Contents

Resuscitation (Adult) ........................................................................................................................... 2

Resuscitation (Paeds) .......................................................................................................................... 7
History ............................................................................................................................................... 10
Physical Exam .................................................................................................................................... 16
Communications ............................................................................................................................... 21
Procedures ........................................................................................................................................ 26
MCI .................................................................................................................................................... 30
Resuscitation (Adult)

1. ACLS – VF, PEA sec to hyperkalemia from missed dialysis (Prof Goh Siang Hong) – May 17
middle aged patient collapsed near hospital, code blue team bringing patient to you
- Straightforward station, manage as per ACLS, defibrillate first, then intubate, rhythm changes to
PEA
- Mention 5H 5Ts, blood gas K 7.0
- Handover to ICU Reg after ROSC

2. IVDA user – heroin, found drowsy at home. Septic shock sec to right sided pneumonia
complicated by metabolic acidosis and DKA (Prof Evelyn Wong) – May 17
- patient is transferred from P2 to P1, prepare resus team
- Take SAMPLE history from concerned wife
- consider causes of AMS, administer naloxone
- CXR shows right middle lobe consolidation, no respiratory failure but has severe metabolic acidosis
with lactate 6, glu 16
- I wanted to intubate patient as haemodynamically unstable but the nurses prompted me not to
- unable to obtain IV access, hence must demonstrate IO insertion
- improves with fluid resus, mention full septic workup, asked on choice of abx, must cover for
possible IE
- start DKA mx and admit to ICU

3. Adult resus – Pneumonia and septic shock – Nov 15

Examiner – Dr Evelyn Wong (SGH)
72 year old man with Parkinson’s Disease. Had cough yesterday with yellowish sputum. Noted by
family to be drowsy today. At triage, BP 88/50, PR , SpO2 79% on RA -> Pushed to P1
No time to prepare beforehand
Have 1 junior doctor first week in EMD(acted by a nurse) and 1 nurse
Will have to speak to ICU registrar at the end

Moaning when you ask him question

GCS E2V2M5
Spo2 pick up to 97% on NRM
H S1S2 no murmur
Creps head bilaterally
Abdo soft
No rashes
Remains hypotensive despite multiple fluid boluses
Ask for CVP to give noradrenaline and it’s done immediately (do not need to demonstrate)

ABG shows severe metabolic acidosis and lactate 6

pO2 500 on NRM
TW 26, Hb and Plt normal
RP shows Cr 155 (no baseline to compare with)
Glu 14
CXR shows bilat lower zone infiltrates
Broad spectrum Abx as per hospital protocol
Need to rule out other causes of hypotension besides septic shock– Other infective foci,
hypovolemic shock from PR bleeding, cardiogenic shock etc.
Some did not intubate as still able to maintain airway and no hypoxemia on ABG
Others intubated in view of hemodynamic instability and to relieve work of breathing
Others argue must speak to family and discuss resus status
When speaking to ICU registrar, just give short summary
Will ask you if you have ruled out other causes and agree to see in ED later
Spot the ultrasound machine in room, offer to do ultrasound, examiner will ask you what you want
to ultrasound
Ultrasound images available - FAST, IVC collapsibility, echo, even have lower limb vein
compressibility

4. Adult resus – VF collapse – Nov 15

Examiner – Prof Fatimah Lateef (SGH)
60 year old man had witnessed collapse. No bystander CPR. Paramedic reach at 10min, first rhythm
VF. Given 2 shocks en route. CPR. Failed LMA insertion.
Given 2 minutes to prepare. Have 1 staff nurse and 1 assistant nurse.
Need to get history from paramedic early as it’s part of marking scheme (or else they will leave)
Come in unresponsive and no pulse. First rhythm VF. May become VF or PEA, some people
eventually had asystole or ROSC for 1 min then asystole.
Need to intubate
Need to ensure nurses doing good CPR and bagging correctly (they will keep making mistakes
despite you correcting them and go back to doing the wrong thing)
Need to mention 5Hs and 5Ts (can offer ultrasound to look for some reversible causes)
Will never get lab results
Examiner ask some candidates when will you stop resus

5. Resus station – ATLS

- Motorcyclist vs vehicle. Has Lt femur fracture and Haemothorax requiring chest tube insertion
- Go through regular ATLS, identify problems from XR and talk about appropriate mx (not expected
to do procedure)
- Surgeon want to thoracotomy in ED for 1.5L of output – say NO! (Need to be clear when certain
things should be done urgently or not

6. Resus station – Adult ACLS

- Came in with Stable VT, discuss mx
- Subsequently pulseless VT – demonstrate defibrillation and further ACLS mx, subsequent ROSC
with ECG showing anteroseptal AMI. Handover to cardiologist

7. Adult resus - ACLS – Nov 14

Old guy chest pain
ECG: ST Anterolateral STEMI
Very long history in the station which I cant quite finish reading the scenario before I entered.
.
Examiner: Dr Vivian (TTSH --- super super super strict during exam, no prompting at all (she is
normally super nice)
One of the objective : correct how ur nurse does the CPR and bagging
Not sure what the other objectives of the station are, most of us find this station weird- -- because
pat kept having VF despite shocking 4-5 x + IV adrenaline + amiodarone given , when say 5H and 5Ts,
examiner will say - no obvious cause found , and cath lab is not ready to recieve patient
ECG: VF, repeat ECG: VF --> VF ---> VF --> finally examiner show u asystole rhtyhm --> quite
demoralizing, as when u leave the station, the examiner tells you ur patient died. So thought I sure
failed the station- but appararently, every candidate was told that the patient died!

8. Adult Resus
Hypotensive septic shock sec to pneumonia .
This status requires u to demonstrate leadership skill in resus, then in the middle of resus, u need to
speak to the daughter to tell her how ill her father is (break bad news) . Pat needs to be intubated.
Examiner: Dr Beng Leong from TTSH – super nice
Questions asked- how much fluid to give, how do assess if u have resus adequately in terms of fluids,
what criteria for pneumonia u know, abx of choice, ionotrope of choice in sepsis

9. ATLS – May 15
Penetrating chest wound. Right sided haemothorax. High fidelity model so you must ascultate the
dummy and pick up sign of decreased air entry on right side. Talk about what you would prepare for
arrival of patient personally I go through the stuff I need via A, B, C. Pt arrive 3 point c-spine
immobilization, decreased GCS, Insert Chest tube dun need to do , your assistant will just stick it on
your dummy. Then say you want to do FAST as part of C then they will get you to read through short
video clips of the FAST images right sided PTX. ( know your seashore and barcode signs, some pple
got confused ). Then they will ask you for reasons for emergent thoracotomy in theatre. Then
handover to trauma team when they arrive.
I mentioned that I would intubate the patient but I think a lot of the others didn’t say they wanted to
intubate. So I dun think it’s an important point.”

10. ACLS – May 15

APO. Do ABC. Do CXR, ECG, ABG. Commence IV GTN and IV furosemide interpret ABG start NIV.
CPAP. Then examiner ask u how would you intubate this patient. Go through the P’s for RSI.
Demonstrate LEMON airway evaluation. Intubate dummy. Post intubation check.

11. Station 6: Resus ATLS (Prof Eillyne Seow) – May 16

You are in a hospital with no obgyn facilities. You are receiving a standby for: 32yo female who's 22w
pregnant. Pedestrian involved in RTA.

