Your way to UK

DR MO SOBHY ACADEMY Page 1 of 54

 Your way to UK

SimMan, also known as the talking manikin, is an adult patient simulator

which is super advanced and ultra-realistic. It is commonly used in
healthcare training in the
UK specially for training of emergency cases. SimMan is one of the most
challenging stations of the PLAB 2 exam.
This highly recommended note sheet will help all the plab2 candidates to
understand those type of stations in better ways, also it would be useful sheet
as complete guide to study the SIMMAN

DR MO SOBHY ACADEMY Page 2 of 54

 Your way to UK
❖ Bullet points for all the simman stations:

• 1.Use the
Airway,Breathing,Circulation,Disability,Exposure(ABCDE)approach to
assess and treat the patient.
• 2.Do a complete initial assessment and re-assess regularly.
• 3.Treat life-threatening problems before moving to the next part of
assessment.
• 4.Assess the effects of treatment.
• 5.Recognize when you will need extra help.Call for appropriate help
early.
• 6.Use all members of the team.This enables
interventions(e.g.assessment, attaching monitors, intravenous access) to
be undertaken simultaneously.
• 7.Communicate effectively- use the Situation, Background, Assessment,
Recommendation
(SBAR) or Reason, Story, Vital signs, Plan (RSVP) approach.
• 8.The aim of the initial treatment is to keep the patient alive, and achieve
some clinical
improvement. This will buy time for further treatment and making a
diagnosis. 9. Remember – it can take a few minutes for treatments to
work, so wait a
short while before reassessing the patient after an intervention.

The aims of the ABCDE approach are:

to provide life-saving treatment

to break down complex clinical situations into more manageable parts
to serve as an assessment and treatment algorithm
to establish common situational awareness among all treatment providers
to buy time to establish a final diagnosis and treatment.

Golden Rules of Simman:

• UniversalPrecautions.
• ID checks
• A- Introduce yourself to patient.
• B- Confirm Patient’s ID- Verbally or Bracelet/wrist band/ Notes
• Taking history from patients:
• Talks = Airway is Patent = Take Short History.
• Confused/Unconscious = I can see my patient is unresponsive I will carry
on with my assessment. (Take Hx once patient regains mental capacity)
• Don’t Look at, ask or even engage in any means with the examiner (He

DR MO SOBHY ACADEMY Page 3 of 54

 Your way to UK
doesn’t exist unless the stem says talk to him).
• Don’t touch the patient until you sign post Examination + Privacy +
Chaperone.
• ABCDE approach always no matter what case you get.
• Pay as you go+do whatever you say.
• If the patient is unconscious, unresponsive, and is not breathing normally
state that and advice on starting CPR.

ASSESSMENT - ABCDE PLUS (GIFTS)

Airway
IF PATIENT TALKING WITHOUT NO ADDITIONAL
SOUNDS (Means patent - MOVE ON)

Occasions to check airway.

1- confused
2- suspected anaphylaxis
3- vomiting or risk of aspiration

Check for noises, FB, secretions, oedema.

GOAL (patent airway) moves on

GIFT 🎁
O2 if not given.

BREATHING

1- CHECK REPARATORY RATE

2- CHEST EXAMINATION (Inspection- Palpation-
Percussion - Auscultation) as traceable deviation and
symmetrical movement.

IF problem related to respiratory system (do complete

examination)
IF not related (auscultate and move on)

🎁
ABG must
CXR > if any positive nding while auscultation
(as suspect pneumonia, heart failure)

DR MO SOBHY ACADEMY Page 4 of 54

fi
 Your way to UK

Goal (suf cient ventilation and oxygenation)

CIRCULATION

BLOOD PRESSURE (update the patient)

PULSE (regular, irregular, fast)
CRT

Any patient with (surgery, procedure, bleeding,

suspected clot , arrhythmia )

You need to go further >> to complete C assessment.

- Check the source of bleeding

- Site of operation / procedure
- Pallor
- Distal pulse
- Heart sounds

Gifts 🎁

Cannula
Bloods
IV uids
IV Medications
ECG
Control bleeding
Massive haemorrge protocol
Take consent

Disability

Check blood glucose.

If concerned about sleepy, confused patient.

1- Conscious level (AVPU)

Alert
Respond to voice.
DR MO SOBHY ACADEMY Page 5 of 54
fl
fi
 Your way to UK
Respond to pain.
Unconscious

2- check pupils
3- Toxicological examination
GIFTS 🎁

Reassessment (Full - monitor & patient & positive

nding & medication effect)

E - Exposure

1- head to toe
2- Temperature
3- detailed medical history
4- skin changes

Gift 🎁
Thermomanagement
Reassessment

Conclusion

1- talk to the patient (diagnosis - further management ,

admit, senior, observation , investigations , referral )

2- Talk to examiner

SBAR Approach

Situation
Background
Assessment
Recommendation

DR MO SOBHY ACADEMY Page 6 of 54

fi
 Your way to UK
•

DR MO SOBHY ACADEMY Page 7 of 54

 Your way to UK

Topics
AIRWAY & BREATHING

• Acute Exacerbation of asthma

• COPD
• Anaphylaxis
• Heart Failure+ AF

CIRCULATION

• Hematemesis
• Post-Partum haemorrhage
• Post Hysterectomy Hypotension
• Bleeding and IN
• Acute limb Ischemia
• Post CS Pain
• Sepsis
• Afib/SVT

DISABLILITY

• Hypoglycaemia
• Opioid toxicity

DR MO SOBHY ACADEMY Page 8 of 54

 Your way to UK

Acute exacerbation of Bronchial asthma

SYMPTOMS OF ASTHMA
• A whistling sound when breathing (wheezing)
• breathlessness
• A tight chest, which may feel like a band is tightening around it • Coughing.

•
• Case scenario and management:

• Where you are:

You are F2 working in A & E.
Who the patient is:
Mr. Tory Jones 35 year old male came with acute shortness of breath.
Other Information:
None
Special Note:
Mr. Tory Jones is represented as a High Fidelity Mannequin.
What you must do:
Take talk to the patient, assess his condition, examine him, do relevant
management and discuss with the examiner if management plan is asked
after 2 minutes bell.

