MSRA (Multi-Specialty Recruitment Assessment) — Questions and Answers

Question 1: You smell alcohol on a colleague who is about to start a clinical shift. What is the most appropriate first action?

Ignore it as you may be mistaken
Speak to them privately and raise it with a senior to ensure patient safety (Correct answer)
Cover their shift quietly and say nothing
Announce it to the whole team

Correct answer: Speak to them privately and raise it with a senior to ensure patient safety

Patient safety requires the colleague to be removed from clinical duties and the concern escalated appropriately.

Question 2: A 62-year-old man with COPD presents with increased breathlessness, green sputum and wheeze. What is the most appropriate first-line treatment for an infective exacerbation?

Inhaled steroids alone
Immediate intubation
Long-term oxygen therapy
Antibiotics and bronchodilators (Correct answer)

Correct answer: Antibiotics and bronchodilators

An infective COPD exacerbation is treated with antibiotics and increased bronchodilators.

Question 3: During a ward round, a consultant makes a clinical error and asks the junior doctor not to document it. What should the junior doctor do?

Comply with the consultant's request to avoid conflict
Document the error but do not tell the patient
Ask the patient if they want to know
Document the clinical facts accurately and escalate the error via incident reporting (Correct answer)

Correct answer: Document the clinical facts accurately and escalate the error via incident reporting

The duty of candour requires honest documentation of errors and transparent reporting through incident systems; concealment is professionally and legally indefensible.

Question 4: A patient prescribed gentamicin requires monitoring. Which parameters are most important to check?

Monthly full blood count
Weekly liver function tests
Renal function and drug trough/peak levels (Correct answer)
Thyroid function tests

Correct answer: Renal function and drug trough/peak levels

Gentamicin is an aminoglycoside antibiotic that is nephrotoxic and ototoxic; monitoring renal function and serum drug levels is essential to prevent toxicity.

Question 5: What format do most CPS questions take?

Single best answer and extended matching questions (Correct answer)
Long essays
Group discussions
Practical bedside examinations

Correct answer: Single best answer and extended matching questions

CPS uses single best answer and extended matching question formats.

Question 6: A relative of a patient asks you for confidential details about the patient's condition, but the patient has not given consent. What should you do?

Explain you cannot share details without the patient's consent (Correct answer)
Tell them to ask the consultant
Share the information as they are close family
Share only the diagnosis but not the prognosis

Correct answer: Explain you cannot share details without the patient's consent

Patient confidentiality must be maintained unless the patient consents to disclosure.

Question 7: Which professional framework underpins the scenarios in the Professional Dilemmas paper?

The Mental Capacity Act alone
The Highway Code
NICE technology appraisals
GMC's Good Medical Practice (Correct answer)

Correct answer: GMC's Good Medical Practice

PD scenarios are based on the GMC's Good Medical Practice principles expected of all doctors.

Question 8: A patient with capacity refuses a treatment you strongly believe they need. What is the most appropriate response?

Treat them anyway in their best interests
Persuade a relative to override the decision
Discharge them immediately for non-compliance
Respect their decision after ensuring they understand the consequences (Correct answer)

Correct answer: Respect their decision after ensuring they understand the consequences

A patient with capacity has the right to refuse treatment once properly informed of the risks.

Question 9: Why is time management considered critical in the MSRA?

Only one question is asked
Marks are not affected by unanswered questions
Both papers have a large number of questions within tight time constraints (Correct answer)
There is no time limit

Correct answer: Both papers have a large number of questions within tight time constraints

Both the CPS and PD papers contain many questions to be completed in limited time, making pacing essential.

Question 10: Good preparation for the Professional Dilemmas paper includes:

Learning ECG criteria
Studying surgical techniques
Familiarity with GMC Good Medical Practice guidance (Correct answer)
Memorising drug doses

Correct answer: Familiarity with GMC Good Medical Practice guidance

Knowing GMC professional standards underpins success in the dilemmas paper.

Question 11: A patient on lithium develops coarse tremor, ataxia, and confusion. What is the most likely diagnosis?

Neuroleptic malignant syndrome
Lithium toxicity (Correct answer)
Serotonin syndrome
Lithium withdrawal syndrome

Correct answer: Lithium toxicity

Lithium toxicity classically presents with coarse tremor (distinct from the fine tremor at therapeutic levels), ataxia, and confusion, progressing to seizures and coma in severe cases.

Question 12: You notice a senior colleague making a prescribing error. What is the most appropriate response?

Raise the concern politely with the colleague directly and ensure the error is corrected (Correct answer)
Ignore it because they are more senior
Correct the prescription yourself without telling anyone
File an anonymous complaint to the hospital board

Correct answer: Raise the concern politely with the colleague directly and ensure the error is corrected

Patient safety requires addressing the error. Speaking directly to the colleague is appropriate first, allowing them to correct it. If the error isn't corrected or there's a pattern, escalation to a supervisor is necessary.

Question 13: A patient discloses that they have been physically abused by a family member. They are an adult with capacity and ask you to keep this confidential. What should you do?

Respect confidentiality absolutely and take no action
Document the disclosure and discharge
Provide support, safety information, and specialist referral; override confidentiality only if there is serious ongoing risk to the patient or others (Correct answer)
Report to the police immediately without the patient's knowledge

Correct answer: Provide support, safety information, and specialist referral; override confidentiality only if there is serious ongoing risk to the patient or others

Adults with capacity can choose not to report abuse; the clinician should offer support and resources, but confidentiality may be breached only when there is a serious and ongoing safety risk that cannot otherwise be managed.

Question 14: A 45-year-old woman presents to A&E five days after a total knee replacement with sudden-onset breathlessness, pleuritic chest pain, and haemoptysis. Her oxygen saturation is 91% on air and heart rate is 112 bpm. What is the most likely diagnosis?

Acute aortic dissection
Spontaneous pneumothorax
Pulmonary embolism (Correct answer)
Community-acquired pneumonia

Correct answer: Pulmonary embolism

Recent major orthopaedic surgery is a major VTE risk factor. Sudden dyspnoea, pleuritic chest pain, haemoptysis, tachycardia, and hypoxia in this context constitute a classic presentation of pulmonary embolism. Pneumonia typically has a more gradual onset with fever; pneumothorax would show absent breath sounds; aortic dissection presents with tearing back pain.

Question 15: You notice a colleague has documented observations in the notes that you are certain were never taken. What should you do first?

Ignore it as it is not your responsibility
Alter the notes yourself to correct them
Report them immediately to the GMC
Speak to the colleague directly to understand what happened (Correct answer)

Correct answer: Speak to the colleague directly to understand what happened

Raising the concern directly first allows clarification and gives the colleague a chance to explain or correct it.

Question 16: What does the MSRA primarily assess for entry into specialty training?

Research publication count
Clinical knowledge and professional judgement (Correct answer)
Surgical dexterity only
Foreign language fluency

Correct answer: Clinical knowledge and professional judgement

The MSRA evaluates both clinical problem-solving and situational/professional judgement.

Question 17: A senior colleague uses a term you consider to be racially offensive toward a patient during a ward round. What is the most appropriate immediate response?

Address it calmly at the time or immediately after, apologise to the patient, and report through the appropriate channel (Correct answer)
Ask another colleague to deal with it
Report directly to the GMC without speaking to the colleague
Ignore it to avoid confrontation in front of the patient

Correct answer: Address it calmly at the time or immediately after, apologise to the patient, and report through the appropriate channel

Discriminatory language toward patients is unprofessional and potentially harmful; addressing it respectfully and promptly, with a formal report if necessary, upholds patient dignity and professional standards.

Question 18: A doctor discovers their colleague is performing procedures while impaired by alcohol. What is the appropriate first action under GMC duty of candour?

Document the observation and review in 1 month
Advise the colleague to self-refer to occupational health
Report immediately to the Clinical Director or nominated responsible officer (Correct answer)
Confront the colleague privately and monitor the situation

Correct answer: Report immediately to the Clinical Director or nominated responsible officer

GMC Good Medical Practice requires doctors to act promptly when patient safety is at risk from a colleague's health, conduct, or performance — escalation to the responsible officer is mandatory.

Question 19: A patient's family member asks you not to tell the patient about their terminal diagnosis. What should you do?

Explore the family's concerns but explain that the patient has the right to know their diagnosis if they wish (Correct answer)
Agree to withhold the diagnosis as the family requested
Refer the decision to the hospital ethics committee
Tell the patient immediately without further discussion

Correct answer: Explore the family's concerns but explain that the patient has the right to know their diagnosis if they wish

While understanding family concerns is important, patients have the right to know their diagnosis (GMC guidance on consent). Explore what the patient wants to know and share information at an appropriate pace, respecting patient autonomy.