Time allocation:
Prepare 2 mins
Management 10 mins

History from paramedics: Pedestrian hit by car flung 3m. Vitals on scene hypotensive 70+, PR 130s,
then given 500mls of fluids fast. Vitals repeated BP became 80+ PR 120
Abrasions over chest and b/l upper limbs
Hypotensive throughout despite fluids 2L, hence needs MTP
Use cardiff wedge to displace uterus.
Special tests: Kleihauer test to look for evidence of maternofetal hemorrhage
FAST: can also look for fetal movements and fetal heart
Usual ATLS otherwise
Who to call? Trauma team. Also can call on call O&G from a supporting hospital

12. Station 1: Resus: AMI (Dr Goh Siang Hong) – May 16

58yo gentleman with chest pain
ECG shown outside room: anterior lateral MI
Defibrillator pic also outside room: it is a Lifepak 12

ETA 3.5mins
You have 2 Nurses with you
Time allocation
Preparation 2 mins
Take history from paramedic 1 min
Manage pt 9mins

Paramedic history: crushing central chest pain with SOB, pt diaphoretic, aspirin 300mg given en
route, 1 plug set slow fluids ongoing, no GTN given, smoker, no past Med hx
Pt arrived. Borderline hypotensive spo2 90%
Focused PE - gallop rhythm bilat creps and ronchi no murmurs no radial radial JVP was raised

Initially borderline vitals, later deteriorated with desaturation and worsening drowsiness
Proceed to RSI
Remember to give 2nd antiplt (whether oral before deterioration, or via NGT after intubation)

13. Blast Injury – Nov 17

You are the A&E senior on shift, and have been called to standby for a patient who suffered injuries
following a bomb blast outside you’re A&E. Please do the following:
1. Prepare your equipment and assign the relevant roles to your nurses in preparation for the arrival
of your patient
2. Manage the patient accordingly
3. Present your patient’s injuries to the examiner, according to mechanism of injury

Tips
- Approach using ATLS principles
- Apply C-collar
- GCS 9 initially, and has persistently low saturations of SpO2 88-90% on RA
- Lung examination normal, no pneumothorax or hemothorax
- Penetrating injury to right LL (paper clip stuck into mannequin) with spurting artery and active
bleeding onto the floor
- Need to demonstrate attempt to achieve hemostasis of right LL wound i.e. direct pressure, offer to
apply tourniquet
- CXR shows bilateral pulmonary contusions
- Pelvis XR normal
- Eventually requires intubation in view of persistently low saturations secondary to pulmonary
contusions
- Requires admission to ICU
- Need to handover case to ICU Reg
- Present injuries according to mechanism of injury to examiner i.e.
primary/secondary/tertiary/quaternary mechanisms

14. Lightning Strike – Nov 17

You are the A&E senior on shift, and have been called to standby for a patient who has been struck
by lightning. Please do the following:
1. Prepare your equipment and assign the relevant roles to your nurses in preparation for the arrival
of your patient
2. Manage the patient accordingly
3. Discuss the complications of a lightning strike with the examiner

Tips
Patient arrives in VF, requiring prolonged resuscitation i.e. CPR/defibrillation. Approach using both
ATLS i.e. apply C-collar etc and ACLS principles. Patient requires crash intubation, at least 4 or more
unsynchronized shocks for persistent VF and IV Adrenaline/IV Amiodarone etc according to ACLS.
Subsequently has ROSC. Need to handover case to ICU Reg. Discuss 5Hs and 5Ts, possible causes of
collapse with examiner, and post-resuscitation bundle.

15. Adult trauma- Nov 18

36/M fall from height, A/B ok, C haemorrhagic shock from pelvic # + use of EZ IO, D ok

16. Adult medical - Nov 18

Severe sepsis, DKA, eventually needed intubation
Resuscitation (Paeds)
1. Paeds trauma – 6 year old boy hit by car and flung 10m (Dr Tham Lai Peng)- May 17
- Comes with spinal board, C Collar and head blocks
- Intracranial injury GCS 6 and hemoperitoneum with haemorrhagic shock
- Need to intubate, and interpret E FAST, CXR/pelvic XR images
- Activate MTP, run 2 cycles of blood 10ml/kg with FFP, platelets
- Discuss disposition, admit vs CHETS transfer to Paeds hospital

2. Paeds Trauma Resus – Nov 15

Paeds Trauma Resus
Examiner – Dr Tham Lai Peng (KKH)
You are ED registrar in a hospital WITHOUT inpatient paediatric service. You receive a standby for 6
year old boy who was cycling and hit by truck, flung 10m.
GCS 11 at scene, BP 80/40, PR 150, SpO2 97% on RA -> drop to 93% en route and paramedic gave O2
via face mask
You have 2 very junior nurses
1.5 min to prepare
Have whiteboard to write WET FLAG

Patient comes in GCS 8 with C-collar on

Airway – moaning, no stridor
Breathing – No trachea deviation. Lungs good a/e bilat. SpO2 ok
Some people immediately intubated as low GCS (others argue need to assess circulation and get IV
access for RSI drugs)
Circulation – weak peripheral pulse. CRT 3-4s. BP 70/40. PR 150
Abdo distended
/Pelvic rock negative
FAST shows free fluid in RHC. Other 3 views normal
Give 20ml/kg fluid bolus and BP remains same.
Give 2nd bolus and BP 80/40 (borderline hypotensive and)
If want to give blood, will ask how much (10ml/kg)
Clarified with Prof Suresh that Paeds generally do not subscribe to concept of permissive
hypotension
Right pupil 1mm, left pupil 3mm. Still GCS E2V2M4
Exposure – Have to specifically say you are looking for bruising before she will tell you there is
bruising over right flank and a bit of swelling over left hip

CXR normal
Pelvic XR shows left NOF fracture. Also have superior pubic ramus fracture (hard to spot)
RSI intubation with manual cervical immobilization (must demonstrate)
The nurse sabo most of us by either passing us the wrong ETT size (despite specifically telling her
what size) or giving us the adult Easi-cap insead of the Pedi-cap or not bagging when you are
checking for ETT position.
Some of us made the cardinal error of intubating without RSI drugs (cos too rushed and stressed),
which was highlighted during the debriefing as a near fatal error.
Trauma team takes forever to come down. If you decide to do CT Brain, CT shows left EDH with
midline shift. Remember that you in a hospital without Paeds service, so some candidates reached a
discussion point about going to OT under adult trauma service VS transfer to a hospital with paeds
capabilities.
3. Paeds: a 5 yr old presenting with fever and seizures. On arrival, still fitting away. PALS. Dx:
meningitis – 2012

4. Paediatric trauma 8/M RTA, A/B ok, C haemorrhagic shock from multiple long bone #, D low
GCS need intubation – Nov 18

5. Resus station – Paeds May 14

- 6 weeker coming in drowsy
- Turns out to be PEA despite recordable vitals – LESSON: even if there are recordable vitals, always
check pulse (basic ABC)
- Intubate child, mx resus and take further hx from mother when she arrives
- Don’t freak out by who you see (examiner is You-know-who) – which I did, hence fail station =|

6. Paeds resus – Nov 2014

6 year old boy- hit by bus, flung 10 metres. Drowsy, hypotensive, tachhycardic. U have 1 nurse and 1
MO. Evaluate accordingly- u got to say what u looking for, then dr tham lp will tell u the findings.
Relatively straightforward case baed on atls and pals.
Examiner: Dr Tham LP from KK
.
A- clear, mannequin has no c-collar
B- decreased air entry over right side with dullness to percuss--> hemothorax, expect to know size of
chest tube
C- she will test u on what type of fluid and volume, assess obvious bleeding and long bone bleeding,
show me landmark for IO insertion
D- pat has anisocoria - what r the measures to prevent sec brain injury, what to use to reduce icp
.
So offer to do cxr and pelvis X-ray for patient- and dr tham will show u.
Ask me what size chest tube (I not sure what is the correct size for paeds)
Also showed a displaced femur # X-ray. And also FAST images

7. Paeds Resus – May 15

6 month old presenting mottled with decompensated shock secondary to sepsis
Quick look – resp effort, colour and activity. When told looks unwell and mottled check for pulse
has pulse go P1
A, B, C high flow o2 15L NRM. Decreased A/E on right
IV access and blood cultures and VBG, hypocount
Asked to identify and describe IO insertion dun need to do
Then examiner will say pt suddenly BP unrecordable / decreased activity
FEEL FOR PULSE!!! Pt no pulse, commence CPR 30:2.
Demonstrate BVM ( select correct size and expected to demonstrate bagging, must have chest rise,
then intubate ( ETT 3.5 uncuffed, straight blade 2 )
Sepsis bundle. IV roscephin 100mg/kg. can run noradrenaline through IO.
Ask for CXR : identify right sided pneumonia and collapse ( ? PTX )

8. Station 11: Paeds resus status epilepticus – May 16

You are in a hospital with no paeds support. You are on standby to receive a 5yo who had facial
twitching and jerking of R upper limb at home and was drowsy afterwards. Patient was drowsy at
scene when paramedics arrived GCS 10. He has developed R upper limb jerking to GTC seizures en
route and given rectal diazepam 5mg 5 minutes ago. You have a junior doctor and nurse with you.

