Oxford Handbook Practice Test Flashcards by Kelvin Sunn Yap

You are working as an FY1 doctor in the Medical Assessment Unit,
seeing Marcin who is a 35-year-old Polish man with very limited
English language skills.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate)
A Attempt a brief history using hand gestures and diagrams.
B Try to contact a member of Marcin’s family to act as an interpreter
over the phone.
C Do not attempt a history without a translator present.
D Skip the history, and focus your management on the examination and
investigations.
E Extrapolate a history based on the limited fi ndings of the ambulance
crew on their initial assessment sheet.

B, E, D, A, C

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During a GP rotation you see Carl, who would like to know the
results of a colonoscopy and CT scan after a joint MDT meeting.
He missed his last appointment, but has been told that the GP should
have access to the report. The results identify a disseminated colorectal
malignancy, although no treatment plan has yet been decided upon.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate)
A Establish what the patient understands about his diagnosis fi rst.
B Refer him back to the gastroenterologist who performed the
colonoscopy.
C Contact the nurse specialist and ask her to telephone the patient as
soon as possible.
D Explain the very poor outcome associated with cancers like the one
Carl has.
E Ask the patient to come back and see you in the afternoon, as you will
need to speak to his hospital doctors fi rst.

A, E, C, D, B

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During a busy urology ward round with your consultant, the nurse
mentions that Frank, who is recovering from a transurethral resection
of prostate, has admitted to feeling low over the last few months.
Choose the THREE most appropriate actions to take in this situation
A Ask the consultant to speak to Frank about his low mood.
B Speak to Frank after the ward round.
C Ask Frank if he is low enough for antidepressants.
D Break away from the ward round to discuss the matter with Frank.
E Ask the nurse to keep any additional patient information until the end
of the ward round to avoid future interruptions.
F Inform your seniors after the ward round, if a referral needs to
be made.
G Tell the patient to speak to someone about his low mood.
H Inform the on-call psychiatrist.

B, F, H

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You are asked to see Jerry, a 55-year-old man who has recently
undergone a colonic resection with defunctioning colostomy. He
wishes to make a complaint against the operating consultant as he feels
that he was not adequately informed about the impact of his stoma.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate)
A Inform the patient that you will relay his concerns to the consultant.
B Apologize on the consultant’s behalf.
C Establish the diffi culties that Jerry has been having with the stoma.
D Defend the consultant by explaining that the formation of a stoma
was documented on the consent form.
E Inform the patient of the complaints procedure and how he might go
about registering a complaint.

C, A, E, B, D

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Your registrar shouts at a medical student in front of a patient.
The medical student comes to fi nd you afterwards in tears and is
uncertain how to react to this treatment.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate)
A Suggest that the student report the registrar to an appropriate person
within the medical school.
B Bleep your registrar and ask him to return to the ward and apologize
to the medical student.
C Apologize on behalf of the registrar, and ask the student not to say
anything to anyone else.
D Suggest that the student talk to the fi rm consultant about the episode.
E Tell the student that they would be less likely to provoke a negative
response if their knowledge base was better.

D, B, A, E, C

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You are a lone FY1 doctor seeing a postoperative patient with
atrial fi brillation and a heart rate of 160 bpm. Before you fi nish
your assessment, the patient starts to mumble incoherently and will not
follow commands or open his eyes.
Choose the THREE most appropriate actions to take in this situation
A Ensure that the patient has a valid Not For Resuscitation order in case
they suff er cardiac arrest.
B Accept that 160 bpm might be normal for this patient.
C Shout for help.
D Ask the nursing staff to put out a peri-arrest call.
E Ensure that you have good intravenous access and give a fl uid
challenge.
F Ask the patient’s family to attend as their relative is probably dying.
G Start chest compressions.
H Ensure that you have adequate airway adjuncts to hand.

C, D, E

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Your FY1 colleague takes a copy of the operating list home every
evening to prepare for the following day in theatre.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate)
A Suggest that your colleague makes a simple list of operations to
take home.
B Take your own list home so that you can prepare for the theatre list
as well.
C Suggest that it is unfair he is ‘getting ahead’.
D Speak to the consultant about your colleague’s behaviour.
E Inform your colleague that he should not be taking home any list containing
confi dential patient information.

E, D, C, A, B

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The registrar asks you to teach two medical students who have
only just begun their training. You have a long list of jobs to complete
and your SHO has just called in sick.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate)
A Tell the registrar that you are too busy to look after students.
B Allow the students to shadow you for half an hour, and then ask them
to leave.
C Ask the students to attempt to take blood from a few of the patients
in exchange for some teaching.
D Allow the students to shadow you completing your routine jobs,
before sending them to take a history from a few patients.
E Postpone your ward jobs in order to teach the students for an hour.

D, A, B, E, C

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Your registrar informs you that there is a peritonitic patient intubated
on the intensive therapy unit (ITU), waiting to be transferred
back to theatre. You have never felt a genuine ‘surgical abdomen’ before,
and are keen to utilize this opportunity.
Choose the THREE most appropriate actions to take in this situation
A Do not examine the patient as you have not obtained consent.
B Send a text message to another FY1 doctor to suggest that he examines
the patient as well.
C Use this opportunity to read up about causes of ‘surgical abdomen’.
D Examine the patient as this is a valuable learning opportunity.
E Try to contact the patient’s next of kin to ask if you can examine the
patient.
F Complete your routine ward tasks before going to see the patient.
G Introduce yourself to the ITU consultant and ask if you can examine
the patient.
H Go and see the patient but do not examine their abdomen.

