Question & Scenario Bank
79 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?