Question 20: A patient on warfarin is started on amoxicillin for a chest infection. What is the most likely effect on their INR?

Increase in INR (Correct answer)
Variable effect depending on dose
Decrease in INR
No change in INR

Correct answer: Increase in INR

Antibiotics reduce gut flora that produce Vitamin K, decreasing its availability and potentiating warfarin's anticoagulant effect, thereby raising the INR.

Question 21: Which statement best describes first-order pharmacokinetics?

The rate of elimination is proportional to the drug concentration (Correct answer)
A fixed amount of drug is eliminated per unit time
Elimination rate is independent of drug concentration
Drug half-life increases as plasma concentration rises

Correct answer: The rate of elimination is proportional to the drug concentration

In first-order kinetics, the rate of drug elimination is proportional to the plasma concentration, resulting in a constant half-life — the majority of drugs at therapeutic doses follow this pattern.

Question 22: A patient taking an ACE inhibitor develops a persistent dry cough. What is the most appropriate management?

Add an antihistamine
Add a short-acting beta-agonist inhaler
Switch to an angiotensin receptor blocker (ARB) (Correct answer)
Reduce the ACE inhibitor dose

Correct answer: Switch to an angiotensin receptor blocker (ARB)

ACE inhibitor cough is caused by bradykinin accumulation; switching to an ARB avoids this mechanism while maintaining renin-angiotensin system blockade.

Question 23: Which statement about MSRA preparation is most accurate?

Only the CPS paper needs practice
No preparation helps
Practising timed questions for both papers improves performance (Correct answer)
Only the PD paper needs practice

Correct answer: Practising timed questions for both papers improves performance

Timed practice across both the CPS and PD papers builds speed, accuracy, and familiarity with formats.

Question 24: Which medication is first-line for an acute exacerbation of asthma in an adult?

Beta-blockers
Inhaled or nebulised salbutamol (Correct answer)
IV magnesium as first step
Oral antibiotics

Correct answer: Inhaled or nebulised salbutamol

Inhaled or nebulised short-acting beta-2 agonists such as salbutamol are first-line in acute asthma.

Question 25: You are asked to see more patients than you feel is safe during an on-call shift. What should you do?

See only the patients you feel comfortable with and ignore the rest
Raise your concerns with the on-call senior and document your concerns about patient safety (Correct answer)
Leave the shift early to maintain your own safety
Work through it without complaining

Correct answer: Raise your concerns with the on-call senior and document your concerns about patient safety

You have a duty to raise concerns about patient safety. Escalate to the on-call senior, clinical supervisor, or site manager, documenting your concerns. Never simply abandon patients or stay silent about unsafe conditions.

Question 26: After the MSRA, how are results typically used by specialties?

Published publicly with names attached
Combined with other criteria to rank candidates for interview or offers (Correct answer)
Used only as a pass/fail certificate with no ranking
Discarded entirely

Correct answer: Combined with other criteria to rank candidates for interview or offers

MSRA scores are combined with other selection criteria to rank applicants for training posts.

Question 27: The MSRA is primarily used to assess applicants for which stage of UK medical training?

Foundation Programme entry
Specialty (ST1/CT1) training recruitment (Correct answer)
Consultant appointment
Medical school admission

Correct answer: Specialty (ST1/CT1) training recruitment

The MSRA is a computer-based test used to recruit foundation doctors into a range of specialty training programmes.

Question 28: Extended matching questions in CPS require you to:

Choose true/false
Write a paragraph
Rank all options
Match a stem to the best option from a longer list (Correct answer)

Correct answer: Match a stem to the best option from a longer list

EMQs provide a themed option list and you select the best match for each stem.

Question 29: When unsure between two close CPS options, the best strategy is to:

Always pick the longest option
Identify which fits the most clues in the vignette (Correct answer)
Skip without marking
Pick randomly immediately

Correct answer: Identify which fits the most clues in the vignette

Weighing the answer that explains the most clinical features improves accuracy.

Question 30: A 32-year-old woman presents with palpitations, weight loss, heat intolerance and a fine tremor. Which result would confirm hyperthyroidism?

Low TSH with high free T4 (Correct answer)
Normal TSH and T4
Low TSH with low free T4
High TSH with low free T4

Correct answer: Low TSH with high free T4

Primary hyperthyroidism is confirmed by a suppressed TSH alongside an elevated free T4.

Question 31: Which of the following best defines the legal standard of capacity under the Mental Capacity Act 2005?

Agreement with the treating clinician's recommendation
The ability to understand, retain, weigh, and communicate a decision (Correct answer)
Having an IQ above a threshold value
The ability to make the right decision

Correct answer: The ability to understand, retain, weigh, and communicate a decision

The MCA 2005 defines capacity as the ability to understand relevant information, retain it, weigh it in the decision, and communicate a decision — irrespective of the wisdom of the choice.

Question 32: A 17-year-old is brought in unconscious following a drug overdose. His parents demand full disclosure of his medical history and current treatment. What is the correct approach?

Discharge to parental care without treatment
Treat the patient, and share only information necessary for immediate care, respecting prior expressed confidentiality preferences where known (Correct answer)
Provide full disclosure to the parents as he is a minor
Refuse to speak to parents at all

Correct answer: Treat the patient, and share only information necessary for immediate care, respecting prior expressed confidentiality preferences where known

Even for minors, confidentiality obligations apply; share information necessary for treatment and safety, but full historical disclosure requires either patient consent or a clear public interest justification.

Question 33: You notice that handovers between shifts on your ward are frequently incomplete, risking patient safety. What is the best action?

Blame the previous shift each time
Only ensure your own handovers are complete
Accept it as how things are
Raise the issue constructively and suggest a structured handover process (Correct answer)

Correct answer: Raise the issue constructively and suggest a structured handover process

Addressing a systemic handover problem with a structured solution improves safety for all patients.

Question 34: Which electrolyte abnormality is most associated with tall, tented T waves on an ECG?

Hyperkalaemia (Correct answer)
Hyponatraemia
Hypokalaemia
Hypercalcaemia

Correct answer: Hyperkalaemia

Hyperkalaemia classically produces tall, tented T waves and can progress to dangerous arrhythmias.

Question 35: What is the most appropriate initial management of a patient presenting with diabetic ketoacidosis?

Subcutaneous insulin only
IV fluid resuscitation, IV insulin infusion, and potassium replacement (Correct answer)
Oral hypoglycemic agents
Bicarbonate infusion as first-line treatment

Correct answer: IV fluid resuscitation, IV insulin infusion, and potassium replacement

DKA management priorities are fluid resuscitation (0.9% saline), IV insulin infusion, potassium monitoring and replacement, and identifying the precipitating cause. Bicarbonate is reserved for severe acidosis (pH <6.9).

Question 36: In an SJT scenario, a patient asks you not to tell their family about their diagnosis. What should you do?

Tell the family anyway
Refuse to treat the patient
Respect the patient's confidentiality if they have capacity (Correct answer)
Document nothing

Correct answer: Respect the patient's confidentiality if they have capacity

A competent adult's confidentiality must be respected unless there is an overriding legal or public-safety reason to breach it.

Question 37: Which of the following is a mandatory notification to the Care Quality Commission (CQC) in England?

All surgical complications
Deaths of service users where abuse or neglect may have contributed (Correct answer)
All clinical complaints
Every medication error regardless of harm

Correct answer: Deaths of service users where abuse or neglect may have contributed

CQC regulations require mandatory notification of deaths where abuse or neglect may be a factor, along with other specified serious incidents, to enable regulatory oversight.

Question 38: A scenario asks you to choose the three most appropriate actions. You should:

Select actions that best protect patients and uphold standards (Correct answer)
Pick the three easiest actions
Choose actions that save you time
Select any three at random

Correct answer: Select actions that best protect patients and uphold standards

The best actions are those most aligned with safety and professional standards.

Question 39: A patient with end-stage renal failure requires analgesia for severe pain. Which opioid is most appropriate?

Morphine
Codeine
Tramadol
Fentanyl (Correct answer)

Correct answer: Fentanyl

Fentanyl is the preferred opioid in renal failure as it has no active metabolites; morphine and codeine accumulate toxic metabolites (morphine-6-glucuronide and norcodeine) that cause prolonged sedation and respiratory depression.

Question 40: You disagree with a management plan made by your consultant for a patient. What is the most appropriate action?

