You are an FY2 in emergency department
Personal Details:
Name: Mr Smith
Age: 40
Medical Record:
Past medical history: None.
Notes:
A 40-year-old man presents to the Emergency Department with severe back pain.
Task:
1. Take a focused history and examine the patient.
2. Discuss the management plan.
Opening Sentence: (In severe pain, holding his back) “Doctor, my back is killing me. I lifted a heavy box at work two days ago, and it’s just got worse and worse. But now something else is happening, and I’m really scared.”
Open History (to give freely): “Paracetamol did nothing”
History to give only if asked:
The right leg feels really weak, and I can’t feel anything properly. The scariest thing is I can’t feel anything when I wipe myself after going to the toilet, and I haven’t been able to pass urine for about eight hours, even though I feel like I need to go.”
ICE (Ideas, Concerns, Expectations):
Ideas: “I thought it was a slipped disc, but this is something else. This is bad, isn’t it?”
Concerns: “What’s happening to me? Am I going to be paralysed?”
Expectation: “I need you to tell me what’s wrong and fix it, now.”
More History (only if asked): You are normally fit and well with no medical problems.
Social History: Works as a manual labourer.
Examination findings: weakness in the right lower leg. Loss of sensation in the genital area.
History of Presenting Complaint:
You have severe back pain. Can you tell me exactly where the pain is?
You said it’s going down both legs. Is that a new symptom for you?
Have you had any numbness or tingling anywhere? You mentioned your feet?
Specific Cauda Equina Red Flag Questions:
Have you had any numbness or altered sensation around your bottom, in the area where you would sit on a saddle?" (Saddle anaesthesia)
Have you had any problems with your bladder? Have you had any difficulty passing urine, or a change in the sensation of your bladder feeling full?" (Bladder dysfunction)
Have you had any problems with your bowels? Have you had any accidents or lost control?" (Bowel dysfunction)
Have you had any weakness in your legs or feet?
ICE (Ideas, Concerns, Expectations):
What did you think was happening when these new symptoms started?
What is your biggest fear right now?
You were expecting a scan. What else were you hoping we could do?
Explain the situation, the likely diagnosis or DD:
Mr Smith, thank you for telling me that so clearly. I know you are in a lot of pain and are very scared. Based on what you’ve told me – the back pain combined with the leg weakness, the numbness around your back passage, and the problems with your bladder and bowels – you have the signs of a condition called Cauda Equina Syndrome.
Addressing and answering the patient’s ICE:
You asked what this is and if you will be paralysed. At the bottom of your spinal cord, there is a bundle of nerves that looks like a horse’s tail – this is what ‘cauda equina’ means. These nerves control your legs, your bladder, and your bowels. It seems that a slipped disc in your lower back is so large that it is pressing on this whole bundle of nerves and crushing them. This is a surgical emergency. If we don’t operate to relieve the pressure on those nerves very quickly, the damage could become permanent, and you could be left with paralysis and permanent bladder and bowel problems.”
Next Steps:
This is now the number one priority in the hospital. I am going to call the on-call spinal surgery team right now. You need an emergency MRI scan of your spine, which we will do within the hour. The surgeons will then decide the next step based on the MRI result.
Manage the pain
I am going to give you some very strong pain relief, like morphine, through a drip. We will also need to pass a small tube, a catheter, into your bladder to drain the urine. Everything is going to happen very, very quickly now.
Have I explained things well? Do you have any questions for me?
The management is a time-critical emergency pathway. 1. State the need for an immediate call to the on-call spinal surgery team. 2. Arrange an emergency MRI. 3. Explain if the diagnosis is confirmed, he will need emergency decompression surgery. 4. Provide immediate supportive care (strong analgesia, urinary catheterisation). 5. Offer to contact family.
What is scenario testing? This case tests the candidate’s ability to recognise one of the most critical surgical emergencies in medicine. It requires rapid identification of the classic red flag symptoms and the initiation of an immediate, life-altering management plan. The communication must be direct, clear, and convey the extreme urgency of the situation.