Time allocation:
Preparation 1.5mins
Management of patient. 10.5mins

Paramedics history: Same as above. No drug allergies, no known past medical history. No diazepam
given at home.

Patient still seizing (only made known if you ask).

Left lateral, NRM, can get junior dr to set plug.
IV lorazepam, IV phenytoin (need to know doses) > seizure stops after phenytoin.
Know precautions for phenytoin - extravasation, ECG monitoring for arrhythmia, hypotension
Re-assessed post abortion of seizures. GCS very poor. Proceed to RSI.

Post RSI - Dr Tham will ask what else you want to do

Given images for CXR, iSTAT (cap gas not ABG), CT brain on request
Arrange for transfer with CHETS team

9. Paediatric Resuscitation – Nov 17

3-month-old baby visited the A&E for SOB of 2 weeks duration. No fever. No known past medical
history. Full-term baby. Born in Batam. On examination, T 36.9, SBP 72, HR 160, SpO2 89% on RA.
Please do the following:

1. Prepare your equipment and assign the relevant roles to your nurses in preparation for the arrival
of your patient
2. Manage the patient accordingly
3. Discuss case with examiner and answer questions accordingly

Tips
- Highly challenging case with difficult diagnosis, and strict examiner (Dr Tham Lai Peng from KKH)
- In paediatric cases with SOB without fever, and low saturations, think CARDIAC
- Ask for murmurs on auscultation and cyanosis early
- This patient had a LLSE PSM. Examiner asked for differentials and I said VSD, TR
- CXR done showed pulmonary congestion with cardiomegaly
- VBG: pH 7.25, pCO2 60, HCO3 25, Electrolytes normal, Glucose 4
- Diagnosis: Biventricular hypertrophy with CCF, b/g VSD
- Required intubation in view of low GCS and RR 6 despite BVM
- REMEMBER to sedate and paralyse patient before intubating even though GCS low – high chance of
forgetting amidst the stress
- Can give Ketamine/Midazolam and Suxamethonium
- Examiner will ask which size ETT – can offer Size 3.5 or 4
- Secure at ETT size x 3
- Explain need for admission to PICU
- Present and handover case to PICU Reg
History
1. Chest pain – 50 year old lady, smoker, hx of lipids (Dr Lim Beng Leong) - May 17
- atypical chest pain history, occurs at rest, 5 mins each time but has radiation to left shoulder. Not
related to exertion. Patient worried about AMI
- Need to evaluate for other causes of chest pain: CCF, dissection, PE, pneumonia, MSK, GERD
- address concerns and discuss management plan. Was asked what if Trop I and ECG are normal

2. Young lady with RIF pain (Dr Benjamin Leong) - May 17

- SP looks in pain the entire exam, do offer analgesia and she will politely decline
- Run through differentials, exclude ectopic pregnancy, gynae vs surgical vs UTI

3. Right ankle pain x2/52 with red eyes and urethral discharge – reiter’s arthritis - May 17
- SP will report right ankle pain as presenting complaint, will not offer anything else unless
specifically asked
- not other joint involvement, no oral ulcers/rash/alopecia/back pain/fever
- must ask sexual history. Went to Bangkok 1/12 ago and had unprotected SI with CSW, now having
urethral discharge x2/52 and red eyes x1/52
- discuss ddx: reiter’s arthritis, gonococcal arthritis, gout/pseudogout, septic arthritis
- counsel patient on safe sex practices, STD screen, contact tracing for partner. Worried about
contracting HIV, but PEP not indicated

4. Giddiness in old man – Nov 15

Examiner – Prof Lim Swee Han (SGH)
Middle aged man presents with giddiness x 1 week. He has a history of hypertension and diabetes on
oral medications. Please take a history (60%)
Discuss how you will examine the patient and your management plans with the examiner (40%).

Non vertiginous giddiness on getting up from lying position, better on lying down.
Even though non vertiginous, must still ask about associated ear symptoms (something which the
examiner prompted me during the discussion)
Have to probe and he will reveal that his GP changed his anti-hypertensive medication 1 week ago.
Also had URTI symptoms and saw another GP a few days ago, finished the medications yesterday.
The guy will not know any of the medication names.
Wrap up your history taking in 6 min so can use the remaining time to discuss with examiner
Discussion can be super broad - from differentials, to what systems are you examining and what you
are looking out for, tests to order in ED

5. Bilat knee pain in young male - urinary symptoms – Nov 15

Examiner Prof Goh Siang Hiong (CGH)
32 year old Chinese man with bilat knee pain x 1 week
Please take a history (60%) and discuss management with the examiner(40%)
From the start, the patient is very lethargic (eyes mostly closed throughout history) and gives vague
answers and needs prompting +++
Atraumatic bilat knee pain a/w fever
Non mechanical pain
Only when specifically asked will he review a history of dysuria and hematuria (no urethral
discharge)
And must get the sexual history about unprotected vaginal intercourse with CSW
Must barrage through the full sexual history, including possible MSM, how many sexual partners,
etc.
Again must wrap up history in 6 min.
Discussion: Differentials of gonococcal arthritis, septic arthritis, reactive arthritis
How will you investigate?
Will you admit? I said I would because he looked lethargic and toxic, but I qualified by saying that I
also have to examine him and do some investigations - Blood, radiological, joint tap, etc
If admit, admit to which dept?
It really depends - can be rheumato, Ortho or even ID depending on the results of your tests and
your hospital admission policy
What medications to give?
I said analgesia, WHO ladder of analgesia
then Abx really iffy.. Cos if he is toxic, then can treat empirically first. But if he is not, then can defer
to inpatient, tap the effusion (if any) before starting Abx

6. Abdo pain – pancreatitis – Nov 15

Examiner – Prof Anantha (SGH)
50 year old man presents with abdominal pain since last night. Please take a history (60%) and
discuss with the patient the possible diagnoses and management (40%)
* This station only involved talking to the patient. The examiner will not talk to you nor give you any
physical examination findings or lab results
Patient will be in obvious discomfort when you first see him. So must offer analgesia (check for drug
allergies and whether he had taken any that day already). Don’t have to say what dose or drug you
are giving.
Sharp constant epigastric pain with radiation to the back since yesterday, worse with lying down, no
relief with Actal (antacids), a/w vomiting x 3 episodes NBNB yesterday, a/w poor oral intake.
Has history of similar pain intermittent gastric pain in the past which he attributed to ‘gastritis’
Drinks 4 bottles of beer on weekends.
If you ask him if he has any previous medical problems, he will say none.
Have to ask SPECIFICALLY if he has history of gallstones before he will tell you that his doctor had
told him before need to remove gall bladder because of gallstones. (I only discovered this during the
discussion when I said that the inpatient team may do an ultrasound to check for gallstones)
Halfway through the history, the patient asked a few candidates: ‘Am I having a heart attack?’ which
is of course still a possibility.
At the end, can score some brownie points by asking if his pain is better after the analgesia, to which
he will say that it’s still too soon.
After 6 min, time to switch gear and summarise and tell him what you think he has and the
differentials. Need to use layman language to explain the tests you will be doing for him and why
need inpatient management for analgesia, IV drip and further investigations.
During discussion, he will ask if he needs to remove gall bladder and don’t people need gall bladder
to live?