Change the plan yourself without telling anyone
Complain to other juniors about the consultant
Raise your concerns respectfully with the consultant and discuss the reasoning (Correct answer)
Follow it silently despite your concerns

Correct answer: Raise your concerns respectfully with the consultant and discuss the reasoning

Constructive discussion clarifies the reasoning and can improve the plan while maintaining professional respect.

Question 41: A patient becomes acutely unwell on the ward while you are mid-way through a non-urgent discharge summary. What is the most appropriate response?

Finish the summary quickly then attend the patient
Continue the summary as the discharge is also time-sensitive
Ask the patient's relatives to find another doctor
Stop the summary and attend to the acutely unwell patient (Correct answer)

Correct answer: Stop the summary and attend to the acutely unwell patient

Clinical urgency takes priority, so an acutely unwell patient must be attended before non-urgent paperwork.

Question 42: You suspect a colleague who is an FY1 is struggling with serious personal problems affecting their clinical performance. The safest and most appropriate initial action is to:

Speak privately to the colleague to offer support and encourage them to seek help, and escalate if patient safety is at immediate risk (Correct answer)
Report them to the GMC without delay
Ignore the situation as it is not your responsibility
Inform the entire team to ensure patient safety

Correct answer: Speak privately to the colleague to offer support and encourage them to seek help, and escalate if patient safety is at immediate risk

The GMC recommends a supportive approach first — talking to the colleague and encouraging occupational health or senior support — while escalating only if patient safety is compromised.

Question 43: A randomised controlled trial reports a p-value of 0.03 and a 95% confidence interval for the mean difference of 0.5 to 4.5 mmHg. What can be concluded?

The p-value and CI are contradictory
The result is not statistically significant
The result is statistically significant but clinical significance requires assessment of the effect size (Correct answer)
The confidence interval confirms clinical significance

Correct answer: The result is statistically significant but clinical significance requires assessment of the effect size

A p-value <0.05 and CI not crossing zero indicate statistical significance, but whether a 0.5–4.5 mmHg difference is clinically meaningful requires separate evaluation.

Question 44: Which clinical areas are commonly covered in the CPS paper?

Only cardiology
A broad range including general medicine, surgery, paediatrics, psychiatry and more (Correct answer)
Only laboratory sciences
Only public health

Correct answer: A broad range including general medicine, surgery, paediatrics, psychiatry and more

The CPS paper samples across the major specialties relevant to early postgraduate practice.

Question 45: Probity in Good Medical Practice mainly refers to:

Honesty and integrity in professional conduct (Correct answer)
Use of social media
Speed of clinical work
Number of patients seen

Correct answer: Honesty and integrity in professional conduct

Probity covers being honest and trustworthy in all professional matters.

Question 46: Which of these is a key professional attribute tested by the PD paper?

Memorisation speed
Empathy and effective communication (Correct answer)
Knowledge of statistics
Manual dexterity

Correct answer: Empathy and effective communication

Attributes such as empathy, communication, and coping with pressure are central to PD assessment.

Question 47: You witness a senior colleague being rude and dismissive to a patient. What is the most appropriate action?

Ignore it because they are senior
Raise your concern with the colleague privately at an appropriate time (Correct answer)
Confront them loudly in front of the patient
Tell the patient to make a formal complaint

Correct answer: Raise your concern with the colleague privately at an appropriate time

A private, professional conversation addresses the behaviour without escalating the situation in front of the patient.

Question 48: A common pitfall in CPS questions is:

Choosing a 'classic' answer without matching all the clinical details (Correct answer)
Eliminating clearly wrong options
Reading the question stem carefully
Watching the clock

Correct answer: Choosing a 'classic' answer without matching all the clinical details

Jumping to a textbook answer without confirming it fits every detail of the vignette often leads to errors.

Question 49: Time management is critical in the MSRA mainly because:

You must handwrite essays
Each question is timed individually
There are many questions in a limited time (Correct answer)
Answers are negatively marked heavily

Correct answer: There are many questions in a limited time

The volume of questions relative to time makes pacing essential.

Question 50: Jane, a sixteen-year-old competitive cyclist and gymnast, trains multiple times a week. Her mother, who is worried about her right knee, accompanies her to the GP office. For the past six months, they have experienced intermittent pain, but despite the mild discomfort, they are worried about how long the symptoms will last. Subsequent investigation revealed that there is no knee swelling or other affected joints, but that kneeling and jumping exacerbate the pain. Jane is in good health overall and has no additional medical history. Examining the area revealed tibial tuberosity tenderness, which grew worse when the knee was extended against resistance. She has a normal gait, no swelling in her knee joints, and complete range of motion in both knees.

Osgood-Schlatter disease (Correct answer)
Pseudogout
Osteochondritis dissecans
Patellofemoral pain syndrome

Correct answer: Osgood-Schlatter disease

Osgood-Schlatter disease is a common cause of knee pain in active adolescents, particularly those involved in sports like cycling and gymnastics that involve repetitive quadriceps contractions. The classic presentation includes pain and tenderness at the tibial tuberosity (just below the kneecap), which is exacerbated by activities such as kneeling, jumping, and resisted knee extension. It is an overuse injury involving inflammation of the patellar tendon insertion.

Question 51: Which antibiotic is commonly first-line for an uncomplicated lower urinary tract infection in a non-pregnant woman?

Nitrofurantoin (Correct answer)
Metronidazole
Gentamicin
Vancomycin

Correct answer: Nitrofurantoin

Nitrofurantoin is a recommended first-line antibiotic for uncomplicated lower UTI in non-pregnant women.

Question 52: The Professional Dilemmas paper is designed to assess a candidate's:

Memorised drug doses
Professional judgement and integrity in workplace situations (Correct answer)
Knowledge of medical history
Surgical technique

Correct answer: Professional judgement and integrity in workplace situations

The PD paper evaluates situational judgement, professionalism, coping with pressure, and empathy.

Question 53: A patient declines a recommended treatment after being fully informed. What should you do?

Respect their autonomous decision (Correct answer)
Treat them without consent
Discharge them immediately
Override them for their own good

Correct answer: Respect their autonomous decision

A competent, informed patient has the right to refuse treatment.

Question 54: A patient on warfarin has an INR of 8.0 with no bleeding. What is the appropriate management?

Give IV heparin
No action needed
Increase the warfarin dose
Withhold warfarin and consider oral vitamin K (Correct answer)

Correct answer: Withhold warfarin and consider oral vitamin K

An INR of 8.0 without bleeding is managed by withholding warfarin and giving oral vitamin K.

Question 55: A 6-month-old infant has a fever, drawing up of the legs and episodes of inconsolable crying with 'redcurrant jelly' stools. What is the likely diagnosis?

Pyloric stenosis
Constipation
Gastroenteritis
Intussusception (Correct answer)

Correct answer: Intussusception

Colicky pain with redcurrant jelly stools in an infant is characteristic of intussusception.

Question 56: LFTs show: ALP 480 U/L, GGT 510 U/L, ALT 65 U/L, bilirubin 55 µmol/L, albumin 38 g/L. What pattern do these results suggest?

Cholestatic liver disease (Correct answer)
Hepatocellular injury
Acute hepatitis
Hepatic synthetic failure

Correct answer: Cholestatic liver disease

Disproportionate elevation of ALP and GGT relative to aminotransferases, with raised bilirubin, is the hallmark of a cholestatic (obstructive) pattern of liver disease.

Question 57: In Clinical Problem Solving, a question describes typical symptoms then asks for the most likely diagnosis. What should you do?

Choose the single best fit for the whole presentation (Correct answer)
Choose two answers
Pick the rarest option
Always select the first option

Correct answer: Choose the single best fit for the whole presentation

Best-of-five items require the single most likely answer for the full clinical picture.

Question 58: What is the Wells score used to assess?

Clinical probability of pulmonary embolism or deep vein thrombosis (Correct answer)
Risk of stroke in atrial fibrillation
Severity of heart failure
Likelihood of appendicitis

Correct answer: Clinical probability of pulmonary embolism or deep vein thrombosis

The Wells score is a clinical prediction rule that estimates the pre-test probability of PE or DVT based on clinical features, helping determine whether D-dimer testing or imaging is appropriate.

Question 59: A patient on carbamazepine develops a skin rash. What is the most important immediate action?

Add sodium valproate and review in 1 week
Stop carbamazepine immediately (Correct answer)
Halve the dose of carbamazepine
Prescribe an antihistamine and continue carbamazepine

Correct answer: Stop carbamazepine immediately

Carbamazepine can cause life-threatening cutaneous reactions including Stevens-Johnson syndrome and toxic epidermal necrolysis; any rash warrants immediate drug discontinuation.

