide is intended as an aid to Host Examiners and their teams in the preparation of
scenarios for Station 5.
Station 5 is the Integrated Clinical Assessment station, designed to examine the candidates’ ability to address
a clinical problem using a combination of focused history taking, examination, and communication skills with
a patient in a way that reflects daily clinical practice.
Candidates will see two cases known as ‘Brief Clinical Consultations’. Each case lasts 10 minutes in total, with
8 minutes of candidate interaction with the patient. A brief summary of a clinical problem, as may be
encountered ‘on the acute medical take’ or ‘in the medical outpatient clinic’ is presented to candidates,
enabling them to take a focused history of the presenting complaint, perform a relevant physical
examination and construct a reasonable differential diagnosis and a management plan. Candidates are also
expected to respond to the patient’s questions or concerns about the diagnosis, the importance of the
problem, the action plan or any other issues that may arise.
During the consultation the candidate need not necessarily complete the history taking element before
examining or discussing the nature of the problem with the patient; the encounter is not intended to be a
‘long case’. This is in contrast to the formal assessment of history taking, physical examination and
communication covered in other stations.
Selection of cases
Station 5 provides the opportunity to assess a wide range of clinical problems across the core medical
training framework (a subsection of the General Internal Medicine (GIM) curriculum – see Appendix 2),
including more acute clinical problems encountered by trainees in their daily practice, which cannot be
assessed elsewhere. The selection of cases should reflect this.
Suitable scenarios include new symptoms and/or signs in a patient presenting on the ward, medical
admissions unit or at the outpatient clinic. The inclusion of patients with acute clinical problems in the exam
can be challenging. Many chronic diseases also have acute presentations and complications which can
realistically be presented in the exam, either as they stand or with some modification of the patient’s own
history. Judicious use of surrogates with no physical signs, or stable patients with a physical sign (e.g. a
carotid bruit) that can be part of a scenario about transient neurological signs, may be used to simulate
acute presentations such as TIA.
Examples of suitable cases/scenarios include:

• an incidental finding, e.g. neck swelling in a patient admitted for cholecystectomy. A complication of
a chronic disease, e.g. a patient with rheumatoid arthritis and early signs of interstitial lung disease
used in conjunction with a history of increasing breathlessness. Differentials to consider include
interstitial lung disease, heart failure, infection, and medication. Similarly, patients with stable
cardiovascular signs such as valvular heart disease could be given an acute history of collapse or
palpitations
• a transient history in a surrogate with no clinical signs, e.g. TIA, palpitations, pulmonary embolism.
Skin, rheumatological, endocrine and eye problems can be included but must be presented as
clinical problems rather than ‘spot diagnoses’.
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Examples of scenarios which do not work well include:
• full new outpatient consultations
• patients with complex histories which involve more than one clinical system
• patients with long-standing chronic conditions presented as if they are newly diagnosed, e.g.
rheumatoid arthritis. Consider instead introducing potential complications of the disease or
treatments
• unfocused scenarios such as a patient presenting with ‘weight loss’. The differential is too wide and
a focused history and examination is not possible within the timeframe.
It is unlikely that cases such as these will be accepted by the College appointed vetter.
Cases should be balanced across the whole of the PACES exam, avoiding two Station 5 scenarios where the
same clinical system or diagnosis is the main focus in both cases, or where there are close similarities in topic
matter with other stations. Complete systems examination that would fully duplicate skills used in Stations 1
and 3 are not required or expected, although physical signs that could be seen in these stations could be part
of a necessary focused examination leading on from the history, e.g. a murmur in a patient who has
collapsed. Some examples of potential scenarios are included in Appendix 2 and Appendix 3 and illustrate
many of the points made above.
Writing scenarios
The generation of scenarios is the responsibility of the Host Examiner.
Your College administrator will send you the current version of the scenario template in plenty of time for
you to write and submit the scenarios. A copy of the template can be found in Appendix 1.
If the patient’s history is to be modified to produce a credible scenario for the candidate to complete within
the allotted timeframe, it is essential when selecting such cases that the patient is capable of delivering the
modified history. In all cases, arrangements must be made to fully rehearse the scenario with the patient or
surrogate prior to the exam.
The template for Station 5 scenarios includes ‘help text’ in each section to provide useful prompts when
writing the scenarios. You should complete every section of the template. Please do not leave blank spaces
or delete sections/headings. If not applicable, please state ‘N/A’ or ‘none’.
The template includes:
Information for the candidate

This provides a brief summary of the clinical problem to be encountered and should provide a clear focus for
the consultation. It needs to contain sufficient, but not too much, information to enable an integrated
assessment of the clinical problem within the allotted 8 minutes. For example:
This woman has been referred by her General Practitioner with a ten year history of rheumatoid
arthritis. She is now complaining of tingling and weakness in her hands.
This encourages the candidate to take a brief focused history of the duration of the problem, including any
additional neurological symptoms, the past medical history and relevant medication, along with a focused
neurological examination to determine whether there is cord compression, or a local pathology such as
carpal tunnel syndrome.
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A table is included for the patient’s physiological observations at the time of their initial presentation, and
can be used to demonstrate pyrexia, hypotension or hypoxia. It is anticipated that ‘observations’ would
generally be used with clinical problems in the acute setting but may also be appropriate in other settings,
e.g. to demonstrate the side effect of a drug or the complication of treatment, such as hypotension. If not
applicable to the scenario, please write ‘N/A’ in the boxes but please do not delete the box. If it is not
relevant to the scenario then it will be removed during the vetting process. No other additional observation
charts should be used.
Information for the patient