C, D, G

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You are a new FY1 doctor in surgery and have been asked to
see a patient in urinary retention that requires a catheter. You
have only ever performed catheterization on a model and are not feeling
particularly confi dent.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate)
A Attempt the procedure after talking to the patient, and then ask for
help if unsuccessful.
B Call the registrar and ask them to supervise your fi rst catheterization.
C Attempt the procedure without warning the patient about your
inexperience.
D Ask another FY1 doctor who is more confi dent with procedures
to help.
E Wait until the end of your shift and then hand the job over to the
night team.

D, A, C, B, E

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You are driving home from your evening on call when you
remember a chest X-ray that needed to be reviewed for a
patient with a newly inserted chest drain. You forgot to hand it to your
colleague who was taking over.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate)
A Put the issue out of your mind—it’s important to ‘turn off ’ after work.
B Make a note to check the result fi rst thing in the morning before the
ward round.
C Drive back to the hospital to check the X-ray yourself.
D Contact the on-call doctor through the switchboard and ask them to
check the X-ray.
E Refl ect about the factors that might have led to forgetting the X-ray.

D, C, E, B, A

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You are working on call covering the medical wards. The registrar
asks you to place a chest drain in a patient with a confi rmed
empyema who is becoming increasingly breathless. As a respiratory FY1
doctor you have seen many chest tubes being inserted, but have yet to
place one. The registrar is very busy and will not be able to help.
Choose the THREE most appropriate actions to take in this situation
A Call the registrar and explain that you cannot safely perform the procedure
alone but would be grateful if he could supervise you.
B Call the registrar back to say that you are unwilling to do as he asks.
C Use the Oxford Handbook for the Foundation Programme to guide your
attempt at independently inserting the chest drain.
D Begin to insert the chest drain and contact the on-call registrar if you
encounter diffi culties.
E Contact your Educational Supervisor at the fi rst possible opportunity
to discuss the appropriateness of this request.
F Contact another senior colleague if the on-call registrar does not
answer or off ers no further support.
G Set up the equipment and explain the procedure to the patient.
H Remind the registrar of the chest drain again in a couple of hours
when he is less busy.

A, F, G

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You are looking after Sally who has become increasingly unwell
due to heart failure, despite maximal diuretic therapy. Both you
and your registrar believe that Sally would benefi t from inotrope therapy
on the ITU. The patient’s son and the nursing staff feel that aggressive
escalation of treatment would not benefi t Sally.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate)
A Refer Sally to the ITU as you are ultimately responsible for the patient.
B Read through the medical notes, and try to understand why the family
and nursing staff might not want to escalate treatment.
C Tell the patient’s brother and nursing staff to think carefully about the
options and that you will do as they want if all members agree.
D Document your discussion with the family and stop all active treatment
in order to ameliorate the patient’s suff ering.
E Contact a senior doctor to ask them to make a decision.

B, E, A, C, D

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You are just starting your shift as the evening on-call medical
FY1 doctor and have been handed over a long list of jobs as
well as answering bleeps from nursing staff . You need to prioritize tasks.
Rank in order the following in response to this situation (1 = Most appropriate;
5 = Least appropriate)
A An upset patient who wants to discuss her forthcoming endoscopy on
the next day.
B An 80-year-old man who has had a fall and hit his head, but
appears lucid.
C A 70-year-old with a past history of myocardial infarction who has just
become unresponsive.
D A 50-year-old man after an elective herniotomy who is still awaiting
prescription laxatives and painkillers before he can be discharged.
E A 30-year-old man with renal colic requiring analgesia review for
‘10/10’ pain.

C, B, E, A, D

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You are working as the orthopaedic FY1 doctor when you
are called by the orthopaedic registrar on your mobile about
a patient who will be arriving on the private ward. He asks you to clerk,
cannulate, and initiate intravenous fl uids, as the patient will be undergoing
elective surgery the following morning.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate)
A Prioritize the preoperative clerking and fl uid administration alongside
your other tasks.
B Contact a responsible person (e.g. duty manager) to ask about the
appropriateness of doing jobs on the private ward.
C Suggest that the registrar comes in to complete the clerking if he has
agreed to see the consultant’s private patient.
D Help if possible, but inform the registrar that this is not a long-term
solution for managing private patients.
E Agree to complete the tasks for a reasonable fee.

A, D, B, E, C

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A 40-year-old patient is admitted for an elective procedure
on your surgery ward. After reading an article in a newspaper
about statins, he tells you he would like them to be prescribed. He is at
low risk of cardiovascular disease.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate)
A Write a prescription for statins.
B Explain that the high cost of statins means they can only be prescribed
to high-risk patients.
C Write to his GP asking them to discuss the patient’s request.
D Inform the patient that he does not have a high enough risk of cardiac
disease to gain suffi cient benefi t from the medication.
E Refer the problem to your consultant.