Question 60: A patient presents with a painful, red, swollen calf after a long-haul flight. What is the most likely diagnosis?

Deep vein thrombosis (Correct answer)
Cellulitis only
Varicose veins
Muscle cramp

Correct answer: Deep vein thrombosis

Unilateral calf pain and swelling after prolonged immobility strongly suggests deep vein thrombosis.

Question 61: A nurse tells you a drug chart you wrote contains a dose she believes is too high. You think it is correct. What should you do?

Ignore her concern as prescribing is your role
Recheck the dose against guidelines and discuss it with the nurse (Correct answer)
Cross it out and let her decide the dose
Tell her to administer it as written

Correct answer: Recheck the dose against guidelines and discuss it with the nurse

A raised safety concern warrants rechecking the evidence and open discussion before the drug is given.

Question 62: In 'multiple-choice/select-three' SJT items, how are marks typically awarded?

Negative marks for any selection
Partial credit for each correct option selected (Correct answer)
Marks only for the single best option
All-or-nothing for getting every option right

Correct answer: Partial credit for each correct option selected

Select-the-three-most-appropriate items usually give partial credit per correct choice.

Question 63: A 22-year-old university student presents with high fever, severe headache, neck stiffness, photophobia, and a rapidly spreading non-blanching purpuric rash. What is the single most important immediate action?

Obtain blood cultures and await sensitivity results before treating
Request an urgent CT head before any treatment
Perform a lumbar puncture to confirm diagnosis
Administer intravenous benzylpenicillin immediately (Correct answer)

Correct answer: Administer intravenous benzylpenicillin immediately

A non-blanching purpuric rash with signs of meningism indicates probable meningococcal septicaemia — a life-threatening emergency. IV benzylpenicillin must be given immediately without waiting for investigations, as delay significantly increases mortality. Lumbar puncture and CT can follow once the patient is stabilised.

Question 64: A hospital audit reveals a systematic issue where a specific consent form omits a significant risk of paralysis for spinal surgery. What is the most appropriate response?

Perform a root cause analysis, update the consent form, and implement a system-wide change with staff education (Correct answer)
Report individual surgeons to the GMC
Inform only the patients who suffered the complication
Update only future consent forms

Correct answer: Perform a root cause analysis, update the consent form, and implement a system-wide change with staff education

Systemic consent failures require a systems-level response: root cause analysis, process redesign, and education to prevent recurrence and uphold the duty of candour.

Question 65: In an SJT scenario you disagree with a senior's management plan that you believe may harm the patient. What is the best action?

Respectfully raise your concern and escalate if needed (Correct answer)
Refuse and ignore the senior entirely
Complain to the patient
Carry out the plan silently

Correct answer: Respectfully raise your concern and escalate if needed

You should raise concerns respectfully and escalate appropriately to protect the patient.

Question 66: Which of the following is the most appropriate initial management for a stable patient with new atrial fibrillation and a fast ventricular rate?

Immediate DC cardioversion
No treatment
Rate control with a beta-blocker (Correct answer)
Thrombolysis

Correct answer: Rate control with a beta-blocker

In a haemodynamically stable patient with AF, rate control with a beta-blocker is an appropriate first-line approach.

Question 67: On exam day, what is a sensible strategy for the Professional Dilemmas paper's tight timing?

Re-read every scenario at least four times
Spend the most time on the first five questions
Go with your first well-reasoned instinct and avoid over-analysing each scenario (Correct answer)
Answer the questions in reverse order

Correct answer: Go with your first well-reasoned instinct and avoid over-analysing each scenario

First well-reasoned judgements and steady pacing prevent running out of time on the SJT paper.

Question 68: Which preparation approach is most effective for the Clinical Problem Solving paper?

Memorising only cardiology in great depth
Timed practice across the listed clinical specialties to build speed and breadth (Correct answer)
Focusing solely on the SJT paper
Reading textbooks cover to cover without practice questions

Correct answer: Timed practice across the listed clinical specialties to build speed and breadth

Broad, timed practice across the covered specialties builds both recall speed and coverage needed for CPS.

Question 69: A 68-year-old woman with known atrial fibrillation presents with sudden left-sided weakness and facial droop lasting 45 minutes before fully resolving. What is the most appropriate next step?

Order an MRI in outpatient clinic
Reassure and discharge
Admit urgently using the ABCD2 score and fast-track TIA pathway (Correct answer)
Start aspirin and review in 2 weeks

Correct answer: Admit urgently using the ABCD2 score and fast-track TIA pathway

A TIA in a patient with AF carries high early stroke risk; same-day neurovascular assessment and urgent investigation are mandatory under the fast-track TIA pathway.

Question 70: A 55-year-old woman has TSH 0.08 mU/L (low), free T4 28 pmol/L (high), and free T3 9.2 pmol/L (high). She is symptomatic with palpitations and weight loss. What is the diagnosis?

Primary hypothyroidism
Subclinical hyperthyroidism
Secondary hypothyroidism
Overt hyperthyroidism (Correct answer)

Correct answer: Overt hyperthyroidism

Suppressed TSH with elevated free T4 and free T3 in a symptomatic patient confirms overt primary hyperthyroidism requiring treatment.

Question 71: You witness a colleague making a prescribing error that has not yet reached the patient. What is best?

Wait to see what happens
Blame the pharmacist
Document it but say nothing
Intervene to correct it before harm occurs (Correct answer)

Correct answer: Intervene to correct it before harm occurs

Preventing harm takes priority, so you should act to correct the error.

Question 72: An ECG shows a rate of 150 bpm, regular, narrow QRS complexes, no visible P waves, and a sawtooth baseline at 300/min. What is the rhythm?

Atrial flutter with 2:1 block (Correct answer)
Sinus tachycardia
Atrial fibrillation
SVT

Correct answer: Atrial flutter with 2:1 block

Atrial flutter typically produces a sawtooth atrial rate of ~300/min; with 2:1 AV block, the ventricular rate is ~150 bpm with regular narrow complexes.

Question 73: The 54-year-old Ramesh is requesting a PSA test at your next appointment because he is concerned after learning that a colleague has been diagnosed with prostate cancer. After discussing the fact that a PSA test is not diagnostic, you schedule one. Of the following, which one wouldn't have an impact on a PSA reading?

An active urinary infection
Had a biopsy on the prostate six weeks prior.
Vigorously worked out the previous 48 hours
Ejaculation 72 hours ago (Correct answer)

Correct answer: Ejaculation 72 hours ago

PSA levels can be temporarily elevated by various factors that irritate or inflame the prostate, including recent prostate biopsy, active urinary tract infections, and vigorous exercise. While ejaculation can also cause a transient rise in PSA, this effect is typically short-lived and usually resolves within 24-48 hours. Therefore, ejaculation 72 hours prior would generally not have a significant impact on a PSA reading, unlike the other options which can cause more prolonged or significant elevations.

Question 74: Why might two doctors applying to different specialties both sit the MSRA?

Specialties never use the same test
It is a random requirement
Many specialties share the MSRA as a common selection assessment (Correct answer)
It is only for one specialty

Correct answer: Many specialties share the MSRA as a common selection assessment

The MSRA is used across numerous specialties such as GP, psychiatry, radiology and others as a shared selection tool.

Question 75: Terry, 52, was recently diagnosed with hypertension, but despite taking his medication as directed, his condition is regrettably still out of control. Upon closer inspection, his potassium level is consistently low, and his sodium level is on the verge of being high. He is otherwise fine; neither his weight nor appearance have changed. Of the following conditions, which one is most likely to be present in him?

Conn’s syndrome (Correct answer)
Cushing’s disease
Phaechromocytoma
Essential hypertension

Correct answer: Conn’s syndrome

Conn's syndrome, or primary hyperaldosteronism, is characterized by resistant hypertension, consistently low potassium (hypokalemia), and often mild elevation of sodium (hypernatremia). The excess aldosterone production leads to increased sodium reabsorption and potassium excretion in the kidneys, causing these specific electrolyte imbalances and contributing to difficult-to-control high blood pressure. This clinical picture makes Conn's syndrome the most likely diagnosis for secondary hypertension.

Question 76: A 25-year-old man presents with acute testicular pain, swelling and a high-riding testis after sudden onset. What is the immediate concern?

Varicocele
Testicular torsion (Correct answer)
Hydrocele
Epididymitis

Correct answer: Testicular torsion

Sudden severe testicular pain with a high-riding testis is testicular torsion, a surgical emergency.

Question 77: A doctor performs a procedure slightly beyond the scope of consent because they encounter an unexpected finding intraoperatively that is easily correctable. What ethical issue arises?