This should be clearly written in language that a patient will understand and should not include any medical
terminology or abbreviations. In order for the station to run in a standardised fashion, patients are required
to give the history as it is set out for them.
Current medications, and doses, should be listed in the scenario but can also be written on a separate piece
of paper which the patient can show to the candidate. Please ensure you use generic drug names only.
To avoid confusion, please exclude any drugs which are not relevant if the patient’s history has been
modified. For example if the scenario focus is on arthritis, and you have modified the history to exclude the
patient’s myocardial infarction, remove the cardiac drugs from the drug list.
In order to prompt the communication aspect of the encounter you should include two questions for the
patient to ask the candidate. These should be phrased as the patient would ask them, e.g. “What is going to
happen to me?” rather than “What is my prognosis?”
Information for the examiners

The key issues for all the clinical skills should be completed (with the exceptions of Skill G and Skill F which
are standard and have been completed already). During the calibration process, examiners will check the
history and physical signs with the patient and agree on the key findings and issues that a candidate must
ascertain for each skill, in order to achieve a satisfactory score.
Please note that for Skill A: Physical Examination you should list the nature and extent of examination the
candidate must perform in order to achieve a satisfactory score, e.g. assesses tone, power and reflexes in
upper limbs, checks for signs of carpal tunnel syndrome. Do not document the physical signs under Skill A
here; these should be listed in Skill B: Identifying Physical Signs.
For Skill D: Differential Diagnosis you should provide a probable diagnosis, and any plausible alternative
diagnoses. If there are no alternatives you should write ‘N/A’ or ‘none’.
Re-use of scenarios
The re-use of Station 5 scenarios is permitted, however, at least half of your scenarios should be newly
written for each diet. Centres must tell their College administrator which scenarios they plan to re-use and
any feedback from their previous use will be checked. You may be asked to modify the scenario in
accordance with the feedback. Re-used scenarios will not generally need to be re-vetted before use and
wherever possible they will retain the same scenario number. Your College administrator will confirm this
with you. Any scenario being re-used will, however, be re-vetted every three years to ensure it remains
relevant to current clinical practice.
If a scenario is re-used but with a different patient with different physical signs and a significantly different
history then this will be classed as a ‘new’ scenario and will be vetted accordingly.
Scenarios should not be re-used on consecutive days.
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Guidance on the use of surrogates
It is permissible to use a patient who cannot converse in English, but who does have abnormal physical signs.
The communication aspects of the case will then be undertaken by a relative (or surrogate relative) who
speaks English and knows (or learns) the relevant history and can relay this, and who will answer and ask
questions, as if they were the patient. They should not act as a translator as this would significantly lengthen
communications and make the consultation unachievable within 8 minutes.
Surrogates with no physical signs can, on occasion, be used to play the part of a patient, but this has a direct
impact on the candidate’s ability to show their competency at identifying physical signs (Skill B). The use of
surrogates without physical signs should be minimised and there should never be a situation where both
Station 5 scenarios involve surrogates with no physical signs. It is suggested that you make these your
‘reserve’ scenarios.
Submission of scenarios for vetting

Your College administrator will advise you of when to submit your draft scenarios and will keep you updated
as they are vetted. The writing and vetting process is outlined in Figure 1.
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College adminstrators contact
Hosts, providing current
scenario template and
submission date.
Host
centres
submit
scenarios.
College
admistrators send
scenarios for
review.
Review process
Scenario Scenario
Scenario amended to be Scenario
accepted. by amended rejected.
reviewer. to Host.
Host amends or
writes new scenario
and submits it for
review.
College
administrators issue
final versions of
scenarios to Hosts.
Figure 1: Writing and vetting process
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Guidelines for vetting Station 5 scenarios
Introduction
The information in this guide is intended to facilitate the vetting process and ensure a consistent approach
to the vetting of Station 5 scenarios across the Federation of Royal Colleges of Physicians. It should be read
in conjunction with the writing guide above, and referred to when vetting scenarios. Together, the two
guides will help to maintain the high quality of all the scenarios that are produced.
General guidance – scenario content

The scenario should be sufficiently focussed to allow a history taking and appropriate clinical examination to
be completed within 8 minutes.
Scenarios which tend to work well include:

• an incidental finding, e.g. neck swelling in a patient admitted for cholecystectomy
• a complication of a chronic disease, e.g. a patient with SLE presenting with pleuritic chest pain
• a transient history in a surrogate with no clinical signs, e.g. TIA, palpitations etc.
Scenarios which do not work well include:

