Station 5 All Sample Scenarios

Compiled by Paces network facebook group
Demonstration scenario: visual problems

in a taxi-driver
New Station 5
INFORMATION FOR CANDIDATES
• You will be asked to see two patients at this station. The clinical
information about one of these patients is given in the box below. You should
have a second sheet giving you information about the other patient.
• 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

abnormal physical signs (if any), your diagnosis or differential diagnosis, and
your plan for management (if not already clear from your discussion with the
patient).
Your role: You are the medical doctor on-call, and have been asked to assess the
eyes of a patient due to have a total knee replacement tomorrow for severe arthritis.
Patient name: Mr John Brown – aged 51 years
This 51 year-old man is due to have a total knee replacement tomorrow as a result of
decreased mobility from severe arthritis. He has noticed that his vision is abnormal.
Your task is to assess the patient’s problems and address any questions or
concerns raised by the patient.
• You should assess the problem by means of a relevant clinical history and
a relevant physical examination. Y o u s h o u ld n o te t h at y o u a r e als o
su p pl i e d w it h a t a p e me as u r e f or th is p a rt of t h e ex a mi n at i on. You
do not need to complete the history before carrying out appropriate
examination.
• You should respond to any questions the patient may have, advise the patient
of your probable diagnosis (or differential diagnoses) and your plan for
investigation and treatment where appropriate.
• You have 8 minutes to complete the task.

in a taxi-driver
New Station 5
INFORMATION FOR PATIENT
The doctors sitting the examination have been asked to assess your problem. They
will have 8 minutes to ask you about the problem and any other relevant issues.
They will also examine you. They should explain to you what they think is wrong
and what action should be taken and answer any questions you have, for example
about the diagnosis, tests that may be needed, or treatment. One of the examiners
will ask them to describe any abnormal examination findings and give their diagnosis.
Your history is described below.
You are: Mr John Brown – aged 51 years
Your problem: v i s i o n p r o b l e m s
You have noticed that you bump into objects in space. Your previous medical history
includes a carpal tunnel decompression (three years’ ago), otherwise there is nothing
of note. You have also noticed excessive sweating.
Your visual appearance has changed markedly. You are not on any medications, and
you have no known allegies. You live with your wife in a bungalow; your grown-up
children have both left home. Your difficulty walking has put great strain on your wife,
who also cares for you. You have a carer that does all your shopping for you (nothing
else). You had been working as a taxi driver, and still hold your licence. However, you
feel that you would like to take early retirement.
You should ask the candidate what could be the cause of your visual problems are.
You should specifically inquire whether the candidate’s findings might affect the
operation tomorrow.
in a taxi-driver
New Station 5
INFORMATION FOR EXAMINERS
Patient: Mr John Brown – aged 51 years
Examiners should discuss and agree the criteria for pass and for fail in the
competencies being assessed.
As a general guide, candidates would be expected to
• make an underlying diagnosis of acromegaly
• examine the visual fields
• make a brief examination of gait
• consider the need for further referral and management
The lead examiner should:
a) Advise the candidate after 6 minutes have elapsed that “You have two
minutes remaining with your patient”
b) Ask the candidate to describe any abnormal physical findings that have been
identified
c) Ask the candidate to give the preferred diagnosis and any differential
diagnosis that is being considered
d) Any remaining areas of uncertainty eg regarding the plan for investigation or

management of the problem may be addressed in any time that remains.
Demonstration scenario: double vision
New Station 5

patient).
Your role: You are the medical doctor on-call, and have been asked to give an
opinion on an ENT patient with chronic sinus infections.
Patient name: Mr Tom Bell – aged 58 years
This 58 year-old man presents with double vision.
a relevant physical examination. You do not need to complete the history
before carrying out appropriate examination.

New Station 5
You are: Mr Tom Bell – aged 58 years
Your problem: d o u b l e v i s i o n
You have been suffering from chronic sinus infections. Your nose feels stuffy all the
time. The GP made a referral to the ENT department, and you are intending for an
one day programmed investigation including CT scan.
You have experienced slowly worsening double vision in the last 7 months. You find
your symptoms improve if you voluntarily shut one eye. You have thought about
making a home-made eye patch. It seems to be worse when looking In a particular
direction, but you are not sure which. You also have been very anxious, restless, and
irritable, think that you have been experiencing mild palpitations. You have also
experienced muscle weakness and a diminishing interest in sex.
You should ask the candidate the candidate what could be the cause of your
double vision. You should specifically inquire whether the candidate’s findings might
have any bearing on his history of sinus infections.
New Station 5
Patient: Mr Tom Bell – aged 58 years
• Obtain a short and accurate description of the problem.
• Suggest that Graves disease is a possible underlying diagnosis.
• Examine the eyes.
• Explain the need for further investigation (if any), a d d r e s s t h e p a t i e n t ’ s

conc erns, and to produc e a s ensible management plan in
liaison with the ENT team.
identified

Demonstration scenario: shortness of
breath in a patient with SLE
New Station 5

patient).
Your role: You are the medical doctor on call asked to see a patient in Casualty with
has burned the tip of her index finger
Patient name: Mrs Elizabeth Smith – aged 33 years
This 33 year old lady complains o f s h o r t n e s s o f b r e a t h . H e r

admission bloods were normal, including an INR of 1.8.

