Question & Scenario Bank
157 structured scenarios across the four ST4 stations. Each has a framework, ideal-answer key points and a consultant-style model answer — tucked behind an accordion so you can attempt before peeking.
A 68-year-old presents with sudden-onset breathlessness, SpO2 88% on air, HR 122, BP 90/60. Walk me through your assessment and initial management.
A 55-year-old is brought in with right-sided weakness that started 90 minutes ago. How would you manage this?
A 45-year-old alcoholic presents with haematemesis and melaena. Outline your approach.
How do you assess and manage an acute exacerbation of COPD presenting with confusion and SpO2 of 84%?
A 22-year-old with type 1 diabetes presents drowsy with glucose 32, ketones 5.6, pH 7.15. Manage this patient.
An 80-year-old has K+ 7.2 on routine bloods. They feel mildly unwell. What is your approach?
Why do you want to pursue this medical specialty at ST4 level?
Tell me about a quality improvement project you have led.
A junior colleague is repeatedly leaving the ward early without finishing handover. How do you handle this?
What is clinical governance and how do you contribute to it as a registrar?
A 78-year-old with metastatic cancer refuses a blood transfusion that you believe is life-saving. What do you do?
You suspect a consultant colleague has been drinking on call. What is your duty?
You are the medical registrar called to review a 28-year-old with worsening asthma. Talk us through your assessment and management.
What are the features of life-threatening asthma, and why is a normal CO2 concerning?
A 72-year-old with known COPD is drowsy and breathless. ABG on 28% O2: pH 7.28, PaCO2 8.5, PaO2 7.2. Manage this patient.
After one hour on NIV the patient's pH is 7.26. How do you proceed?
What are the contraindications to NIV?
How would you decide whether a COPD patient is appropriate for invasive ventilation?
ICU say the patient is not for intubation and the patient is deteriorating. What would you tell the family?
Invasive ventilation is not appropriate and the patient is deteriorating. How would you manage them now?
How would you manage suspected SVC obstruction?
A 22-year-old woman with T1DM is admitted with her third DKA in 6 months. How would you manage her?
How would you approach the conversation if you suspected insulin omission for weight control?
A 72-year-old woman is confused with sodium 114 mmol/L. How would you manage her?
A 45-year-old with known Addison's presents with vomiting, hypotension and confusion. How would you manage her?
A 35-year-old woman has palpitations, tremor and weight loss with suppressed TSH and elevated free T4. How would you approach this?
She tells you she is trying to conceive. How does that change your management?
A 68-year-old man is constipated and confused. Calcium is 3.3 mmol/L. How would you manage him?
A 72-year-old with T2DM on insulin is found confused at home; capillary glucose 2.3 mmol/L. Manage him.
A 32-year-old woman has irregular periods, galactorrhoea and elevated prolactin. How would you approach this?
A 72-year-old man arrives in ED with sudden right-sided weakness and slurred speech, started 1 hour ago. Walk us through your management.
What are the key contraindications to thrombolysis in acute stroke?
What stroke mimics must you consider, and what would you do if CT shows haemorrhage instead?
Give a 1-minute presentation on your role as a medical registrar.
Why Respiratory Medicine?
Why Endocrinology & Diabetes?
What defines the mindset shift from medical registrar to endocrinology trainee?
How do you prioritise when there are three sick patients simultaneously?
What is your current Personal Development Plan?
What is a weakness you are actively working on?
During a busy shift, how do you find opportunities to learn?
A consultant from another specialty refers a patient you don't think needs admission. How do you handle it?
Community Acquired Pneumonia with High NEWS2 — manage the first hour.
Deliver a 4-minute interesting case presentation followed by 4 minutes Q&A.
Anterior STEMI complicated by cardiogenic shock — talk us through your management.
A senior colleague tells you 'we don't Datix things like that here'. How do you respond?
A patient on the respiratory ward coughs up >250ml of blood. Manage.
