What is the OET Medicine format?

Four sub-tests. Listening (about 45 minutes, 42 items) and Reading (60 minutes, 42 items) are the same for every profession. Writing (about 45 minutes) and Speaking (about 20 minutes) are specific to yours — these questions are written for MEDICINE. Reading Part A is separately timed: 15 minutes to find specific information across four short texts on one clinical topic. Parts B and C share the remaining 45 minutes. Listening runs in three parts: extracts from consultations, then short workplace extracts, then presentations and interviews. Writing is one letter built from case notes — for doctors usually a referral to a specialist or a discharge or transfer letter, sometimes a letter to a patient or a non-clinical reader. Speaking is two role-plays with an interlocutor, based on cards from your own profession — for doctors, consultations rather than ward interactions. Each sub-test is scored 0–500 in 10-point steps and reported as a grade from A to E. 350 is Grade B. Which grade YOUR regulator wants, and whether it will accept sub-tests from more than one sitting, is a question for that regulator's own website — check the GMC, AHPRA, the Medical Council of Ireland or the ECFMG pathway directly. We do not restate those numbers here, because the ones printed on coaching sites are frequently out of date and a wrong one can cost you a resit fee.

Are these OET Medicine practice questions free?

Yes. All 247 questions, with answers and explanations, are on one page with no sign-up, no login and no paywall. The page works with JavaScript switched off and once loaded it works offline.

Where do these questions come from?

They were written by language models and then cross-checked: every question was sent back to a different model with the answer removed, and only the ones where the second model independently chose the same answer are on this page. 194 of 247 have passed that check. Nobody who has sat the OET Medicine has reviewed them yet, so treat them as practice, not as an official answer key.

OET Medicine Practice Questions 2026 — Free, with Answers and Explanations

Q: What is the OET Medicine and who takes it?

Occupational English Test — Medicine, set by Cambridge Boxhill Language Assessment. Doctors — international medical graduates — sitting OET Medicine on a route to practise in the UK, Ireland, Australia, New Zealand, Singapore or the Gulf, or through the ECFMG pathway. Nurses want the nursing test instead: Writing and Speaking are profession-specific and the two are not interchangeable.

Read this before you trust an answer. These questions were written by language models, not cut from past papers. Every one was then sent back to a different model with the answer hidden, and only the ones where the second model independently picked the same answer are on this page — 194 of 247 so far. That is a floor, not a guarantee: two models can agree and still be wrong, and nobody who has sat the OET Medicine has reviewed these yet. Use them to practise the shape of the test. For the official format and scoring, go to Cambridge Boxhill Language Assessment. Found a wrong answer? Tell us and we will pull it.

What the OET Medicine actually is

Four sub-tests. Listening (about 45 minutes, 42 items) and Reading (60 minutes, 42 items) are the same for every profession. Writing (about 45 minutes) and Speaking (about 20 minutes) are specific to yours — these questions are written for MEDICINE.
Reading Part A is separately timed: 15 minutes to find specific information across four short texts on one clinical topic. Parts B and C share the remaining 45 minutes.
Listening runs in three parts: extracts from consultations, then short workplace extracts, then presentations and interviews.
Writing is one letter built from case notes — for doctors usually a referral to a specialist or a discharge or transfer letter, sometimes a letter to a patient or a non-clinical reader.
Speaking is two role-plays with an interlocutor, based on cards from your own profession — for doctors, consultations rather than ward interactions.
Each sub-test is scored 0–500 in 10-point steps and reported as a grade from A to E. 350 is Grade B.
Which grade YOUR regulator wants, and whether it will accept sub-tests from more than one sitting, is a question for that regulator's own website — check the GMC, AHPRA, the Medical Council of Ireland or the ECFMG pathway directly. We do not restate those numbers here, because the ones printed on coaching sites are frequently out of date and a wrong one can cost you a resit fee.

Doctors — international medical graduates — sitting OET Medicine on a route to practise in the UK, Ireland, Australia, New Zealand, Singapore or the Gulf, or through the ECFMG pathway. Nurses want the nursing test instead: Writing and Speaking are profession-specific and the two are not interchangeable.

Tap an option to check it. Your score appears here.

Reading Part A — finding it fast 28 questions

Part A is a SEARCH task under time pressure, not a comprehension task: four short texts on one clinical topic and 15 minutes to locate specific facts.