New Station 5
You are: Mrs Elisabeth Smith – aged 33 years
Your problem: s h o r t n e s s o f b r e a t h
You are right-handed, and work as a secretary. This evening, you were making some
soup on the stove, when you accidentally put your finger on the hot hob. You did not
realize this at the time, but you ran your right index finger until the tap for a long
period of time. It hurts a lot, but your husband with whom you live gave you some
aspirin.
Last week, you returned from a holiday with your husband in Japan. Last night, you
felt very short of breath. You do not normally feel short of breath. You were diagnosed
with SLE (systemic lupus erythematosus) seven years’ ago. You have had a series of
recurrent thromboembolic events (which have been clots in your lung). You are
routinely on warfarin.
Your other medication history only includes the OCP (pill). You do not have any
known drug allergies. You smoke 8 packs of cigarettes per week; you have never
drunk alcohol. You do not take any elicit drugs. There is no family history of medical
problems.
You have been found to be lupus anticoagulant positive, and your INR is normally
well controlled (but you do know now at what level.)
symptoms. You should also ask what he/she would recommend as regards your
employment. You were due into work tomorrow; you get paid by the hour.
New Station 5
Patient: Mrs Elisabeth Smith – aged 33 years
• Obtain a detailed history – including the actual timescale of her shortness of

breath.
• Appreciate that a pulmonary embolic event will have to be excluded.
• Examine the lung fields.
• Explain the need for further investigation, a d d r e s s t h e p a t i e n t ’ s

conc erns, and to produc e a s ensible management plan.
identified

Demonstration scenario: difficulty
breathing in a patient with ankylosing
spondylitis
New Station 5

patient).
Your role: You are the medical doctor on-call, and have been asked to give an
opinion on an orthopaedic patient being assessed for an oseotomy.
Patient name: Mr Julian Evans – aged 52 years
This 58 year-old man is to undergo an osteotomy at some date soon for his spinal
deformity due to ankylosing spondylitis. He is complaining of ‘difficulty breathing’.
a relevant physical examination. Y o u s h o u ld n o te t h at y o u a r e als o
su p pl i e d w it h a t a p e me as u r e f or th is p a rt of t h e ex a mi n at i on. You
do not need to complete the history before carrying out appropriate
examination.

spondylitis
New Station 5
You are: Mr Julian Evans – aged 52 years
Your problem: d i f f i c u l t y b r e a t h i n g
You have been suffering from ankylosing sponditis for about 16 years. Nowadays the
things that trouble you most are the fact that people notice that you have a stooped
posture, and that you have difficulty in tying your shoelaces.
You are currently very stressed as you are unemployed. Your problems breathing
have come on in the last 2 months. 3 months ago, your sister got divorced, which was
very traumatic. She was quite healthy apart from suffering a panic disorder. You left
boarding school at the age of 15, and you have had difficulty in holding down jobs due
to lack of relevant skills (it is perceived). In fact, you hated boarding school.
You are on diclofenac for your joint stiffness, which you believe to run in your family.
Your mother had ulcerative colitis; no other medical conditions run in the family. You
have no known drug allergies; you have never drunk alcohol or smoke.
You should ask the candidate what could be the cause of your breathing
difficulties. You should specifically inquire whether the candidate’s findings might
affect an operation in the future.
spondylitis
New Station 5
Patient: Mr Julian Evans – aged 52 years
• appreciate that the patient may be suffering from a panic disorder
• consider relevant diagnoses for difficulty breathing in such a patient.
• examine the chest
• consider the need for further referral and management
identified

Demonstration scenario: easy bruising
INFORMATION FOR THE CANDIDATE Scenario N°
MRCP(UK) PACES
Station 5: BRIEF CLINICAL CONSULTATION
Patient details: Mrs XX aged 55

Your role: You are the medical doctor on call
You will be asked to see two patients at this station. The clinical information about one of these
patients is given in the box below. You should have a second sheet giving you information about
the other patient.
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 you discussion with the patient).
Referral text:
Clinical problem: This lady is attending the outpatient clinic for review of her asthma. She is
worried that she seems to be bruising very easily.
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 appropriate
examination.
• Advise the patient of your probable diagnosis (or differential diagnoses), and your plan for
• Respond directly to any specific questions which the patient may have.
Any notes you make must be handed to the examiners at the end of the station
NOT TO BE SEEN BY CANDIDATES
INFORMATION FOR THE PATIENT Scenario N°
MRCP(UK) PACES
You are: Mrs XX aged 55
History of current problem

