You are an FY2 in a large GP practice. Over several months, you have been reviewing a 29-year-old woman, Ms H, for persistent pelvic pain. She has opened up to you about domestic strain, financial instability, and emotional loneliness. She often praises your kindness and says she feels “finally understood by someone.” Today, after a long consultation exploring worsening symptoms and psychosocial triggers, she hesitates at the door and quietly asks if you would “meet for coffee somewhere outside the surgery - not as doctor and patient, just as friends.”
She adds that she has no one else she can confide in and that she “promises never to mention anything inappropriate.” She reassures you she would be fine seeing another GP for clinical matters, insisting that the “friendship” would be separate. She appears genuinely distressed and worries you will discharge her if she has “crossed a line.”
You recall she has experienced significant trauma, and you do not wish to cause harm by rejecting her harshly. You also realise she has an appointment with you again in two days to review new ultrasound results. You sense that mishandling this moment could destabilise her further, yet professional boundaries must be maintained.
What is the most appropriate action?
Your practice has an unofficial staff WhatsApp group. One evening, a GP posts a photograph of a patient’s handwritten complaint letter (with the name mostly, but not entirely, obscured) and writes: “Guess who this is - he complains every month.” Several colleagues respond with laughing emojis.
A receptionist then replies describing the patient’s mental health problems in detail, unaware this may breach confidentiality. The conversation continues, and someone refers to the patient as “a nightmare but harmless.”
You feel uncomfortable. It is informal, outside NHS systems, and clearly unprofessional - but also socially risky to challenge. Meanwhile, you recall that the same patient is due for a safeguarding review.
Select the THREE most appropriate actions:
Select 3 answers. 0 of 3 selected
You are an FY2 in a large practice where repeat prescriptions are handled by a workflow team involving clinical pharmacists, receptionists, and GPs. Recently, you notice several unusual prescription patterns from a new locum pharmacist - such as approving early benzodiazepine requests without flagging concerns.
Today, a receptionist pulls you aside, whispering that the pharmacist “seems overwhelmed” and “keeps asking questions that seem too basic for their role,” such as calculating simple dosage intervals. You then overhear the pharmacist telling another staff member they are “not fully familiar with the prescribing system yet” and haven’t had proper orientation but “felt embarrassed to ask.”
Later, while reviewing a patient’s medication record, you spot a potentially dangerous dose error entered under the pharmacist’s name. Before you can clarify, the pharmacist leaves early, saying they need to “pick up their child,” and asks you to “just sign off any queries that come up tonight.”
You now face a dilemma: the pharmacist may be unsafe, the reception team is hesitant to escalate, and the GP Partner who booked the locum tends to dismiss trainee concerns.
What is the most appropriate action?:
Choose the THREE most appropriate actions:
Select 3 answers. 0 of 3 selected
You are a GPST working late. A senior partner you respect asks you to quickly sign off a repeat prescription for a patient you have never met. The medication is high-risk and requires monitoring. When you hesitate, the partner says, “I know this patient well - it’s fine. We’re already behind and the pharmacy is chasing.”
You feel uncomfortable but are aware this partner completes your end-of-placement report. You also know the practice is under pressure and that refusing may slow patient care.
What is the most appropriate action:
You are nearing the end of a difficult rotation. You have managed several complaints, safeguarding cases, and emotionally demanding consultations. Your educational supervisor reminds you that your portfolio needs reflective entries.
You feel torn: reflection feels important, but revisiting recent cases brings back anxiety and self-doubt. You worry that honest reflection could be misinterpreted if ever scrutinised. At the same time, avoiding reflection feels like avoidance rather than resilience.
What is the most appropriate action:
You are nearing the end of an already overbooked surgery when a patient attends demanding antibiotics for ongoing sinus symptoms. They arrive visibly irritated, immediately stating they “don’t have time for another argument”. As you explain your assessment, they interrupt repeatedly and accuse previous GPs of “not caring”. You feel the tension rising and are conscious of both the waiting room and the risk of complaint.
What is the most appropriate action:
A patient attends after receiving incorrect advice from you during a previous telephone consultation. You realise your guidance was based on an outdated protocol. The patient followed the advice and experienced ongoing symptoms but no serious harm. They now ask, “Why didn’t this work?”
What is the most appropriate action:
A patient attends late, visibly rushed, and says they only have “two minutes”. They have multiple concerns but want quick reassurance. You sense they are not fully engaged and may miss important advice.
Which THREE actions are most appropriate?
Select 3 answers. 0 of 3 selected
You are a GP partner seeing a 67-year-old man with newly diagnosed atrial fibrillation. He lives alone, is independent, and appears well informed after “weeks of reading online forums.” You outline anticoagulation options, but he firmly states he does not want medication and prefers “natural management.” You are aware his CHA₂DS₂-VASc score suggests clear benefit from treatment. You feel uneasy, conscious that your afternoon clinic is running late and that you may not see him again for months. He asks, “You’ll respect my choice, won’t you?”
What is the most appropriate action:
You are consenting a patient for an urgent referral investigation. He nods throughout but gives minimal responses. You suspect he may not fully understand but he says, “Yes, yes, whatever you think.”