•
Patient : Gasping for air.

You : Acknowledge Breathlessness. + can you tell me what happened?

Patient: I can’t
Breath.
Depending on severity of SOB :
Patient : 1- Can answer Qs with full sentences = take short history.
DR MO SOBHY ACADEMY Page 9 of 54
 Your way to UK
SOB Analysis ? Had it before? Cough? Fever? Chest Pain? Calf Pain?
Medications?
Medical Conditions ? Allergies? Exercise ? Smoking ? Home Condition
( Pets + Carpets
). Job? Surgery. Travel ? smoker’s cough?
2- Can’t finish one sentence = postpone Hx and start your
assessment.

• Management

• Ideally put in Semi-Setting position.

Monitor Either
1- Ideally I should attach the monitor
2- I can See my patient is attached to the monitor.
Monitor :
O2% = 86% , H.R. = 92 b/min, RR = 20.
Patient : - 1- Talks Airway is Patent.
2- Not talking or struggling Check Airway.
Interfere ( ABCDE )

A Airway. ( Check for any obstruction )

O2 Low = give 100% O2 high flow rate 15L/min via face mask.
O2 :- A- Improves = If not asked Hx ask now, if asked move on. B- Not =
Move on to B.

B Breathing.

1- Examine chest in order ( Inspection. Palpation. Percussion.

Auscultation ).

2-Auscultation = wheeze = Change mask to Nebuliser Mask

( Salbutamol 5mg can be Repeated 2-3 times every 20mins via oxygen
driven nebuliser mask 6L/min).
3- Take ABG.

C. Circulation.

1- Check : Capillary Refill + Pulse + BP + Insert 1 Cannula.

2- Take Blood (Relevant Investigations ( Inflammatory and infection markers

+ routine blood + ECG

3- Re-asses O2 : A- Improve = continue your assessment.

DR MO SOBHY ACADEMY Page 10 of 54

 Your way to UK
B- Still Low = Add Ipratropium bromide 0.5 mg once only.

. Dishability.

1- Check : Blood Sugar 2- Re-assess O2 :

A – Improved = Continue your assessment.
B – Still Low = verbalise salbutamol can be repeated every 150 20 minutes
and Add Hydrocortisone 100mg I.V or Methylprednisolone 160mg I.M. If
tolerates orally can be thing prednisolone orally 40-50 mg.

Exposure.

1- Check Abdomen : ( Quickly ) / LL / + Temperature.

2- Re-assess O2 : A- Improved = start Discussion with Pt.

Start Discussion :
How are you feeling now? Explain condition. Admit. Involve Senior. Further
Inv (PEFR). Advise Regarding ( Attacks. Triggers. Inhalers). Once
discharged refer to Asthma Clinic. Safety Netting.

DR MO SOBHY ACADEMY Page 11 of 54

 Your way to UK

Acute exacerbation of COPD

• Chronic obstructive pulmonary disease (COPD) is a chronic illness that can

be

DR MO SOBHY ACADEMY Page 12 of 54

 Your way to UK
• periodically punctuated by acute worsening of symptoms characterised
clinically
by increased dyspnoea, cough, sputum production and sputum
purulence. This
acute worsening of symptoms has been termed acute exacerbation of
COPD
(AECOPD).

How should I assess a person with an acute exacerbation of COPD?

• Marked breathlessness and tachypnoea.

Pursed-lip breathing and/or use of accessory muscles at rest.
New-onset cyanosis or peripheral oedema.
Acute confusion or drowsiness.
Marked reduction in activities of daily living.

•
Assess patient with same ABCDE approach, after you have taken all your
universal precaution sand introduce yourself, check patient ID and age.
Otherwise, initially give patients with COPD oxygen via a Venturi 24% mask
at 2-3 l/min or Venturi 28% mask at a flow rate of 4 l/min or nasal cannula at
a flow rate of 1-2 l/min (if a 24% mask is not available).
•
Assess the severity of the exacerbation by measuring RR, O2
saturations, degree of air entry, tachycardia, BP, peripheral perfusion,
conscious level, mental state If hypoxic, give controlled 24–35% O2 via
Venturi face mask to aim for SaO2 88–92%, salbutamol nebuliser; establish
venous access
• Check blood gas
• Request a CXR
• Perform ECG
• Check bloods for WCC, CRP, potassium, etc.
• Optimise volume status
• Take a brief history, if possible. Important to know what patient’s
•
normal functional status is like such as exercise tolerance and the need
for help with activities of daily living. Old hospital notes are helpful
regarding severity of disease and whether previous decisions have
Getting Started on Mobile 12 been made regarding ventilation or
resuscitation
•
•Nebuliser bronchodilators—salbutamol 2.5–5mg and Ipratropium 500
micrograms on arrival and 4–6-hourly. Run nebuliser with air, not O2
•Continued O2 therapy, aiming to maintain saturations between 88%~~92%

DR MO SOBHY ACADEMY Page 13 of 54

 Your way to UK
•
•Consider antibiotics if any signs of infection
•Oral steroids prednisone short course for all patient admitted to the
hospital
•
•Consider IV Aminophylline if not improving with nebulisers

Maximum management of COPD exacerbation

• O2 via venturi mask (target 88-92)

• Nebulisers (salbutamol & Ipratropium) – Delivered by Air ]
• Short course of steroids (prednisolone)
• Consider antibiotics if any signs of infection while assessment

ANAPHYLAXIS

What is Anaphylaxis?
• Anaphylaxis is a severe and potentially life-threatening reaction to a trigger
such as an allergy.
• It is also known as anaphylactic shock.
• Anaphylaxis usually develops suddenly and gets worse very quickly.

Symptoms of anaphylaxis
• feeling lightheaded or faint
• breathing difficulties – such as fast, shallow breathing
• wheezing
• a fast heartbeat
• clammy skin
• confusion and anxiety
• collapsing or losing consciousness
• There may also be other allergy symptoms,
• including an itchy, raised rash (hives);
• feeling or being sick; swelling
• (Angioedema)

Case scenario: post-operative bleeding. After the blood the patient

complaining from SOB.