QRISK3 cardiovascular risk calculator: Initiate statin therapy in adults aged 40‑84 when 10‑year risk is 10% or higher. For patients with diabetes aged 40‑75, the threshold is lowered to 7.5%. In patients with chronic kidney disease stage 3 (eGFR 30‑59), the same 10% threshold applies.
1. What 10‑year QRISK3 risk percentage triggers statin initiation in a 55‑year‑old patient with diabetes?
Answer: C. The passage specifies that for patients with diabetes aged 40‑75 the threshold is 7.5%. Candidates may mistakenly choose the general 10% threshold, overlooking the diabetes‑specific cut‑off.
Clinical trial of low‑dose aspirin for primary prevention (ASPREE). Participants: 19,114 adults ≥70 years, median follow‑up 4.7 years. Primary outcome (major cardiovascular events) occurred in 2.5% of aspirin group vs 2.9% of placebo. Absolute risk reduction: 0.4%. Number needed to treat (NNT) to prevent one event over 5 years: 250. Major bleeding occurred in 1.9% aspirin vs 1.5% placebo.
2. What was the reported absolute risk reduction for major cardiovascular events with aspirin?
Answer: A. The passage gives the absolute risk reduction as 0.4%. Other percentages (0.5, 1.0, 0.2) are mentioned elsewhere in the text (e.g., bleeding rates) and can trap candidates who scan too quickly.
Referral criteria for suspected heart failure (NICE 2022). Refer urgently (within 2 weeks) if any of: (1) New onset dyspnoea at rest, (2) Systolic blood pressure <90 mmHg, (3) Serum NT‑proBNP >2000 pg/mL, (4) Rapid weight gain >5 kg in 1 week. Routine referral (within 6 weeks) if NT‑proBNP 400‑2000 pg/mL with stable symptoms. No referral needed if NT‑proBNP <400 pg/mL and no red‑flag symptoms.
3. What NT‑proBNP level mandates an urgent referral within 2 weeks?
Answer: A. Urgent referral is triggered by NT‑proBNP greater than 2000 pg/mL. The 400‑2000 range is for routine referral, and <400 pg/mL requires no referral. Option D is a distractor that appears in the text as part of the routine range but is not the urgent threshold.
Guideline for dose adjustment of the antihypertensive drug lisinopril in chronic kidney disease: - eGFR 90–120 ml/min/1.73 m²: start 10 mg once daily. - eGFR 60–89 ml/min/1.73 m²: start 5 mg once daily. - eGFR 30–59 ml/min/1.73 m²: start 2.5 mg once daily. - eGFR <30 ml/min/1.73 m²: avoid lisinopril. If serum potassium rises above 5.5 mmol/L, reduce the dose by half. Repeat serum creatinine and potassium every 4 weeks after any dose change.
4. At what eGFR level should lisinopril be avoided according to the guideline?
Answer: A. The passage states that lisinopril should be avoided when eGFR is less than 30 ml/min/1.73 m². The other ranges are for starting doses, not avoidance.
Summary of a randomised controlled trial of the antibiotic ceftriaxone in community‑acquired pneumonia: - 300 patients were randomised to ceftriaxone 1 g IV twice daily or placebo. - The primary outcome was clinical cure at day 14. - Clinical cure was achieved in 240/150 (80%) of the ceftriaxone group and 120/150 (80%) of the placebo group. - The absolute risk reduction was 0%. - The number needed to treat was not calculable because the cure rates were identical.
5. What was the absolute risk reduction for clinical cure with ceftriaxone compared with placebo?
Answer: C. The extract explicitly says the absolute risk reduction was 0%. The other figures are not mentioned in the passage.
Referral criteria for a patient with suspected pulmonary embolism according to the 2023 NICE guideline: - Symptoms: sudden onset dyspnoea, pleuritic chest pain, or haemoptysis. - Clinical prediction: Wells score ≥4. - D‑dimer: >500 ng/mL. - Imaging: CT pulmonary angiography (CTPA) is recommended if the Wells score is high and D‑dimer is positive. - If the patient is pregnant, a ventilation‑perfusion scan is preferred. The guideline recommends urgent referral within 24 hours for any patient meeting all three criteria.
6. Within how many hours should a patient meeting all three criteria be referred urgently?
Answer: A. The passage states urgent referral within 24 hours. The other times are not mentioned.
Drug monograph for the antidiabetic agent empagliflozin: - Indication: type 2 diabetes mellitus, adults with eGFR ≥45 ml/min/1.73 m². - Starting dose: 10 mg once daily. - Dose escalation: increase to 25 mg once daily after 4 weeks if HbA1c remains above target. - Contraindication: eGFR <45 ml/min/1.73 m². - Monitoring: serum creatinine and eGFR every 3 months. - If eGFR falls to 30–44 ml/min/1.73 m², reduce dose to 10 mg once daily. - If eGFR falls below 30 ml/min/1.73 m², discontinue the drug.
7. At what eGFR threshold should empagliflozin be discontinued?
Answer: A. The passage says discontinue when eGFR falls below 30 ml/min/1.73 m². The other numbers are for indication or monitoring, not discontinuation.
NICE guideline NG214: Management of type 2 diabetes in adults. Table 1.2: Blood pressure targets. For adults with type 2 diabetes and no albuminuria, the target systolic blood pressure is less than 140 mmHg and diastolic less than 90 mmHg. For adults with type 2 diabetes and albuminuria (ACR > 3 mg/mmol), the target systolic blood pressure is less than 130 mmHg and diastolic less than 80 mmHg. If the patient is on an ACE inhibitor or ARB, the diastolic target remains less than 80 mmHg regardless of albuminuria status.
8. According to the guideline, what is the target diastolic blood pressure for an adult with type 2 diabetes and albuminuria who is not taking an ACE inhibitor or ARB?
Answer: A. The text states that for adults with type 2 diabetes and albuminuria, the target diastolic blood pressure is less than 80 mmHg. The clause about ACE inhibitors or ARBs does not change this specific diastolic target, it only reinforces it. Option B is the target for patients without albuminuria. Options C and D are not mentioned in the text.
British National Formulary: Warfarin. Dose adjustment in renal impairment. For patients with a creatinine clearance (CrCl) of 15 to 29 mL/min, the initial dose should be reduced by 50% and INR monitored more frequently. For patients with a CrCl of less than 15 mL/min, warfarin is generally contraindicated due to increased bleeding risk and unpredictable metabolism. In patients with a CrCl of 30 to 59 mL/min, standard dosing may be used with weekly INR monitoring.
9. What is the recommended initial dose adjustment for a patient with a creatinine clearance of 20 mL/min?