A patient on long-term prednisolone presents shocked after gastroenteritis. Manage.
Why do you want to pursue this specialty at ST4 — and what have you done to evidence that commitment?
An 82-year-old presents after a witnessed syncopal episode. ECG shows complete heart block with a ventricular escape of 28 bpm. BP 84/52. How will you manage?
A 70-year-old with known HFrEF (EF 25%) presents with acute breathlessness, frothy sputum, bilateral crackles to the apices, SpO2 86% on air. Talk us through your management.
Present an interesting case from your clinical practice in 4 minutes that demonstrates registrar-level decision-making.
A 28-year-old with known UC presents with 10 bloody stools per day, abdominal pain, HR 112, temp 38.2. Talk through your assessment and management.
A 52-year-old with gallstones presents with severe epigastric pain, lipase 2400, lactate 4.2, SpO2 90% on air, oliguric. Walk us through your management.
A 55-year-old presents with malaise, haemoptysis and creatinine 420 (baseline 90). Urine dip: blood +++, protein ++. How will you proceed?
A 68-year-old with newly diagnosed myeloma presents drowsy and dehydrated. Adjusted calcium 3.8 mmol/L. Manage.
An 87-year-old with dementia is admitted after two falls and confusion. CFS 7, lives alone, normally walks with a frame. Manage the admission.
A 92-year-old with end-stage dementia is admitted with aspiration pneumonia. The patient lacks capacity. One daughter insists on 'everything including ITU', the son wants comfort care. How will you proceed?
Your trust audit shows 35% of >75s are discharged on >10 medications. You've been asked to lead a QI project to reduce inappropriate polypharmacy. Outline your approach.
A young trauma patient becomes acutely breathless and hypotensive. Trachea deviated to the right, absent breath sounds on the left. What now?
A 40-year-old develops urticaria, lip swelling and wheeze 10 minutes after starting IV co-amoxiclav. BP 78/40. How do you manage?
It is 02:00. ED has 22 patients waiting for medical beds, 6 breaching the 12-hour standard. The site manager is asking you to make decisions. How do you approach this?
The ED consultant insists a patient is 'medical' and must be admitted under you. After reviewing, you believe the patient is primarily surgical. The ED consultant becomes confrontational. How do you handle this?
You are the sole medical registrar on take. The surgical FY1 bleeps you for help with a deteriorating post-op patient because the surgical registrar is in theatre. ED has 4 unseen referrals. What do you do?
Your FY1 sustains a needle-stick injury from a known HIV/Hep C positive patient at 04:00. She is exhausted and asks if she can 'just deal with it in the morning'. How do you respond?
Your FY1 prescribed 10x the correct dose of digoxin to an elderly patient who has now developed bradycardia and nausea. The FY1 is in tears. How do you manage this?
You are the medical registrar. Three crash bleeps go off in 60 seconds: a peri-arrest on AMU, a cardiac arrest on the stroke ward, and a deteriorating GI bleed in ED. How do you prioritise?
A 64-year-old with known ischaemic cardiomyopathy presents with pulmonary oedema, BP 82/50, lactate 4.5, creatinine doubled in 24 h. Walk me through your management.
A 58-year-old post-anterior STEMI on the CCU has had 4 episodes of VF in the last hour, each requiring DC shock. He is now intubated. How do you manage VT/VF storm?
A 52-year-old with a mechanical mitral valve (on warfarin, INR 1.4) presents with acute dyspnoea, muffled mechanical clicks on auscultation, and pulmonary oedema. How do you proceed?
A 34-year-old man, tall and thin, presents with sudden interscapular pain, BP differential 30 mmHg between arms, and a new diastolic murmur. How would you proceed?
A 48-year-old with known alcohol-related cirrhosis re-bleeds 6 hours after band ligation. BP 80/50, Hb dropped from 78 to 62. What now?