You have come to the clinic for a routine appointment to review your asthma. You are feeling well
and your asthma is not causing you any problem at present. Today you mention that you seem to
be coming out in bruises very easily. They come on your upper arms, forearms, thighs and shins;
you do not remember bumping or injuring yourself. You find them unsightly and keep yourself
covered up to prevent people commenting on them.
Background information
Past medical and surgical history

You had an episode 2 months ago when your left eye suddenly became all red. You were told it
was nothing to worry about and it faded over several weeks. You have not had any other
bleeding, eg from nose, gums, urine, bowel or vagina.
You have had asthma for 30 years and this flares up regularly for no obvious reason. You peak
flow test is usually 350.
Family history
Your father died of a heart attack at the age of 65 years. Your mother is well and aged 82 years.
You have two daughters aged 26 and 21 years. They are both in good health.
Medication record
Current medications (if relevant)

You are taking Symbicort inhaler twice daily. You have steroid tablets (prednisolone) at home for
use if you become wheezy and your peak flow test goes down below 250. You take 4 or 5
courses lasting about 10 days every year.
You take an aspirin a day because you think it is good for you.
Personal history
Relevant personal, social, occupational or travel history

You are in good general health and do not have other health problems apart from your asthma.
You own a dog. You eat a balanced diet.
Occupational history
You work as a secretary in a lawyers’ office.
Physical examination
Relevant clinical findings

Mildly Cushingoid features with rounded face and central obesity. The skin is thinned and there is
bruising of the arms and legs. There are some purple coloured striae on the lateral aspects of the
abdominal wall.
You have some specific questions for the doctor at this consultation:
- Why do I bruise so easily?
- What tests, if any, are needed?
- What can be done to stop it happening?
INFORMATION FOR THE 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 eg 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 five skill domains on the mark sheet.
Examiners are reminded that, during the calibration process, the patient should be rehearsed and
specific aspects of the scenario that require clarification or emphasis should be discussed. 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…

Problem: Easy bruising

Candidate’s role: Medical doctor on call
Patient’s name: Mrs XX aged 55
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

Clinical Obtain a detailed history of the current problem and enquire about bleeding
Communication elsewhere.
Skills (C) Obtain the drug history and note the frequent oral steroid use.
Confirm satisfactory diet.
Physical Examine the affected areas, look at appropriate places for purpura.
Examination (A)
Clinical Discuss the causes of easy bruising.

Judgement Check platelet count.
(E)
Managing Address the patient’s concerns about her bruising.

Patients’
Concerns (F)
Identifying Identify Cushingoid appearance. Identify bruising on arms, hands, thighs

Physical Signs (B) and over shins.
Differential Probable Diagnosis:

Diagnosis (D) →Skin thinning and bruising secondary to steroid therapy.
Plausible alternative diagnoses:

→Cushings syndrome.
Thrombocytopaenia (ITP).
Maintaining See marksheet.

Patient Welfare
(G)
Demonstration scenario: possible
pulmonary embolus
New Station 5

patient).
Your role: You are the medical doctor on call.
Patient name: Miss Anne Higgs – aged 25 years
This 25 year old lady complains o f b e i n g s h o r t o f b r e a t h .

pulmonary embolus
New Station 5
You are: Miss Anne Higgs – aged 25 years
Your problem: shortness of breath
You first experienced your shortness of breath a few days’ ago. This was
accompanied by a stabbing chest pain, which is much worse when you take a deep
breath in or when you bend over.
There is nothing of note in your previous medical history. You gave one child, born
from a normal vaginal delivery 8 months’ ago. There is, however, a family history of
blood clots. You are on no prescription medication, otherwise than the oral
contraceptive pill.
You have never have had any similar episodes. You smoke probably ten cigarette
packets per week, and you are a social drink. You have never tried any recreational
drugs.
You should ask the candidate the candidate what might be wrong with your
lungs. You are worried about a clot – might that be the problem? What should be
done to sort this out?
pulmonary embolus
New Station 5
Patient: Miss Anne Higgs – aged 25 years
• Obtain a detailed history – including any contraindications to anticoagulation
• Appreciate that PE requires to be excluded.
• Examine the lungs.
• Explain the need for further investigation and start heparin pending the
result.
identified

Demonstration scenario: possible DVT
MRCP(UK) PACES

the other patient.
Referral text:
Clinical problem: This lady complains of pain in her left calf and she feels it may be swollen.
Your task is to:

examination.
MRCP(UK) PACES

You thought your left calf was a little swollen and tight-feeling over the past two days and today it
is quite painful when you walk.
You noticed the first day after arriving in Egypt that your calf was slightly uncomfortable and this
lasted the whole time you were away. You thought it was probably due to the heat although you
were surprised that only 1 leg was affected. Now, since coming home, the problem has not eased
but has got worse.
You do not feel breathless nor do you have any chest pain.

You tend to have mild discomfort in the left knee from a cartilage injury when you played tennis
some years ago. You do not have any other joint problems.
You are not aware of any problem with the veins in your legs.
Family history
You have an older sister who had a DVT following a gall-bladder operation several years ago.
Medication record

Oral contraceptive pill.
Personal history

You went on holiday to Egypt 3 weeks ago and you returned home 1 week ago.
You have 3 children aged 12, 10 and 7.
You smoke 15 cigarettes per day
You work as a secretary.