Answer: A. The patient's CrCl of 20 mL/min falls within the range of 15 to 29 mL/min. The text explicitly states that for this range, the initial dose should be reduced by 50%. Option B applies to CrCl 30-59 mL/min. Option C applies to CrCl less than 15 mL/min. Option D is not mentioned in the text.
Summary of the RE-LY trial: Rivaroxaban versus warfarin in patients with atrial fibrillation. The primary endpoint was the composite of stroke, systemic embolism, or cardiovascular death. In the 15 mg once-daily group, the annual rate of the primary endpoint was 2.1% compared with 2.4% in the warfarin group (hazard ratio 0.88; 95% CI 0.78 to 0.99; P=0.03). In the 20 mg once-daily group, the annual rate was 2.2% compared with 2.4% in the warfarin group (hazard ratio 0.95; 95% CI 0.84 to 1.07; P=0.43). Major bleeding rates were 3.0% for 15 mg, 3.6% for 20 mg, and 3.3% for warfarin.
10. What was the annual rate of the primary endpoint in the 20 mg rivaroxaban group?
Answer: B. The text states that in the 20 mg once-daily group, the annual rate of the primary endpoint was 2.2%. Option A is the rate for the 15 mg group. Option C is the rate for the warfarin group. Option D is the major bleeding rate for the 20 mg group, not the primary endpoint rate.
NICE guideline NG214: Management of type 2 diabetes in adults. Section 1.4: Referral to specialist care. Refer to a specialist diabetes team if the patient has any of the following: HbA1c above 69 mmol/mol (8.5%) on two separate occasions despite optimized therapy; recurrent severe hypoglycemia; significant weight loss; or evidence of end-organ damage such as retinopathy, nephropathy, or neuropathy. Note that an HbA1c of 53 mmol/mol (7.0%) is the target for most adults, but referral is not triggered solely by this value if other criteria are not met.
11. According to the guideline, what HbA1c level on two separate occasions triggers a referral to a specialist diabetes team?
Answer: B. The text explicitly states that referral is indicated if the HbA1c is above 69 mmol/mol (8.5%) on two separate occasions. Option A is the general treatment target, not the referral threshold. Options C and D are not mentioned in the text as referral criteria.
Metformin dose adjustment in renal impairment (extract from SmPC). The usual starting dose is 500 mg once or twice daily, increasing to a maximum of 2000 mg daily in divided doses with meals. In patients with an eGFR of 45 to 59 mL/min/1.73 m squared, the total daily dose should not exceed 1000 mg. In patients with an eGFR of 30 to 44 mL/min/1.73 m squared, the total daily dose should not exceed 500 mg. Metformin is contraindicated in patients with an eGFR below 30 mL/min/1.73 m squared, and should be temporarily withheld in patients undergoing radiocontrast studies or with acute illness predisposing to hypoperfusion. Renal function should be assessed at baseline and at least annually thereafter; in patients with an eGFR between 30 and 59, reassessment is recommended every 3 to 6 months.
12. According to the guideline, what is the maximum total daily dose of metformin in a patient with an eGFR of 40 mL/min/1.73 m squared?
Answer: C. The skill here is matching the patient's eGFR to the right band. 40 falls in the 30 to 44 range, where the cap is 500 mg. 1000 mg is the cap for 45 to 59, 1500 mg never appears in the extract, and 2000 mg is the maximum only in normal renal function. A candidate scanning fast often grabs the 1000 mg figure because it is the most prominent dose cap mentioned.
Referral criteria for suspected heart failure in primary care (adapted from NICE NG106). Refer urgently, with specialist input within 2 weeks, in patients with a raised NT-proBNP above 2000 ng/L (above 2360 pmol/L). Refer for specialist assessment within 6 weeks when NT-proBNP is between 400 and 2000 ng/L (472 to 2360 pmol/L) and there is no prior history of heart failure. For patients with NT-proBNP below 400 ng/L (below 472 pmol/L) but persistent symptoms, consider alternative diagnoses and recheck NT-proBNP after at least 2 weeks if symptoms continue. A normal ECG does not rule out heart failure, and measurement should be repeated sooner if there is an intercurrent illness that may have caused a transient rise.
13. Within how many weeks should a patient with an NT-proBNP of 600 ng/L and no prior history of heart failure be referred for specialist assessment?
Answer: D. The distractor is the 2 week figure, which corresponds to NT-proBNP above 2000 ng/L. A value of 600 ng/L falls in the 400 to 2000 band, which routes the patient to the 6 week pathway. The 12 week figure does not appear in this extract, and 4 weeks is not a stated interval. The scanning skill is reading off the band that contains the patient's number, not the most prominent urgency threshold in the box.
Statin initiation thresholds in primary prevention (summary of QRISK3 guidance). Offer atorvastatin 20 mg daily to adults with a 10 year QRISK3 score of 10 percent or higher for a first cardiovascular event, after discussing the risks and benefits. If a patient has type 2 diabetes and is aged 40 to 84, QRISK3 is not required to start therapy; atorvastatin 20 mg may be offered on the basis of diabetes alone. Consider high intensity statin therapy in patients with a QRISK3 above 20 percent, defined as atorvastatin 40 to 80 mg or rosuvastatin 20 mg. Do not offer statin therapy for primary prevention in patients over 84 years, as the absolute benefit is unproven. QRISK3 should be recalculated at least every 5 years, or sooner if a new risk factor such as smoking or chronic kidney disease develops.
14. According to the guidance, at what 10 year QRISK3 score is high intensity statin therapy recommended?
Answer: C. The figure 10 percent is the lower threshold for offering any statin, and it is the figure most candidates fixate on because it is mentioned first. High intensity therapy is keyed to a QRISK3 above 20 percent, so the trigger here is 20 percent. 5 percent does not appear in the extract, and 15 percent is not a stated cut-off either. The scanning signal is the phrase high intensity, which sits in its own sentence and is easy to miss.
Contrast induced nephropathy prophylaxis (hospital guideline). Before iodinated contrast, check the most recent creatinine within the preceding 7 days in any outpatient and within 24 hours in any inpatient or patient with acute kidney injury. Withhold metformin on the day of the contrast study and for 48 hours afterwards, until renal function has been rechecked and confirmed to be within 10 percent of baseline. Intravenous normal saline at 1 mL/kg/hour is recommended for patients with an eGFR of 30 to 44 mL/min/1.73 m squared, starting 12 hours before and continuing for 12 hours after the procedure. For patients with an eGFR of 45 or above, oral hydration is considered adequate. N-acetylcysteine is no longer recommended as routine adjunctive therapy on the basis of current trial evidence.