D, B, C, E, A

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After a ward round, you are approached by one of the patients
who says that they are ‘scared’ and no longer want a bronchoscopy
the following day.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate)
A Discuss the patient’s decision with the nursing staff .
B Explain the benefi ts of the procedure and insist that she receives it no
matter what.
C Explore alternative investigations.
D Establish the patient’s concerns.
E Take the patient to see a coronary angiography being performed.

D, C, A, B, E

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You are working in paediatrics and have made two attempts at
cannulating a 7-year-old with diabetic ketoacidosis. The mother
is becoming quite frustrated and refuses any further attempts.
Choose the THREE most appropriate actions to take in this situation
A Tell the mother that the next attempt will be successful.
B Explain that you will ask a colleague to try if the next attempt fails.
C Encourage oral intake and clearly document that the parent refused
cannulation.
D Stop the fl uids and resite the cannula if the patient deteriorates.
E Tell the mother that her daughter will probably die without intravenous
fl uids.
F Document the number of attempts at cannulation afterwards.
G Persist with cannulation attempts as the mother cannot refuse treatment
on her child’s behalf.
H Explain carefully why a cannula is necessary.

B, F, H

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You are an FY1 doctor reviewing patients with your consultant.
The consultant tells Doug, a 30-year-old man, that he has a
staghorn calculus and must have an operation which will leave a nephrostomy.
The consultant leaves once the consent form is signed but Doug
looks as if he still has more questions.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate)
A Tell the patient that your consultant will come back later to answer
questions.
B Explain that you will come back shortly in case he has any more
questions.
C Insist that the consultant stays until he has answered the patient’s
questions.
D Continue with reviewing patients with the consultant but see Doug
later to answer any questions.
E Let your consultant continue reviewing other patients alone but
remain behind to answer Doug’s questions.

B, D, E, C, A

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You have received several complaints from the nursing staff
about Michael, who has learning diffi culties and has been mobilizing
unsafely around the ward. He has become increasingly challenging
to manage.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate)
A Ask whether a ‘special’ nurse can be assigned for one-to-one care.
B Attempt to explain to Michael, as far as possible, that it is unsafe for
him to move around the ward.
C Suggest distracting interventions.
D Prescribe ‘as-required’ (PRN) sedation.
E Prescribe sedation when Michael becomes particularly agitated and
endangers himself or others.

B, C, A, E, D

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Jessie was admitted under the gastroenterology team for
chronic abdominal pain. Investigations have not yielded any
fi ndings, and your consultant believes that the patient should be discharged
with follow-up from the pain team. The patient and her family
do not believe she can go home with such severe pain.
Choose the THREE most appropriate actions to take in this situation
A Delete the patient from your list so that she can remain an inpatient
for a few more days.
B Explore Jessie’s concerns about going home.
C Promise that you will ensure that the pain team appointment is made
within two weeks.
D Tell Jessie the bed is needed for more urgent cases.
E Carefully explain the nature of chronic abdominal pain.
F Ensure that the pain team is involved with discharge planning so that
appropriate analgesia can be provided in the community.
G Prescribe ‘as-required’ (PRN) oral morphine until the patient is
discharged.
H Tell Jessie that she needs to learn to accept the pain as it cannot be
helped.

B, E, F

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Six hours ago you prescribed intravenous antibiotics for a surgical
patient for a suspected pelvic abscess. During your afternoon
ward round you fi nd that the antibiotics have still not been given
by the nurse.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate)
A Contact the pharmacy and seek advice about how to prepare the
infusion yourself.
B Inform the Ward Sister that the antibiotics have been dangerously
delayed.
C Ensure that the nurse understands the importance of giving antibiotics
promptly.
D Approach the nurse on her break and insist that she prepares the
intravenous antibiotics immediately.
E Allow the nurse to complete her jobs without further instruction—
she will administer the infusion when she has time.

C, B, D, A, E

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Your SHO prescribes a large dose of gentamicin for a patient
with severe renal failure. You notice this when rewriting the
drug chart, thankfully before this renotoxic drug was administered. Your
SHO thanks you for stopping the prescription in time.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate)
A Inform the hospital pharmacy.
B Record a critical incident form for a near miss.
C Inform your consultant at the next available opportunity.
D Do nothing further as the SHO simply forgot that caution is needed
when prescribing gentamicin for patients with renal impairment.
E Note ‘renal impairment’ somewhere appropriate on the drug chart.

B, A, C, E, D

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While eating lunch in the hospital canteen, you overhear a
nurse describing a junior doctor as ‘incompetent’. The doctor
is readily identifi able but the nurse seems unaff ected by the attention she
is attracting from surrounding diners.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate)
A Speak to the nurse on the ward later on to explain that such comments
in a public environment are unprofessional.
B Let the nurse know that she can be overheard by other diners.
C Speak to someone in the nursing hierarchy to reinforce the message
about not publicly undermining colleagues.
D Let the junior doctor concerned know what was said about him.
E Do nothing as this is a public venue and the nurse is on her break.

B, A, C, E, D

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25. An FY1 colleague who works on your ward consistently struggles to take blood from patients. The samples he has successfully obtained are usually haemolysed. Rank in order the following actions in response to this situation (1 = Most appropriate; 5 = Least appropriate) A Ignore the problem as it is your colleague’s concern. B Email his Clinical Supervisor. C Contact your consultant immediately to inform him of your colleague’s diffi culties. D Help your colleague improve on the ward and by using a skills laboratory if there is one. E Suggest that your colleague asks a senior for help.