7. 20+ /M p/w haematuria. Take history and present / give differentials. Discuss management-
2014
- pt had haematuria with penile discharge. Also had conjunctival injection (wearing sunglasses!) and
joint pains. Had unprotected SI ~1 month ago
- Dx likely Reiter’s syndrome

8. 50/F p/w painless PV bleeding for 1 month. Take history, present / give differentials. Briefly
discuss management - 2014
- pt had painless spotting (showed spotting diary when asked) with hot flushes
- Dx likely perimenopausal

9. Paeds hx taking from an anxious mother

6 month old came in for crying x1/7 .
Pls take a hx from mother, demonstrate targeted examination on the mannequin and explain to the
mother abt possible diagnosis .
.
Feedback- further hx reveals intermitent crying, child curl up leg occasionally.
Symtpoms suggestive of moderate dehydration.
Otherwise well child with no pmhx.
P/e exam- demonstrate how to assess hydration status , abdo findings sausage like mass found in
rhc, no hepatomegaly.
Talk abt investigations.
Dr tham will then show u ultrasound image of intusseption. What are the features of intusseption on
US ?
Management of dehydration and intusseption
9. NAI – mother brings kid in for knee swelling. History dodgy. Shown XR with healing fractures (a
few) and picture of bruises. Explain need for admission
- Must stand firm about need for admission – if necessary, make police case

10. Hx station + p/e + investigation station on Peripheral arterial disease – Nov 14

Hx: pat having ulcer + night pain, relieves on hanging legs out of bed. Claudication hx.
Show how to examine for PVD
Diagnosis- critical limb ischaemia/peripheral arterial disease
Show u pic of ulcer - difference btw neuropathic and arterial ulcer
What is normal value of ABPI?
What is ABPI? (what value over what value?)
Demonstrate buerger test.

11. Abdo pain + traveller s diarrhoea +severe dehydration. Went to India previously – Nov 14

12. Hx taking- vertiginous giddiness – Nov 14

Elderly man - is on prazosin(newly started by gp for bph), atenolol, enalapril. U suspect giddiness is
due to prazosin. To advise pat on what to do

13. HEAT EXHAUSTION!!! – May 15

Joker go and run 42km marathon without proper training, then LOC, abdo and muscle cramps. There
are a few components to this station. First take history – illicit that it’s not real syncope coz pt still
aware of what was going on around him. Second explain diagnosis and treatment. Address concerns
about rhabdo and stroke. Third – talk about how to prevent this in the future ( train properly,
hydrate, rest, stop if unwell during run, do not attempt marathon as he just recovered from URTI last
week )

14. Take history for giddiness – May 15.

BPPV. Discuss how to differentiate between central and peripheral vertigo. Talk about dix hallpike
and explain epley’s manoeuvre

15. STD, urethral discharge.

Korean man went Thailand had sex with CSW, used condom but condom broke. Now has urethral
discharge. No reiter’s. Counsel management, abstain sex, use barrier contraception. IM Rosc +
doxycycline. – May 15

16. Alcohol history taking and general history taking of heavy drinker coming in with epigastric
pain and tea coloured urine. Give differentials and investigations – May 15

17. Station 12: Bilateral knee pain history (Dr Lim Beng Leong) – May 16
32yo chinese male with bilateral knee pain for 2 weeks. Please take a history and explain
management plan to the patient.

Time allocation:
History 6 mins
Management 4 mins

History - bilateral knee pain 2/52 a/w morning stiffness and not worse with movement. No fever.
Dysuria for last 10/7, eye pain for 10/7. Had unprotected SI with CSW in BKK 2/12 ago. Denies
further SI since that incident.
Diagnosis: Reactive arthritis, Ddx: gonococcal
Discuss Mx with examiner (was supposed to be with patient but Dr Lim modified it)

18. Station 7: Fever and AMS (examiner from CGH hiding behind curtain) – May 16
Take history from Mr Simon Tan, the son of Mr Andrew Tan, a 73yo gentleman who presents with
fever and confusion.
Vitals - Temp 39 BP 110/80 PR 120 Spo2 92% on RA

Time allocation:
Take history. 6 mins
Explain likely diagnosis and differentials. 2 mins
Explain initial management. 2 mins

History from son - fever 3/7, next day developed cough and shortness of breath, today nausea,
vomiting and suddenly could not recognise son. No other localising symptoms. No contact/travel
history. Dx: Pneumonia.

No examiner input

19. Station 2: abdominal pain history (Prof Anantha) – May 16

48yo guy abdo pain and vomiting. Take a history and evaluate his risk factors. Discuss differentials
with patient.

Time allocation:
History taking 4 mins
Evaluate risk factors 4 mins
Discuss differentials and most likely diagnosis 2 mins
History from pt: central epigastric pain radiating to back. Precious history of gallstones. Also drinks
alcohol ++
Routine abdo pain questions
No examiner input, jsut explain to the patient what his likely diagnosis is

20. NAI – Nov 17

30-year-old mother brings 6-month old boy who has noted to have pain and deformities over
bilateral lower limbs, as well as multiple bruises over his trunk. Please do the following:

1. Assess the child, review the x-rays done and determine what injuries he has
2. Explain your management of his injuries
3. Counsel on the possibility of non-accidental injury and answer any questions the mother has

Tips
This was a rather challenging station as the simulated patient was a really wonderful actress, who
would react in anger every time you seem to suggest that this might be an NAI. During history-
taking, it appears clear that the mother is unlikely to be the perpetrator, but the boy has other
caregivers at home i.e. an uncle and aunty who might have been culprit. X-rays show a tibial shaft
fracture. Must explain that this is unusual as child is not at weight-bearing age. Proceed to offer to
do above knee backslab, give analgesia. Explain need to get MSW involved, and that will have to
make this a police case in view of possibility of NAI, and admit boy for his safety.

21. Hematuria – Nov 17

50-year-old man presents to your A&E with painless hematuria. Vitals stable. Please take a history,
present your differentials and discuss the case with the examiner.

Tips
- Significant PMH of prostate ca s/p ?TURP
- Explain must consider recurrence of prostate ca
- Look for complications i.e. anemic symptoms, ARU
- Advise for outpatient follow-up with Urology

22. Epigastric pain – Nov 17

40-year-old man presents to your A&E with epigastric pain. Vitals stable. Please take a history,
present your differentials and discuss the case with the examiner.

Tips
- Classic presentation of pancreatitis with epigastric pain radiating to the back, worse with lying
down and relieved with sitting up
- Need to look for causes, especially gallstones
- TAKE THOROUGH DRINKING HISTORY – this patient turns out to be alcoholic which is the likely
cause
- Turns out later on we found out that had to CAGE questionnaire him as well (which he fulfills), and
counsel accordingly
- Explain must consider more life-threatening causes i.e. perforated ulcer, AAA etc

23. Giddiness – Nov 17

40-year-old man presents to your A&E with giddiness. He has a significant PMH of Hypertension. O/E
SBP 160. Rest of vitals normal. Please take a history, present your differentials and discuss the case
with the examiner.