15. How long before contrast administration should intravenous normal saline be started in a patient with an eGFR of 35 mL/min/1.73 m squared?
Answer: A. The distractor 24 hours is the creatinine window for inpatients, not the saline start time. The distractor 6 hours is plausible and is exactly the kind of half-measure a candidate invents under pressure, but it does not appear in the extract. The salt load guideline sits in its own sentence and pairs 12 hours before with 12 hours after, so the answer is 12 hours. The scanning skill is keeping the creatinine window separate from the prophylaxis window, since both are time-based figures in adjacent sentences.
According to the British Thoracic Society guidelines for the management of chronic obstructive pulmonary disease (COPD), a post-bronchodilator forced expiratory volume in one second (FEV1) of less than 50% predicted with a FEV1 of less than 30% predicted is classified as Global Initiative for Chronic Obstructive Lung Disease (GOLD) stage 4. Patients in this stage should be considered for long-term oxygen therapy if their resting arterial oxygen tension (PaO2) is less than 7.3 kPa (55 mmHg) or if their PaO2 is between 7.3 and 8.0 kPa (55 and 60 mmHg) with evidence of peripheral cyanosis or polycythaemia. Annual spirometry is recommended for all patients in GOLD stage 4 to monitor disease progression.
16. What is the minimum FEV1 percentage predicted that classifies a patient as GOLD stage 4?
Answer: C. The correct answer is found in the passage where it states 'a post-bronchodilator FEV1 of less than 50% predicted with a FEV1 of less than 30% predicted is classified as GOLD stage 4.' The key phrase is 'less than 30% predicted,' which directly answers the question. The other options are incorrect because they do not match the threshold stated in the passage.
The National Institute for Health and Care Excellence (NICE) guidelines for type 2 diabetes management recommend initiating metformin in patients with a body mass index (BMI) greater than 35 kg/m² and an HbA1c level of 6.5% or higher. For patients with a BMI between 30 and 35 kg/m², metformin should be considered if the HbA1c level is 6.0% or higher. Dose adjustments are required if the estimated glomerular filtration rate (eGFR) falls below 45 mL/min/1.73 m². Metformin should be discontinued if the eGFR drops below 30 mL/min/1.73 m².
17. At what HbA1c level should metformin be considered for patients with a BMI between 30 and 35 kg/m²?
Answer: C. The passage specifies 'HbA1c level of 6.0% or higher' for patients with a BMI between 30 and 35 kg/m². This directly answers the question. The other options are incorrect as they do not match the stated threshold.
The American College of Cardiology/American Heart Association (ACC/AHA) guidelines for the management of hypertension recommend initiating antihypertensive therapy in patients with a systolic blood pressure (SBP) consistently above 140 mmHg or a diastolic blood pressure (DBP) consistently above 90 mmHg. For patients with diabetes or chronic kidney disease, the target DBP should be less than 80 mmHg. In patients with stage 2 hypertension (SBP ≥ 160 mmHg or DBP ≥ 100 mmHg), combination therapy is recommended. Patients with resistant hypertension (SBP ≥ 150 mmHg despite three or more antihypertensive medications) should be referred to a specialist for further evaluation.
18. What is the target diastolic blood pressure for an adult with type 2 diabetes and hypertension?
Answer: D. The passage states 'the target DBP should be less than 80 mmHg' for patients with diabetes. This is the correct answer. The other options are incorrect as they do not match the guideline's specified target.
The European Society of Cardiology (ESC) guidelines for the management of atrial fibrillation (AF) recommend initiating oral anticoagulation in patients with a CHA₂DS₂-VASc score of 2 or higher. For patients with a CHA₂DS₂-VASc score of 1, oral anticoagulation should be considered in those with additional risk factors such as prior stroke, transient ischemic attack (TIA), or vascular disease. The ESC also recommends that patients with AF and a left atrial diameter greater than 50 mm on echocardiography should be evaluated for potential structural heart disease. Warfarin dose adjustments are guided by the International Normalized Ratio (INR) target of 2.0 to 3.0, and direct oral anticoagulants (DOACs) should be used with caution in patients with severe renal impairment (eGFR < 15 mL/min/1.73 m²).
19. At what CHA₂DS₂-VASc score should oral anticoagulation be initiated in patients with atrial fibrillation?
Answer: B. The passage specifies 'a CHA₂DS₂-VASc score of 2 or higher' for initiating oral anticoagulation. This is the correct threshold. The other options are incorrect as they do not match the guideline's recommendation.
For patients with chronic kidney disease (CKD) and type 2 diabetes, the following dose adjustments for metformin are recommended based on estimated glomerular filtration rate (eGFR): - eGFR ≥ 45 mL/min/1.73 m²: no adjustment required - eGFR 30–44 mL/min/1.73 m²: reduce initial dose by 50% and monitor closely - eGFR < 30 mL/min/1.73 m²: metformin contraindicated due to risk of lactic acidosis Repeat eGFR measurements should be performed every 3 months in stable patients or at least annually in those with fluctuating kidney function.
20. How often should a patient with CKD and stable eGFR of 35 mL/min/1.73 m² have their eGFR reassessed?
Answer: B. The passage states that repeat eGFR measurements should be performed every 3 months in stable patients, regardless of their exact eGFR value. The distractor 'every 6 months' (A) and 'annually' (C) are incorrect because the guideline specifies a shorter interval for stable patients. Option D is incorrect because it introduces a condition ('if stable') that is not explicitly stated in the passage.
The QRISK3 score is used to assess cardiovascular risk and guide statin initiation. High-intensity statin therapy is recommended for individuals with a 10-year QRISK3 score above 10%. For patients with a QRISK3 score between 5% and 10%, moderate-intensity statin therapy is advised. The guideline also specifies that statins should be initiated within 3 months of diagnosis in patients with a QRISK3 score ≥ 10% and known cardiovascular disease.