There is oedema of the left ankle and calf to the level of the knee. The superficial veins in the left
leg are more prominent than on the right leg. The left calf is tender. There are no clinical features
of pulmonary embolism: The pulse rate is normal, the jugular venous pulse is not elevated and
the pulmonary second sound is normal. Blood pressure is not low.
- What might be the problem with my leg; could it be a clot?
- What will be done to sort this out?
DATE CYCLE
MRCP(UK) PACES
remains.
Continued on next page

Problem: Possible DVT

Candidate’s role: Medical doctor on call.
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 Obtain a detailed history including any contraindications to anticoagulation.
Communication Obtain the family history of DVT
Skills (C)
Physical The left calf is swollen compared to the right leg. The superficial veins in the
Examination (A) left lower leg are dilated and the left calf is tender. There are no clinical
features to suggest PTE.
Clinical Appreciate that DVT requires to be excluded.

Judgement Explain the need for venous Doppler studies and start heparin pending the
(E) result.
Managing Explain to the patient that a clot in the leg is possible. Explain the
Patients’ investigations which will support this diagnosis. Also explain that heparin will
Concerns (F) be started immediately in order to prevent any spread of the clot.
Identifying Identify the clinical features of a DVT. Show that there are no obvious signs
Physical Signs (B) of a PTE.
Probable Diagnosis:
Differential →Left leg DVT
Diagnosis (D)
Ruptured Baker’s Cyst
Lymphoedema of the left leg.
Maintaining See marksheet

Patient Welfare
(G)
Demonstration scenario: goitre
MRCP(UK) PACES

the other patient.
Referral text:
Clinical problem: This lady was admitted to the orthopaedic ward for a carpal tunnel release
operation.
She mentioned to the orthopaedic doctors that she has swelling in her neck and they have
asked for the opinion of a physician. You were asked by your consultant to see the patient and
to assess the suspected swelling in her neck.
Your task is to:

examination.
MRCP(UK) PACES

You are in the orthopaedic ward and you mentioned to the admitting doctor that your neck
seemed swollen. You do not have any of the symptoms your sister had when her thyroid was
underactive. Indeed you feel quite well.
Your weight is stable; your skin and hair are normal. You do not seem to feel the heat or the cold
anymore than anyone else. Your bowel works normally. You do not have a problem with
swallowing.

You have been suffering from pain in your right forearm and a numb or tingly feeling in your right
hand – affecting your 3rd, 4th and 5th fingers. The aching in your arm is worse at night and you
have found it more and more difficult to get comfortable. The problem has been present for
several years and was worse when you were pregnant with your daughter 3 years ago but
improved for a time after that.
A trapped nerve in your wrist has been diagnosed and you are having a short admission to have
the nerve released.
Family history
Your sister, who is 38, has an underactive thyroid.
Medication record

You are on no medications.
Personal history

You work as a typist and find that the pain and numbness of your hands is beginning to hamper
your work.
You are a typist.

There is a smoothly enlarged goitre. There is no bruit to hear. The gland does not extend below
the level of the manubrium. The patient is clinically euthyroid. There are also signs of bilateral
median nerve damage with reduced light touch sensation over the distribution of the median
nerves.
- Why does my neck seem swollen?
- Is there something wrong with my thyroid gland?
- Are any tests required, and if so, what will these be?
DATE CYCLE
MRCP(UK) PACES
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 eg
regarding the plan for investigation or management of the problem may be addressed in any
time that remains.
Examiners are reminded that, during the calibration process, the patient should be rehearsed
and specific aspects of the scenario that require clarification or emphasis should be discussed.
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.

Problem: Goitre
Clinical Note the history of neck swelling and the family history of thyroid disease.
Communication Enquire about symptoms of disturbed thyroid function.
Skills (C)
Physical Examine the neck.

Examination (A) Examine for signs of overactive and underactive thyroid gland
Clinical Identify that the swelling in the neck is a smoothly enlarged thyroid gland.
Judgement Conclude that the patient is clinically euthyroid.
(E)
Managing Confirm to the patient that her thyroid gland does seem enlarged but
Patients’ reassure that the gland seems to be working normally.
Concerns (F)
Identifying Identify the smooth and symmetrical thyroid enlargement.

Physical Signs (B) Note absence of bruit.
Confirm clinical euthyroid state.
Differential Probable Diagnosis:

Diagnosis (D) →Early Hashimoto’s thyroiditis.