None — intraoperative flexibility is always permissible
The extension must be justified by an imminent threat to the patient's life or health that could not reasonably be deferred (Correct answer)
Only a problem if the outcome is poor
Acceptable if the patient had signed a general surgical consent

Correct answer: The extension must be justified by an imminent threat to the patient's life or health that could not reasonably be deferred

Extending a procedure beyond consent is only defensible when deferral would pose an immediate risk to life or health; convenience or efficiency does not justify exceeding the scope of consent.

Question 78: A 72-year-old man taking warfarin for atrial fibrillation develops sudden-onset left-sided facial droop, arm weakness, and slurred speech that resolves completely within 40 minutes. What is the most appropriate initial investigation?

MRI brain with diffusion-weighted imaging
Non-contrast CT head (Correct answer)
Transthoracic echocardiogram
Carotid Doppler ultrasound

Correct answer: Non-contrast CT head

This presentation is consistent with a TIA. In a patient on anticoagulation, a non-contrast CT head must be performed first to exclude intracranial haemorrhage before any management decisions are made. Although diffusion-weighted MRI is more sensitive for detecting early ischaemia, excluding a bleed takes priority, particularly in anticoagulated patients.

Question 79: What is the typical answer format for the Clinical Problem Solving paper?

Oral viva
OSCE stations
Essay responses
Best-of-five and extended matching questions (Correct answer)

Correct answer: Best-of-five and extended matching questions

CPS uses single best answer and extended matching question formats.

Question 80: A CPS stem describes classic features of a condition with one distractor symptom. The best approach is to:

Identify the overall clinical pattern rather than over-weighting a single symptom (Correct answer)
Choose the rarest diagnosis available
Always select the first option alphabetically
Pick the diagnosis matching the distractor symptom

Correct answer: Identify the overall clinical pattern rather than over-weighting a single symptom

Recognising the overall pattern, not one distractor, leads to the correct single best answer.

Question 81: A 65-year-old woman presents with macrocytic anaemia, peripheral neuropathy, and a sore tongue. She had a total gastrectomy 5 years ago. What is the most likely cause?

Hypothyroidism
Iron deficiency
Folate deficiency
Vitamin B12 deficiency (Correct answer)

Correct answer: Vitamin B12 deficiency

Total gastrectomy removes the source of intrinsic factor, leading to vitamin B12 malabsorption and resulting in megaloblastic anaemia with subacute combined degeneration of the cord.

Question 82: Urinalysis shows: protein 3+, blood 1+, and microscopy reveals red cell casts. Serum creatinine has doubled in 2 weeks. What does this suggest?

Nephrotic syndrome
Benign prostatic hypertrophy
Nephritic syndrome with rapidly progressive glomerulonephritis (Correct answer)
Urinary tract infection

Correct answer: Nephritic syndrome with rapidly progressive glomerulonephritis

Red cell casts with haematuria, proteinuria, and rapidly rising creatinine is the hallmark of nephritic syndrome with rapidly progressive glomerulonephritis requiring urgent renal biopsy.

Question 83: Which ethical principle underpins the obligation to obtain informed consent before any medical procedure?

Justice
Non-maleficence
Autonomy (Correct answer)
Beneficence

Correct answer: Autonomy

Informed consent is rooted in the principle of autonomy — the patient's right to make informed decisions about their own body and treatment.

Question 84: A junior doctor is asked to obtain consent from a patient for a complex bowel resection they have never performed. What is the ethically correct action?

Obtain consent but note they are not the operating surgeon
Obtain consent as instructed and document it
Ask the patient to sign a generic consent form
Refuse and ensure the consenting clinician has the knowledge and skill to perform the procedure (Correct answer)

Correct answer: Refuse and ensure the consenting clinician has the knowledge and skill to perform the procedure

GMC guidance states that consent should be obtained by a clinician who has sufficient knowledge of the procedure to answer questions; delegating to an uninformed person renders consent invalid.

Question 85: A consultant asks you to prescribe a medication for a patient you have not assessed and whose notes you cannot access. What is the most appropriate first action?

Ask a nurse to prescribe it instead
Prescribe it but document that the consultant instructed you
Politely decline and explain you must review the patient before prescribing (Correct answer)
Prescribe it because a senior colleague requested it

Correct answer: Politely decline and explain you must review the patient before prescribing

You remain personally accountable for any prescription, so you must assess the patient and review information before signing.

Question 86: During a busy shift you realise you cannot safely complete all your tasks alone. What is the most appropriate action?

Prioritise by clinical urgency and ask a senior for help (Correct answer)
Leave the tasks for the next shift without handover
Complete only the easiest tasks first
Attempt everything quickly and hope for the best

Correct answer: Prioritise by clinical urgency and ask a senior for help

Prioritising by urgency and seeking help ensures the most important patient needs are met safely.

Question 87: The Professional Dilemmas paper is based on which framework?

ATLS protocols
GCS scoring
NICE prescribing only
Good Medical Practice and situational judgement (Correct answer)

Correct answer: Good Medical Practice and situational judgement

It tests application of GMC Good Medical Practice principles to workplace scenarios.

Question 88: A 58-year-old smoker has a chronic cough, haemoptysis and unintentional weight loss. What is the most appropriate initial imaging?

MRI brain
Echocardiogram
Abdominal CT
Chest X-ray (Correct answer)

Correct answer: Chest X-ray

A chest X-ray is the appropriate first-line investigation for suspected lung cancer.

Question 89: Which behaviour best demonstrates good professional integrity in a PD scenario?

Being honest about an error and acting to correct it (Correct answer)
Deleting the documentation
Falsifying a record to avoid blame
Blaming a junior

Correct answer: Being honest about an error and acting to correct it

Honesty (candour) and taking corrective action align with GMC professional standards.

Question 90: You are the on-call FY2 and receive multiple simultaneous bleeps. How should you prioritise?

Answer bleeps in the order received regardless of content
Ask the nurses to handle the less urgent bleeps
Attend to your existing patient before responding to any bleep
Rapidly triage all bleeps by clinical urgency and attend to the most life-threatening situation first (Correct answer)

Correct answer: Rapidly triage all bleeps by clinical urgency and attend to the most life-threatening situation first

On-call prioritisation requires rapid triage of all outstanding tasks by clinical urgency — life-threatening situations take precedence over time-based order of receipt.

Question 91: You realise mid-procedure that you have consented the patient for the wrong side. The patient is under anaesthetic. What should you do?

Ask a colleague to make the decision
Proceed on the correct side as you know what the patient needs
Proceed and document the error post-operatively
Stop the procedure, inform the anaesthetist and consultant, wake the patient if safe, and re-consent properly (Correct answer)

Correct answer: Stop the procedure, inform the anaesthetist and consultant, wake the patient if safe, and re-consent properly

A wrong-site or wrong-consent discovery requires immediate cessation of the procedure, transparent escalation, and re-consent before proceeding — the Never Events framework mandates this.

Question 92: During a busy night shift, a colleague asks you to co-sign a drug chart for a medication you did not administer or check. What should you do?

Sign but add a note that you were not present
Sign as a professional courtesy to help your colleague
Report the colleague to the GMC immediately
Decline to sign and explain that co-signing implies you verified the medication was given correctly (Correct answer)

Correct answer: Decline to sign and explain that co-signing implies you verified the medication was given correctly

Co-signing a drug chart implies verification of administration; signing for something you did not witness is dishonest and constitutes a serious documentation and patient safety breach.

Question 93: A 30-year-old woman presents with butterfly rash, joint pain, fatigue, and a positive ANA. Complement levels are low. What is the most likely diagnosis?

Rheumatoid arthritis
Systemic lupus erythematosus (Correct answer)
Dermatomyositis
Scleroderma

Correct answer: Systemic lupus erythematosus

The malar butterfly rash, polyarthritis, positive ANA, and low complement (consumed by immune complex deposition) are classic features of SLE.

Question 94: A patient asks you directly whether the operation they are about to have carries a risk of death. The consultant has not discussed this. What is the appropriate response?

Reassure the patient that the risk is negligible to avoid anxiety
Tell the patient to ask the consultant
Confirm that significant risks exist and ensure the consultant discusses them with the patient before proceeding (Correct answer)
Proceed with the pre-operative checklist and do nothing

Correct answer: Confirm that significant risks exist and ensure the consultant discusses them with the patient before proceeding

Patients have a right to information about material risks; if consent is inadequate the clinician must ensure it is corrected before surgery — deceiving the patient breaches the duty of candour.