A 28-year-old with known UC is admitted with 10 bloody stools/day, T 38.2, HR 110, Hb 92, CRP 95. Walk me through inpatient management.
A 22-year-old presents 36 hours after a staggered paracetamol overdose. INR 6.8, creatinine 220, pH 7.28, lactate 5, drowsy (GCS 12). What is your management?
A 56-year-old with epigastric pain radiating to the back, lipase 5x ULN, T 38.5, HR 115, BP 95/55, lactate 3.5. USS: gallstones, dilated CBD 9 mm. How do you manage?
A 32-year-old has been fitting for 35 minutes despite 2 doses of IV lorazepam and a phenytoin load. How do you proceed?
A 71-year-old wakes with right hemiplegia and global aphasia (NIHSS 18). Last seen well 9 hours ago. CT: no haemorrhage, dense MCA sign. How do you proceed?
A 45-year-old presents with progressive 5-day ascending weakness, areflexia, FVC 1.1 L (predicted 4.0) and a weak cough. How do you manage?
A 40-year-old presents with 24 h of headache, fever, confusion (GCS 13) and a focal seizure. How do you proceed, and what if the LP is delayed?
A 79-year-old with end-stage heart failure and an implantable cardioverter defibrillator is receiving repeated shocks in his final days. His wife asks you to 'turn it off'. How do you approach this?
A patient who has just received an appropriate ICD shock tells you he intends to keep driving because he needs his car for work. What is your duty?
Your centre's audit shows the proportion of STEMI patients achieving door-to-balloon within 90 minutes has fallen from 82% to 61% over six months. You have been asked to lead the response. Outline your approach.
Why cardiology, and what have you done that evidences that commitment?
A patient you consented and assisted with has sustained a colonic perforation during a therapeutic colonoscopy and requires emergency surgery. The consultant who performed it asks you to 'let them settle before we get into all that'. What do you do?
A patient with decompensated alcohol-related liver disease asks you whether he will be considered for a transplant. He relapsed two months ago. How do you handle this conversation?
Your unit has a backlog of 900 overdue surveillance colonoscopies and the waiting list is growing. You have been asked to lead a response. How would you approach it?
Why gastroenterology, and what have you done that evidences that commitment?
A patient with newly diagnosed epilepsy tells you she has not informed the DVLA and intends to keep driving her children to school. How do you proceed?
You are asked to tell a patient that his investigations are consistent with motor neurone disease. How would you approach this consultation?
Your hyperacute stroke unit's median door-to-needle time is 68 minutes against a national target of 45. Outline how you would lead a project to improve it.
Why neurology, and what have you done that evidences that commitment?
An 84-year-old with stage 5 CKD and severe frailty is approaching the need for renal replacement therapy. His son insists he should start dialysis. How would you approach this?
A 58-year-old on haemodialysis for four years tells you he wants to stop. He has capacity. How do you respond?
Your trust's AKI e-alerts show that only 48% of stage 2 and 3 alerts receive a documented senior review within 24 hours. You have been asked to lead the improvement work. Outline your approach.
Why renal medicine, and what have you done that evidences that commitment?
Why geriatric medicine, and what have you done that evidences that commitment?
An inpatient on your ward sustained a fractured neck of femur after an unwitnessed fall. The trust is conducting a patient safety incident investigation. As the registrar, what is your role?
Your trust wants to expand same-day emergency care to reduce admissions. You have been asked to develop a pathway for one condition. How would you approach it?
You are the medical registrar on a night shift where two of the four SHOs are absent and no locum has been found. How do you manage the shift, and what do you do afterwards?
An 84-year-old admitted with a urinary tract infection becomes agitated and is trying to leave the ward at 02:00. How do you manage this?
A 79-year-old presents after her third fall in two months, one of which was witnessed and involved a brief loss of consciousness. How would you assess her?
An 88-year-old care home resident with dementia sustains a fractured neck of femur. What are the priorities in the first 24 hours?