21. What is the threshold QRISK3 score for initiating high-intensity statin therapy?
Answer: B. The passage clearly states that high-intensity statin therapy is recommended for a QRISK3 score above 10%. Options A (5%), C (15%), and D (20%) are incorrect because they either do not meet the threshold or exceed it unnecessarily. The reasoning here is to identify the precise threshold mentioned in the text.
For patients with atrial fibrillation (AF) and a CHA₂DS₂-VASc score of 2 or higher, oral anticoagulation is recommended to reduce stroke risk. The guideline provides the following thresholds: - CHA₂DS₂-VASc score ≥ 2: oral anticoagulation recommended - CHA₂DS₂-VASc score ≥ 1: consider oral anticoagulation in high-risk patients (e.g., those with previous stroke or transient ischemic attack) The CHA₂DS₂-VASc score includes the following components: Congestive heart failure (1), Hypertension (1), Age ≥ 75 years (1), Diabetes mellitus (1), Stroke/TIA (2), Vascular disease (1), Age 65–74 years (1), Sex (female) (1).
22. What is the threshold CHA₂DS₂-VASc score for initiating oral anticoagulation in patients with atrial fibrillation?
Answer: B. The passage states that oral anticoagulation is recommended for a CHA₂DS₂-VASc score of 2 or higher. The correct threshold is explicitly 2. Options A (1), C (3), and D (4) are incorrect because they either do not meet the guideline threshold or are higher than necessary. The reasoning is to pinpoint the exact score mentioned for initiating anticoagulation.
Guideline for dose adjustment of amoxicillin in renal impairment: - eGFR ≥ 60 mL/min/1.73 m²: standard dose 500 mg three times daily. - eGFR 30‑59 mL/min/1.73 m²: reduce to 500 mg twice daily. - eGFR 15‑29 mL/min/1.73 m²: reduce to 250 mg twice daily. - eGFR <15 mL/min/1.73 m² or on dialysis: 250 mg once daily. - For patients >80 kg, increase each dose by 25 % provided eGFR ≥30.
23. According to the guideline, what is the recommended amoxicillin dose for a patient with an eGFR of 22 mL/min/1.73 m²?
Answer: C. The passage lists the dose for eGFR 15‑29 mL/min/1.73 m² as 250 mg twice daily. The other numbers refer to different eGFR ranges, so they are plausible distractors.
Summary of the HEART-IT trial (2022) evaluating early invasive strategy in NSTEMI: - Primary composite endpoint (death, MI, or urgent revascularisation) occurred in 8.2 % of the early invasive group versus 11.5 % of the conservative group (risk difference 3.3 %). - Median time to invasive angiography was 12 hours (IQR 8‑24) after randomisation. - Subgroup analysis showed patients aged ≥75 years had a 9.7 % event rate with early invasive versus 13.4 % with conservative. - At 30‑day follow‑up, major bleeding was 2.1 % in the invasive arm and 1.4 % in the conservative arm.
24. What was the median time to invasive angiography after randomisation in the HEART-IT trial?
Answer: A. The passage explicitly states the median time was 12 hours. The other times are mentioned as parts of the inter‑quartile range or are unrelated, making them tempting but incorrect.
Referral criteria for suspected pulmonary embolism (PE) in primary care (NICE 2021): - Wells score ≥4 AND D‑dimer >500 µg/L → urgent CT pulmonary angiography. - Wells score 2‑3 AND D‑dimer >1000 µg/L → consider V/Q scan. - Wells score ≤1 → no imaging required unless clinical deterioration. - For patients on anticoagulation for >6 weeks, repeat D‑dimer threshold is 800 µg/L regardless of Wells score.
25. In a patient not on anticoagulation, what D‑dimer level triggers a V/Q scan when the Wells score is 2?
Answer: C. The passage states that with a Wells score of 2‑3 the D‑dimer threshold is >1000 µg/L for a V/Q scan. The other values appear elsewhere (500 µg/L for CT, 800 µg/L for anticoagulated patients) and are plausible distractors.
Drug monograph: Apixaban for atrial fibrillation - Standard dose: 5 mg twice daily. - Reduce to 2.5 mg twice daily if two or more of the following are present: age ≥80 years, body weight ≤60 kg, serum creatinine ≥1.5 mg/dL (≈133 µmol/L). - Contraindicated in patients with hepatic disease associated with coagulopathy and in those with a baseline INR >1.5 not on anticoagulation. - No dose adjustment required for eGFR ≥15 mL/min/1.73 m²; avoid if eGFR <15. - Onset of action: within 3 hours; peak plasma concentration at 3‑4 hours.
26. What is the apixaban dose for a 82‑year‑old patient weighing 58 kg with serum creatinine 1.6 mg/dL?
Answer: A. The patient meets all three dose‑reduction criteria (age ≥80, weight ≤60 kg, creatinine ≥1.5 mg/dL), so the guideline recommends 2.5 mg twice daily. The other options misuse frequency or ignore the reduction criteria, but the numbers are all present in the monograph, creating realistic distractors.
Guideline for dose adjustment of the anticoagulant dabigatran in patients with chronic kidney disease: • eGFR ≥ 80 mL/min/1.73 m² – standard dose 150 mg twice daily. • eGFR 50–79 mL/min/1.73 m² – reduce to 110 mg twice daily. • eGFR 30–49 mL/min/1.73 m² – reduce to 75 mg twice daily. • eGFR < 30 mL/min/1.73 m² – contraindicated. The guideline also recommends a repeat eGFR measurement every 3 months in patients with eGFR 30–49 mL/min/1.73 m².
27. At what eGFR range is dabigatran dose reduced to 75 mg twice daily?
Answer: A. The passage states that for eGFR 30–49 mL/min/1.73 m² the dose is reduced to 75 mg twice daily. The other options refer to different dose levels or contraindication.
Summary of the 2023 NICE guideline on statin therapy for primary prevention: • Statin therapy is recommended for adults aged 40–75 with a 10‑year cardiovascular risk ≥ 10%. • High‑intensity statins are advised for those with a 10‑year risk ≥ 20%. • Moderate‑intensity statins are advised for those with a 10‑year risk between 10% and 19%. • The guideline advises a 12‑month review of lipid profile after initiation. The guideline also notes that a 10‑year risk of 15% is the threshold for considering moderate‑intensity statins.
28. What 10‑year cardiovascular risk percentage is the threshold for considering moderate‑intensity statins?
Answer: D. The passage explicitly states that a 10‑year risk of 15% is the threshold for considering moderate‑intensity statins. The other figures relate to different intensity categories or are not thresholds for moderate‑intensity.