Question 95: Which of the following is a contraindication to metformin use?

eGFR < 30 mL/min/1.73m² (Correct answer)
BMI > 35 kg/m²
Type 2 diabetes with HbA1c > 7%
Age > 70 years

Correct answer: eGFR < 30 mL/min/1.73m²

Metformin is contraindicated in severe renal impairment (eGFR < 30) because impaired excretion leads to accumulation and risk of potentially fatal lactic acidosis.

Question 96: What scoring system is used to assess stroke severity in MSRA clinical scenarios?

CHA2DS2-VASc score
NIH Stroke Scale (NIHSS) (Correct answer)
Glasgow Coma Scale
ABCD2 score

Correct answer: NIH Stroke Scale (NIHSS)

The NIHSS quantifies stroke severity by assessing consciousness, gaze, visual fields, facial palsy, motor function, ataxia, sensory function, language, dysarthria, and extinction/inattention.

Question 97: A 19-year-old female presents with recurrent episodes of palpitations, sweating, and anxiety relieved by eating. Fasting glucose is 2.1 mmol/L with elevated insulin levels. What is the diagnosis?

Addison's disease
Type 1 diabetes mellitus
Insulinoma (Correct answer)
Reactive hypoglycaemia

Correct answer: Insulinoma

Whipple's triad (symptoms of hypoglycaemia, low blood glucose, and relief with glucose) with elevated fasting insulin strongly suggests an insulin-secreting insulinoma.

Question 98: A patient's family pressures you to withhold a serious diagnosis from a competent patient. What should you do?

Withhold the diagnosis as the family requested
Explain the patient has a right to know and discuss it with them sensitively (Correct answer)
Document the diagnosis but never mention it
Tell the patient bluntly without preparation

Correct answer: Explain the patient has a right to know and discuss it with them sensitively

A competent patient has the right to information about their own health, communicated sensitively.

Question 99: You are repeatedly asked to stay late beyond your contracted hours, affecting your wellbeing. What is the most appropriate action?

Leave on time without informing anyone of unfinished work
Discuss the workload with your educational supervisor or rota coordinator (Correct answer)
Quietly keep staying late indefinitely
Refuse all future shifts

Correct answer: Discuss the workload with your educational supervisor or rota coordinator

Raising persistent workload concerns through the proper channels addresses both safety and your wellbeing.

Question 100: You are running an hour behind in clinic and patients are visibly frustrated. What is the most appropriate action?

Ask patients to rebook for another day
Rush each consultation to catch up
Skip the histories to save time
Apologise to waiting patients and ask reception to keep them updated (Correct answer)

Correct answer: Apologise to waiting patients and ask reception to keep them updated

Honest communication and updates maintain trust without compromising the quality of each consultation.

Question 101: You make a drug error that causes no harm to the patient. What is the most appropriate action?

Only tell a colleague informally
Report it through the incident system and inform a senior (Correct answer)
Say nothing as no harm occurred
Delete the relevant entry from the chart

Correct answer: Report it through the incident system and inform a senior

Near-miss and no-harm errors should still be reported so the system can learn and improve safety.

Question 102: A patient with schizophrenia refuses antipsychotic medication. He is currently detained under Section 3 of the Mental Health Act. Can treatment be given without consent?

Yes — immediately on detention with no restrictions
Yes — Section 3 allows treatment for mental disorder without consent after 3 months under Part IV MHA (Correct answer)
No — detention does not authorise treatment without consent
Only with a second opinion from an independent doctor from admission

Correct answer: Yes — Section 3 allows treatment for mental disorder without consent after 3 months under Part IV MHA

Under Part IV of the Mental Health Act, a patient detained under Section 3 can be treated for mental disorder without consent after 3 months, subject to second opinion (SOAD) safeguards.

Question 103: A junior colleague appears intoxicated on shift. What is the most appropriate first action?

Post about it online
Ignore it to avoid conflict
Ensure patient safety and escalate to a senior (Correct answer)
Send them home secretly

Correct answer: Ensure patient safety and escalate to a senior

Patient safety must be protected and the concern escalated through proper channels.

Question 104: In CPS, a vignette gives age, symptoms, and a key investigation result. The investigation is most useful for:

Distracting you from the diagnosis
Confirming you should guess
Replacing the history entirely
Narrowing the differential to the best answer (Correct answer)

Correct answer: Narrowing the differential to the best answer

Investigation findings help confirm or exclude options to reach the single best answer.

Question 105: A competent adult patient refuses a blood transfusion on religious grounds despite life-threatening haemorrhage. What should the clinician do?

Apply for emergency court order to override the patient
Respect the refusal, document it, and provide alternative management (Correct answer)
Refer the patient to psychiatry
Administer the transfusion to save the patient's life

Correct answer: Respect the refusal, document it, and provide alternative management

Competent adults have an absolute right to refuse treatment, even if that decision may result in death; the clinician must respect this, document clearly, and offer all alternative measures.

Question 106: A scoring feature of the PD ranking questions is that:

Negative marking applies to every wrong move
Only the top-ranked answer scores
All questions are pass/fail
Partial marks are awarded for near-correct orderings (Correct answer)

Correct answer: Partial marks are awarded for near-correct orderings

PD ranking items use partial scoring, so orderings close to the ideal still earn some marks.

Question 107: A terminally ill patient with capacity asks the doctor to administer a lethal dose of medication. What is the legal position in England and Wales?

Illegal — active euthanasia is not lawful (Correct answer)
Legal if the patient has a valid advance directive
Permitted under the doctrine of double effect
Legal if two doctors agree the patient is terminally ill

Correct answer: Illegal — active euthanasia is not lawful

Active euthanasia — intentionally administering a lethal agent — remains illegal in England and Wales regardless of patient consent or terminal prognosis.

Question 108: Which of the following medications routinely requires therapeutic drug level monitoring in clinical practice?

Atorvastatin
Amlodipine
Phenytoin (Correct answer)
Lisinopril

Correct answer: Phenytoin

Phenytoin has a narrow therapeutic index and exhibits non-linear (zero-order) pharmacokinetics at higher doses, making plasma level monitoring essential to ensure efficacy and avoid toxicity.

Question 109: You are a general surgery physician employed by the Foundation (F2). The end of your night shift is almost here. Following a traffic accident, Sarah, the F2 who will take over for you, informs you that her mother is critically ill. Sarah says she doesn't want time off ""on her record"" and has shown up for work as usual in spite of this. Choose the 3 most appropriate actions to take in this situation.

Option G: Let the ward consultant know that Sarah's mother exists.
Option F: Find out from medical staffing* if Sarah's shift can be filled by another F2 doctor. (Correct answer)
Option E: Inform Sarah that patient safety might be compromised if she stays at work. (Correct answer)
Option H: Make the suggestion that Sarah take her break and go see her mother.
Option A: Tell Sarah to schedule a visit with occupational health*..
Option D: Offer to take over Sarah's responsibilities.
Option C: Notify Sarah's educational supervisor* that she is worried about her record being impacted by her time off.
Option B: Provide Sarah with support and a chance to discuss things. (Correct answer)

Correct answer: Option F: Find out from medical staffing* if Sarah's shift can be filled by another F2 doctor.

Providing Sarah with support and a chance to discuss her situation is crucial for her well-being and demonstrates empathy. It allows her to express her concerns about her critically ill mother and her reluctance to take time off, which helps you understand her perspective and offer appropriate solutions. This approach prioritizes the welfare of a colleague in distress, fostering a supportive and compassionate work environment.

Question 110: The MSRA is delivered in which format at test centres?

An oral examination by a panel
A computer-based exam at Pearson VUE test centres (Correct answer)
A handwritten paper exam
A take-home open-book test

Correct answer: A computer-based exam at Pearson VUE test centres

The MSRA is a computer-based assessment taken at Pearson VUE centres.

Question 111: According to NICE guidelines, which antihypertensive is recommended as first-line for a patient aged 55 or older with uncomplicated hypertension?

Calcium channel blocker (Correct answer)
ACE inhibitor
Beta-blocker
Thiazide-like diuretic

Correct answer: Calcium channel blocker

NICE recommends a calcium channel blocker as Step 1 treatment for patients aged 55 or over, as renin-angiotensin system blockers are less effective in this age group due to lower plasma renin activity.

Question 112: Which is the best preparation strategy for the Professional Dilemmas paper?

Practising scenarios and understanding GMC principles (Correct answer)
Reading surgical atlases
Only revising anatomy
Memorising drug doses

Correct answer: Practising scenarios and understanding GMC principles

Familiarity with situational judgement scenarios and GMC guidance prepares candidates best for the PD paper.