A 71-year-old is referred with fever, confusion and hypotension but no obvious source of infection. Talk us through your approach.
A 76-year-old's creatinine has risen from 95 to 310 over three days following a CT with contrast and an emergency laparotomy. How would you assess and manage this?
A 44-year-old presents with two weeks of progressive peripheral oedema, urine protein:creatinine ratio 780 mg/mmol and albumin 18 g/L. How would you proceed?
An audit shows that only 55% of patients started on NIV have a documented escalation plan before treatment begins. You have been asked to improve this. Outline your approach.
Your trust reports 42 severe inpatient hypoglycaemic episodes per month requiring rescue treatment. You have been asked to lead a project to reduce them. Outline your approach.
You are bleeped at 03:00 about a ward patient whose NEWS2 has risen from 3 to 9 over four hours. How do you approach this?
A 72-year-old man with metastatic prostate cancer is referred at 21:00 with eight days of progressive thoracic back pain and new leg weakness. Walk me through your immediate management.
A 64-year-old woman, day 9 after adjuvant chemotherapy, rings the 24-hour triage line with rigors and a temperature of 38.7 at home. How do you manage this?
A 34-year-old man admitted with newly diagnosed high-grade lymphoma is oliguric with a potassium of 6.9 and ECG changes. How do you manage him?
A 58-year-old woman, 11 days after her third cycle of pembrolizumab, presents with 9–10 watery stools a day and abdominal pain. How would you assess and manage her?
Why medical oncology, and what have you done that evidences that commitment?
Critically appraise a phase III trial design. Take one that has changed your practice.
Three patients on your oncology bay have developed febrile neutropenia in 36 hours, two with the same resistant organism, and the ward is dangerously short-staffed. What do you do?
A 74-year-old with metastatic pancreatic cancer is admitted under the acute take, which has documented a ceiling of care and 'not for further chemotherapy'. The patient says he wants to keep fighting. How do you manage this?
A 71-year-old with metastatic lung cancer lacks capacity and his family is demanding third-line chemotherapy. How do you respond?
An FY2 tells you they gave carboplatin at 1.4 times the correct dose and asks you not to say anything. What do you do?
A 72-year-old on apixaban presents 3.5 hours from onset with dense right hemiparesis, aphasia and gaze deviation — NIHSS 16. Is he eligible for thrombolysis?
A 65-year-old hypertensive man presents with sudden left hemiparesis, headache and vomiting — GCS 11, BP 210/110. CT shows a large right basal ganglia haemorrhage. How do you manage the first hour?
A patient wakes with a dense left hemiparesis; the exact time of onset is unknown and they were last seen well over 12 hours ago. Can they still be treated?
A patient presents with acute vertigo, diplopia and dysarthria, then rapid progression to reduced consciousness — evolving toward locked-in syndrome. What is your approach?
Why stroke medicine, and what have you done that evidences that commitment?
Your hyperacute stroke unit's median door-to-needle time is 55 minutes against a national target of under 30. Outline how you would lead a project to improve it.
A stroke patient with severe expressive and receptive aphasia needs a decision about a PEG tube. The team disagree about whether he has capacity. How do you approach this?
A 27-year-old man who has sex with men has fever, rash, oral ulcers and lymphadenopathy three weeks after a new partner. His point-of-care HIV test is reactive. What happens now?
A woman treated with ceftriaxone 1 g for pharyngeal and cervical gonorrhoea has a positive test of cure with no re-exposure. Culture shows ceftriaxone resistance. How do you manage her?
A 19-year-old woman with learning difficulties has secondary syphilis, attends with a controlling older man, describes gifts for sex and refuses to name partners. What do you do?
A woman at 32 weeks' gestation has her first-ever episode of painful genital ulceration. The obstetricians ask whether she needs a caesarean section. How do you advise?
A man who has sex with men has severe proctitis. Gastroenterology found 'possible Crohn's' on sigmoidoscopy. What is your approach?