• patients with complex histories which involve more than one clinical system
• patients with long-standing chronic conditions presenting as if they are newly diagnosed
• a simple history which nevertheless involves examination of more than one system, e.g. unexplained
weight loss
• a diagnosis which can be spotted “at the end of the bed”, e.g. a new case of acromegaly.
If you feel that a scenario is not going to work well, you should consider the following options:
• a discussion (email or telephone) with the host/scenario writer about how they think the scenario
will work, then make any necessary adjustments
• make adjustments with added comments as required
• reject the scenario, preferably with feedback comments for the Host.
You should check and correct the spelling of medical conditions, investigations and treatments etc. Other
spelling, grammar and punctuation issues will be corrected by the College administrator.
You should identify any scenarios which involve the same clinical system and remind Hosts that they are not
to be used together in the same cycle.
Please remove all the red, italicised help-text from the scenario as you carry out your review.
Specific guidance
Information for the candidate:
• check that there is sufficient, but not too much, detail provided in the ‘Clinical Problem’ section. This
should be limited to 2 to 5 lines
• check that the table of ‘Physiological Observations’ is relevant, appropriate and sufficient. You
should delete the table if you feel it is not appropriate to the scenario.
Information for the patient:

• remind the Host (either directly or through the College Administrator) that if a patient’s history has
been altered to fit the scenario then the patient must be sufficiently well rehearsed.
• any medical terminology and abbreviations should be changed to language patients will understand
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• check that only generic drug names are used (generic names do not require capitalisation)
• check that the patient’s questions are phrased as a patient would ask them. If there are more than
two questions given, you should choose the two best questions and delete the others.
Information for the examiners:

• check that it is clear whether a patient or a surrogate is being used
• all text boxes for the Clinical Skills should be completed in accordance with the ‘help text’ given in
the scenario template – see Appendix 1.
Please note that Skills F and G (Managing Patient’s Concerns, and Maintaining Patient Welfare) have been
pre-populated and should not have been altered by the scenario writer.
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APPENDIX 1: Scenario template
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INFORMATION FOR THE CANDIDATE
Scenario N°
Note to hosts & vetters: explanatory / help text in italics should be removed prior to final exam version.
MRCP(UK) PACES
Station 5: BRIEF CLINICAL CONSULTATION

Please avoid scenarios which duplicate cases / examination skills tested in other stations. Ensure the history &
examination can be covered in the time available – this may require modification of the patient’s history and
background details.
Patient details: (Preserve anonymity: use gender & age pre-vetting, add name post-vetting for exam use.)
Insert text here
Your role: E.g. doctor on call / in the outpatient clinic / in the medical admissions unit. Insert text here
You have 10 minutes with each patient. The Examiners will alert you when 6 minutes have elapsed and
will stop you after 8 minutes. In the remaining 2 minutes, one Examiner will ask you to report on any
abnormal physical signs elicited, your diagnosis or differential diagnoses, and your plan for
management (if not already clear from your discussion with the patient).
Referral text:
Clinical problem: Please provide a clear focus for the consultation which must be realistic and believable. Limit it
to 2 to 5 lines. Insert text here
Please add observations to the table below that are relevant to the case. You may write ‘normal’ or N/A.
Physiological observations for the patient above Reading on arrival
Respiratory rate (respirations per minute)
Pulse rate (beats per minute)
Systolic blood pressure (mm Hg)
Diastolic blood pressure (mm Hg)
Oxygen saturations (%)
Temperature 0C
Other relevant observation data (units if applicable)
Your task is to:

• Assess the problem by means of a brief focused clinical history and a relevant physical examination.
You do not need to complete the history before carrying out an appropriate examination.
• Advise the patient of your probable diagnosis (or differential diagnoses), and your plan for
investigation and treatment where appropriate.
• Respond directly to any specific questions / concerns which the patient may have.
Any notes you make may be taken into the examination room for your reference, but must be handed to the
Examiners at the end of the station.
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INFORMATION FOR THE PATIENT
Scenario N°
NOT TO BE SEEN BY CANDIDATES
MRCP(UK) PACES

Candidates will have a very limited time (8 minutes) with you to gather all the information they require,
perform an examination and explain what further tests or treatments they would like to arrange, as well as
answer your questions. The scenario below may be based upon your case, however some aspects of your
medical history may have been simplified or left out from the scenario for the purpose of the exam e.g.
other health problems, previous tests and treatments. It is very important that you stick to the history given
below and do not deviate from it. This is essential to ensure that the exam is fair for all candidates. Those
organising the exam will contact you before the exam to run through the scenario with you. Please read
through the history carefully beforehand and you will have the opportunity at that point to answer any
questions or concerns you may have.
Please complete each section, keeping the information provided brief and relevant to the focus of the scenario, using
language the patient will understand.
You are: (Preserve anonymity, use gender & age pre-vetting, add name post-vetting for exam use.) Insert text
here.
History of current problem

If using a patient, you must state whether the history (content, complexity, duration, medications etc) has been
modified for the exam or is real. If modified to enable delivery of the scenario in the time available, you must ensure
the patient can deliver the modified history.
Information to be volunteered at the start of the consultation

Maximum of 4 lines. Insert text here
Information to be given if asked

Include information that expands on the presenting problem. Insert text here
Background information
Past medical and surgical history

Remember to remove any known diagnoses unless the candidate is to be told of diagnoses by the patient. If the past
history is complex and not relevant, cut some of it out, ensuring the patient understands the changes. Insert text
here.
Relevant family history

Insert text here
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Scenario N°
Medication Record
Current medications (You may wish to bring a list of your treatment and show it to the doctor if asked.)
Insert text here
Personal history
Relevant personal, social or travel history