Reading Part B — workplace documents 31 questions

Six short workplace texts in the real test — a trust policy update, an equipment or assay manual extract, an email to the clinical team, a section of a prescribing guideline, a safety alert — each with one question about its MAIN POINT or its purpose.

Dear Team, With immediate effect, all blood glucose monitoring devices in Ward 4 must be recalibrated using the new Accu-Chek Guide software. This update addresses recent discrepancies in readings reported by the diabetes team. Prescribers are reminded to document these readings in the patient’s electronic health record under the ‘Diabetes’ tab. The previous version of the software is no longer compatible with the new insulin pumps. Please ensure compliance by the end of the day. Best regards, Clinical Informatics Department
1. What is the main purpose of this email?
Answer: C. The main purpose is the instruction to recalibrate devices with the new software ('instruct all staff to recalibrate... with immediate effect'). While discrepancies are mentioned (option D), the email’s core directive is the recalibration command. Options A and B are true statements but secondary details, not the main point. Option C is the only one that captures the imperative action required.
Safety Alert: Urgent Action Required Following reports of incorrect administration of the new anticoagulant Xabrin, all prescribers are advised to double-check patient allergies and contraindications before prescribing. This supersedes the guidance issued in March 2023. If any adverse reactions occur, escalate to the on-call registrar immediately. The pharmacy team will provide additional training sessions on Monday, 12th October. Trust Pharmacy Department
2. What is the main point of this safety alert?
Answer: A. The main point is the urgent action required ('double-check patient allergies and contraindications'), as this is the core safety measure being reinforced. While options B, C, and D are true statements, they are supporting details rather than the primary directive. The alert’s purpose is to prevent incorrect administration, which is addressed by option A.
Trust Policy Update: Infection Control Measures in Outpatient Clinics Effective from 1st September 2023, all outpatient clinics must adhere to the following measures: 1. Hand hygiene stations will be installed at every entrance. 2. Patients with respiratory symptoms must be directed to the dedicated triage area. 3. Surface disinfection protocols will be reviewed quarterly. This update aims to enhance patient and staff safety in line with recent outbreaks. For further details, refer to the updated policy document on the intranet. Trust Infection Control Team
3. What is the main purpose of this policy update?
Answer: C. The main purpose is to improve safety ('enhance patient and staff safety in line with recent outbreaks'). While options A, B, and D are specific actions outlined in the policy, they are details supporting the broader goal of safety enhancement. The update is written to address outbreaks, making option C the correct main point.
Prescribing Guideline Update: Use of Opioids in Chronic Pain Management The following changes are effective immediately: 1. Maximum daily dose of morphine equivalents is now 120mg. 2. Prescribers must document the rationale for opioid prescription in the patient’s notes. 3. A mandatory review of opioid prescriptions is required every 90 days. This guideline aims to align with national best practices and reduce opioid-related risks. For further clarification, contact the Pain Management Team. Trust Pharmacy and Pain Management Services
4. What is the main purpose of this prescribing guideline update?
Answer: D. The main purpose is the overarching goal ('align with national best practices and reduce opioid-related risks'). Options A, B, and C are specific procedural changes, but the update’s intent is broader—it is designed to improve prescribing practices nationally. The guideline’s purpose is not just one change but the collective aim of safety and compliance.
Dear Team, Following the recent audit, we are updating the protocol for administering intravenous (IV) fluids in the paediatric ward. From now on, all IV fluids must be checked by a second nurse before administration, regardless of the patient’s age or fluid type. This change is to reduce the risk of medication errors, particularly in high-pressure situations. Please ensure all staff are trained by the end of this week. Best regards, [Clinical Lead]
5. What is the main purpose of this email?
Answer: A. The main purpose is to introduce the new policy (double-checking IV fluids) and its immediate effect. Option B is true but is not the main purpose—it is background context. Option C is a detail (training deadline) rather than the main point. Option D is incorrect because the policy applies universally, not just to specific cases.
Safety Alert: Urgent Action Required All prescribers are reminded that the new antibiotic, Ceftazidime-Avibactam, must not be used in patients with a history of severe hypersensitivity to beta-lactam antibiotics. This supersedes the guidance issued in March 2023. Failure to comply may result in severe allergic reactions. Please escalate any concerns to the on-call registrar immediately. Trust Pharmacy Team
6. What is the main point of this safety alert?
Answer: A. The main point is the urgent warning about contraindications (severe hypersensitivity). Option B is true but is a detail (superseding old guidance). Option C is a procedural instruction (escalation) rather than the core warning. Option D is incorrect as it contradicts the alert’s key message.
Policy Update: Infection Control in Endoscopy Units With immediate effect, all endoscopy units must implement hand hygiene protocols as outlined in the updated WHO guidelines. This includes using alcohol-based hand rubs for at least 30 seconds before and after each procedure. Exceptions will only be made for staff with documented allergies to alcohol-based products, subject to approval from the Infection Control Team. Failure to comply will result in temporary suspension of endoscopy privileges. Trust Infection Control Department
7. What is the main purpose of this policy update?
Answer: A. The main purpose is to enforce the new hand hygiene policy. Option B is a detail (exceptions process). Option C is a consequence, not the main purpose. Option D is incorrect because the policy applies universally, not just to high-risk cases.
Clinical Team, The new laboratory assay for Vitamin D levels has shown inconsistent results when compared to the previous assay. While the new assay is more sensitive, it has been observed to overestimate levels in patients with chronic kidney disease by up to 30%. We recommend that all results for this patient group be cross-verified with the old assay until further notice. The laboratory will provide additional training sessions next week. Best regards, [Laboratory Manager]
8. What is the main purpose of this email?
Answer: A. The main purpose is to address the inconsistency (overestimation) and request cross-verification. Option B is a detail (training announcement). Option C is a positive aspect but not the main concern. Option D is incorrect as the email does not instruct discontinuation.
Prescribing Guideline Update: Management of Hyperglycaemia in Acute Care This update modifies the prescribing guidelines for managing hyperglycaemia in acute care settings. Insulin regimens must now include a basal-bolus approach for patients with severe hyperglycaemia (glucose > 18 mmol/L). Insulin doses should be adjusted every 4 hours based on blood glucose levels. Prescribers are reminded to monitor for hypoglycaemia and to use glucose monitoring devices for real-time feedback. This update applies to all acute care units and supersedes the previous guidelines.
9. What is the main purpose of this prescribing guideline update?
Answer: B. The main purpose is the introduction of a new insulin regimen (basal-bolus) for severe hyperglycaemia, which is the core change. Options A and C are important details but not the main point. Option D is a procedural note, not the primary directive of the update.
The Trust has updated its policy on the use of intravenous (IV) antibiotics. With immediate effect, all clinicians must record the indication for IV therapy in the electronic prescribing system and obtain a second opinion for any patient over 65 years old. The policy supersedes the guidance issued in 2018 and aligns with the new national antibiotic stewardship targets. Prescribers are reminded to review the duration of therapy at each review appointment and to document the rationale for any extension.
10. Why was this policy update issued?
Answer: D. The text states the policy aligns with new national stewardship targets, which is the overarching reason for the update. The other options are specific details of the policy.
Safety Alert: Recent audits have identified an increased incidence of medication errors involving the new 5mg tablet of amlodipine. The alert lists three changes: 1) the tablet will now be packaged in a blister pack with a patient‑specific label, 2) pharmacists must double‑check the dose before dispensing, and 3) prescribers are required to enter the dose into the electronic prescribing system. The alert is issued to reduce the risk of accidental overdose.
11. What is the primary aim of this safety alert?
Answer: C. The alert’s purpose is to reduce overdose risk; the other items are details of the measures to achieve that aim.