Why Genitourinary Medicine and HIV, and what have you done that evidences that commitment?
Your service introduced online STI testing with home sampling kits a year ago. The commissioner asks whether it is working. How would you evaluate it?
A 14-year-old attends with her mother, who demands contraception for her. Alone, the girl describes a 21-year-old 'boyfriend' who gives her alcohol. The mother becomes aggressive when you mention social services. What do you do?
A patient on boosted darunavir was prescribed simvastatin as an inpatient and has developed rhabdomyolysis. He asks you, 'Did something go wrong?' How do you respond?
A 23-year-old with type 1 diabetes is drowsy with pH 6.92, glucose 34, ketones 6.1 and potassium 3.1. Two hours into the DKA protocol his ketones have not fallen. What do you do?
A 54-year-old on chemotherapy, last cycle 9 days ago, is febrile at 38.8, BP 88/52 and lactate 4.2 with no obvious source. How do you manage the first hour?
A 68-year-old, 6 weeks post drug-eluting stent on aspirin and clopidogrel, presents with haematemesis, Hb 68, BP 92/58 and dynamic ST changes. How do you manage the competing priorities?
A 34-year-old woman at 28 weeks' gestation presents with sudden breathlessness, BP 84/50, and right heart strain on echo. How do you manage this, and what about thrombolysis in pregnancy?
A 58-year-old on a thiazide presents with a generalised seizure and a sodium of 112 mmol/L. How do you correct it, and what are the limits?
Why General Internal Medicine, and what evidences your commitment to the unselected take?
It is 03:00 in winter, the emergency department is overflowing, and specialty wards refuse to take boarded medical patients. As the medical registrar, how do you respond?
A patient has a valid Advance Decision refusing ventilation and CPR. Now critically unwell, the family demand 'everything'. How do you respond?
A 26-year-old woman with asthma is drowsy with a near-silent chest despite nebulisers, steroids and IV magnesium.
A 68-year-old man with severe COPD (FEV1 32% predicted, home oxygen 2 L, MRC 4, independent with a stick) was started on NIV 3 hours ago for an exacerbation.
A 59-year-old man with bronchiectasis and an aspergilloma has massive haemoptysis while on apixaban.
A 64-year-old man with type 2 diabetes was admitted 4 days ago with left lower lobe pneumonia.
A 47-year-old woman, 6 days after an elective laparoscopic hysterectomy, collapsed on the ward.
A 74-year-old man with idiopathic pulmonary fibrosis (diagnosed 3 years ago, on nintedanib, baseline FVC 62%, walks 200 m) presents with 10 days of worsening breathlessness and dry cough.
A 52-year-old man, previously well, presents with 4 days of fever, productive cough, diarrhoea and confusion.
A 31-year-old man, who moved from a high-incidence country 2 years ago and works in a warehouse, presents with 2 months of cough, night sweats and 7 kg weight loss.
A 44-year-old man has 3 weeks of progressive breathlessness on exertion and a dry cough.
A 61-year-old smoker presents with 2 weeks of facial swelling, headache on bending, and breathlessness.
A 70-year-old man with severe bullous COPD had a 12 F Seldinger chest drain inserted 4 days ago for a right secondary pneumothorax.
A 39-year-old woman with idiopathic pulmonary arterial hypertension, managed by a national PH centre and on macitentan, tadalafil and a continuous subcutaneous treprostinil infusion, presents with 5 days of worsening breathlessness, ankle swelling and two presyncopal episodes.
A 23-year-old woman with cystic fibrosis, under a regional adult CF centre 80 miles away, presents to your district general hospital with a 1-week pulmonary exacerbation.
A 56-year-old man (BMI 52) is brought in by ambulance after his wife found him difficult to wake.
A 48-year-old man who keeps racing pigeons presents with 8 hours of fever, rigors, dry cough and breathlessness, starting 6 hours after cleaning out his loft.