Insert text here
Occupational history
Insert text here
Physical examination
Specify the examination to be undertaken and the findings e.g. the doctor will examine your stomach area and you
indicate that it is sore when they press under your ribs. Insert text here.
You have 1 or 2 specific questions / concerns for the doctor at this consultation.
Please note them down on a small card to remind you during the exam.
Phrase them as the patient would ask them. Some may be general, e.g. What is wrong with me? Others may be more
specific, e.g. How will this impact my lifestyle?
1. Insert text here
2. Insert text here
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INFORMATION FOR EXAMINERS
Scenario N°
DATE CYCLE
MRCP(UK) PACES
Examiners should advise candidates after 6 minutes have elapsed that “You have two minutes remaining
with your patient”. If the candidate appears to have finished early remind them how long is left at the
station and enquire if there is anything else they would like to ask or examine. If they have finished, please
remain silent and allow the candidate that time for reflection.
The Examiner should ask the candidate to describe any abnormal physical findings that have been identified.
The Examiner should also ask the candidate to give the preferred diagnosis and any differential diagnoses
that are being considered. Any remaining areas of uncertainty e.g. regarding the plan for investigation or
management of the problem may be addressed in any time that remains.
Examiners should refer to the marking guidelines in the seven skill domains on the mark sheet.
Examiners must fully rehearse the scenario with the patient / surrogate during calibration. The boxes on
the next page indicate areas of potential interest in this case which both Examiners should consider, along
with any other areas they feel appropriate. Examiners must agree the issues that a candidate should address
to achieve a Satisfactory award for each skill and record these on the calibration sheet provided. Examiners
should also agree the criteria for an Unsatisfactory award at each skill.
Continued on next page…
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INFORMATION FOR THE EXAMINERS
Scenario N°

Problem: Brief summary (no more than 2 lines) of the problem. Insert text here.
Candidate’s role: As noted on the first page. Insert text here.
Patient details: (Preserve anonymity: use gender & age pre-vetting, add name post-vetting for exam
use.) Insert text here.
Patient or surrogate? Patient / surrogate / patient with surrogate giving history (you must delete the
options NOT applicable).
Examiners are reminded that the boxes below indicate areas of potential interest, but are not intended as absolute
determiners of Satisfactory performance. It is for the Examiners to agree and record the specific criteria they will assess
the candidate on during the calibration process.
Clinical skill Key issues (please complete each box)
Clinical Include the key points of the history that the candidate must establish to achieve a
Communication Satisfactory score. Insert text here.
Skills (C)
Physical Include the nature and extent of the examination that the candidate must do to achieve a
Examination (A) Satisfactory score. If further examination is desirable but may not be possible due to time
constraints, make this clear. Avoid requiring a full system examination that duplicates those
undertaken in Stations 1 and 3. Do not document the physical findings here – use the box
below (skill B). Insert text here.
Clinical Judgement List the further assessments, tests, and any other treatment / management e.g. referral,
(E) that the candidate must mention in order to achieve a Satisfactory score. Make it clear if
there are further items that may be desirable to mention, but not essential to achieve a
Satisfactory score. Insert text here.
Managing Patients’ Addresses the patient’s questions and concerns in an appropriate manner.
Concerns (F)
Identifying List the physical signs (and important negatives) that the candidate must identify in order
Physical Signs (B) to achieve a Satisfactory score. Make it clear if there are signs that are ‘softer’ or less
relevant and not essential to identify in order to achieve a Satisfactory score. Insert text
here.
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Scenario N°
Differential Probable Diagnosis:

Diagnosis (D) Insert text here
Plausible alternative diagnoses:

Insert text here or specify ‘none’
Maintaining Patient See marksheet.

Welfare (G)
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APPENDIX 2: CMT Curriculum
17
The examples below are based on the ‘Top Medical Presentations’ as defined in the GIM curriculum (http://www.jrcptb.org.uk/trainingandcert/
Pages/ST1-ST2.aspx#cmtcurricassess), and require an integrated approach using many of the skills, attitudes and behaviours that a satisfactory
candidate should demonstrate.
Please note it is essential, especially if using a real patient with a modified history, that the patient is fully rehearsed prior to the exam.
Presentation Scenario Suitable for Patient/surrogate Key issues to be identified