25. D, E, B, C, A

26. You are fi nding it particularly diffi cult to work with your new SHO. She is condescending, undermines your management, and has often belittled you in front of senior colleagues. Choose the THREE most appropriate actions to take in this situation A Adopt a more subordinate position as her junior colleague. B Ask your colleagues within the medical team whether they fi nd your SHO diffi cult to work with. C Do nothing, provided that her behaviour does not impact on clinical care. D Ensure that your jobs are done well to avoid avoidable criticism. E Remind the SHO about your relative inexperience in medicine. F Speak to a senior colleague for advice. G Discuss your feelings with the SHO. H Try to challenge your SHO’s clinical knowledge in an eff ort to impress her.

26. D, F, G

27. You have just started working on the care of the elderly ward. Despite your relative inexperience, you are certain that your consultant has recklessly discharged unwell patients many times over a four-week period. However, he is well regarded on the ward by patients and nurses. You have never heard another doctor complain about his practice. Choose the THREE most appropriate actions to take in this situation A Ask your consultant about specifi c discharges with which you are unhappy. B Contact the GMC to raise your concerns. C Record the events clearly on your medical blog. D Do nothing as you are alone in thinking that the consultant’s decisions are fl awed. E Do nothing as you have no real proof of poor practice. F Discuss your concerns privately with another senior colleague. G Contact your Educational Supervisor. H Inform the Medical Director.

27. A, F, G

28. You are clerking a young child in the preoperative admissions clinic. You note that the parents are somewhat untidy, with dirty hands and clothes. You consider what to document in the medical notes. Rank in order the following actions in response to this situation (1 = Most appropriate; 5 = Least appropriate) A Complete your detailed entry in the notes once you have clerked everyone at the preoperative assessment clinic. B Briefl y summarize your clinical assessment. C Document the impression that you have formed of the parents’ suitability for raising the child. D Document your detailed physical examination fi ndings of the child. E Write your notes once your senior colleagues agree with your fi ndings.

28. D, B, A, E, C

29. You have just completed your assessment of a patient who is hypotensive and asked the nurses to administer intravenous fl uids. You are bleeped by another ward to say that a patient is pyrexial. While you are taking this call, your crash bleep summons you to a third ward. Rank in order the following actions in response to this situation (1 = Most appropriate; 5 = Least appropriate) A Many doctors carry crash bleeps and you should prioritize the patient you are currently treating. B Attend the crash call but return later to document your assessment retrospectively. C Document your current assessment of the patient who is hypotensive and then attend the crash call. D See the febrile patient after the crash call and then return to document your approach to the hypotensive patient. E Don’t document anything as the unwell patients are a priority.

29. B, D, E, C, A

30. You are being shadowed by a medical student while on call. You receive three bleeps in quick succession: a respiratory patient looking increasingly unwell, blood cultures needed for a febrile patient, and a disgruntled relative wanting to complain about your consultant. Choose the THREE most appropriate actions to take in this situation A Ask the medical student to assess the respiratory patient, and you will review shortly afterwards. B Review the respiratory patient with the medical student. C Suggest that the student takes blood from the febrile patient. D Review the respiratory patient alone. E Do the blood cultures fi rst in case the patient’s fever subsides. F Suggest that the student speaks to the disgruntled relative. G Meet the relative by yourself on the ward. H Speak to the relative together with a nurse in a side room.

30. B, C, H

1. During your own ward round, you hear a healthcare assistant (HCA) behind a curtain being verbally abusive towards a patient. The patient is disabled and known to have challenging learning disabilities. The patients and staff around the bay do not intervene. Rank in order the following actions in response to this situation (1 = Most appropriate; 5 = Least appropriate) A Show your disapproval to the staff in the bay for not responding. B Contact the Care Quality Commission anonymously to avoid raising the issue with employees of your Trust. C Ask if other staff have noticed similar behaviour from the HCA. D Approach the curtain and ask to speak with the HCA. E Discuss the issue with the nurse in charge (e.g. Matron) upon their arrival.

1. D, E, C, B, A

2. A patient’s niece is concerned about the standard of care her relative is receiving and asks you whether she should make a complaint and how to go about doing so. Rank in order the following actions in response to this situation (1 = Most appropriate; 5 = Least appropriate) A Establish what she is concerned about and escalate the issues accordingly. B Direct her to the Patient Advice and Liaison Service (PALS) in case they are able to assist her better. C Off er to investigate but explain that a formal complaint is unlikely to resolve matters. D Agree regarding her assessment and encourage her to proceed with a formal complaint. E Notify the Sister in charge that a patient’s relative is concerned about standards of care and a complaint may be received in this regard.