Tips
- Approach to giddiness i.e. vertiginous vs non-vertiginous
- This patient had non-vertiginous giddiness, however had peripheral symptoms i.e. worse with head
movement, episodic, no other neurological signs or symptoms
- Examiner will ask you for your impression – peripheral cause but most consider potential life-
Physical Exam
1. Respi exam – ILD and RA Hands (Prof Suresh) – May 17
- interpret CXR and discuss inv and mx plan

2. Knee exam – OA knees (Dr Mohan Tiru) – May 17

- Malay lady with left knee pain, b/g bilat chronic knee pain. Can figure its OA from the start but run
through the steps of exam, be careful not to cause pain
- offer gait examination but examiner said no need
- Read Knee XR showing OA changes
- Differentials and mx plan

3. Middle aged male p/w Left upper limb weakness and numbness that started 2 hours ago - Left
CVA (Dr Tay Seow Yian) – May 17
- this was a very challenging station due to time constraints
- need to first perform a full neuro exam of upper limbs, patient had left CVA with pronator drift,
power 4/5, more brisk reflexes, sensation otherwise intact (paper clip and cotton wool available)
- offer to examine lower limbs and cranial nerves, listen for carotid bruit and cardiac exam
- then need to perform the NIHSS Scoring (clipboard with NIHSS checklist available), go through the
individual components, need to check visual fields, cortical signs, etc.
- then discuss the investigations to perform and subsequent mx
- NIHSS score was 2 hence mention no indication for thrombolysis though currently still within
window, to observe closely for further deterioration and activate protocol if NIHSS> 4

4. Back and lower limb – PID with left radiculopathy - Nov 15

Examiner – Prof Tay Seow Yian (TTSH HOD)
This patient presents with low back pain x 1 week without any trauma. Please examine his back and
lower limbs (80%) and present your findings as you examine him. Discuss with the examiner (20%)
Patient is sitting on a chair when you come in
Declines analgesia
Can examine sitting up in chair first, will only find tenderness over L4
Truncal flexion limited due to pain
Gait normal
Next examine lying down
SLR of left leg 30 degrees: pain radiates down to calf
Lasegue and bow-string positive
Cross sciatica positive
No focal neuro deficits
Didn’t have to do sensation

At the end, offer to check for palpable bladder and anal tone
After presenting your findings, the examiner say good. I was left with 1 min, so he ask me if I want to
examine any other systems. I was stunned and say I can check his pulses, check his hip ROM. Not
sure what else. Maybe examine abdo for pulsatile mass?

5. CVS - Aortic valve replacement, chest pain – Nov 15

Examiner – Dr Vivienne Siu (TTSH)
This man presents with chest pain. with no SOB. Please examine him (70%), present your findings
(10%), and your management (20%)
Patient is lying totally supine initially. Have to prop the bed up 45 degrees
Midline sternotomy scar
Metallic S2
Apex beat not deviated
No murmurs
No complications of CCF, pulmonary HTN, valve failure, overwarfarinisation, hemolytic anaemia
The most straightforward case

6. Respi – Bronchiectasis, hx of TB – Nov 15

Examiner – Dr Lim Beng Leong (TTSH) (same station with same findings and same examiner as
MMed Prep course in Mar 2015)
This patient has a history of TB, diabetes and hypertension. He now presents with cough with
greenish sputum. Please examine him (70%) and discuss with examiner (30%)
No clubbing
Bilat coarse creps in lower half of lungs
Dx: Brochiectasis. Ddx: ILD
According to Prof Suresh, patient had rheumatoid hands

Questions asked: what are the possible etiologies of ILD in a man of his age in the local context? This
question makes sense if you saw the rheumatoid changes in his hands
Shows CXR and asks you to interpret. CXR is actually different from patient’s scenario. It shows this
spiciulated looking mass in the right middle zone. Asks you to describe and how you know it’s right
middle and not upper zone.
He then says if this patient only had symptoms x 1 week -> then what is the diagnosis
3 most common bacterial causes of pneumonia

7. CVS examination – prosthetic heart valve (not sure how many) – May 14

8. Respiratory examination – bronchiectasis with clubbing. – May 14

9. Neuro examination – Rt hemiplegia – May 14

- Stem for this quite weird – I think it was to examine for neurological system and I went straight to
exam LL since the stem said he had difficulty walking but it seems you were expected to examine
both UL / LL? Anyway I just concluded LL by saying I’ll examine UL to localise

10. Forearm examination - AVF – May 14

- AVF supposed to be infected – stem say come for elbow pain / swelling from dialysis centre (missed
HD). Go in and find the AVF is near the wrist!
- So go back to basic principles – look, feel, move
- Stem eventually goes on to discuss AVF with subcutaneous gas likely nec fas with hyperK (ECG
showing tall T waves). Discuss mx and complications (eg steal syndrome, ischaemic limb etc)

11. Hand examination – supposed to be combined with teaching station but cut short – May 14
- Examine per usual hand and discuss likely diagnosis (RA hands – swan neck / Boutenniere’s)
- Explain basis behind deformities

12. Knee examination – OA knees – May 14

- This station quite strange – pt obviously had TKR on Rt and the stem was to examine Rt knee I think
so in the end examined Lt knee

13. Face examination post punch injury to Eye – May 14

- Will show XR – discuss diagnosis and management
14. P/E – CVS exam - Nov 14
stem- pat has chest pain. no sob. Examine CVS.
Tink they can't find patient at the last min. Examiner will tell u patient has no signs beforehand.
Signs examiner tell u- left radial pulse weaker, EDM, no collapsing pulse.
Offer ddx- aortic dissection
How to manage

15. P/E – Neurology . Pat came in for fall. examine LL – Nov 14

Did not require to examine upper limb.
Diagnosis- Parkinson's

16. Pat with DM and joint pain. c/o cough with greenish sputum. Examine respi – Nov 14
Lungs- fine creps, may have some joint deformity as well. Prob ILD. I said prob due to RA/cytotoxic in
view of joint pain hx. Offered Bronchiectasis in view of hx

17. LL neuro examination for fall. Parkinsonism. Decreased sensation on Right compared to left. Pt
super slow at walking. Please do gait assessment last. – May 15

18. CVS examination. 2 metallic valves. Prof mohan took this station. Everyone passed – May 15

19. Knee examination. What other investigations other then Xrays – FBC/ RP/ uric acid. Examiner
will show you results and get you to interpret– May 15

20. Station 13: CVS (Dr Vivian Siu) – May 16

55yo gentleman with exertional chest pain for 1/52 with no shortness of breath, cough or fever. He
has hx of DM on oral medications. Please examine his cardiovascular system. Summarise your
findings and explain your management plan to the patient.

Time allocation:
PE 6 mins
Summary of findings 2 mins
Management 2 mins

Dx: Aortic valve replacement with no complications

21. Station 8: Punched eye (Prof Tham KY) – May 16

28yo punched in left eye by neighbour. Please examine his eye and face.

Time allocation:
Examination 7 mins
Summary 1 min
Interpretation of investigation and management 2 mins

Examination findings: L periorbital hematoma, infraorbital anaesthesia, diplopia on lateral gaze

XRs (OM view, lateral, AP) : inferior orbital wall fracture, black eyebrow sign (air within orbit) +/-
tripod fracture

22. Station 3: Shoulder examination (Prof Tay Seow Yian) – May 16

55yo gentleman with R shoulder pain for 2/52 but worse over the last week. He was gardening when
he had the pain, worse over the last week now unable to wear shirt. Examine the right shoulder.
Present your findings. Discuss differentials.
Time allocation:
Examination 7 mins
Summaries 1 min
Discuss differentials 2 mins

Findings: supraspinatus tendinitis.Limited flexion/extension, abduction, int rotation. Ddx: frozen

shoulder.

23. Cervical Spine Examination – Nov 17

35-year-old man presents to your A&E with neck pain with radiation down his right arm following a
RTA. He was sitting in the backseat and was unrestrained. Please do a cervical spine examination,
and offer ONE special test. Proceed to carry out this special test. Suggest to the examiner and
discuss a clinical criteria that is used to determine if a patient requires further cervical spine imaging
in the setting of trauma.