Start your station by the information given by the nurse.

I can see that you struggling to breath, is this happened after taking this
blood.
DR MO SOBHY ACADEMY Page 14 of 54
 Your way to UK

DR MO SOBHY ACADEMY Page 15 of 54

 Your way to UK
Any itchiness? any other symptoms?
My lip swollen up any my hand is itchy. And dizziness

NO delay – I am suspecting a severe allergic reaction to the blood you

are taking so we need to manage it urgently.

Call for help.

2. Remove the source/ trigger – elevate the legs
3. Intramuscular Adrenaline 0.5-1.0mg/ml (1:1000 conc.)- can repeat
after 5 minutes.
4. Establish airway- Give high flow oxygen 100 % e NRM

You can continue history.

Cough? Fever? Chest Pain? Calf Pain? Medications? Medical Conditions?
Allergies? smoker’s cough?
MMA

• Treatment:

• Monitor Either:
• 1- Ideally I should attach the monitor
• 2- I can See my patient is attached to the monitor.
• Monitor : O2% = 84%, BP = 90/60. H.R. = 120.
• Note: Patient is hypotensive, tachycardia and tachypnoeic • Interfere
( ABCDE )

B- Breathing

• 1- Examine chest in order ( Inspection. Palpation. Percussion.

Auscultation )
• 2- On Auscultation = Wheeze = Change mask to Nebuliser Mask (Repeat
2-3 times every 20mins via oxygen driven nebuliser mask 6L/min).
• 3- Take ABG.

•
C. Circulation:
• 1- Check : Capillary Refill + Pulse + BP + Insert TWO large bore IV
cannulas
• 2- Take Blood (Relevant Investigations - Blood Group. Cross Matching.
Inflammatory and infection markers + routine bloods). + ECG
• 3-BP
•A- Give I.V. Fluids (HARTMAN SOL or NS) 500ml every
DR MO SOBHY ACADEMY Page 16 of 54
 Your way to UK
10-15mins up to 2L within 1st hr.
• B- O2 Still Low = Repeat Salbutamol 5mg ( 2nd )
• BP Low = Raise Legs to elevate BP.
Nebuliser mask

D. Disability
• 1- Check : Blood Sugar + Temperature.
• 2- As my patient is talking to me and is obeying commands, her
GCS seems to be 15/15.
• 2- Re-assess BP :
• A – Low = Add another 500ml of Hartmaan/ NS.
• B – Assuming 5mins have passed repeat Adrenaline dose.

E. Exposure

1- Check Abdomen : ( Check wound/ incision site , Bleeding. Discharge.

Swelling
).
• 2- Check Private Area = Remove catheter if its latex and Insert silicone
Catheter (
Monitor Urine output).
• 3- Check Abdomen/Chest/Legs ( Rash ) = Give Chlorpheniramine 10-20mg
I.V.
• 4- Re-assess Bp :
• A- Still Low = Add Another 500ml Fluids.
• B- Improved = Start discussion with Patient

Discussion either with Patient or Examiner.( ISBAR)

How are you feeling now?

Explain the situation: You seem to be having an Anaphylactic reaction which
is an allergic reaction to the blood which you are receiving. I have stopped
the blood and given you some O2 and IV Fluids.
Involve Senior.
Document in patient Notes.
I would like to send the blood you are receiving to the lab to cross match and
see if you are receiving the correct blood or not. If it is not
the correct blood, then I will have to fill an incident form.
Will check if taking any medication you allergic to

DR MO SOBHY ACADEMY Page 17 of 54

 Your way to UK

DR MO SOBHY ACADEMY Page 18 of 54

 Your way to UK

Heart failure with or without Atrial fibrillation.

DR MO SOBHY ACADEMY Page 19 of 54

 Your way to UK
How does patient presents to you..
• Shortness of breath • Dizzy
• Palpation

station...

• Who you are:

• You are FY2 in A&E.
• Who the patient is:
• Mr. Barry Allen, aged 75, has come to the A&E with shortness of breath
and palpitations.
• Other information::None
• Special note:
• Patient is conscious and oriented.
• What is your task:
• Please talk to him, assess and manage him, and discuss the management
plan with the him.
First, Ideally put in Semi-Sitting position or propped up position. (Verbalise,
don’t move the mannequin)
• Monitor - before talking, ensure the O2 supply.

•
•

DR MO SOBHY ACADEMY Page 20 of 54

 Your way to UK

• • I can See my patient is attached to the monitor.

DR MO SOBHY ACADEMY Page 21 of 54

 Your way to UK
• • ABCDE Approach

A- Airway :

O2 Low = give 100% O2 high flow rate 15L/min via face mask to maintain
saturation of 94% - 98% after ruling out smokers cough.

B- Breathing:

Examine chest in order ( Inspection. Palpation. Percussion. Auscultation ).

• 2- Auscultation = Bilateral crackles = Fluids in the lungs.
• 3- Take Chest X-ray (Pulmonary oedema) + ABG.
a CXR with findings of Heart Failure {Cardiomegaly and Pulmonary oedema
or Bilateral pleural effusions).

C-circulation

1- Check : Capillary Refill + Pulse ( Irregular) + BP + Insert 1 Cannula.

2- Take Blood (Relevant Investigations ( Heart Attack markers + Heart failure
Markers + routine bloods. + ECG (AF)

• 3- Re-asses O2 + BP :
A- O2 Still Low = Give Furosemide 50-100mg I.V.
AF =Call Senior=Digoxin 0.75 – 1mg over 2hrs Loading dose.\

• C- If Pt distressed = Opioids/ Morphine ( very small dose)- Monitor carefully

• D-If SystolicBP>90=2puffsSLGTN(800µ)

D-Disability

Check : Blood Sugar

2- Re-assess.

Exposure
1- Check Abdomen : ( Quickly ).
2- Check Private Area = insert Catheter + Check LL for oedema.
3- Temperature
4- Re-assess.

Pt should improve = Start Discussion :

How are you feeling now? Explain condition. Admit. Involve Senior. Involve
Heart
Specialist for Further Investigations

DR MO SOBHY ACADEMY Page 22 of 54

 Your way to UK
( Echo, Holter ECG, BNP). Advise Regarding ( Condition .Life style
modifications). Once discharged refer to Heart Clinic.