patient/surrogate question(s) for
candidate
Breathlessness 50-year-old woman with long Patient with systemic Is this due to my Check obs (HR, BP, SaO2), listen to heart
history of systemic sclerosis sclerosis (may or may scleroderma? and chest, looks for signs of right heart
presents with increasing not have chest signs). failure. Identifies pulmonary
breathlessness over several hypertension/ILD/COPD as differentials.
months. Smoker. Suggests PFTs, CXR and echo as initial
investigations.
Confusion – acute 65-year-old man binge drinking Surrogate for history, Can I go home? Checks obs (including temperature, BM),
for several years since death of patient for checks for head injury, neuro screen.
wife. Neighbour found him examination (e.g. with Appropriate differential including
wandering in the street, confused. stigmata of chronic alcohol withdrawal, infection, subdural
Day 3 hospital admission and liver disease). haematoma, Korsakoffs.
nursing staff ask you to review the
patient as he remains confused
and wandering off the ward.
Acute back pain 65-year-old woman, long history Surrogate or patient. Is this something Identifies steroid use as risk factor for
of poorly controlled asthma, serious? osteoporotic vertebral fracture. Palpates
sudden onset, no neurological spine, screens lower limb neurology.
symptoms or history of trauma. Is it related to my Investigations to exclude secondary
asthma? causes osteoporosis, arranges
DEXAscan.
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candidate
Blackout/collapse 70-year-old woman/man presents Patient (with aortic Can I still play golf? Checks obs (asks for postural BPs).Feels
with several episodes of collapse stenosis). pulse, listens to heart, checks
when golfing. Further questioning medication list. Arranges for ECG, echo
reveals worsening chest pain on etc.
exertion and exercise induced
syncope.
Falls 70-year-old woman admitted with Patient has early (not Why am I falling? Checks obs (incl. BP) and drug chart,
increasing frequency of falls and florid) Parkinson’s injury screen, neuro screen and
difficulty getting up from her disease. identifies features of Parkinson’s
chair. disease.
Abdominal pain 30-year-old woman presents with Surrogate. Is this something to do Asks re: last menstrual period. Check
several days’ history of abdominal with my coil? obs chart, examines abdomen, must ask
pain and vomiting. Had a coil for pregnancy test. Differential includes
inserted 3 weeks ago. Can I go home? gastroenteritis, ectopic pregnancy.
Recognises risk factors for ectopic
pregnancy.
Headache 65-year-old man with 3-week Patient or surrogate. Can you give me any Look for signs of temporal arteritis,
history of headache. On further tablets for this? neuro screen upper and lower limbs.
questioning he has muscle aches, Arranges TAB and discusses steroid
stiffness in his arms and thighs treatment.
and some jaw claudication.
Fits/seizure 50-year-old man, known epilepsy Surrogate. Why am I having more Looks for reasons for increased seizure
on AEDs. Presents with increasing seizures? frequency e.g. recent infection,
frequency of seizures. Lives alone compliance with meds, any potential
and drinks ‘more than he should.’ drug interactions. Potential alcohol
withdrawal. Neuro screen.
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candidate
Haematemesis and Patient with long standing RA Patient. Is this related to my Takes drug history, establishes NSAID as
melaena presents with melaena. Increasing tablets? likely culprit. Checks obs (HR, BP),
knee pain over several months examines abdomen, offers to perform
not helped by painkillers. pr. Further investigations, discuss
Medications include naproxen analgesia.
(taking extra tablets on empty
stomach) and oral
bisphosphonate.
Jaundice Difficult to examine in this station, unless a patient / surrogate with yellow sclerae can be found.
Palpitations 25-year-old woman with Patient (e.g. with Am I having heart Checks obs, examines for goitre and
recurrent episodes of palpitations. goitre) or surrogate. attacks? peripheral thyroid signs. Listens to
Well at present. heart.
Vomiting/nausea Patient with known AF (digoxin on Patient with AF. Is this due to my pills? Checks obs. Listens to heart and lungs.
medication list). Recent chest Differential includes potential drug
infection and given clarithromycin interaction between digoxin and
by GP. clarithromycin, antibiotic related GI
upset.
Weakness/paralysis 50-year-old lorry driver presents Surrogate, or patient Can I still drive? Checks obs chart (notes hypertension).
with transient symptoms of right with a carotid bruit or Looks for cardiovascular risk factors in
arm weakness, smoker. murmur. history, neuro screen, explains
diagnosis, further investigations e.g.
carotid doppler.
Management of patients Not possible to examine in this station.
requiring palliative and
end of life care
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candidate
Chest pain 35-year-old woman with known Patient. Is this to do with my Checks obs, listens to chest, examines
SLE. Presents with pleuritic chest lupus? calves, differential includes PTE,
pain and SOB on exertion. pleurisy, pericardial effusion. Arranges
appropriate investigations e.g. ECG, CXR,
echo, V/Q or CTPA, lupus anticoagulant
etc.
Acute and chronic kidney Patient with ESRF attends for Patient with ESRF and Is my fistula still Check obs, including temperature.
disease regular dialysis complaining of AV fistula. working? Examine fistula site for evidence of
fever and pain in fistula arm. infection, assess for signs of ischaemia
Will I still be able to in distal limb. Appropriate management
get dialysed? including U&Es, CRP, blood cultures,
renal review.
Fever 55 year old admitted with ACS Patient or surrogate. Am I having another Checks obs. Auscultates heart and lungs,
develops temperature of 38.5°C heart attack? looks for signs of infection e.g. cannula
and chest pain on day 3 of site. Differential – Dressler’s, hospital
admission. acquired infection, soft tissue infection
from cannula.
Patient with heart Is this related to the Checks obs (temperature, HR, BP,
Patient with known valvular heart murmur. infection in my toe? urinalysis). Looks for stigmata of
disease presents with fever. subacute bacterial endocarditis.
Recent soft tissue infection of Do I need more
great toe but didn’t complete antibiotics?
course antibiotics.
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candidate
Rash 30-year-old man with psoriasis Patient with psoriasis Is this related to my Looks for nail changes, examines hands
attends for review in clinic. and nail changes but psoriasis? and feet for synovitis/dactylitis.
Incidentally complains of pain in no clinical synovitis. Assesses range of spinal movement and
his hands and feet (PIPs, DIPs). What can I take for SI joint tenderness. Recognises nail
Increasing stiffness in his back first the pain? changes increase likelihood of
thing in the morning. developing PsA. Advises NSAIDs,
arranges X-rays hands, feet and SI joints.
35-year-old woman with RA well Patient with RA. Will I get chickenpox? Checks obs (including temperature).
controlled on anti-TNF therapy Listens to chest, looks for vesicles.
and methotrexate, attends Is there anything I can Advises patient to stop anti-TNF and
Rheumatology clinic for routine do to stop myself methotrexate. Check varicella
review. She mentions her 6-year- catching it? antibodies if not immune and
old son has got chickenpox and administer VZ immunoglobulins.
she can’t remember having it
herself. She has a new cough and
feels generally unwell.
30-year-old presents to the Surrogate. Can I go home? Establishes potential allergen from
Emergency department with rash history. Checks obs (HR, BP, SaO2).
which developed in a restaurant 4 How can I stop this Examines skin for rash, auscultates
hours ago. Rash has resolved but happening again as it’s chest. Management – antihistamine,
they feel itchy and wheezy. terrifying? period of observation then send home if
improving, referral for allergen testing
etc.
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candidate
Limb pain/swelling 30-year-old pregnant woman Surrogate or patient. Will this harm my Checks obs (HR, BP including postural
presents with ‘faint.’ Further baby? drop), examines calves, auscultates
questioning gives history of chest. Differential includes DVT / PTE,
increasing SOB on exertion and a Will I need any tests postural hypotension in pregnancy,
painful tender calf. and will they be safe muscular pain. Explains investigations –
for my baby? U/S leg, liaise with obstetrics.
Poisoning 30-year-old patient has taken 16 Surrogate with Have I damaged my Establishes risk factors for suicide, other
paracetamol tablets over a 24 feigned epigastric liver? toxins and liver damage. Checks obs.
hour period in an attempt to cure tenderness Examines for liver disease and feels
a headache. The headache has What can be done epigastrium. Arranges bloods (U&E, LFT,
now gone, but a friend advised about it? FBC, clotting, paracetamol level). Knows
him that he could have liver of guidelines for treatment of
damage. Further info: patient paracetamol poisoning.
drinks 40–50 units of alcohol per
week
Cough 52-year-old man with recent Surrogate. Can you give me Check medication list. Assess for signs of
STEMI. Further info: newly something to stop this heart failure.
commenced on ACE inhibitors. cough?
Diarrhoea 65-year-old patient recovering Patient or surrogate. Is this caused by my Check obs (HR, BP, temperature),
from CAP. Been on a tablets? medications, examines abdomen, looks
cephalosporin. Do I need to go into a for evidence of dehydration.
single room? Demonstrates knowledge of appropriate
infection control measures.
23
APPENDIX 3: Examples of suitable Station 5 scenarios
1: Postural hypotension
2: Infective discitis
24
Scenario N°
MRCP(UK) PACES