2. A, E, B, C, D

3. You review a patient in the medical assessment unit with your SHO after seeing the patient and clerking them in yourself. The SHO is happy with your entry in the medical notes and agrees to complete a work-based assessment for examining the patient, despite having not seen you examine the patient. Choose the THREE most appropriate actions to take in this situation A Tell the SHO that you need more detailed feedback if you are to develop as a doctor. B Thank the SHO and ask if you could present the case to her later for your own experience. C Ask the SHO to watch you examine the patient and then complete an assessment. D Ask the SHO if he will complete two work-based assessments at the same time. E Examine the patient as formally as possible, even though you are not being assessed. F Thank the SHO and forward him an electronic form to complete. G Examine the patient a few hours later when someone might be available to assess you. H Tell your Educational Supervisor how diffi cult it is to get senior colleagues to complete formal assessments

3. B, C, E

4. A patient whom you have looked after for several weeks approaches you and hands you a cheque for a substantial amount. She insists, despite your protests, that you take the gift for all the hard work you have done for her on the ward. Choose the THREE most appropriate actions to take in this situation A Take the cheque and then ask an appropriate person within the Trust whether this is allowed. B Suggest that the patient donates the money to the hospital charity. C Tell the patient you will only accept half the amount she has off ered. D Covertly return the cheque to the patient’s husband on his next hospital visit. E Ensure the patient has signed a written statement to avoid accusations of criminality. F Ask the patient to consider her decision very carefully. G Thank the patient but politely refuse her off er. H Refer to a senior in the Trust for advice.

4. F, G, H

5. An obstetrics and gynaecology audit reveals that your consultant appears to have worse mortality outcomes than the national average. You consider what to do in light of these fi ndings. Rank in order the following actions in response to this situation (1 = Most appropriate; 5 = Least appropriate) A Inform the Care Quality Commission about your consultant’s mortality fi gures, as this is an issue of patient safety. B Email the other consultants for advice about the data. C Discuss your fi ndings with the consultant alone. D Submit the audit report without the consultant’s data. E Obtain further patient and perioperative data on the consultant’s cases.

5. C, E, B, A, D

6. Your consultant asks you to look after all her patients including those on the private ward of the hospital. You feel stretched by the additional tasks and regularly leave work after your scheduled hours. Rank in order the following actions in response to this situation (1 = Most appropriate; 5 = Least appropriate) A Ignore bleeps from the private ward; if the consultant wants you he will contact you. B Arrange a meeting with your consultant to discuss your workload. C Ask private patients to consider returning to the NHS ward. D Explain the situation to another consultant. E Ask the consultant for additional reimbursement in return for providing more of your time for assisting with his private patients.

6. B, D, C, E, A

7. You receive a bleep from your consultant asking you to consent Mrs Robbins, who is third on today’s theatre list for an inguinal hernia repair. You have received teaching from the consultant about the theory of hernias a few months ago although you have never seen a hernia repair. You also have a mounting list of ward jobs which need to be completed before lunch-time teaching. Rank in order the following actions in response to this situation (1 = Most appropriate; 5 = Least appropriate) A Explain to the consultant that you are not able to consent the patient as you do not have the necessary experience. B Ask the on-call surgical registrar to take the consent. C Consent the patient immediately. D Complete your urgent ward jobs before attempting to consent the patient. E Ask the senior surgical Ward Sister to show you how to consent properly for this operation.

7. A, B, E, C, D

8. Your registrar asks you to book an urgent colonoscopy for one of the ward patients to ‘exclude a gastrointestinal bleed’. The patient has not given any symptoms that you feel would indicate this and you are struggling to articulate a good reason on the request form. Rank in order the following actions in response to this situation (1 = Most appropriate; 5 = Least appropriate) A Explain to your consultant you cannot order the colonoscopy as you disagree that it is appropriate. B Ask your team’s SHO whether they can explain why the colonoscopy is necessary. C Ask the registrar what the scan is for. D Tell the endoscopist you disagree with doing the scan but have been told that it is urgent. E Book an abdominal CT scan instead and later reconsider the colonoscopy based on the results.

8. C, B, D, A, E

9. The overnight on-call SHO identifi es an error on your patient’s drug chart, in which you have prescribed methotrexate instead of metronidiazole. She has spotted and corrected it before the drug was administered but feels that your clinical supervisor should be informed. You feel this is probably due to staff shortages on your ward. Rank in order the following actions in response to this situation (1 = Most appropriate; 5 = Least appropriate) A Accept responsibility while explaining factors that contributed to the error. B Explain to the SHO that this was not your fault because the hospital has failed to staff the ward to safe levels. C Refl ect on the error and its reasons using your e-portfolio to avoid this happening again. D Ask the SHO not to contact your Clinical Supervisor as this was an isolated error. E Ask to meet your Clinical Supervisor to discuss the error and your concerns about staffi ng levels.

9. E, A, C, B, D

10. The nurse asks you to see a trauma patient who has just become conversant on the ITU ward. He wants to know whether he is likely to be able to walk again given his pelvic fractures. You are certain that he will be able to walk, but are unsure how long he will need to remain on bed-rest and do not remember much else about the management of pelvic fractures. Rank in order the following actions in response to this situation (1 = Most appropriate; 5 = Least appropriate) A Off er to ask the consultant to come by and answer the patient’s questions. B Go away and read up about the management of pelvic fractures so you are able to answer these questions. C Tell the patient that he will be able to walk after suffi cient bed-rest. D Explain how most patients with pelvic fractures do recover their mobility after suffi cient bed-rest but you will help fi nd out the plan in his case. E Explain how you are unable to answer complex technical questions given your junior position within the clinical team.