Haemorrhage .

PBH

You are an FY2 working in the Obstetrics and Gynaecology.

Who the patient is:
Mrs. Jefferson aged 35, multigravida, had her 5th Delivery an hour ago.
She is bleeding. Nurse called you.
Other Information:
There is a midwife in the cubicle.
Special Note:
None.
What you must do:
Assess the patient and do the initial management.

DR MO SOBHY ACADEMY Page 23 of 54

 Your way to UK

Depending on patient’s condition : ensure O2 supply before talking. Start

with the information provided / Do not start with how can I help you.

Patient : 1- Conscious and Can answer Qs with full sentences = take short
history.

Bleeding ( Since when. How much? Heart Racing? Dizziness? ?

Medications ( Blood thinners )? Medical Conditions ( Bleeding Disorders ) ?
Allergies? smoker’s cough?

2- Can’t finish one sentence or confused = postpone Hx and start your

assessment.

Monitor Either
1- Ideally I should attach the monitor
2- I can See my patient is attached to the monitor.
Monitor :
O2 = Normal or Slightly Decreased. BP = 80/60. H.R. = 120 b/min.
Patient : - 1- Talks Airway is Patent.
2- Not talking or struggling Check Airway.
Interfere ( ABCDE )

A- Airway.

1- O2 Low = O2 Low = give 100% O2 high flow rate 15L/min via face
mask. 2- O2
2- Normal = Move to B.

B- Breathing.

1- Examine chest ( Auscultation ).

2- ABG.

C. Circulation

Check: Capillary Refill + Pulse + BP + cold peripheries

Check the source of bleeding.
Check the tummy (site of operation)
Insert 2 Cannula. + ECG

DR MO SOBHY ACADEMY Page 24 of 54

 Your way to UK
SHOCKED ?
Call for help.
Activate major haemorrhage protocol.
Take Blood (Relevant Investigation (Blood Group Cross matching + routine
blood inv. Iron studies. Clotting profile. KFT. LFT/ 6 units of o negative
bloods )
Take consent for bloods.
IV fluids 1 Liter

Abdomen – Bulky uterus ( CS wound for Bleeding. Swelling. Skin

color changes ).
Give Oxytocin 5-10 Units I.M/I.V. + Uterine Massage. Verbalize

D. Disability.

Check: Blood Sugar

Re-assess BP
Improved = Continue your assessment
Still Low = O- blood 6 units start pt on 2 units 2ml/min and re-assess.

E. Exposure.

insert Catheter (urine output

Temperature

Start Discussion: SBAR WITH THE EXAMINER

Admit. Involve Senior.

Causes and what to do next:

1- WILL CHECK WITH MY SENIOR AND BNF TO GIVE OXYTOCIN IV

INFUSION (UP TO 40 UNITS

2- CHECK IF THE PLACENTA FULLY DELIVERED

3- CHECK FOR ANY OTHER SOURCE OF BLEEDING (ANY INJURIES

WHICH MIGH NEED SUTURING)

Bimanual compression then Balloon tamponade / Haemostatic brace

suturing / Bilateral ligation of uterine arteries / Hysterectomy if needed

DR MO SOBHY ACADEMY Page 25 of 54

 Your way to UK

Post operative pain management

Morphine

Morphine max dose Oral solution 10mg/5mL over 4-6 hours

After intrathecal administration which can only prescribe oral

morphine for first 24 hours after consulting with senior.

Station..
• Where you are:
• You are FY2 in the Obstetric department.
• Who the patient is:
• Mrs. Ayla Hudson , a 35 years old lady, had a cesarean section 8
hours back.
• Other Information:
• The nurse asked you to see the patient.
• Special Note: None
• What you must do:
DR MO SOBHY ACADEMY Page 26 of 54
 Your way to UK
• Talk to her, assess her, address her concern and discuss
management with her.

Surgical notes
• Surgery was done 8 hours ago.
• Surgery was uneventful with delivery of twins.
• Placenta was completely removed with blood loss of 250ml.
• Surgery was done under spinal using diamorphine.
• Vital Chart: HR: 95, SP02: 99, RR: 19, BP: 130/70, T:37.4C, ECG:
Sinus Rhythm

• Patient: I am in severe Pain.

• You: Acknowledge + use the notes ( I know that you have
done a surgery and the nurse and you are in pain)

Patient: 1- Take short history.

SOCRATES? Had it before? Chest Pain? SOB? Leg Pain? Deliver

(Instrumentation. Injury. Baby. Breast-Feeding). Constipation
(Passed atus). Urinary Retention. Haemorrhage). Medications?
Medical Conditions? Allergies? (Check the wound site and vitals for
internal bleeding)

A- Airway.
Since Patient is talking assume, Airway is patent.

B- Breathing

1- Examine chest (Auscultation).

2- Take ABG.

C. Circulation.
1- Check: Capillary Re ll + Pulse + BP + Insert 1 Cannula.

DR MO SOBHY ACADEMY Page 27 of 54

fl
fi
 Your way to UK
2- Take Blood (Relevant Investigations (Infection Markers + routine
bloods).
3- Depending on Pain Score (Give oral Diclofenac /Naproxen) – IV
paracetamol
4- check abdomen ( CS wound for Swelling. Bleeding. discharge).
Site op operation
5- Check private part for possible source of bleeding

D-Disability.
Check: Blood Sugar.
Reassess the pain.

E. Exposure
1- Temperature
2- Re-assess
B- Still in Pain = Assess Score ( Give 5mg Morphine orally.).

Start Discussion
• How are you feeling now? • Explain condition.
• If still in pain Involve Senior. • Further Investigations Simple rules
on pain killers: If pain score is 8 or more you better start with
Morphine, however there are some rules on Morphine:
• If intrathecal or spinal morphine/diamorphine is administered less
than 24 hours ago
• then we can only prescribe oral morphine 10mg every hour 4 hours

Negotiate with the paint about your uncertainty about giving

morphine with the intrathecal one- CI of morpholine could be over
dose, contraption which could affect the wound healing

DR MO SOBHY ACADEMY Page 28 of 54

 Your way to UK

Post Operative pain-

Internal bleeding .
Same approach but the patient unstable
Check abdomen in C part – Acute abdomen.