Select the THREE most appropriate actions:
Select 3 answers. 0 of 3 selected
An elderly patient with multiple carers attends after a recent hospital admission. Medication changes have been made, but neither the patient nor carers are clear what has stopped or started. You notice discrepancies between the discharge summary and repeat prescriptions. The carers are anxious and ask you to “just tell us what to give.”
What is the most appropriate action:
During a particularly intense week, a colleague becomes tearful after a difficult consultation and says they “can’t do this anymore.” They quickly apologise and return to work. You are both busy, and there is no obvious immediate risk, but the comment lingers with you.
Select the THREE most appropriate actions:
Select 3 answers. 0 of 3 selected
You are a salaried GP supervising an FY2 doctor in a busy training practice. During a morning surgery, the FY2 repeatedly runs over time and emerges from consultations looking flustered. You overhear parts of one consultation and feel the plan was safe but poorly structured. There is little time between patients, and you are conscious that interrupting may undermine their confidence. At the same time, reception is dealing with complaints about waiting times, and you feel pressure to keep the clinic moving.
What is the most appropriate action:
You are reviewing a complex care plan created by multiple services. While clinically sound, it requires significant self-management. The patient nods through explanations but later phones reception confused and frustrated. Other professionals feel their input has already been extensive and are resistant to revisiting the plan.
Select the THREE most appropriate actions:
Select 3 answers. 0 of 3 selected
CLINICAL QUESTIONS
A 47-year-old White man with hypertension and diabetic nephropathy. Which drug should be started first-line?
A 59-year-old Black African woman with essential hypertension. Which agent is first-line?
A 33-year-old woman with newly diagnosed hypertension planning pregnancy. Which antihypertensive is most suitable?
A 41-year-old woman presents with recurrent episodes of vertigo lasting hours, associated with tinnitus and fluctuating hearing loss.
Most likely diagnosis?
A 38-year-old man wakes with sudden profound left-sided hearing loss. No pain, normal otoscopy, Rinne positive bilaterally.
Most likely diagnosis?
A 55-year-old woman has gradual progressive unilateral hearing loss and intermittent imbalance. She denies episodic vertigo.
Most likely diagnosis?
A 35-year-old woman with fatigue, hyperpigmentation, and low morning cortisol requires diagnostic confirmation.
A 52-year-old man with confirmed bilateral adrenal hyperplasia refuses surgery.
A 41-year-old woman with proximal myopathy and purple striae requires a reliable screening test.
A 7-year-old girl has several daily episodes where she suddenly stops talking, stares blankly, and blinks rapidly. Each lasts 10-15 seconds and she resumes activity immediately with no post-ictal confusion.
Most likely diagnosis?
A 17-year-old boy experiences brief, sudden jerks of both arms shortly after waking. They have caused him to drop items. No loss of consciousness.
Most likely diagnosis?
A 24-year-old woman collapses at college with a prolonged episode of whole-body thrashing. Bystanders report eye closure with resistance to opening. She quickly becomes alert afterwards.
Most likely diagnosis?
A 44-year-old woman develops fever and cough 72 hours after being admitted for pancreatitis. CXR shows a new right lower lobe infiltrate.
Most likely diagnosis?
A 32-year-old man presents with a 10-day history of dry cough, headaches and arthralgia. CXR shows patchy bilateral interstitial infiltrates. Sputum PCR pending. He is otherwise stable.
Most likely diagnosis?
A 78-year-old man with confusion, RR 32/min, BP 92/56, urea 10 mmol/L.
CURB-65 severity score?
A 9-year-old girl presents with frequent "blank spells" lasting 10 seconds with immediate recovery. EEG confirms absence seizures.
Which SINGLE medication is first-line?
Which of the following patients should be referred for LTOT assessment?
A 30-year-old wants an LNG-IUS. Pelvic ultrasound shows a markedly distorted cavity due to submucosal fibroids.
Most appropriate advice?
A patient is diagnosed with ANCA-associated vasculitis with renal involvement (creatinine 340 µmol/L, crescents on biopsy).
Best induction therapy?
A 28-year-old man repeatedly stops oral antipsychotics leading to relapse. He agrees to long-term medication but struggles with adherence.
Best management?
A 77-year-old man with permanent AF has HR 112 bpm, breathlessness on exertion. eGFR normal. No asthma.
Which drug is most appropriate first-line?
A 30-week infant develops respiratory distress 20 minutes after birth. CPAP is started. FiO₂ remains at 0.40 to maintain saturations.
What is the most appropriate next step?
A 78-year-old woman in a care home has unintentionally lost 7% of her body weight over 3 months. Her BMI is 18 kg/m² and she has had reduced intake for the past 5 days. What is her MUST score category?
A 78-year-old woman presents with acute back pain; X-ray confirms T12 wedge fracture due to osteoporosis.
Next most appropriate step?
A 54-year-old man presents with unilateral lower-leg erythema, warmth, swelling, and fever. No abscess, no purulence. No penicillin allergy.
Most appropriate initial antibiotic?
A 64-year-old man with myeloma presents with confusion, polyuria, and calcium of 3.35 mmol/L. What is first-line management?