Question 113: You are about to discharge a patient when the pharmacist calls to say there is a potentially dangerous interaction between two medications just prescribed. What should you do?

Hold the discharge, review the interaction, and modify the prescriptions before the patient leaves (Correct answer)
Tell the pharmacist to manage it in the community
Ask the nurse to advise the patient verbally about the interaction
Proceed with discharge as the patient is clinically stable

Correct answer: Hold the discharge, review the interaction, and modify the prescriptions before the patient leaves

A pharmacist warning about a dangerous drug interaction requires immediate clinical review and prescription modification before discharge to prevent patient harm.

Question 114: A patient is found to have capacity but requests a treatment that the doctor believes is not clinically indicated. What is the most appropriate response?

Refuse and discharge the patient
Refer to another doctor without explanation
Prescribe the treatment to maintain the therapeutic relationship
Explain the clinical rationale, explore the patient's concerns, and offer appropriate alternatives (Correct answer)

Correct answer: Explain the clinical rationale, explore the patient's concerns, and offer appropriate alternatives

While patients can refuse treatment, they cannot demand a clinically unjustified intervention; the doctor should explain their reasoning, understand the patient's concerns, and offer evidence-based alternatives.

Question 115: A 4-year-old child presents with fever, stridor, and a 'barking cough' that is worse at night. What is the most likely diagnosis?

Epiglottitis
Croup (laryngotracheobronchitis) (Correct answer)
Foreign body aspiration
Bacterial tracheitis

Correct answer: Croup (laryngotracheobronchitis)

A barking cough with stridor that worsens at night in a young child is the hallmark presentation of croup, typically caused by parainfluenza virus.

Question 116: You are asked by a friend, who is not your patient, to prescribe antibiotics for them informally. What is the best response?

Decline and advise them to see their own GP (Correct answer)
Prescribe a small amount only
Prescribe them as a favour
Give them some from the ward stock

Correct answer: Decline and advise them to see their own GP

Prescribing for friends without a proper clinical assessment is inappropriate and they should consult their own doctor.

Question 117: A colleague asks you to cover an extra shift when you are already exhausted and unsafe to work. The most appropriate first action is to:

Decline and explain that fatigue would compromise patient safety (Correct answer)
Ignore the request entirely
Agree immediately to be a team player
Report the colleague to the GMC

Correct answer: Decline and explain that fatigue would compromise patient safety

Patient safety takes priority, so declining due to unsafe fatigue is the most appropriate action.

Question 118: When a PD question asks for the 'least appropriate' action, you should select the option that:

Best protects the patient
Involves a senior
Most clearly breaches professional standards or risks patient safety (Correct answer)
Documents the event

Correct answer: Most clearly breaches professional standards or risks patient safety

The least appropriate action is the one that most violates professional duties or endangers patients.

Question 119: A 29-year-old woman with a previous ectopic pregnancy presents with a 6-week history of amenorrhoea, left iliac fossa pain, and sudden onset of right shoulder tip pain. Her blood pressure is 78/50 mmHg and heart rate is 136 bpm. What is the most likely diagnosis?

Ovarian torsion
Ruptured ectopic pregnancy (Correct answer)
Acute appendicitis
Threatened miscarriage

Correct answer: Ruptured ectopic pregnancy

Shoulder tip pain results from diaphragmatic irritation caused by haemoperitoneum — blood collecting under the diaphragm after intra-abdominal haemorrhage. Combined with haemodynamic instability, amenorrhoea, and a prior ectopic pregnancy (a major risk factor), the diagnosis is a ruptured ectopic pregnancy until proven otherwise. This is a surgical emergency.

Question 120: A study reports a relative risk reduction of 30% for a new drug compared to placebo. The control event rate is 6%. What is the absolute risk reduction?

6%
30%
1.8% (Correct answer)
4.2%

Correct answer: 1.8%

Absolute risk reduction = relative risk reduction × control event rate = 0.30 × 6% = 1.8%; the NNT would be 1/0.018 ≈ 56 patients.

Question 121: You are asked to cover an additional ward at short notice, leaving your own patients with reduced cover. What is the most appropriate action?

Agree without raising any concern
Leave your ward and cover the other one
Discuss the staffing concern with the senior on call before agreeing (Correct answer)
Refuse outright and stay where you are

Correct answer: Discuss the staffing concern with the senior on call before agreeing

Raising the safety implications with a senior allows a balanced decision about safe cover for all patients.

Question 122: A 65-year-old patient presents with acute chest pain, sweating, and shortness of breath. The ECG shows ST elevation in leads II, III, and aVF. What is the most likely diagnosis?

Pulmonary embolism
Inferior ST-elevation myocardial infarction (Correct answer)
Aortic dissection
Pericarditis

Correct answer: Inferior ST-elevation myocardial infarction

ST elevation in leads II, III, and aVF indicates an inferior STEMI, typically caused by right coronary artery occlusion, requiring urgent reperfusion therapy.

Question 123: A medical student asks to perform a procedure on a patient that the student has never done before, without supervision. What is the best response?

Allow it since students must learn somehow
Explain the student must be supervised for a first attempt (Correct answer)
Refuse and tell the student to stop trying procedures
Let the student do it and watch the outcome

Correct answer: Explain the student must be supervised for a first attempt

First attempts at a procedure require supervision to protect both patient safety and the student's learning.

Question 124: In CPS, an extended matching question typically provides:

One stem and one answer
Only images
A themed list of options used across several stems (Correct answer)
A free-text box

Correct answer: A themed list of options used across several stems

EMQs give a list of possible answers under a theme, with multiple vignettes each requiring the best match.

Question 125: Which approach best fits a CPS diagnosis question with limited time?

Skip all questions about investigations
Always choose the longest answer
Identify key clinical features and match to the single best fit (Correct answer)
Read every option twice before the stem

Correct answer: Identify key clinical features and match to the single best fit

Spotting discriminating clinical features quickly and matching them to the best option is the efficient strategy.

Question 126: A patient does not speak English well and you are unsure they understood the consent discussion. What should you do?

Proceed and assume they understood
Arrange a professional interpreter before proceeding (Correct answer)
Use a family member to translate quickly
Use simple gestures to confirm consent

Correct answer: Arrange a professional interpreter before proceeding

Valid consent requires genuine understanding, so a professional interpreter should be used.

Question 127: A 6-week period of nasal discharge, eye itching, and sneezing is exhibited by an 8-year-old boy who has a family history of atopy in July. With the diagnosis confirmed, which of the following would be the best course of action?

No further investigation required (Correct answer)
ELISA test
Patch test
Skin prick test

Correct answer: No further investigation required

The boy's symptoms of nasal discharge, eye itching, and sneezing, occurring seasonally (in July for six weeks) with a family history of atopy, are highly characteristic of seasonal allergic rhinitis, commonly known as hay fever. Given this clear clinical picture and a confirmed diagnosis based on history, further diagnostic tests like patch tests, ELISA, or skin prick tests are generally not required. The focus should be on symptom management and avoidance strategies.

Question 128: A patient with type 2 diabetes has an HbA1c of 75 mmol/mol despite metformin. What is the most appropriate next step?

Add a second oral hypoglycaemic agent (Correct answer)
Immediately start insulin only
Reduce metformin dose
Stop all medication

Correct answer: Add a second oral hypoglycaemic agent

When metformin alone fails to control HbA1c, adding a second agent such as a sulfonylurea or SGLT2 inhibitor is appropriate.

Question 129: A patient lacks mental capacity and has no advance directive. What framework governs treatment decisions in England and Wales?

The Mental Health Act 1983
Common law best interests standard only
The Human Rights Act 1998
The Mental Capacity Act 2005 (Correct answer)

Correct answer: The Mental Capacity Act 2005

The Mental Capacity Act 2005 governs decision-making for incapacitated adults, requiring clinicians to act in the patient's best interests after consulting those close to them.

Question 130: You realise you gave a patient incorrect information about their diagnosis earlier today. What is the most appropriate action?

Wait to see if it causes any problem
Ask a colleague to tell them instead
Contact the patient promptly to correct the information and apologise (Correct answer)
Document the correct information only in the notes

Correct answer: Contact the patient promptly to correct the information and apologise

Duty of candour requires promptly correcting the error directly with the patient and apologising.

Question 131: A GP receives a Subject Access Request (SAR) from a patient requesting their full medical records. Under GDPR/UK GDPR, what is the maximum response time?

7 days
28 days
30 days (one month) (Correct answer)
3 months

Correct answer: 30 days (one month)

Under UK GDPR, organisations must respond to a Subject Access Request within one calendar month (approximately 30 days) of receiving the request.