Call for help.

Activate major he protocols.
Cannula / Bloods
IV uids
Pain killers (Morphine IV )
Take consent.

If not improved in D – Please Give 2 unites of O negative bloods.

Senior and investigations scans immediately and possible theatre.

Hematemesis.
Common causes of vomiting blood include: •
•
• gastritis
stomach ulcers
heart burn and acid reflux
•
alcohol-related liver disease

Symptoms

• Vomiting of blood
• Dizziness
DR MO SOBHY ACADEMY Page 29 of 54
fl
 Your way to UK
• Palpitation
• have rapid or shallow breathing • have cold, clammy, pale skin
• have tummy pain • have black poo

• 1- Upper GI bleed- maybe has medical hx of Osteoarithtis

• 2- Endoscopy- post procedure injury

How to manage??

Start your station with the information provided please / avoid how can I
help[ you. Short history
Analysis of vomiting - abdominal pain, fever, urine, stool ( Black )
MMA ( blood thinner / bleeding disorder )
Why endoscopy

First, Ideally put in Re-position ( semi-setting position - no recovery

position) , to prevent Aspiration
(Verbalise, don’t move the mannequin)

• Monitor
• I can See my patient is attached to the monitor. • ABCDE Approach
Ensure O2 supply before short history

A- Airway

• 1- Talks Airway is Patent.

• 2- Check Airway ( Check for any secretion )
• O2 Low = Give O2 Low = give 24-40% O2 6L/min via Nasal Cannulae.
• O2 :- A- Improves = If not asked Hx before ask now
• If already asked move on to B.

Breathing:

Examine chest in order:

Inspection. Auscultation
Take Chest X-ray +ABG

Circulation:

DR MO SOBHY ACADEMY Page 30 of 54

 Your way to UK
1-Check:

• Capillary Refill + Pulse + BP

• Abdomen : Site of procedure
• ECG

• Shocked
• Call for help
• Activate major he protocol
• Insert TWO large bore IV cannulas.
• Take Blood ( Blood Group Cross matching + routine blood
• invx. Iron studies. Clotting profile. KFT. LFT ) 6 units of O negative bloods.
• Take consent for bloods .
• I.V. Fluids - 500 mL of warmed crystalloid solution (0.9% Normal
• Saline) in 5-10 minutes if the patient is Hypotensive or 1 L if the patient is in
shock) - 1L up to 2L within 1st hr.
• Fluids might be Pre-warmed Hatman solution/ NS
• Fluid rate- 25-30ml/kg/24h)

Disability:

1- Check : Blood Sugar• As my patient is talking to me and is obeying

commands his GCS seems to be 15/15
• 2- Re-assess BP : A – Improved = Continue your assessment.
• B Still Low = Pre-warmed uncrossed O- blood 6 units
• Start pt on 2 units of blood 2ml/min and re-assess.

Exposure:

1- Check Temperature.
2- Check Private Area : Insert Catheter (urine output).
• 3- Re-assess BP :
• A- Improved = start Discussion with Pt.
• B-StillLow=Add moreBlood.Once blood arrives, give blood.

Discuss with the patient

Admission

Urgent referral to GIT team (Might be a complication of the procedure ) –

Might need to be repeated to check the source of bleeding

DR MO SOBHY ACADEMY Page 31 of 54

 Your way to UK

To consider PPI Initially by intravenous infusion

Initially 80 mg, to be given over 40–60 minutes, then (by continuous
intravenous infusion) 8 mg/hour for 72 hours, subsequent dose then
changed to oral therapy.

Bleeding & INR

Where you are:

You are an FY2 working in the A&E .
Who the patient is:

Mr. James Green aged 75 has complaints of PR bleeding, please access

and manage accordingly

A Airway

• Patient : -
Talks Airway is Patent.
Not talking or struggling Check Airway.
O2 Low = give 100% O2 high flow rate 15L/min via face mask. (Saturation
will improve)

2- O2 Normal = Move to B.

Talk with the patient ( short history )

Bleeding analysis - any pain - abdominal pain - fever - vomiting - urine
- any bleeding anywhere else - procedure ( colonoscopy ) - why -
Medical conditions ( analysis ) - medications ? ( warfarin analysis )
any recent antibiotics or food which could affect warfarin or any
overdose

Listen to chest / request ABG

C.Circulation

DR MO SOBHY ACADEMY Page 32 of 54

 Your way to UK
Check : Capillary Refill + Pulse + BP
Check abdomen - site of procedure
Check private part ( source of bleeding )

Call for help

Activate the haemorrhage protocol / if minor don’t activate
Insert 2 wide-bore cannula. Give 500 pls of Hartman solution
Take Blood ( INR Blood Group Cross matching +routine bloods - Iron
studies. Bleeding and Clotting profile . KFT. LFT).

Give IV/Oral Vit K 3mg - minor bleeding – Check INR after 6 hours
Give PCC – Major bleeding (50 units/kg) – Check INR after 15 mins and at
6 hours
If not fresh frozen plasma

D - Disability

Check : Blood Sugar

• 2- Re-assess BP :
– Improved = Continue your assessment.

E- Exposure
Temperature
Insert catheter
Reassessment

Discuss with the patient

Urgent haematologist
Senior
GIT
Follow up INR

Acute limb ischemia

DR MO SOBHY ACADEMY Page 33 of 54

 Your way to UK

What is Acute limb ischaemia •

Acute limb ischemia (ALI) is defined as a sudden decrease in arterial blood

flow to a limb.
• ALI is a vascular emergency and can lead to extensive tissue necrosis,
which may
ultimately result in limb amputation or even death.

Causes:

• Embolism (in association with atrial fibrillation) • Thrombosis of existing

disease
• Prostheses
• Aneurysms
• Trauma

Risk factors

DR MO SOBHY ACADEMY Page 34 of 54

 Your way to UK
• Diabetes mellitus
• Obesity
• Hypertension
• Hypercholesterolemia

Clinical examination

• Marble white appearance of the skin • Absent limb pulses on palpation

• Cold limb
• Muscle weakness
• Gangrene

Station..