→Early multinodular goitre.
Maintaining
Patient Welfare See marksheet
(G)
Demonstration scenario: visual loss
MRCP(UK) PACES
Patient details: Mr XX aged 55

Your role: You are the medical doctor on call.
the other patient.
Referral text:
Clinical problem: This man has been treated for hypertension for some time and it has been well
controlled on losartan alone. Yesterday, he lost vision for a period. This needs further
investigation.
His blood pressure today is 145/85.
Your task is to:

examination.
MRCP(UK) PACES
You are: Mr XX aged 55

Yesterday, after a day off when you had a game of golf, you were feeling entirely well, but in the
early evening you noticed that your vision was getting dim and blurred. There was no pain in the
eye. You asked your wife to look at your eye and it looked normal and was not red.
When you covered your right eye with you hand you realised you could still see perfectly, but
when you covered your left eye everything was dull. Then, after about five minutes your vision
went completely dark in the left eye but stayed ok in your right.
Your speech was unaffected and there was no limb weakness or tingling. Your vision returned in
about 30 minutes.
You have not had headaches recently. You have not had anything like this before and you have
never had a mini-stroke or TIA.
Today you feel perfectly well.

You have had hypertension for 15 years.
You don’t think you have ever had your cholesterol checked.
Family history
Your father had a stroke when he was 65 years old and lost his speech and his ability to walk. He
died aged 70 from pneumonia.
Medication record

Losartan for your hypertension.
Personal history

You are married with 3 teenage children. You are right-handed. You smoke ten cigarettes a day.
You work as a postman.

Physical examination is entirely normal. In particular visual acuities are normal in both eyes and
visual fields are intact. There is no weakness of arms or legs and there is no alteration in light
touch sensation. The blood pressure may be slightly elevated. Pulse is regular. Heart sounds
are pure. There are no carotid bruits.
- What caused this to happen?
- Am I at risk of having a stroke?
- Should I have any tests arranged?
DATE CYCLE
MRCP(UK) PACES
remains.

Problem: Visual loss

Patient’s name: Mr XX aged 55

Clinical Obtain a history and establish that the problem as monocular and painless.
Communication Identify the risk factors of hypertension and smoking.
Skills (C)
Physical Key examination points should include acuity, papillary reactions,

Examination (A) fundoscopy, heart rhythm, carotid bruits and murmurs.
Some candidates may find the time to check for peripheral neurological
signs, other evidence of vascular disease, evidence of xanthelasmata.
Clinical Recommend at least carotid Doppler studies and lipid evaluation and
Judgement intensification of secondary preventative treatment.
(E)
Managing Discuss the likely diagnosis with the patient. Explain that treatments will be
Patients’ started to reduce the risk of future stroke. Explain the importance of
Concerns (F) undertaking Doppler scanning of the neck.
Identifying The patient has no abnormal physical signs.

Physical Signs (B)
Probable Diagnosis:
Differential →Amaurosis fugax
Diagnosis (D)
→Insert text here
Maintaining See marksheet

Patient Welfare
(G)
Demonstration scenario: unilateral
diaphragmatic weakness
New Station 5

patient).
Your role: You are the medical doctor on-call, and have been asked to give a
Medical patient undergoing a routine elective cystoscopy,
Patient name: Mr Geoff Ball – aged 53 years
This 53 year-old man reported in passing that he gets short of breath when
Immersed in water.

New Station 5
You are: Mr Geoff Ball – aged 53 years
Your problem: s h o r t n e s s o f b r e a t h o n
swimming
A year ago, due to investigations for blood in your urine, you were found to have a
polyp in your bladder. This was resected. You undergo regular cystoscopy, and you
are attending for one to be performed under local anaesthetic tomorrow.
In passing, you mentioned to the junior surgeon that you always get short of breath
when you plunge yourself in water. You do not know what causes this, but as soon as
you come out of water, your breathing returns to normal.
breathing symptoms. You should specifically inquire whether the candidate’s findings
affect your operation going ahead tomorrow.
New Station 5
Patient: Mr Geoff Ball – aged 53 years
• Obtain a short and accurate description of the problem.
• Suggest that an unilateral diaphragmatic weakness is possible on the basis of

the clinical signs, but that a pleural effusion in reality might have to be excluded.
• Examine the lung fields.
• Explain the need for further investigation (if any), a d d r e s s t h e p a t i e n t ’ s

conc erns, and to produc e a s ensible management plan.
identified

Station 5
• You will be asked to see two patients at this station. The clinical information
about one of these patients is given in the box below. You should have a
second sheet giving you information about the other patient.
• 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 abnormal
physical signs (if any), your diagnosis or differential diagnosis, and your plan
for management (if not already clear from your discussion with the patient).
Your role: You are the medical doctor on call in a general hospital.
Patient name: Jane Smith
This lady is an in-patient in a dermatology ward for treatment of leg ulcers. She
has had longstanding diabetes, currently treated with Insulin. Earlier today she
complained to the ward nurses that she had transiently lost vision.
She has been reviewed by a junior dermatologist who requests a review by the
medical registrar.
Your task is to assess for the likely cause of the visual problem and explain to
the patient whether any further action is needed
• You should assess the problem by means of a relevant clinical history and a
relevant physical examination. You do not need to complete the history