Mrs MI aged 45.
Patient details:
Your role: You are the doctor on duty in the medical admissions unit.
You have 10 minutes with each patient. The Examiners will alert you when 6 minutes have elapsed and will
stop you after 8 minutes. In the remaining 2 minutes, one Examiner will ask you to report on any abnormal
physical signs elicited, your diagnosis or differential diagnoses, and your plan for management (if not
already clear from your discussion with the patient).
Referral text:
Clinical problem: Please will you see this woman who had an uncomplicated myocardial
infarction five weeks ago. She now feels rather lethargic.
Please will you rule out a further myocardial infarction.

Respiratory rate (respirations per minute) 22
Pulse rate (beats per minute) 56
Systolic blood pressure (mm Hg) 105
Diastolic blood pressure (mm Hg) 65
Oxygen saturations (%) 96
Temperature 0C 36.8
Your task is to:

Assess the problem by means of a brief focused clinical history and a focused relevant physical
examination. You do not need to complete the history before carrying out an appropriate
examination.
Review any observation charts that are supplied
Advise the patient of your probable diagnosis (or differential diagnoses), and your plan for
investigation and treatment where appropriate.
Respond directly to any specific questions which the patient may have.
25
Scenario N°
MRCP(UK) PACES

You are: Mrs MI aged 45.

You have felt really lethargic over the last week, and have felt unable to do your normal activities. You are
disappointed because you felt you were starting to make a recovery after your recent heart attack. You
had a heart attack five weeks ago and you are very worried that this could be another one. You could ask
your first question here if you get the opportunity.

The lethargy started about one week ago. You tried the angina spray but it did not help, it just gave you a
bad headache and made you feel very dizzy.
You have noticed dizziness when getting up out of a chair over the last week. You almost fell over the first
time, but have now learned to get up carefully.
You have not had any further chest pains or discomfort.
You have wondered whether your tablets are responsible for making you feel like this.

You had a heart attack five weeks ago. It all happened so quickly – you were rushed into hospital and had
an angiogram immediately. The doctors opened up the heart artery with a balloon (angioplasty) and put a
stent in. You were told all your other heart arteries were fine and that the stent and tablets should help to
stop further problems. You were told that smoking was at least partly to blame and that you must stop if
possible. You were in hospital four days and went home with lots of tablets. You have been on the cardiac
rehabilitation programme for three weeks, but felt too lethargic to go this last week. You were going to
ask them about your symptoms, but now feel too worried, hence you came back to hospital.
26
Scenario N°
Your father had a heart attack in his fifties but he is still alive (now aged 70).
Medication record
Current medications (You may wish to bring a list of your treatment and show it to the doctor if asked.)
Aspirin 75 mg once daily, ramipril 10 mg once daily, bisoprolol 5 mg once daily, clopidogrel 75 mg once
daily, atorvastatin 80 mg at night, GTN (glyceryl trinitrate) spray as needed.
All this is new, you were not taking any regular medication before the heart attack. You don’t like taking
all these tablets and you wonder if they are causing some of your current symptoms. Your family doctor
increased the ramipril from 5 mg to 10 mg two weeks ago, as per the hospital’s advice.
Personal history