Tips
- Use NEXUS criteria as it is easier to discuss and explain
- Can offer Spurling’s / Hoffman’s / Lhermitte’s signs. I offered Hoffman’s but in the end as I
had time left the examiners got me to demonstrate all of them

24. CVS Examination – Nov 17

60-year-old man presents to your A&E with chest pain. He has a significant b/g of single vessel
disease. Please proceed to do a cardiac examination on him and present your findings to the
examiner.
Tips
- Giveaway station! Must grab marks.
- Patient had classic MVR with metallic S1, normal S2
- No complications on examination

25. Elbow Examination – Nov 17

30-year-old man presents to your A&E with right elbow pain following a fall. Please do an elbow
examination on him.

Tips
- Remember to ask if patient wants analgesia at start of consult!
- Unexpected case to come out for PE so make sure to practice all your various PEs even if you think
they are unlikely to come out
- Patient had a FOOSH, tenderness over radial head on examination
- Demonstrate that you are looking for open wounds, neurovascular deficits
- Examine upper and lower joint as well to look for associated injuries i.e. scaphoid fracture
- Elbow XR shows undisplaced radial head fracture and posterior fat pad sign
- Need to do above elbow backslab, give analgesia, and TCU Ortho x 1 week for review
- They made this case more difficult with patient wincing in pain throughout consult and physical
examination

26. Stroke, neuro exam based on NIHSS scoring – Nov 18

27. CVM Exam – Nov 18

28. Abdo Exam – Nov 18

29. MSK Exam – Nov 18

Communications
1. Break bad news – paeds drowning – May 17
- 3 year old girl with mother who left her unattended at swimming pool for 10mins. Then found her
unconscious in pool. Called paramedics, initial rhythm asystole, continued on 40mins resus in ED
without ROSC. All reversible causes of collapse ruled out and rewarmed to 36 degrees without
improvement. Team decides to terminate resus efforts.
- Mother is distraught, blames herself for negligence so need to counsel her as well
- Husband currently overseas, can offer to help contact him
- Discuss coroner’s case, mother has concerns about this

2. Needlestick injury in 3rd year medical student (Prof Tham Kum Ying) – May 17
- SP was a LKC medical student who was clerking an indian foreign worker admitted to ward for GE
symptoms. After setting IV line for fluids, accidentally poked herself when about to dispose the
sharp.
- Need to cover the history of the incident, her immunization status, PMH/gynae hx, not sexually
active
- History of donor. No known HIV test, no IVDA/tattoos/high risk behaviour
- Explain risk of transmission of Hep B/C/HIV and address her concern about HIV transmission
- explained benefits vs risk of PEP and not indicated to start now due to low risk of patient
- arrange follow up at occ health clinic, and raise incident report at DO
- Address her concern about not being able to get into residency if she catches HIV

3. Man with rhabdomyolysis, bilateral LL pain after 10km run with CK 6000 and Cr 200 (Dr Jane) –
May 17
Your MO has seen him and advised for admission. However patient requesting for AOR discharge.
- SP was a reasonable chap, not angry
- clarify history, LL Pain is bearable, declines analgesia, does not exercise much usually but training
up for marathon
- explain medical indication to be admitted and benefits of treatment – worsening renal impairment,
rhabdomyolysis can cause compartment syndrome, hyperkalemia
- explore patient’s wishes to be discharged due to work commitments
- determine mental capacity and sign AOR form
- come up with a mutual discharge plan, red flag advice

4. Breaking bad news to mother of 5 year old boy who drowned - Nov 15
Examiner – Prof Malcolm Mahadevan (Prof does not establish any eye contact with you once you
enter)
5 year old boy was found face down in swimming pool
Bystander CPR done
PEA on scene by paramedic
Asystole when arrive in ED
Intubated, CPR, 10 doses of adrenaline given already and still asystole

Talk to the mother, ask the circumstances around the event (30%), break the bad news (10%),
explain the futility of further resus (40%), other communication as necessary (20%)
Mother is a very good Caucasian actor
When you go in, she rises and asks to see her son
She will be very chirpy at first and talk about how lovely and well behaved her son is
Patient previously well
Playing in condo pool with other children.
Then found floating face down
Lifeguard pull out and did chest compressions
(should have asked about AED use)
She follow patient in ambulance to hospital, paramedics did chest compressions all the way
At some point, she will get up and try to walk to the door and says she wants to see her son now
Once you explain the situation and break the bad news, she will give an Oscar-worthy performance.
From denial to anger to bargaining
Will start blaming herself and cry ++
Really nothing much you can do once she starts crying
Offer tissue (which was actually on the examining table. Prof Malcolm was a bit annoyed that we all
went to the sink to take the paper towels instead)
Offer to speak to family (she will pass you her phone and ask you to speak to her mother)
When near the end, say you will go back in to check on resus efforts and do what’s best for the child.
Have a nurse stay with her to offer her support till her family members come.

5. NAI – Sexual abuse - 3 yr old girl with chlamydial trachomatis - Nov 15

Examiner – Dr Shawn Goh (KTPH)
3 year old girl was seen by a GP yesterday for vaginal discharge. Swabs sent and given antiseptic
wash. Swabs positive for chlamydia trachomatis. GP called mother today and told her to come ED
immediately.
The girl has no significant past history and uneventful birth history. You do not have to enquire
about the medical history.
The patient is fretful and does not allow physical examination.
You have called the gynae who is busy and can only review patient in the ward.
You can ask about the social history as appropriate to the consult
Convince the mother that the girl needs to be admitted. (20 - 30%)

Mother will be puzzled why the GP asked her to come.

Mother is a single mother of one and works as bar hostess at night. Has a boyfriend of 1.5 years. On
probing, there is also a male tenant in the house who is the boyfriend’s friend. Girl is also sometimes
left in the care of another friend in the daytime.
You have to say that you suspect sexual abuse.
She will be taken aback and reply whether you think the boyfriend abused her.
Have to be diplomatic and say you do not know who did it.
Have to involve police, have to involve social worker
Explain what will be done in the ward and gynae will see.
If you explain nicely, mother agrees for admission

6. Heat exhaustion after marathon - Nov 15

Examiner – Dr Francis Lee (KTPH)
young man finished 42km marathon and LOC at finishing line.
He is brought to the treatment tent
You are the doctor in the treatment area.
He is now alert but complains of bilat lower limb numbness
His initial vitals are Temp 39. Tachycardic. BP normal
Please take a history (60%) and address his concerns (40%)

Similar to Part C in May 2015, patient will ask you early on whether he has heat stroke.
He only remembers that he felt light-headed at the finishing line, then woke up and saw his friend
attending to him.
He claims to have drank fluids at all the rehydration stations.
Have to probe and he will reveal that he has not been training adequately because of work
commitments (only run 1x a week, 2-4 km each time) A bit unbelievable as someone with that
training volume won’t even be able to complete 42km (whatever)
Also having some non febrile URTI for past few days but not taking medications.