Question 132: A patient asks you whether a treatment error made by another doctor caused their complication. What should you do?

Be honest, explain what you know, and escalate appropriately (Correct answer)
Refuse to discuss it at all
Blame the patient's underlying condition
Deny that any error occurred

Correct answer: Be honest, explain what you know, and escalate appropriately

Duty of candour requires honesty with patients about what happened while escalating to those responsible.

Question 133: In the case of an 80-year-old delirious inpatient who has removed his third cannula today, which medicine would be the most appropriate?

Oral Haloperidol (Correct answer)
IM Chlorpromazine
Rectal Diazepam
Oral Quatiepine

Correct answer: Oral Haloperidol

Haloperidol is a first-generation antipsychotic commonly used for the acute management of severe agitation and psychotic symptoms in delirium, especially when non-pharmacological interventions have been unsuccessful. In an elderly, delirious inpatient who is actively interfering with medical care (removing cannulas), oral haloperidol is an appropriate choice to help manage agitation and reduce the risk of further self-harm or disruption. It is generally preferred over benzodiazepines for delirium due to a lower risk of paradoxical agitation or respiratory depression.

Question 134: A patient who lacks capacity needs an urgent decision and no relatives are available. What should guide your action?

Act in the patient's best interests using available information (Correct answer)
Ask the patient to decide despite lacking capacity
Delay until a relative can be found
Refuse to treat until consent is obtained

Correct answer: Act in the patient's best interests using available information

When a patient lacks capacity and no representative is available, urgent care proceeds in their best interests.

Question 135: A 35-year-old woman presents with fatigue, weight gain, cold intolerance, and constipation. TSH is markedly elevated with low free T4. What is the first-line treatment?

Carbimazole
Levothyroxine (Correct answer)
Propylthiouracil
Radioactive iodine

Correct answer: Levothyroxine

Primary hypothyroidism confirmed by elevated TSH and low free T4 is treated with oral levothyroxine replacement therapy.

Question 136: A 15-year-old patient presents alone requesting oral contraception. She demonstrates good understanding of the risks and benefits. What does the Fraser competency assessment determine?

Whether a court order is needed
Whether the specific treatment can be provided without parental knowledge if the patient is competent (Correct answer)
Whether parents must be notified regardless of the patient's wishes
Whether the patient can consent to any treatment without parental involvement

Correct answer: Whether the specific treatment can be provided without parental knowledge if the patient is competent

Fraser guidelines allow a clinician to provide contraception to a competent young person under 16 without parental consent if specific criteria are met, respecting confidentiality.

Question 137: A 28-year-old woman in her third trimester presents with right upper quadrant pain, elevated liver enzymes, and thrombocytopenia. What syndrome should be considered?

HELLP syndrome (Correct answer)
Viral hepatitis
Cholestasis of pregnancy
Acute fatty liver of pregnancy

Correct answer: HELLP syndrome

HELLP syndrome (Hemolysis, Elevated Liver enzymes, Low Platelets) is a severe complication of pre-eclampsia presenting with this triad in late pregnancy.

Question 138: A 40-year-old woman has recurrent episodes of unilateral throbbing headache with nausea, photophobia and visual aura. What is the most likely diagnosis?

Cluster headache
Tension headache
Temporal arteritis
Migraine (Correct answer)

Correct answer: Migraine

Unilateral throbbing headache with aura, nausea and photophobia is typical of migraine.

Question 139: Jenny arrives to discuss her baby's potential for hip developmental dysplasia—she is twelve weeks along and her friend's child just underwent surgery for the condition. Which of the following is not a risk factor for a person's developmentally dysplastic hip dysplasia (DDH)?

Female sex
Polyhydramnios (Correct answer)
Breech presentation
First born

Correct answer: Polyhydramnios

Developmental Dysplasia of the Hip (DDH) has several known risk factors, including female sex, first-born status, and breech presentation, all of which can influence fetal positioning and hip development. Polyhydramnios, which is an excessive amount of amniotic fluid, typically provides more space for fetal movement, making it less likely to restrict hip development. In contrast, oligohydramnios (too little amniotic fluid) would be a risk factor due to restricted movement.

Question 140: Which underlying principle should guide most Professional Dilemmas answers?

Protecting senior colleagues from scrutiny
Maximising personal career advantage
Patient safety and acting within your competence (Correct answer)
Avoiding any extra work

Correct answer: Patient safety and acting within your competence

Patient safety and working within your competence are the core principles of professional judgement.

Question 141: A 50-year-old male presents with central crushing chest pain radiating to the left arm, diaphoresis, and nausea. ECG shows ST elevation in V1–V4. What is the immediate priority?

IV heparin and thrombolytics if PCI unavailable within 120 min
Oral nitrates and observation
Primary PCI within 90–120 minutes (Correct answer)
CABG

Correct answer: Primary PCI within 90–120 minutes

Anterior STEMI requires primary percutaneous coronary intervention (PCI) as the first-line reperfusion strategy, targeting a door-to-balloon time within 90–120 minutes.

Question 142: A patient on long-term prednisolone is scheduled for major surgery. What is the most critical perioperative consideration?

Start a proton pump inhibitor on the day of surgery
Stop prednisolone 48 hours before surgery
Double the prednisolone dose post-operatively
Administer hydrocortisone cover for adrenal insufficiency (Correct answer)

Correct answer: Administer hydrocortisone cover for adrenal insufficiency

Long-term corticosteroid use suppresses the hypothalamic-pituitary-adrenal axis; IV hydrocortisone cover is required perioperatively to prevent an Addisonian crisis during the physiological stress of surgery.

Question 143: A pharmaceutical company offers a doctor a paid speaking engagement with flights and accommodation to promote their new drug. What should the doctor do?

Accept as it is a legitimate educational opportunity
Decline if the arrangement could reasonably be seen as influencing prescribing behaviour (Correct answer)
Accept provided the drug is on formulary
Accept and declare the interest only if asked

Correct answer: Decline if the arrangement could reasonably be seen as influencing prescribing behaviour

GMC guidance prohibits accepting gifts or hospitality that could influence, or appear to influence, clinical decisions; sponsored engagements tied to product promotion fall into this category.

Question 144: You are offered a place at a conference funded by a pharmaceutical company that makes a drug you prescribe. What is the most appropriate response?

Declare the potential conflict of interest and follow trust policy (Correct answer)
Accept without telling anyone
Refuse all educational opportunities
Accept and increase prescribing of their drug

Correct answer: Declare the potential conflict of interest and follow trust policy

Industry-funded opportunities create potential conflicts of interest that should be declared and managed transparently.

Question 145: A patient on warfarin presents with an INR of 8.0 and minor bleeding. What is the most appropriate management?

Give IV vitamin K and fresh frozen plasma immediately
Continue warfarin at a reduced dose
Administer protamine sulfate
Stop warfarin and give oral vitamin K (Correct answer)

Correct answer: Stop warfarin and give oral vitamin K

For INR >5.0 with minor bleeding, warfarin should be stopped and oral vitamin K (1-5mg) administered. IV vitamin K and FFP are reserved for major or life-threatening bleeding.

Question 146: A patient refuses a blood transfusion on religious grounds despite being severely anemic. What is the correct approach?

Administer the transfusion when they are asleep
Discharge the patient immediately
Ask their family to override their decision
Respect their decision after ensuring they have capacity and understand the risks, and explore alternative treatments (Correct answer)

Correct answer: Respect their decision after ensuring they have capacity and understand the risks, and explore alternative treatments

A competent adult has the right to refuse treatment, even if it may lead to death. Ensure the patient has capacity, provide full information about risks, document the refusal, and explore alternative management options.

Question 147: A pharmaceutical representative offers you an expensive gift in exchange for promoting their medication. What should you do?

Decline the gift as it represents a conflict of interest that could influence prescribing decisions (Correct answer)
Accept it as it's a common industry practice
Accept it but declare it to your department
Accept it and prescribe whatever you think is best anyway

Correct answer: Decline the gift as it represents a conflict of interest that could influence prescribing decisions

Accepting gifts from pharmaceutical companies creates conflicts of interest and may bias prescribing. GMC guidance requires doctors to be honest about financial interests and avoid conflicts that could affect patient care.

MSRA (Multi-Specialty Recruitment Assessment)

The MSRA is a computer-based exam used by NHS England to assess doctors applying for specialty training. It evaluates Clinical Problem Solving across 12 medical topic areas and Professional Dilemmas covering professional judgment, ethics, and communication.

147

Questions

170 min

Time Limit

70%

To Pass

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