• Where you are:

• You are FY2 working in A&E.
• Who the patient is:
• A 55 years old male, Mat walker, presented with a history of severe pain
in his right leg since this morning.
• OtherInformation:None.
• SpecialNote;
• Mr. Walker is represented as a high fidelity mannequin.
• What you must do:
Talk to him, take history ,and assess the patient, do relevant examination
and appropriate management.

Patient : I am In Pain.
• You : Acknowledge + can you tell me what happened?
• Patient: My leg Hurts.
• Patient :

Take short history. SOCRATES ?Explore the pain? Which leg? Score the
pain? Calf pain ?Trauma? Had it before? Chest Pain? SOB? Heart
Racing? Fever ? Travel? Mobility? Medications? Medical Conditions ?
Allergies? smoker’s cough?

Monitor
• Monitor Either:
• 1- Ideally I should attach the monitor
• 2- I can See my patient is attached to the monitor.
• Monitor :
• O2%=Normal,H.R.=110b/min.ECG=AF
• Interfere ( ABCDE )

DR MO SOBHY ACADEMY Page 35 of 54

 Your way to UK
A- Airway

• Since Patient is talking assume Airway is patent. ( Move quickly )

B- Breathing

• 1- Examine chest in order (Auscultation ).

• 2- Take ABG.

C. Circulation

• Check : Capillary Refill + BP

Pulse >> Check Lower Limbs :
(Pain -pallor -pulseless -paralysis -parasthesia -perishing cold).
Keep checking until you find a pulse

• Right Limb: Pale/Bluish discolouration, cold compared to other leg,

Extremely tender, / No dorsalis pedis pulse felt / Prolonged Cap Refill time.

• Left Limb: Normal

• Heart: S1 S2 heard Murmur: Yes/no

- Insert1Cannula / TakeBlood (HeartAttackMarkers

Clotting Profile + D dimer + routine bloods) .

- Request ECG - AF ?
- Depending on Pain Score (Paracetamol and either Weak or
strong opioids ( Morphine 5mg I.V. )
- Give Oxygen (To increase oxygen perfusion in the legs
regardless of SPO2)
- Blood thinner- 5000 units intravenous heparin
- Give IV fluids

Learning Bite

All patients with acute limb ischaemia should receive analgesia,

oxygen and heparin. All patients with acute limb ischaemia should
be referred urgently to a vascular specialist.
DR MO SOBHY ACADEMY Page 36 of 54
 Your way to UK

D. Disability

• 1- Check : Blood Sugar

2- Re-assess Pain
• B- Still in Pain = Assess Score ( Give Accordingly) Ex ( Paracetamol or
AddnAnother 5mg Morphine I.V.).

Start Discussion :

• How are you feeling now?

• Explain condition.
• Give Oxygen (Reperfusion- to save the leg) + Blood thinner.
• Admit.
• Involve Senior.
• Further Invx ( Doppler US).
• Immediate referral to vascular surgeon.
• Involve Heart specialist.
• Advise Regarding life style modifications.
• Once discharged refer to Vascular Clinic

DR MO SOBHY ACADEMY Page 37 of 54

 Your way to UK

Arrhythmia
195

What is arrhythmia?

• Any change from the normal sequence of heart's impulses causing the heart to
beat too fast, too slow, or erratically. This can prevent the heart pumping ef ciently.

The main types of arrhythmia are:

- atrial brillation (AF) – this is the most common type, where the heart beats
irregularly and faster than normal
- supraventricular tachycardia – episodes of abnormally fast heart rate at rest
bradycardia – the heart beats more slowly than normal

DR MO SOBHY ACADEMY Page 38 of 54

fi
fi
 Your way to UK

- - heart block – the heart beats more slowly than normal

and can cause people to collapse

- ventricular brillation – a rare, rapid and disorganised rhythm of heartbeats that

rapidly leads to loss of consciousness and sudden death if not treated immediately

Causes and Risk Factors

Coronary artery disease.Irritable tissue in the heart (due to genetic or acquired

causes).
High blood pressure.
Changes in the heart muscle (cardiomyopathy). Valve disorders.
Electrolyte imbalances in your blood, such as sodium or potassium imbalances.
Injury from a heart attack.

DR MO SOBHY ACADEMY Page 39 of 54

fi
 Your way to UK

Common triggers for an arrhythmia are

• viral illnesses,
• alcohol,
• tobacco,
• changes in posture, • exercise,

• drinks containing caffeine,

• certain over-the-counter and prescribed medicines. • illegal recreational drugs.

Symptoms

Palpitations / feeling dizzy / fainting / short of breath / Fluttering in the chest

• / Slow heartbeat / Chest pain • Sweating • syncope

Treatment

• Anti-arrhythmicdrugs
• Heart-ratecontroldrugs
• Anticoagulantorantiplatelettherapy
• Electricalcardioversion
• Catheterablation
• permanent pacemaker
• Implantable cardioverter-de brillator (ICD)

Lifestyle changes: smoking / alcohol /caffeine

AF Management

A- Oxygen / ECG / Heart sounds / Check : Capillary Re ll + Pulse + BP +

Insert 1 Cannula. / Take Blood (( Heart Attack markers + Heart failure Markers +
Clotting Pro le + D dimer + routine blood )

Re-asses O2 + BP :A- Choose from:-

1- B-Blockers.
2- Verapamil.
B- If AF more than 48hrs give LMWH. ( consider LMWH after assessing bleeding
and clotting score as CHAD VASc and ORBIT score

DR MO SOBHY ACADEMY Page 40 of 54

fi
fi
fi
 Your way to UK

Station..
Where you are: You are FY2 working inA&E.

Who the patient :

A 45 year old man, Paul walker has presented with dizziness, anxiety and shortness
of breathe. It has been happening for the rst time , he also complained of some
heaviness in the chest.
Other Information: He went for jogging in the morning and this happen suddenly.
SpecialNote;
Mr. Paul walker is represented as a high delity mannequin.