You are married, and have two children aged 12 and 16.
You stopped smoking (20 cigarettes a day) at the time of your heart attack – you are determined never to
start again!
You do not drink alcohol.
You are a saleswoman in a car showroom.
The doctor will want to feel your pulse and listen to your heart. They may want to take your blood
pressure with you lying down and then standing up. If you do stand up, you feel a bit dizzy and stagger a
bit - hold onto something (such as the bed) but do not fall over. After a minute you feel OK.
You have 1 or 2 specific questions for the doctor at this consultation. Please note them down on a small
card to remind you during the exam.
1. Have I have had another heart attack?
2. Is this a side effect of the tablets I’ve been taking since my heart attack?
27
Scenario N°
DATE CYCLE
MRCP(UK) PACES
that are being considered. Any remaining areas of uncertainty eg regarding the plan for investigation or
28
Scenario N°

Patient with a recent MI, presents with lethargy and low BP following an
Problem:
increase in the ACE inhibitor dose.
Candidate’s role: Doctor on duty in the medical admissions unit.
Patient details: Mrs MI aged 45.
Patient or surrogate? Surrogate.
Clinical Establish nature of lethargy, excluding recurrent angina, heart failure and GI bleed
Communication symptoms.
Skills (C) Obtain detail of recent myocardial infarction.
Review drug treatment, note recent increase in ramipril.
Check to assess severity of illness – airway, breathing, circulation.

Physical Asks for / looks at the observations.
Examination (A) Offers to do lying and standing BP.
Feels pulse, listens to heart and lungs.
Immediate tests: U&E, FBC, ECG to exclude AKI, bleed, MI.

Clinical Judgement Would probably not need a troponin.
(E) Would advise withholding ACEI and then restarting lower dose.
Probably does not need to stay in hospital once AKI and GI bleed excluded – could
go home with instructions for GP follow-up.
Concerns (F)
Identifying Identifies that the patient is stable, not shocked, but has postural hypotension.
Physical Signs (B) No other abnormal physical signs.
29
Scenario N°

Probable Diagnosis:
Differential Postural hypotension related to increased ramipril dose.
Diagnosis (D)
Lethargy induced by β-adrenoceptor blocker.
Dehydration secondary to AKI induced by ACE inhibitor.
Maintaining Patient See marksheet

Welfare (G)
30
Scenario N°
MRCP(UK) PACES

Mrs ID aged 72.
Patient details:
Your role: You are the doctor on call.
You have 10 minutes with each patient. The Examiners will alert you when 6 minutes have elapsed and will
stop you after 8 minutes. In the remaining 2 minutes, one Examiner will ask you to report on any abnormal
physical signs elicited, your diagnosis or differential diagnoses, and your plan for management (if not
already clear from your discussion with the patient).
Referral text:
Clinical problem: This woman has been referred by her family doctor with severe back pain. She lives on
her own and is struggling to cope at home. She is known to have osteoporosis and her family doctor is
concerned she may have had another vertebral fracture.

Respiratory rate (respirations per minute) 18
Pulse rate (beats per minute) 90
Systolic blood pressure (mm Hg) 150
Diastolic blood pressure (mm Hg) 85
Oxygen saturations (%) 98 on air
Temperature 0C 38.0
Your task is to:

Assess the problem by means of a brief focused clinical history and a focused relevant physical
examination. You do not need to complete the history before carrying out appropriate examination.
Review any observation charts that are supplied.
Advise the patient of your probable diagnosis (or differential diagnoses), and your plan for investigation
and treatment where appropriate.
Respond directly to any specific questions which the patient may have.
31
Scenario N°
MRCP(UK) PACES

You are: Mrs ID aged 72.

One week ago you noticed a dull pain in the middle of your back which has not gone away and is getting
steadily worse. It is now there all the time and any movement is now painful. You just don’t feel right in
yourself and as you live on your own, daily activities such as washing and dressing are becoming
increasingly difficult. You have had a fracture in your back in the past and are concerned that this may be
related.

You have not fallen recently.
The back pain has not come on suddenly; it started gradually one week ago and is now present constantly.
It wakens you from sleep at night.
You have also been feeling feverish and sweaty and a bit shaky at times.
You feel washed out, tired and just not right.
You haven’t felt like eating much over the past week and may have lost a little weight (a few pounds) over
that time, but you haven’t noticed a significant loss of weight.
You did have a small cut on your toe about one month ago which oozed pus. The family doctor gave you a
course of antibiotics but you didn’t complete the course as they made you feel sick.
You have no cough, breathlessness or sputum. You have not coughed up any blood.
Your bowels are working fine with no change in habit or blood from the back passage / in the stool. You
are not going to the toilet more frequently and have not had any episodes of bowel or urinary
incontinence.