Equipment Manual – Portable Ultrasound Machine (Model X200). The manual states that the machine must be powered by a 12V DC supply and that the probe should be sterilised using 70% isopropyl alcohol before each patient. The manual also recommends using a probe cover for patients with infectious diseases and advises that the machine be stored in a temperature‑controlled room between 18°C and 24°C. The manual is intended to guide staff on safe and effective use of the device.
12. What is the main purpose of this manual extract?
Answer: D. The extract’s purpose is to provide overall guidance on safe use; the other statements are specific recommendations.
Prescribing Guideline Update – Anticoagulation in Atrial Fibrillation. The guideline now recommends that all patients with a CHA2DS2‑VASc score of 2 or more should receive a direct oral anticoagulant (DOAC) unless contraindicated. It also introduces a new monitoring protocol for renal function every 6 months and clarifies that warfarin should be reserved for patients with mechanical heart valves. The update is issued to standardise care and improve patient outcomes.
13. What is the principal reason for this guideline update?
Answer: B. The guideline was updated to standardise care and improve outcomes; the other points are specific changes within that aim.
Clinical Incident Review: Venous Thromboembolism Prophylaxis Post-Surgery. Following three recent near-miss events in the surgical wards where postoperative patients experienced delayed pharmacological VTE prophylaxis due to ambiguous prescription charting, all surgical staff are reminded that mechanical prophylaxis must be applied immediately upon return from theatre, but pharmacological agents require a distinct consultant-signed medication chart within four hours. The purpose of this review is to standardise the charting process and eliminate delays in administering low-molecular-weight heparin.
14. What is the main purpose of this clinical incident review?
Answer: D. Option D captures the overarching purpose stated at the end of the text. Options A, B, and C mention true details or requirements from the text, but they are specific components rather than the primary reason for issuing the review.
To all medical staff. Please be advised that the electronic patient record system will undergo essential scheduled maintenance this Saturday between 0100 and 0400 hours. During this brief window, access to historical patient notes and electronic prescribing will be offline. Paper charts must be used for any urgent drug administration during the outage. The primary objective of this notification is to ensure continuity of safe prescribing by alerting teams to the upcoming downtime and fallback procedures.
15. What is the primary objective of this notification?
Answer: C. Option C correctly identifies the overarching goal of the communication. Options A, B, and D are factual statements drawn from the text, but they describe specific details or mechanisms rather than the main reason for sending the message.
Guidance on Out-of-Hours Lumbar Puncture. Due to a recent rise in complications arising from unsupervised diagnostic lumbar punctures performed overnight, the trust is updating its policy with immediate effect. All foundation doctors must now be directly supervised by a senior registrar or consultant when performing lumbar punctures between the hours of 2000 and 0800. This instruction supersedes the interim guidance issued in March and aims to safeguard patient safety during out-of-hours procedures.
16. What is the main purpose of this policy update?
Answer: A. Option A states the ultimate goal of the policy update. Options B, C, and D are true facts mentioned in the text, but they serve as context or specific rules rather than the primary purpose of the document.
Departmental Memo: Handover Protocol Compliance. Recent audit data across the medical division indicate that weekend handovers are frequently omitting critical resuscitation ceiling discussions for deteriorating patients. Clinicians are reminded that every weekend handover must explicitly document the escalation ceiling for any patient with a national early warning score exceeding four. This requirement is vital for ensuring that junior staff on duty have clear instructions, thereby preventing inappropriate emergency calls and distress to families.
17. What is the main point of this departmental memo?
Answer: C. Option C encapsulates the core directive of the memo. Options A, B, and D represent supporting audit findings, specific procedural rules, or secondary benefits, rather than the primary point of the communication.
Dear Team, With immediate effect, all prescribers must use the new electronic prescribing system for controlled substances. This change follows the recent cybersecurity breach that exposed previous paper-based records. The system will require two-factor authentication and a daily password reset. Training sessions have been scheduled for next week, and non-participation will result in temporary suspension of prescribing privileges. Please ensure all current prescriptions are migrated by the end of this month. Non-compliance will be escalated to the on-call registrar. Regards, Clinical Governance Team
18. What is the main purpose of this email?
Answer: C. The main purpose of the email is to enforce the switch to the new electronic prescribing system for controlled substances (signal: 'With immediate effect, all prescribers must use...'). Options A, B, and D describe details (the breach, password resets, and training) rather than the overarching directive. The email combines the mandate and compliance procedures into one clear purpose.
Trust Policy Update: Visitor Restrictions in Acute Wards To mitigate the spread of respiratory infections, visitors to acute wards will now be limited to two per patient, with a maximum stay of 30 minutes. Exceptions will be granted for end-of-life care or patients under 16 years old. Staff are reminded that visitors must wear masks at all times and undergo hand hygiene upon entry. This policy takes effect from Monday, 15th October 2023. Non-compliance will be managed through a three-stage warning system, as outlined in the Infection Control Protocol (Section 4.2).
19. What is the main purpose of this policy update?
Answer: B. The policy’s core aim is infection control (signal: 'To mitigate the spread of respiratory infections...'). Options A, C, and D describe supporting details (warning system, mask rules, and exceptions) rather than the overarching goal. The update combines these elements to achieve its primary purpose.
Prescribing Guideline Update: Antibiotic Stewardship in Outpatient Clinics Recent data shows a 20% increase in antibiotic resistance in outpatient clinics over the past year. To address this, prescribers are reminded to adhere to the ‘Start Smart Then Focus’ approach for all new prescriptions. This includes: 1. Narrowing the spectrum of antibiotics where possible after 48 hours of treatment, 2. Ensuring duration does not exceed 7 days unless clinically justified, 3. Documenting the rationale for broad-spectrum antibiotics in patient records. The Trust’s Antibiotic Stewardship Team will conduct audits of compliance. Non-compliance may result in mandatory education sessions. This update replaces the 2022 guideline, which lacked specific duration limits.
20. What is the main point of this guideline update?
Answer: C. The update’s focus is combating resistance through protocol changes (signal: 'To address this...'). Options A, B, and D describe individual measures (audits, documentation, and data comparison) rather than the collective goal of stricter stewardship. The update ties these actions to a broader objective: improving prescribing practices.
Trust Notice – Updated Venous Thromboembolism (VTE) Prophylaxis Policy Effective 1 May 2024, all adult in‑patients must receive pharmacological VTE prophylaxis within 12 hours of admission unless contraindicated. Mechanical prophylaxis should be added for patients with a BMI > 35 kg/m2 or those immobilised for > 48 hours. Documentation of risk assessment and prophylaxis plan must be entered in the electronic health record before the end of the first shift. This policy supersedes the guidance issued in November 2023.
21. What is the main point of this policy update?
Answer: A. The central purpose of the notice is to ensure that all adult in‑patients receive pharmacological VTE prophylaxis within 12 hours of admission. The other statements are true details but not the primary reason for the update.
Subject: Revised Blood Glucose Monitoring Protocol Dear Clinical Team, Please be advised that, with immediate effect, capillary blood glucose (CBG) measurements for patients on insulin infusion must be taken every hour during the first six hours of therapy, then every two hours thereafter, provided the glucose level remains between 4.0 and 10.0 mmol/L. If the reading falls outside this range, increase monitoring frequency to every 30 minutes and notify the on‑call registrar. This change replaces the previous protocol which allowed 4‑hourly checks after the initial six‑hour period. Thank you for your cooperation.
22. What is the primary purpose of this email?
Answer: B. The email’s main point is to announce the new requirement for hourly CBG checks during the first six hours of insulin infusion. The other options are true statements but are secondary details.