10. D, A, B, E, C

11. A written complaint is made against you regarding your management of a patient who was readmitted with an obstructed hernia. You had seen the patient and felt that he had a ‘benign’ abdomen, but had failed to document your fi ndings in any further detail. The patient required emergency surgery to relieve the obstructed and incarcerated hernia upon readmission 24 hours later. Choose the THREE most appropriate actions to take in this situation A Record your formal response and inform your defence organization. B Amend your written entry to honestly refl ect the clinical fi ndings that you encountered that led you to believe the patient could be discharged. C Respond to the complaint at a moment of convenience, as the clinical care of your current patients remains your priority. D Refl ect on the case and what you could do diff erently to mitigate the risk. E No further action is required, as it refers to a post that you have now rotated out of. F Explain the factors, including short staff , long hours, and fatigue, that led to you being unable to complete a thorough clerking of every patient. G Amend the written notes to include features that might have been present that are likely to absolve the Trust of any possible complaint. H Give an accurate description of events within the timeframe requested.

11. A, D, H

12. You fi nd yourself having not had a break or eaten anything since starting your Sunday shift fi ve hours ago. You are feeling fatigued and identify that you have begun incorrectly writing a fl uid prescription chart. Having corrected your error, you attempt to leave the ward for a break, at which point the nurse in charge asks you to clerk the preoperative elective patient who has come in the day before his surgery. Choose the THREE most appropriate actions to take in this situation A Tell the nurse that she should not bother you for such a routine task. B Ask the nurse to attempt a brief clerking which you will review on your return. C Suggest to the nurse that preoperative clerkings can be completed by the day team the following day, and that this is not a job for the on-call doctor. D Off er to clerk the patient after your break. E Briefl y ‘eyeball’ the patient and if he looks well go for your break. F Ask how urgent the clerking is, e.g. any immediate drugs the patient needs prescribing, and then use this to prioritize the task. G Complete the patient clerking immediately. H Explain to the Ward Sister that you intended to have a short break.

12. D, F, H

13. You are working on the gastroenterology ward and have performed several ascitic drain insertions under the supervision of the registrar. Your registrar insists he is confi dent with your performance and asks you to perform one independently, although you realize you have never actually obtained consent for this procedure. Rank in order the following actions in response to this situation (1 = Most appropriate; 5 = Least appropriate) A Obtain verbal consent with the Ward Sister as a witness. B Seek legal advice prior to beginning the consent process. C Obtain verbal consent before documenting in the medical notes that ‘the patient has been consented’ in the notes. D Decline to perform the procedure as only registrars and consultants are able to provide consent. E Complete a formal written consent form.

13. E, C, A, D, B

14. You reach the end of your shift on a general surgery ward and receive a phone call from the nurse coordinator informing you of a long list of jobs which she insists are completed today. You have consistently fi nished two hours late every day this week. Rank in order the following actions in response to this situation (1 = Most appropriate; 5 = Least appropriate) A Finish for the day and review the tasks in the morning. B Ask the coordinator to speak with the on-call doctor to review the tasks. C Ask the coordinator to do what she is able to herself, before contacting the on-call doctor if she feels there is anything else that must be done before tomorrow. D Assess the jobs and complete as many tasks as possible within the next hour. E Identify and complete the most urgent tasks before handing over to the on-call doctor.

14. E, B, C, D, A

15. A hip CT scan for an orthopaedic patient demonstrates a small abdominal mass of undetermined signifi cance, and the radiologist recommends repeat imaging at one month. Rank in order the following actions in response to this situation (1 = Most appropriate; 5 = Least appropriate) A Ask the patient to inform his GP of the CT fi nding and need for further tests, as soon as he is discharged from the hospital. B Ask a nurse to explain the report fi ndings and follow-up treatment required. C Highlight on the discharge letter this fi nding, and the requirement for a delayed imaging, D Contact the patient’s GP to inform them of this fi nding. E Arrange an orthopaedic follow-up appointment for further management of the abdominal mass.

15. D, A, C, E, B

16. You are bleeped by the hospital’s senior matron regarding the ‘code black bed crisis’ in the hospital. Having spoken to your consultant she is now instructing you to discharge three surgical patients immediately. Meanwhile you have been called to see a patient who is unwell on one of the outlying wards. Rank in order the following actions in response to this situation (1 = Most appropriate; 5 = Least appropriate) A Phone the registrar and ask if there are any spare doctors to assist with your tasks. B Sympathize with the severity of the bed crisis but explain how you have more urgent matters to deal with, and refer her to your registrar. C Take a few minutes to complete a very brief discharge of the three patients before attending to the care of the unwell patient. D Ask the matron to complete the discharge letter but agree to sign a blank copy in advance to facilitate a fast discharge. E Agree to complete the discharge letters once you have stabilized your unwell patient.

16. E, B, A, C, D

17. You are sharing ward jobs with another FY1 doctor on a busy medical ward. After quickly dividing the tasks, you later fi nd that your colleague has begun an ascitic drain on the incorrect liver patient. Choose the THREE most appropriate actions to take in this situation A Allow your colleague to complete the task as it risks looking more unprofessional stopping the procedure part way through. B Tell the FY1 doctor to report himself to the GMC for not confi rming the patient’s identity. C Complete a critical incident form. D Ask the FY1 doctor to stop performing the procedure immediately. E Allow your colleague to insert the drain, before explaining to the patient that it was in order to obtain an ascitic fl uid sample to exclude infection. F Obtain an abdominal ultrasound to confi rm correct drain placement. G Accept total responsibility for this error. H Suggest that the FY1 doctor apologizes for the error.