You have osteoporosis and have had a fracture of a bone in your back as a result of this.
32
Scenario N°

Your mother broke her hip after a minor fall in her early seventies.
Medication record
Current medications (You may wish bring a list of the treatment and show it to the doctor if asked.)
Alendronate 70 mg once a week.
Calcichew D3 Forte, 2 tablets daily.
Personal history

You are widowed. You have never smoked but enjoy the occasional glass of sherry.
You are a retired primary school teacher.
The doctor will want to examine your back. If they press down the middle of your spine, please tell them
that it is painful just over your spine in the middle of your back. They may wish to examine the power in
your legs and test your reflexes. You have normal power in your legs and normal sensation.
You have 1 or 2 specific questions for the doctor at this consultation.

Please note them down on a small card to remind you during the exam.
• Have I had another fracture in my back?
• Why am I feeling generally unwell?
33
Scenario N°

DATE CYCLE
MRCP(UK) PACES
that are being considered. Any remaining areas of uncertainty eg regarding the plan for investigation or
34
Scenario N°
Woman with a history of osteoporosis and vertebral fracture presents with

Problem:
gradual onset constant and worsening back pain and fever, preceded by
cutaneous infection ?discitis.
Candidate’s role: Doctor on call.
Patient details: Mrs ID aged 72.
Patient or surrogate? Surrogate.
Establishes symptoms of gradual onset constant back pain with fever, not in
Clinical keeping with osteoporotic fracture.
Communication Establishes risk factors for discitis in history (preceding soft tissue infection, failure
Skills (C) to complete antibiotics and probable bacteraemia with seeding in previously
fractured vertebrae).
Establishes no symptoms suggestive of acute cord compression.
Looks at the observations and assesses severity of septic shock.

Physical Palpates spine looking for spinal tenderness, conducts focal neurological
Examination (A) examination of lower limbs, assessing tone, power and reflexes. Indicates the wish
to formally check sensation and perform rectal exam to assess anal tone and
perianal sensation.
Indicates the need to look for signs of endocarditis (skin lesions, murmur etc).
Immediate management – close observation, assess for signs of sepsis syndrome,

Clinical Judgement fluid balance.
(E) Commence empirical antibiotics e.g. IV flucloxacillin based on likely staphylococcal
infection after several sets of blood cultures.
Immediate tests: X-ray of spine and if abnormal MR scan of spine looking for
evidence of discitis, cord compression.
Blood cultures, FBC, U&Es, CRP.
Discusses the need for discussion with senior on call and liaison with microbiology
and surgical colleagues re: appropriate antibiotic therapy and surgical drainage.
Recognises that abnormal bone e.g. previous fracture acts as a nidus for infection.
Concerns (F)
35
Scenario N°
Identifying Identifies pyrexia, hypotension and sepsis.

Physical Signs (B) Identifies spinal tenderness and establishes no signs of acute cord compression.
Probable Diagnosis:
Differential Infective discitis presumed secondary to bacteraemia following incompletely treated soft tissue
infection.
Diagnosis (D)
Osteoporotic fracture, alternative source of sepsis.
Maintaining Patient See marksheet

Welfare (G)
36
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MRCP(UK) Guidelines for

A guide to writing and vetting

GUIDELINES FOR WRITING STATION 5 SCENARIOS

GUIDANCE ON THE USE OF SURROGATES

SUBMISSION OF SCENARIOS FOR VETTING

GUIDELINES FOR VETTING STATION 5 SCENARIOS

GENERAL GUIDANCE – SCENARIO CONTENT

APPENDIX 1: SCENARIO TEMPLATE

APPENDIX 2: CMT CURRICULUM

APPENDIX 3: EXAMPLES OF SUITABLE SCENARIOS

Examples of suitable cases/scenarios include:

The template includes:

Information for the candidate

Information for the patient

Information for the examiners

Scenarios should not be re-used on consecutive days.

Submission of scenarios for vetting

Figure 1: Writing and vetting process

General guidance – scenario content

Scenarios which tend to work well include:

Scenarios which do not work well include:

Information for the patient:

Information for the examiners:

Station 5: BRIEF CLINICAL CONSULTATION

Your task is to:

NOT TO BE SEEN BY CANDIDATES

Station 5: BRIEF CLINICAL CONSULTATION

History of current problem

Information to be volunteered at the start of the consultation

Information to be given if asked

Past medical and surgical history

Relevant family history

Relevant personal, social or travel history

NOT TO BE SEEN BY CANDIDATES

Station 5: BRIEF CLINICAL CONSULTATION

Continued on next page…

NOT TO BE SEEN BY CANDIDATES

Clinical skill Key issues (please complete each box)

NOT TO BE SEEN BY CANDIDATES

Differential Probable Diagnosis:

Plausible alternative diagnoses:

Maintaining Patient See marksheet.

Presentation Scenario Suitable for Patient/surrogate Key issues to be identified

Station 5: BRIEF CLINICAL CONSULTATION

Please will you rule out a further myocardial infarction.

Physiological observations for the patient above Reading on arrival

Your task is to:

NOT TO BE SEEN BY CANDIDATES

Station 5: BRIEF CLINICAL CONSULTATION

You are: Mrs MI aged 45.

History of current problem

Information to be volunteered at the start of the consultation

Information to be given if asked

Past medical and surgical history

Relevant family history

Relevant personal, social or travel history

NOT TO BE SEEN BY CANDIDATES

Station 5: BRIEF CLINICAL CONSULTATION

Continued on next page…