What you must do: Talk to him, take history, and assess the patient, do relevant
examination and appropriate management.

Your monitor

DR MO SOBHY
• Note: Patient hasAF, HR is increased, and other vitals are normal. So, continue
with History. Keep monitoring the vitals while you are taking History

DR MO SOBHY ACADEMY Page 41 of 54

fi
fi
 Your way to UK

A- Patent - Give O2 if needed

B- Listen to chest - check RR - request ABG

C- Check BP , Pulse ( irregular ) , CRT , Heart sounds ? Murmur , cannula, bloods,

ECG ( AF ) - Consider BB or CCBs as a rate control

D- Blood sugar

E- Temperature - detailed medical history

Start Discussion :

• How are you feeling now?

• Explain condition.
• Continue Oxygen if SPO2 is low
• Admit.
• Involve Senior( rhythm control )
• Immediate referral to heart specialist. Echo - Assess the need for Anticoagulant

Why do I have this condition?

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

• This is a serious condition, so we need to admit and treat you immediately. I

am going to arrange for some blood tests.I am going to refer you to
specialists called Cardiologist. Depending upon your result, they might have
to give you some medication to control your heart beat and rhythm.

Management of SVT

A- Intact - O2 if needed

B- Listen to chest - ABG

DR MO SOBHY ACADEMY Page 42 of 54

fi
 Your way to UK

C-

I.V. Access.
FBC.U&E.TFT.LFT.

Vagal maneuvers/ Carotid massage if unsuccessful move to next.

Adenosine (By rapid intravenous injection
Initially 6 mg, administer into central or large peripheral vein and give over 2 seconds,
cardiac monitoring required, followed by 12 mg after 1–2 minutes if required, then 12 mg
after 1–2 minutes if required, increments should not be given if high level AV block
develops at any particular dose.Verapamil 5-10mg I.V.

D - Blood sugar / reassess

E- Temperature / detailed medical history / Abdomen / Reassess

Start discussion

Admit

Senior

Cardiology

DR MO SOBHY ACADEMY Page 43 of 54

 Your way to UK

Sepsis

Symptoms of sepsis
• Low blood pressure
• Pale and cool arms and legs
• Chills
• Bluish discolouration of the digits or lips (cyanosis) • Difficulty in breathing
DR MO SOBHY ACADEMY Page 44 of 54
 Your way to UK
• Decreased urine output
• Confusion
• Dizziness

The station :

Drowsy
• Shortness of breathe
• Confused
• Comatose
• Their vitals would be:
• SPO2- 88% Might be low
• Pulse: 100+ Tachycardia
• BP: <90/60 Hypotension
• RR: Tachypnea

• Temp 39+ Raised- Feverish + Chills

• Note:Patient is hypotensive and tachycardic. Her temperature is raised
Patient: I am short of Breath + Dizzy.

• Depending on severity of Confusion of patient :

Ensure O2 supply before talking to the patient

1- Can answer Qs = Take short history. SOB Analysis ? Had it before?

Cough? Fever? Chest Pain? Medications? Medical Conditions ? Allergies?
Smoker’s cough?

2- Can’t Respond = Postpone Hx and start

Assessment.

Ideally put in Semi-Setting position.

• Monitor
• 1- Ideally I should attach the monitor
• 2- I can See my patient is attached to the monitor.
Patient : -
1- Talks Airway is Patent.
2- Not talking or struggling Check Airway. Interfere ( ABCDE )

A- Airway.

• ( Check for any obstruction )

• O2 Low = give 100% O2 high flow rate 15L/min via face mask
with reservoir bag.
DR MO SOBHY ACADEMY Page 45 of 54
 Your way to UK
O2 :-
• A- Improves = If not asked Hx before, then ask Hx now.
• if already asked then move on.
• B – Move on to B.

B- Breathing.

• 1- Examine chest in order ( Inspection. Palpation. Percussion.

Auscultation ).
• 2- Auscultation = Coarse Crackles.Unilateral
• 3- Take Chest X-ray + ABG ( Lactate More than 2 )
• Normal lactate levels- (0.4-2 mg/dl)
• (Keep in mind if high- its indication of ITU)

C. Circulation.

• 1- Check : Capillary Refill + Pulse + BP + Insert TWO large bore IV

cannulas.+ ECG

• 2- Take Blood ( Blood Culture + BS + C-reactive + Protein + U&E

+lactate + Creatinine + Clotting Screen+ FBC).
• 3- BP Low : Give I.V. Ringer Lactate 500ml over 10-15mints up to 2L in
1st hour + broad spectrum antibiotics

D. Disability.

• 1- Check : Blood Sugar

• 2- Re-assess BP :
• A – Improved = Continue your assessment.
• B – Still Low = Repeat 500ml RL.

E. Exposure.

1- Check Abdomen : ( Quickly ).

2- Temperature (High Temp). Give paracetamol IV 1 gm

3- Check Private Area = Catheter inserted = check urine bag = remove

insert New one + Send urine for Urine dipstick + Culture. catheter and

Start Discussion : Patient or Examiner Sepsis - not chest infection or

UTI ( sepsis and the possible source off infection depends on ur
finding - Chest, urine or both )

DR MO SOBHY ACADEMY Page 46 of 54

 Your way to UK
• How are you feeling now? • Explain condition.
• Admit
• Involve Senior.
• Once Culture results arrive change antibiotics accordingly.

Hypoglycaemia
when the blood glucose levels drop below the specified limits (4 mmol/L or
72mg/dL)

Causes

• Taking too much insulin

• skipping or delaying a meal
• not eating enough carbohydrate
foods in your last meal, such as bread,
cereals, pasta, potatoes and fruit
• Exercise, especially if it's intense or
unplanned
• drinking alcohol

How does patient presents to you in simman station?

Drowsy - Unconscious - Comatose

Station..

• Who are you:

You are FY2 in A&E.
• Who is the patient:
Mr Mohamed Aidan , 58 -year-old, was brought into the hospital by
ambulance as he was found unconscious.
• Special note:

DR MO SOBHY ACADEMY Page 47 of 54

 Your way to UK
• None
• What is your task:
• Please talk to the patient, assess the patient do the initial management.