Station 5
The doctors sitting the examination have been asked to assess your problem.
They will have 8 minutes to ask you about the problem and any other relevant
issues. They will also examine you. They should explain to you what they think
is wrong and what action should be taken and answer any questions you have,
for example about the diagnosis, tests that may be needed, or treatment. One of
the examiners will ask them to describe any abnormal examination findings and
give their diagnosis.
You are: Mrs Jane Smith – aged 55 years
Your problem: sudden transient loss of vision.
You have had diabetes for 10 years. You were admitted last week because your leg
ulcers were painful.
You have had regular diabetic eye checks but have never had laser therapy. You can
read a newspaper and see the television usually.
Today at around midday you realised that you could not see properly. It seemed as if
one eye was not working perfectly and when you closed your right eye you could not see
at all. You had no headache. You were alarmed but felt nothing else wrong. You
reported it to a nurse. After about five minutes your vision slowly came back and now
feels back to normal.
You have never had a stroke or TIA. You have had “mild blood pressure.”
You are on a variety of medications (there will be a drug chart on the bed.)
You have had no other symptoms recently apart from pain from your leg ulcers – you
wondered if the painkillers were too strong.
You were alarmed at this happening to you and will ask the doctor:
Was this caused by my painkillers doctor?
Will it happen again?

Station 5
Patient: Mrs Jane Smith – age 55 years
Examiners should discuss and agree the criteria for pass and for fail in the skills
being assessed.
• Elicit the fact that the visual loss appeared monocular and was transient
and now appears back to normal
• Elicit the fact that although the patient has diabetes they have no history of
diabetic eye complication requiring treatment
• Examine the acuity, fields, fundi, and pulse for AF and carotid bruit.
• Reassure the patient that this was not caused by her painkillers and
suggest further review by ophthalmology and diabetes teams, with
emphasis on tight control of risk factors, carotid dopplers, maybe echo?
b) Ask the candidate to describe any abnormal physical findings that have
been identified
d) Any remaining areas of uncertainty eg regarding the plan for investigation

or management of the problem may be addressed in any time that
remains.
INFORMATION FOR THE CANDIDATE
Training Scenario N°001
SAMPLE HOST CENTRE-2017.3
MRCP(UK) PACES
Patient details: Mrs XX aged 45.

Your role: You are the doctor 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: This woman had an uncomplicated myocardial infarction five weeks ago. She now feels
lethargic. Please examine her and rule out a further myocardial infarction.
Physiological observations for the patient above Reading on arrival

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
0
Temperature C 36.8
Other relevant observation data (units if applicable) N/A
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 appropriate examination.
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.
INFORMATION FOR THE PATIENT
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.
You are: Mrs XX aged 45.

You are in: the medical admissions unit.
Information to be volunteered at the start of the consultation

You have felt lethargic over the past week and have been 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.
Information to be given if asked

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 past 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
in a stent. 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 for 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 week. You were going
to ask them about your symptoms but now feel too worried, so you came back to hospital.
Relevant family history

Your father had a heart attack in his fifties but he is still alive at the age of 70.
Medication record
Current medications (Please bring a list of your treatment with you 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 of 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
Relevant personal, social or travel 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 not to
start again. You do not drink alcohol.
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 alright.
You have a few 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 had another heart attack?
2. Is this a side effect of the tablets I’ve been taking since my heart attack?
INFORMATION FOR THE EXAMINERS

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
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.

Problem: Recent myocardial infarction with lethargy and low BP following an increase in
the ACE inhibitor dose.
Candidate’s role: The doctor in the medical admissions unit.
Patient’s name: Mrs XX aged 45.
Patient or surrogate: Surrogate.
Clinical setting: The medical admissions unit.

Clinical Communication Establishes nature of lethargy, excluding recurrent angina, heart failure and GI
Skills (C) bleed symptoms.
Obtains detail of recent myocardial infarction.
Reviews drug treatment, note recent increase in Ramipril.
Physical Examination (A) Checks to assess severity of illness – airway, breathing, circulation.
Asks for / looks at the observations and notes relatively low BP.
Offers to do lying and standing BP.
Feels pulse, listens to heart and lungs.
Clinical Judgement (E) Immediate tests: U&E, FBC, ECG to exclude AKI, bleed, MI.
Would probably not need a troponin.
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.
Managing Patients’ Addresses the patient’s questions and concerns in an appropriate manner.
Concerns (F)
Identifying Physical Signs Identifies that the patient is stable, not shocked, but has relatively low blood
(B) pressure.
No other abnormal physical signs.
Differential Diagnosis (D) Probable Diagnosis:

Postural hypotension related to increased ramipril dose.

Lethargy induced by β-adrenoceptor blocker.
Dehydration secondary to AKI induced by ACE inhibitor.
Maintaining Patient Treats the patient respectfully, sensitively and ensures comfort, safety and
Welfare (G) dignity. Does not cause physical or emotional discomfort or jeopardise safety.
MRCP(UK) PACES

Your role: You are the doctor 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
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 that she may have had another vertebral fracture.