He ask why need to go hospital

What tests will be done
How to prevent it from happening in the future

7. Breaking bad news – father passed away. Planned for coroners – May 2014
- Setting quite strange – examiner was hiding behind curtain. Almost didn’t see her. Please bring
tissue! Otherwise standard breaking bad news

8. Coms station – Counseling newly diagnosed 20+ woman on T1 DM and complications May 14
- Address concerns (she mentioned about pregnancy and mx of DM during pregnancy) – can be quite
far ranging discussion (Med school all over again…)

9. 19 yr old - 40 tablets of panadol + 2 drugs father has for heart - Nov 14

Suicide risk assessment
Pat wants to go home

10. Comms station – Nov 14

communication - end of life issue- pat with mulitple met lung ca
Hypotensive, hypoxic , sob.
Main focus is to Speak to daughter abt end of life issues and advocate comfort care

11. Counselling station - Nov 14

young woman- incidental found to hv h/c of 18.
newly diagnosed dm- counsel and advise on complications.
I also talked about hyper and hypoglycaemia

12. Breaking bad news – May 15. Onco patient come in sob. Poor response to therapy. Speak to
daughter to DNAR. Get her to agree about comfort care. Ask if oncologist has spoken about
prognosis and whether current chemo/radio therapy is for comfort or are they still aiming for
treatment. Pace yourself for this. Quite a bit to cover especially if you have to be extra PR

13. Counseling station. – May 15

Speak to mother of 6y old boy with mod – severe exacerbation of asthma. Explaine treatment so far.
Explore why pt has such poor asthma control. dun use spacer, use direct inhalation from inhaler,
dun use steroid inhalers coz scared of stuff she read about steroid on the web… I got the mum to juz
demo how she administers the inhaler then u can correct the technique and reinforce use of spacer.
Then explain why must use steroid inhaler and that effects are local with rare systemic transference.
Then say u have to admit child coz still need o2 and needs observation since bad exacerbation. This
child’s exacerbation is likely triggered by URTI so dun keep criticizing the mother that THIS current
exacerbation is purely because of her bad technique and non compliance. Close the loop at end of
session by saying that ward team will go through proper technique of using space chamber and
inhalers on discharge
14. Station 14: Break bad news – May 16
70yo gentleman found unconscious by maid on sofa. Asystole on scene. Done CPR by paramedics.
8mg adrenaline IV given and CPR ongoing for 30mins. Resuscitation efforts have been terminated.
Please speak to patient’s relative.

Time allocation:
Explore events surrounding collapse 2 mins
Explain to relative what has happened and break the news that patient has already been declared
dead. Address her concerns. 4 mins
Explain the process thereafter. 4 mins.

Patient’s daughter is in the room pacing around. Need to confirm identity. History is patient last seen
well at breakfast, only has HTN on meds, 2 years ago had syncope episode but cardiologist say no
diagnosis. Otherwise well for past few days. ADL independent, ambulant.
Break news, daughter cry, ask why never shock patient.
Explain need to be coroner’s case, daughter will say don’t want post mortem.

15. Station 4: AOR discharge – May 16

40yo lady with history of DM with cough and fever 1 week. CXR shows R lower zone pneumonia.
Your MO has already evaluated the patient, diagnosed her with community acquired pneumonia and
advised for admission to respiratory ward but patient is refusing admission.

Time allocation:
Explain diagnosis and need for admission 2 mins
Explore concerns why patient does not want admission and risks of not admission 4 mins
Talk to patient process of AOR discharge 4 mins

16. Advise against admission – Nov 17

60-year-old man with b/g ESRF on HD 1/3/5, comes in as he had missed dialysis the previous day. He
is well and asymptomatic. Vitals stable. Requests for admission as is concerned about complications
such as fluid overload. Also had a bad experience in the past requiring intubation and ICU stay.
1. Assess patient
2. Advise on disposition plan

Tips
- Assess for any indications for dialysis for which he had none
- Patient will push for himself to be admitted, as although he is well and asymptomatic, he has
heard bad stories of ESRF patients going into fluid overload if they do not get dialysis punctually
- I offered to contact Renal for outpatient dialysis today and then discharge home after
- Other option is allowing discharge and dialysis the next day which is also supposedly an
acceptable answer

17. AOR discharge – Nov 17

50-year-old man comes in with 2 weeks of fever, breathlessness and cough. Also has been having
small amounts of hemoptysis. O/E Vitals stable, SpO2 97% RA. CXR shows RUL consolidation. Please
carry out the following:
1. Explain possible diagnosis to patient
2. Explore any other concerns this patient may have
3. Advise on disposition
Tips
- Advise for admission but patient will express that he is keen to be discharged
- Patient in the end had 2 other concerns which he will not raise unless you specifically ask
him if he has other concerns: 1. Financial concerns, 2. Concerns about HIV as he has history of sexual
contact with CSWs.
- Proceed to counsel him on risk of more severe infections with HIV, possibility of PCP, and
need for HIV screening and contact tracing
- Counsel him appropriately on risks, determine if he is mental capacity to decide for
discharge against medical advice

18. Comms breaking bad news for DDIL pt – Nov 18

19. Comms w mother of paeds pt w suspected sexual assault – Nov 18

Procedures
1. PV and speculum exam, LIF pain with urethral discharge (Dr Goh E Shaun) – May 17
- Take quick history and obtain consent for examination
- Stem states that MO has already done abdo exam and found LIF and suprapubic tenderness
- Perform procedure on pelvic trainer, can feel retained condom but DO NOT Remove without direct
visualization
- Remove the condom during the speculum examination, perform endocervical and high vaginal
swabs
- Explain inv and need for UPT/pelvic ultrasound, worry about PID ?tuboovarian abscess
- need for abx and O&G management
- Address patient concerns about emergency contraception, long term contraception, contact
tracing, STD screening

2. T&S in forearm laceration (Dr Sim Tiong Beng) – May 17

- Guy got cut by beer bottle at a bar, bleeding profusely. No picture of wound given. Need to
demonstrate T&S on the SP
- Take AMPLE history, determine tetanus status, review XR to ensure no FB, ask about hand
dominance, occupation
- Obtain consent for T&S, and staff nurse available to assist you
- Inspect wound, V shaped laceration.
- Need to demonstate a corner stitch for flap repair
- Discharge advice and follow up plan for dressing and STO

3. T&S – Nov 15 (rpt 2012)

Examiner – Dr Seet Chong Meng (KTPH)
Elderly lady with DM and AF on warfarin had a mechanical fall on gravel road. Sustained a laceration
of the right forearm. Bleeding has stopped. Consent for T&S and LA has been taken. Tetanus
immunisation is up to date. Talk to the patient (10%), perform T&S on the trainer and explain your
steps aloud (70%) and give discharge advice (20%)
The examiner asked me to examine the patient’s arm (even though it it’s not part of the marking
scheme). The patient has a piece of masking tape on her arm with a curvy line drawn in black
marker. I just make sure no NV deficits then explained again to her what I’m about to do and said
ideally I will like to get an Xray to check for FB. Verbalise all your steps from cleaning and draping, LA
and suturing. There was no cannula provided to irrigate the wound. The examiner stopped me after
1 suture. After I gave my discharge advice, the examiner asked if I was intending to let it heal by
primary intention. It was a strange question because otherwise, why would I be asked to suture in
the first place?

4. Abdo pain and vaginal discharge in young woman - PV, speculum, condom in vagina,
counselling – Nov 15
Examiner – Prof Tham Kum Ying (TTSH)
A 24 year old woman presents to the ED with lower abdominal pain and vaginal discharge. Your
junior resident has performed an abdo exam and found tenderness in the LIF and suprapubic region.
Explain what you will do to the patient (20%), do the necessary physical exam (70%) and give the
appropriate advice (10%)
Obtain consent
PV and speculum
Proctoscopes are also displayed to trick you.
There is cervical excitation and left adnexal tenderness
Condom found on speculum exam -> remove with forceps
The SP gave different answers to candidates regarding the time of the last sexual intercourse - from
2 days ago to 1 week ago.
Counsel on emergency contraception, STIs, etc.

5. T+S of forearm laceration 2014

- Do focused history (standard) and directed physical examination. Explain post-T+S care and do T+S
(suggest explain everything first before T+S – I don’t think they are expecting to stitch the whole
wound up; just a few can already so grab the other marks too!)