17. C, D, H

18. A patient’s relative asks you to speak with her sister, who is increasingly worried about the Hartmann’s procedure and stoma formation planned for her tomorrow. Choose the THREE most appropriate actions to take in this situation A Ask the relative to explore any concerns and get back to you if there’s anything that you can help with. B Speak to the family to identify any of the patient’s concerns. C Talk the patient through the procedure and answer any questions she might have. D Ask the patient to share her to express her concerns. E Inform the patient that she may risk compromising the safety of other patients if she does not decide whether to go ahead with the surgery. F Explain to the patient how she should not worry about stomas as they are easily reversed. G Inform your surgical seniors promptly if the patient appears to show doubt about the procedure. H Arrange an urgent psychiatry referral.

18. C, D, G

19. A transplant patient has attended the GP practice at which you are working having agreed to assist you with the teaching of a group of medical students. Unfortunately the patient appears particularly distressed as her husband has recently been admitted to hospital and, despite ten minutes of conversation, remains particularly tearful. Rank in order the following actions in response to this situation (1 = Most appropriate; 5 = Least appropriate) A Explore the patient’s personal circumstances and current concerns in order to impart valuable lessons in communication skills. B Provide a lecture-based teaching on transplants. C Try to ignore the issue, and perform a brief examination of the patient’s abdominal system. D Continue with the bedside teaching as planned, explaining that patients with chronic diseases often become emotional for a variety of reasons. E Try to provide bedside teaching, but inform the patient that you would be happy to stop if she wishes.

19. B, E, C, D, A

20. A patient is readmitted to the A&E for the fi fth time in three months with recurrent leg pains. The patient has been reviewed extensively by numerous medical doctors, emergency doctors, and the patient’s GP, but the patient remains anxious about these intermittent attacks. You complete a full work-up and establish no new fi ndings, and in the context of his previous admissions accept that there is nothing more you are able to off er. Your registrar is insistent that you review your patients more expeditiously. Rank in order the following actions in response to this situation (1 = Most appropriate; 5 = Least appropriate) A Explore the patient’s psychological and social well-being despite prolonging your assessment of the patient. B Explore whether the patient wishes to consider alternative/complementary therapies. C Refer the patient to another colleague in the A&E. D Explain to the patient that you have only a limited time to spend with each patient and that you cannot off er him anything else. E Refer the patient to a pain specialist.

20. A, C, B, E, D

21. Steven is a 40-year-old paranoid schizophrenic who has returned to your ward with a severe chest infection. You attempt to recommence intravenous antibiotics as decided by the medical team, but the patient refuses. Steven’s mother is distressed at the delay in treatment, stating that ‘this happens every time’ and gives you permission as his mother to begin treatment. Rank in order the following actions in response to this situation (1 = Most appropriate; 5 = Least appropriate) A Defer the decision to a senior colleague. B Administer the intravenous antibiotics irrespective of Steven’s wishes. C Ask the mother to help establish whether Steven has capacity to decide for himself. D Attempt to establish whether Steven lacks capacity by reading through the medical notes. E Assess Steven’s capacity for refusing this treatment.

21. E, A, D, C, B

22. Your consultant asks you to make a patient referral to the drugs and alcohol liaison service in order to arrange methadone replacement for an intravenous drugs user, during the afternoon ward round. The patient already appears to be suff ering with withdrawal symptoms. The registrar later informs you that you might spend an hour trying to locate the correct offi ce and arranging the referral, and you should instead defer the referral until tomorrow as there are plenty of more important patients and problems to deal with. Rank in order the following actions in response to this situation (1 = Most appropriate; 5 = Least appropriate) A Ask the shadowing student doctor to attempt to locate the offi ce and make the referral, even though referrals are exclusively made by doctors. B Complete the jobs that your registrar has asked you to do, before attempting to refer the patient to the drug and alcohol service at the end of the day. C Follow the registrar’s instructions and make the referral fi rst thing in the morning. D Explain the importance of treating withdrawal and suggest that your tasks be reprioritized. E Issue a formal complaint to your consultant that the registrar is neglecting this patient.

22. D, B, A, C, E

23. A patient appears more confused than you previously recall during your ward round, and you feel this is not in keeping with his previously diagnosed condition. Choose the THREE most appropriate actions to take in this situation A Quickly examine the patient, with a view to performing a more detailed review tomorrow. B Explain to the patient that you will return to review him in more detail after the ward round. C Consider requesting appropriate investigations. D Document in the notes that the patient appears more confused, and continue with the ward round. E Establish his Abbreviated Mental Test Score (AMTS). F Suggest that the patient be transferred to the psychiatric ward for further assessment of his mental function. G Perform a full history and examination at a risk of delaying the entire ward round. H Move on quickly so that you can continue the ward round.