Oxygen saturations (%) 98 on air
Temperature 0C 38.0
Your task is to:

You do not need to complete the history before carrying out an appropriate examination.
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.
MRCP(UK) PACES

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, for
example 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 beforehand to run through the scenario with you.
Please read through the history carefully as you will have the opportunity at that point to raise any questions
or concerns you may have.
You are: Mrs XX aged 72.

You are in: the medical admissions unit.

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 started gradually around 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 you think you 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. Your toe improved in
a few days and is now back to normal.
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.

Your mother broke her hip after a minor fall in her early seventies.
Medication record
Current medications (Please bring a list of your treatment with you and show it to the doctor if asked.)
Alendronate 70 mg once weekly.
Calcium carbonate (Calcichew D3 Forte) two 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.
Physical Examination
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 one or two specific questions / concerns for the doctor at this
consultation.
1. Why am I feeling so unwell?


DATE CYCLE
MRCP(UK) PACES
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, eg regarding the plan for investigation or
Examiners should refer to the marking guidelines in the seven skill domains on the marksheet.
the next page indicate areas of potential interest in this case which both examiners should consider, along

Problem: Osteoporosis and vertebral fracture with back pain and fever preceded by
cutaneous infection.
Candidate’s role: The doctor in the medical admissions unit.
Patient or surrogate: Surrogate.
Clinical setting: The medical admissions unit.
absolute determiners of Satisfactory performance. It is for the examiners to agree and record the specific

Clinical Establishes symptoms of gradual onset constant back pain with fever, not in
Communication keeping with osteoporotic fracture.
Skills (C) Establishes risk factors for discitis in history (preceding soft tissue infection,
failure to complete antibiotics and probable bacteraemia with seeding in
previously fractured vertebrae).
Establishes no symptoms suggestive of acute cord compression.
Physical Examination (A) Looks at the observations to assess for septic shock.
Palpates spine looking for spinal tenderness, conducts focal neurological
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).
Clinical Judgment (E) Immediate management – close observation, assess for signs of sepsis
syndrome, fluid balance.
Commence empirical antibiotics eg IV flucloxacillin based on likely
staphylococcal infection after several sets of blood cultures.
Immediate tests: x-ray of spine, 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.
Recognises that abnormal bone eg previous fracture acts as a nidus for infection.
Concerns (F)
Identifying Physical Signs Identifies pyrexia, hypotension and sepsis.

(B) Identifies spinal tenderness and establishes no signs of acute cord compression.

Infective discitis presumed secondary to bacteraemia following incompletely
treated soft tissue infection.

Osteoporotic fracture with an alternative source of sepsis.
INFORMATION FOR THE CANDIDATE
MRCP(UK) PACES

Patient details: Mr JS aged 70.
Your role: You are the doctor in the medical assessment 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
Referral text:
Clinical problem: This man has developed pain and swelling in his finger. He has a history of controlled heart
failure, hypertension, mild stable renal impairment and type 2 diabetes.

Oxygen saturations (%) 98
Temperature 0C 37.1
Your task is to:

You do not need to complete the history before carrying out appropriate examination.
• 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.
MRCP(UK) PACES

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.
You are: Mr JS aged 70.

You are in: the medical assessment unit.
Please note that your medical details have been modified for the purposes of the examination.

You have developed pain and swelling in your finger. The pain has not been relieved by paracetamol so
you went to see your doctor who has sent you to hospital for further assessment.

The pain in your finger started two days ago. The joints in your finger have become swollen. Your finger is
so swollen and tender that you cannot bear to use that hand or let anything touch it. You do not recall any
injury to your hand or finger.
You vaguely remember something similar some years ago but had forgotten about it until this latest
episode. The episode settled after taken ibuprofen for a week.
You have discomfort in your hips and knees which you have put down to arthritis. The doctor has told you
it is due to ‘wear and tear’. You take paracetamol as required and this usually helps.

You were diagnosed with type 2 diabetes 10 years ago, which you control by diet and medication
(metformin).
Six years ago, you had a heart attack which was treated with angioplasty and a stent followed by
medication. You were told there was moderate damage to the heart muscle. You currently experience
mild breathlessness if you push yourself but you don’t experience angina.
You have high blood pressure which was diagnosed at the same time as diabetes. It has been a bit higher
over the last few months so your doctor added some more medication.
The doctor has advised you that your kidneys are not working 100% but they are stable. You haven’t had a
blood test to check your kidneys for about three months.
You used to have indigestion but this is now controlled by medication.