6. Teach medical student how to use ophthalmoscope

- Standard teaching station – go through whole procedure, get student to demonstrate (have more
than enough time). Then discuss Ophthlamoscopy findings (not sure what it is ?HTN retinopathy)

7. Woman with PV bleed , PV exam - Nov 14

35/Female , known hx of endometriosis came in for left iliac fossa pain with PV bleeding.
Abdo exam reveals suprapupbic tenderness and LIF tendenress.
No mention about UPT in question.
Perform relevant physical examination for the patient (so offer to do abdo exam + pelvic exam.
exptecd to demonstrate speculum exam)
Explain to the patient the possible diagosis
Examiner: Prof Thum ky TTSH - she didnt prompt much
**
Feedback:
- I felt abit confused as this was my first station (haven’t warmed up yet) as I cannot take hx from
patient and just so many possible diagnosis to consider
- rem to ask for chaperon , rem to ask for adequate lighting
- Dont go and say sterile examination/ need sterile gloves- PV examination no need to be sterile!

8. T & S station. Wound care advice – Nov 2014

Man with left forearm laceration involved in RTA. wound contaminated with mud.
Only injury sustained is laceration over forearm
Patient is unsure about his tetanus vaccination.
Perform procedure (T & S - Y shape laceration)
Choose appropriate suture.
Give wound care advice
Examiner: Prof fatimah SGH
**
- I offered two options for this station- 1) wound debridemt in OT by HRM in view of contamination
2) After wound irrigation, then T & S in EMD by me
- i said give tetanus immunoglobulin + vaccination on contralateral arm in view of contamination
with mud
- method to stitch Y-laceration: simple interrupted suture vs vertical mattress
- pls know post T & S advice well

9. Procedure – CVP – Nov 14

Teach a mo how to insert cvp.
Station will provide US and mannequin.
Questions asked- where is ur surface marking, how to tell carotid artery vs ijv, how do u know u r in
(can aspirate freely)
Examiner: Dr Beng Leong from TTSH
Comments: the mannequin was super hard – needle cant quite go in, so I kept poking and poking
10. Fundoscopy – Nov 14
Teach med student how to do fundoscopy .
They show u pict of CRAO- how to manage.

11. Suturing – Stellate wound, brief history I just screened for head injury symptoms. Then the
examiner rush me to sew etc, kept saying “ imagine the u finished irrigation, imagine the sterile field
is up” then have to do post suture management and give HI advice. – May 15

12. PV examination --> lost condom. Pace your examination so that u have time to counsel at the
end. – May 15

13. Station 10: FAST – May 16

Motorcyclist hit and flung. Now complaining of left costal pain and epigastric pain. You have decided
to do an extended FAST for the patient.
Shown picture of ultrasound and knobology outside the room: (we have never used this machine
before)

Time allocation:
E-FAST 7 mins
Summarise findings 1 min
Discuss diagnosis and differentials 2 mins

Have to do ultrasound on a normal patient. Will refuse to do subcostal view because painful++ Can
do parasternal long axis with abdominal probe or from apex.

While discussing with examiner findings, nurse informs you that pt now giddy. Examiner ask what do
you want to do. Reassess patient and repeat FAST
FAST findings shown on computer - L pneumothorax, free fluid above spleen
Management of above.

14. Station 9: Procedural sedation – May 16

6yo boy FOOSH at playground. No open wounds, neurovascularly intact. Patient requires M&R in ED
under ketamine sedation (IM/IV).
Picture of radius/ulna fracture AP/lat view shown

Time allocation:
Explain diagnosis.
Check for contra-indications for ketamine sedation.
Counsel and explain process of sedation (process, risks, benefits)

XR available in room as well.

15. Station 5: Digital block – May 16

25yo gentleman got cut by right middle finger clean blade when he was opening the packaging. You
need to perform a digital block for the patient for T&S.
Time allocation:
Take history, especially pertaining to digital block 1 mins
Do neurovascular examination of the finger 2 mins
Take consent for digital block 3 mins
Perform digital block 3 mins
Give discharge advice 1 min
VERY loaded station, time management was essential

16. M&R of anterior shoulder dislocation – Nov 17

30-year-old male comes in following a shoulder dislocation. Please counsel him on management of
his injury. Perform the procedure in a method of your choice and provide the patient with post-
procedure advice after. You do not need to take consent for procedural sedation.

Tips
- Do a quick assessment, and review of x-rays to confirm diagnosis of anterior shoulder
dislocation
- Choose a M&R technique you are most comfortable with
- Take informed consent for M&R
- Remember to do airway assessment pre-procedure
- Advise on drugs you will use for procedural sedation, and reversal agents you want on
standby
- Demonstrate your chosen technique on patient
- Apply arm sling after
- Provide post-procedure advice

17. NVD – Nov 17

30-year-old lady who is 37 weeks pregnant comes into you’re A&E, clearly in labour. On examination
she is already noted to have crowning. Please proceed to carry out a normal vaginal delivery of the
baby.

Tips
1. Will need to do NVD with proper hand manoeuvres. Remember to unwind cord from baby’s
head, cut umbilical cord, and carry out controlled cord traction during delivery of placenta. Also have
to talk through episiotomy and subsequent repair.
2. After delivery, will need to attend to baby in incubator (please remember to ask for this at
the start of the station). Dry, suck, stimulate, need to calculate APGAR score as well

18. Femoral nerve block for femur shaft fracture – Nov 18

19. T&S – Nov 18

20. Bier’s block for distal radius # – Nov 18

MCI
1. MCI (Dr Lee Wee Yee) – May 17
- It is 2300 in your ED. A tanker explodes 1km away from your hospital. Your ED has been activated
to receive an unknown number of casualties. Despite how to prepare for this scenario (60%) and
how you would triage the casualties (40%)
- Run through the MCI song that Dr Keith has taught
- Can screen for chemical /radiation agents but no need for duodote

2. MCI – Airplane with 150 passengers crash into residential apartment – Nov 15
Examiner – Prof Suresh
You are the senior doctor on duty in the ED. You receive a call about an airplace with 150 passengers
which skidded off the runway and crashed into a residential apartment. You are expecting the first
patients to come in 10 min. Explain how you will respond (60%) and triage these 10 patients (40%).
Use Keith’s MCI management outline
Mention FMT and capabilities (6 x P1, 12 x P2, 30 x P3)
Triage patients using Triage sieve or sort

3. MCI management – Minibus coming in with 5 patients from cinema with symptoms of
cholinergic poisoning (DUMBBELLS)
- Discuss initial activation and management
- Triage the 5 patients (based on history / clinical presentation / vitals) and management

4. MCI dirty bomb blast. – May 15 Just talk through the prepare your dept stuff , then triage pts
deck. Please go and find out what is the precise name and type of mask and PPE…. I didn’t know
hahaha… so I just described. But the examiner was the super nice Prof from CGH so quite chillax.

5. Station 15: MCI (Prof Suresh) – May 16

There were 6 explosions heard at the shopping centre 2km away from the hospital. Your casualties
are anticipated to arrive in 10mins.
Please come up with a management plan.
Sieve and sort protocol provided in picture outside and in room.

Time allocation:
Management plan 7 mins
Triage first few patients in 3 mins

Standard MCI
Questions: know how many people in FMT (2 Dr 4 nurses to despatch at 15mins, 45mins and 2h),
how many people FMT can cope with (6 P1, 12 P2s, 30 P3s), who else to activate, what to do if
supplies not enough, your doctors in ED asking what they are supposed to do
When triaging the patients, they gave us triage tags (please look in front and behind) front has age
and sex, back has symptoms, signs, vitals.
Based on triage sieve there were no P1s. Prof say nurse now asking no P1s, whether want to
uptriage patients and some of the patients not suitable for P3.

6. MCI – Nov 17
You are the senior doctor on shift and receive a call for a potential MCI involving a fire in a nearby
building. Please prepare you’re A&E and manage the situation.

Tips
- Do memorise the entire MCI song i.e. authenticate the call, activate MCI protocol, prepare
your stuff/staff/supplies and triage incoming patients accordingly