Patient : Comatose. ( please check for response - shout - shake lightly

)

• You : Acknowledge Unresponsiveness ?

• Confirm ID by medical record or bracelet or ID.
• Start Assessment Immediately.
• Patient: Drowsy?
• You: Confirm ID and take Hx if able to.
• What history you need to ask?
• Drowsy? Since when? What happened? Diabetic? Triggering factors?
Missed meal? Overdose of insulin? Stress? Sweat? Tummy pain?
Vomiting?

Try and talk to the patient:

• Patient is not talking back Tap on the shoulders:
• Patient is not responding again.
• Patient is UNCONSCIOUS.
• Now check whether the patient is breathing or not?
• Look/ Listen/ Feel: Patient is breathing - his airway is patent

Monitor
• 1- Ideally I should attach the monitor
• 2- I can See my patient is attached to the monitor.
• NOTE: Vitals are Stable
• As the patient is Unconscious and Breathing. Continue with
ABCDE approach and keep an eye on the vitals

A-Airway

( Check for any obstruction ) as patient is drowsy or comatose.

• O2 Low = give 100% O2 high flow rate 15L/min via face mask.
• O2 Normal = Move to B.

B- Breathing.

1- Examine chest in order ( Inspection. Auscultation ).

2- Take Chest X-ray + ABG.

DR MO SOBHY ACADEMY Page 48 of 54

 Your way to UK
C. Circulation.

1- Check : Capillary Refill + Pulse + BP + Insert 1 Cannula.

2- Take Blood ( routine blood)
3- ECG

D. Disability

• Check : Blood Sugar + Temperature + Pupillary Reflexes.

• BS Low :If the blood sugar is less than 4.0 mmol in an unconscious
patient > give an initial dose of 50 mL of 10% glucose solution
intravenously. Repeat blood glucose measurements to monitor the effects
of treatment. If there is no improvement consider further doses of 10%
glucose.

E- Exposure
.
Check Abdomen / LL ( Quickly ).
Detailed medical history
Re-assess BS = Low = Give Another Dextrose dose (re-assess
after 15mins).
Check Private Area = Insert Catheter.

Re-assess BS: A- Improved = start Discussion with Pt.

B- Still Low = Give Another Dextrose Dose.
Give further doses of intravenous 10% glucose every minute until the
patient has fully regained consciousness, or a total of 250 mL of 10%
glucose has been given.

If not diabetic and patient is alcohol related

Give him By intravenous infusion Vitamin B substances with ascorbic
acid / Pabrinex
2–3 pairs 3 times a day for 3–5 days, followed by 1 pair once daily for a
further 3–5 days or for as long as improvement continues.

Start discussion with the patient

Admission
Senior review
Awaiting bloods and observation
Carbohydrate containing meal
If alcohol - Consider Thiamine when admitted

DR MO SOBHY ACADEMY Page 49 of 54

 Your way to UK

OPIOID TOXICITY
Serious side effects to be aware of include1:
• A bluish or purplish hue to the skin.
• Agitation or irritability.
• Changes in heartbeat (either rapid, irregular, or slowed). • Confusion.
• Difficulty urinating or pain during urination.
• Drowsiness.
• Dry mouth.
• Extreme sleepiness.
• Severely slowed or irregular breathing
• Fainting.
• Fever.
• Hallucinations (either visual or auditory).

Station

You are FY2 in A&E.

• 75 years old Ali wilson male in A&E.
• He came to A&E before 1 week with complaint of fall from height. He was
diagnosed with low back trauma. Fracture was excluded. He was
prescribed with Two types of doses of oral morphine.

DR MO SOBHY ACADEMY Page 50 of 54

 Your way to UK

• He was having CKD.

• Now presented with feeling of sleepiness.
• No other medical condition or medication No allergies
• Patient kept complaining of sleepiness during the history and on the half
way of history / he felt asleep.

• Task: Take hx and assess and manage

Monitor
Oxygen saturation 82 %
Respiratory rate 8, (Low) (12-20 bpm) no chest sound.
Blood pressure 90/ 60mmhg
Heart rate 110 bpm
ECG showing: tachycardia
RBS-5 mmol/L,
Pupil- 1mm diameter (normal 4mm)

History ( ensure O2 supply before talking )

Start with the finding and information
Morphine analysis
Apart from sleepy ? Any other symptoms
Dry mouth ?
Medical condition ? ( analysis )
Medications ( Any others )
Allergies

A- Airway

Check airway
Check SPO2:-
If low- Give high flow oxygen 100% through NRM 15L/Min
If normal- Before move on to B• Take focused history:

B- Breathing
Check RR
Diagnose Morphine toxicity from the Focused history and Monitor RR-<8
Insert cannula immediately, then give NALOXONE IV- start from 0.4 mg >
upgrade 0.8mg > upgrade 0.8mg >upgrade 2mg>
upgrade 4mg> upgrade Up to 10 mg) (after 1 minute of intervals verbalise)

1- Examine chest in order (Auscultation). no chest sound.

DR MO SOBHY ACADEMY Page 51 of 54

 Your way to UK
2- Take Chest X-ray + ABG.
3- Achieve some improvement

C- Circulation

1- Check : Capillary Refill + Pulse + BP + Insert 2 Cannula.

2- Take Blood ( routine blood , Kidney function ).
3- Check BP- if low- Give Hartman Solution 1L over 15-30 mins and then
give IV NALOXONE- Continue
4- ECG

D- Disability

• 1- Check : Blood Sugar + GCS and please check for the pupils and
reassss

- Exposure

• 1- Check Abdomen : ( Quickly ) Temperature

• 2- Check Private Area = Catheter inserted
• 3- Re-assess BP and pupil
• A- Improved = start Discussion with Pt.
• B- Still Low = Add 500ml HS and Naloxone

Good luck

DR MO SOBHY ACADEMY Page 52 of 54

 Your way to UK

DR MO SOBHY ACADEMY Page 53 of 54

 Your way to UK

DR MO SOBHY ACADEMY Page 54 of 54