None of your family have experienced anything similar.
Medication record
Current medications (Please bring a list of your treatment and show it to the doctor if asked.)
Amlodipine 5 mg once daily,
Aspirin 75 mg once daily,
Atorvastatin 40 mg at night,
Bendroflumethiazide 2.5 mg once daily,
Bisoprolol 2.5 mg twice a day,
Eplerenone 25 mg once daily,
Lansoprazole 15 mg once daily,
Metformin 500 mg three times a day,
Paracetamol 1 g up to four times a day as required,
Ramipril 5 mg twice a day.
If asked, say that the bendroflumethiazide was started four weeks ago for your blood pressure.
Personal history

You stopped smoking at the time of your heart attack. You do not drink alcohol.
You are a retired teacher.
Physical Examination
The doctor will examine your hands. They may also wish to examine your other joints, such as knees and
feet. They may check the appearance of your ears.
You have a few specific questions / concerns for the doctor at this consultation.
1. Why are my fingers so painful?
2. What tests and treatment do I need?


DATE CYCLE
MRCP(UK) PACES

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
Examiners should refer to the marking guidelines in the seven skill domains on the mark sheet.
the next page indicate areas of potential interest in this case which both Examiners should consider, along

Problem: Acute gout in a patient with IHD, DM, HF and CKD.

Candidate’s role: The doctor in the medical assessment unit.
Patient details: Mr JS aged 70.
Patient or surrogate: Patient with modified history.
Clinical setting: The medical assessment unit.
Clinical Communication Focused history of joint pain and swelling, including the previous episode.
Skills (C) Explores all likely causes of joint symptoms, noting pre-existing O/A.
Establishes PMH and treatment.
Notes drug history and establishes new treatment with diuretic in relation to
onset of symptoms.
Physical Examination (A) Notes physiological observation, including borderline pyrexia.

Examines hands & knees, offers to examine other joints.
Checks ears for gouty tophi.
Clinical Judgment (E) Investigates: FBC, WCC, CRP/ESR. Renal function & urate level. Checks diabetes
and cholesterol control. Joint x-ray may be required. Joint aspiration if there is
significant fluid / suggestion of infection.
Treats: NSAID or colchicine with appropriate advice, aware of preventative
treatment with allopurinol.
Advises: role of diuretics, alternative BP control.
Concerns (F)
Identifying Physical Signs Right index finger is swollen over the pip and dip joints.
(B) Skin redness and tenderness. No significant fluid collection.

Acute gout precipitated by introduction of diuretic.

Infected joint.

Station 5 All Sample Scenarios

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Demonstration scenario: visual problems

INFORMATION FOR CANDIDATES

• In the remaining 2 minutes, one examiner will ask you to report

Patient name: Mr John Brown – aged 51 years

• You have 8 minutes to complete the task.

INFORMATION FOR PATIENT

Your history is described below.

You are: Mr John Brown – aged 51 years

INFORMATION FOR EXAMINERS

Patient: Mr John Brown – aged 51 years

As a general guide, candidates would be expected to

• make an underlying diagnosis of acromegaly

• examine the visual fields

• make a brief examination of gait

• consider the need for further referral and management

The lead examiner should:

d) Any remaining areas of uncertainty eg regarding the plan for investigation or

INFORMATION FOR CANDIDATES

• In the remaining 2 minutes, one examiner will ask you to report

Patient name: Mr Tom Bell – aged 58 years

This 58 year-old man presents with double vision.

• You have 8 minutes to complete the task.

INFORMATION FOR PATIENT

Your history is described below.

You are: Mr Tom Bell – aged 58 years

INFORMATION FOR EXAMINERS

Patient: Mr Tom Bell – aged 58 years

As a general guide, candidates would be expected to

• Obtain a short and accurate description of the problem.

• Suggest that Graves disease is a possible underlying diagnosis.

• Examine the eyes.

• Explain the need for further investigation (if any), a d d r e s s t h e p a t i e n t ’ s

The lead examiner should:

d) Any remaining areas of uncertainty eg regarding the plan for investigation or

INFORMATION FOR CANDIDATES

• In the remaining 2 minutes, one examiner will ask you to report

Patient name: Mrs Elizabeth Smith – aged 33 years

This 33 year old lady complains o f s h o r t n e s s o f b r e a t h . H e r

• You have 8 minutes to complete the task.

INFORMATION FOR PATIENT

Your history is described below.

You are: Mrs Elisabeth Smith – aged 33 years

INFORMATION FOR EXAMINERS

Patient: Mrs Elisabeth Smith – aged 33 years

As a general guide, candidates would be expected to

• Obtain a detailed history – including the actual timescale of her shortness of

• Appreciate that a pulmonary embolic event will have to be excluded.

• Examine the lung fields.

• Explain the need for further investigation, a d d r e s s t h e p a t i e n t ’ s

The lead examiner should:

d) Any remaining areas of uncertainty eg regarding the plan for investigation or

INFORMATION FOR CANDIDATES

• In the remaining 2 minutes, one examiner will ask you to report

Patient name: Mr Julian Evans – aged 52 years

• You have 8 minutes to complete the task.

INFORMATION FOR PATIENT

Your history is described below.

You are: Mr Julian Evans – aged 52 years

INFORMATION FOR EXAMINERS

Patient: Mr Julian Evans – aged 52 years

As a general guide, candidates would be expected to

• appreciate that the patient may be suffering from a panic disorder