23. C, E, G

24. A patient attending your GP informs you that he has recently been diagnosed with alcohol-related seizures, and has been asked by the hospital doctors to discuss the matter with you in terms of his work. He is a self-employed taxi driver and is the sole provider for his wife and family of three children, and refuses to inform the DVLA. Choose the THREE most appropriate actions to take in this situation A Document the advice you have given to the patient. B Explain the reasonable possibility of another seizure. C Call the taxi licence issuer to have his taxi licence revoked. D Agree that he is probably not a danger but that he should inform the DVLA nonetheless. E Call the DVLA anonymously but keep this from the patient to maintain his trust. F Tell the patient that you must inform the taxi licence issuer and call them even if he refuses consent. G Inform the patient that you will need to inform the DVLA if he refuses. H Ask the patient’s wife to bring in his driving licence to the practice so it can be destroyed.

25. A physiotherapist informs you that she has seen a nurse take money from the wallet of a demented patient. Rank in order the following actions in response to this situation (1 = Most appropriate; 5 = Least appropriate) A Ask the physiotherapist to establish some more details fi rst by speaking to the patient before making her claim. B Establish exactly what the physiotherapist saw before informing the Ward Sister. C Report the incident to your Clinical Supervisor. D Confront the nurse and ask her to empty her pockets. E Make a non-urgent phone call to your local police station.

25. B, C, A, D, E

26. Morning handover from night SHOs to junior doctors working during the day appears to be increasingly rushed, and you have noted on several occasions blood tests and investigations not eff ectively handed over. You feel this may be related to the speed with which the handover takes place, although the registrars and consultants appear to be happy with the pace of the morning handover. Rank in order the following actions in response to this situation (1 = Most appropriate; 5 = Least appropriate) A Highlight your concerns if you identify another urgent task that is not handed over, but otherwise do not mention it for fear of causing diffi culties. B Speak with your Clinical Supervisor to explain that handover is inadequate. C Register formal complaints for those colleagues whom you feel might be responsible for information not being handed over in the past. D Ensure that your own handover is eff ective. E Organize a meeting with the other junior doctors to explain your concerns regarding the effi cacy of your handover.

26. E, B, C, D, A

27. Your SHO colleague is going through a separation with his wife and is scheduled to attend numerous civil court hearings over the coming weeks. His performance does not seem to be aff ected but you think that he does seem more despondent than usual. Rank in order the following actions in response to this situation (1 = Most appropriate; 5 = Least appropriate) A Email your consultant immediately, as you are obliged to ensure patient safety. B Explore how your colleague is feeling and what kind of support they feel they need. C Advise your colleague to see a counsellor. D Continue to observe your colleague’s performance at work, but do not mention this matter to anyone else for the moment. E Advise your colleague to speak to their Educational Supervisor.

27. B, E, D, C, A

28. You are an FY1 doctor working at a GP surgery and seeing 42-year-old Kimberly, who has returned after one week with continuing joint discomfort. At the end of the consultation she seems relieved, as she found the last internal examination quite uncomfortable and was hoping to avoid another again today. Looking through the computerized notes you cannot fi nd any note of an internal examination by your FY1 colleague during her last visit, and are unsure why this would have been performed. Choose the THREE most appropriate actions to take in this situation A Speak to the FY1 doctor during the lunch-time practice meeting. B Ask the patient to refer herself back to the colleague who performed the examination to seek an explanation. C Explain to the patient what you think has happened. D Establish more details about Kimberly’s symptoms and what the examination involved. E Inform the senior GP partner in charge. F Ask the patient not to disclose anything about the incident to anyone else until your seniors at the practice have discussed the matter with her. G Approach your FY1 colleague and ask him to describe his review of the patient last week. H Inform your deanery’s training director.

28. D, E, G

29. You are struggling to schedule an induction meeting with your Clinical Supervisor. Despite this you feel you have received an adequate induction by the registrars on your fi rm, and feel well supported and able to perform your clinical duties safely. Your supervisor eventually agrees to meet and complete the form between endoscopy cases, and only manages to spend a few minutes speaking to you. After completing the online form he asks you to co-sign the form so the meeting can be offi cially registered on your e-portfolio. Choose the THREE most appropriate actions to take in this situation A Try to identify a more convenient time to sign this form in the near future. B Report your Clinical Supervisor to the deanery. C Co-sign the form to confi rm that the meeting took place and you have completed your formal Clinical Supervisor meeting. D Ask your Educational Supervisor to act as your Clinical Supervisor. E Ask your Clinical Supervisor to arrange for a suitable replacement. F Refuse to co-sign the form at this moment G Continue the rotation and persist with similar meetings, accepting that supervisors often have very busy schedules. H Organize a meeting with the Foundation Programme Director.

29. A, E, F

30. Ethel is a patient on the orthopaedic ward making a slow recovery from a neck of femur fracture. At the moment she is receiving physiotherapy for 15 minutes a day, but you feel that she would benefi t from a more intensive regime. Rank in order the following actions in response to this situation (1 = Most appropriate; 5 = Least appropriate) A Continue with the current physiotherapy regime. B Instruct the physiotherapist to double the duration of time spent with Ethel to help expedite her discharge. C Speak to your orthopaedic seniors and other multi-disciplinary team members to ascertain what they feel about the patient’s current physiotherapy regime. D Invite Ethel and her next of kin to the next multi-disciplinary meeting to raise their concerns at the current level of physiotherapy off ered. E Ask the physiotherapist whether Ethel would benefi t from additional physiotherapy input.

30. E, C, A, D, B