Department of Radiology – Contrast Media Guidelines Update Effective 1 July 2024, contrast agents with iodine concentration above 300 mg/mL must not be used in patients with an estimated glomerular filtration rate (eGFR) below 30 mL/min/1.73 m2 unless the clinical benefit outweighs the risk and a nephrology consult is obtained. For all other patients, the previous limit of 350 mg/mL remains. In addition, all contrast‑enhanced studies must be logged in the new Contrast Registry within 24 hours of the procedure. This amendment supersedes the guidance issued in March 2024 and aligns with the latest NICE recommendations.
23. What is the main point of this guideline amendment?
Answer: D. The primary aim of the amendment is the restriction on high‑iodine concentration contrast agents for patients with severely reduced renal function. The other options are true but serve as supporting details.
Trust Policy Update – Effective 1 March 2026 All clinical staff are reminded that the Trust’s policy on the use of high‑dose opioid analgesia has been revised. The new policy states that any dose above 200 mg morphine equivalents per day must be authorised by the on‑call registrar and documented in the patient’s electronic record. The policy supersedes the previous guidance issued in 2024 and introduces a mandatory review of opioid use at each multidisciplinary team meeting. Staff are required to complete the new training module on opioid stewardship by 30 April 2026.
24. Which of the following best describes the reason this policy update was issued?
Answer: D. The passage states that the policy has been revised to introduce a mandatory review of opioid use at each multidisciplinary team meeting. While the other statements are true details of the policy, they are not the main reason for the update.
Email to the Clinical Team – 5 May 2026 Dear colleagues, Following the recent audit of our surgical ward, we have identified a significant rise in postoperative infections linked to the use of a particular brand of surgical gloves. The audit recommends that all surgical teams switch to Brand X gloves, which have a lower contamination rate. The change will be implemented from 1 June 2026. Please ensure that the new gloves are stocked in all operating theatres and that staff are trained on the correct donning technique. Thank you for your cooperation. Regards, Clinical Governance Lead
25. What is the main point of this email?
Answer: D. The email’s primary aim is to instruct teams to switch to Brand X gloves from the specified date. The other statements are supporting details.
Equipment Manual Extract – 20 March 2026 Section 4.2 – Calibration of the automated blood gas analyser 1. The analyser must be calibrated daily using the supplied calibration kit. 2. Calibration should be performed between 07:00 and 09:00 to avoid interference with peak patient flow. 3. The calibration log must be signed by the nurse in charge and retained for 12 months. 4. If the analyser fails to meet the accuracy criteria, it must be taken out of service and reported to the Biomedical Engineering team. Failure to comply with these steps may result in inaccurate patient readings and potential clinical risk.
26. Why was this section of the equipment manual written?
Answer: B. The section’s purpose is to provide a clear, step‑by‑step calibration procedure. The other statements are details within that procedure, not the main reason for the passage.
Trust memo regarding outpatient venipuncture clinics. Phlebotomy services have noted a rise in mislabeled specimen tubes leading to delayed diagnostics. With immediate effect, all nursing staff accompanying outpatient clinics must verify patient identity using three distinct identifiers prior to drawing blood. This supersedes the previous two-identifier policy issued in March. Training modules will be available on the staff intranet next month.
27. What is the primary purpose of this departmental memo?
Answer: B. Option B is correct because the memo is issued to mandate the new three-identifier process to address mislabeling, making the protocol change the main point rather than the background context or future training. Options A, C, and D state facts mentioned in the text, but they are supporting details or background context rather than the primary operational directive of the communication.
Urgent Medicines Safety Alert for inpatient wards. Recent incidents indicate that intravenous potassium chloride is occasionally being administered without adequate dilution, posing a severe risk of fatal cardiac arrhythmia. Prescribers are reminded that concentrated potassium ampoules must never be stored in ward stock lockers. All such ampoules must be returned to pharmacy by Friday close of business.
28. Why was this safety alert issued to inpatient wards?
Answer: B. Option B is correct because the overarching risk of improper dilution drives the entire alert and justifies the operational demands. Options A, C, and D are specific compliance steps or outcomes mentioned in the text, but they serve as measures to address the central hazard identified in the opening sentences.
Guidance excerpt from the Acute Assessment Unit. Patients presenting with acute non-traumatic chest pain must receive a standard 12-lead electrocardiogram within ten minutes of arrival. Triage nurses are authorized to initiate this procedure independently without prior medical assessment. Junior doctors must review the resulting trace immediately upon completion and escalate abnormal findings to the on-call cardiology registrar without delay.
29. What is the main point of this clinical guideline excerpt?
Answer: C. Option C captures the overarching objective of the passage, which is to streamline the rapid assessment and escalation pathway for chest pain. Options A, B, and D are specific procedural rules detailed within the workflow, but they are subordinate steps designed to achieve the primary goal of rapid patient management.
Email from the Directorate of Nursing regarding shift handovers. Ward rounds frequently overrun, delaying the afternoon multidisciplinary team meeting. Effective Monday, morning ward rounds must conclude strictly by twelve noon to allow adequate preparation time. Consultants are requested to prioritize essential clinical reviews during the early part of the ward round and defer non-urgent discussions to the afternoon multidisciplinary session.
30. What is the primary objective of this email communication?
Answer: B. Option B states the direct operational change demanded by the email to solve the scheduling conflict. Options A, C, and D are supporting suggestions, secondary outcomes, or background context mentioned in the text, making them details rather than the core objective.
To: All medical and nursing staff, Ward 4B From: Dr R. Mehta, Consultant Geriatrician, Clinical Lead for Falls Subject: Post-fall assessment — supersedes memo of 14 March Colleagues, Following the trust-wide falls audit completed last month, the post-fall rapid assessment checklist has been revised. Prescribers are reminded that the requirement to obtain a CT head within four hours of an unwitnessed fall in any patient on anticoagulation remains unchanged and is not affected by this update. The change concerns patients who are NOT on anticoagulation: a CT head is now required only where there is a documented focal neurological deficit, persistent confusion beyond baseline, or a second fall within 24 hours. Bedside assessment, lying and standing blood pressure, medication review and a falls risk screen must still be completed for every patient within two hours of the fall, irrespective of anticoagulant status. Please ensure all clinical staff on Ward 4B are aware of the revised criteria and that the new checklist is in use from Monday. The updated form is available on the intranet under Clinical Guidelines > Falls > Adult Inpatient.
31. What is the primary purpose of this email?
Answer: B. The email is written to communicate a specific change to the post-fall protocol. The author explicitly states what is NOT changing (the CT rule for anticoagulated patients is 'unchanged and is not affected by this update') and then details what IS changing: the imaging criteria for non-anticoagulated patients, including the new conditions that now trigger a CT head. The audit, the bedside assessment, and the two-hour window are all mentioned, but each is either context (the audit prompted the review) or an unchanged requirement (the two-hour bedside screen still applies to everyone). The document was written to get the new criteria into clinical use from Monday, not to repeat existing rules. Option A reverses what the email says about anticoagulated patients. Option C mistakes the audit for the purpose. Option D describes a requirement that the email explicitly notes is unchanged.

Reading Part C — attitude and argument 30 questions

Part C is two long texts on healthcare topics of general professional interest, where the questions ask about the writer's ATTITUDE, the function of a phrase, or what a quoted expression means in its context.

The rise of defensive medicine has created a culture where clinicians feel compelled to order unnecessary tests and treatments to protect themselves from litigation. While patient safety is paramount, this approach often leads to overdiagnosis and increased healthcare costs. A consultant in internal medicine once remarked, 'We are not doctors; we are insurance assessors.' This sentiment highlights how the fear of malpractice can distort clinical judgment. The solution lies not in abandoning caution but in fostering an environment where genuine medical errors are addressed transparently, without punitive consequences.
1. What does the writer imply about the current approach to defensive medicine?
Answer: B. The writer implies that defensive medicine leads to unnecessary interventions because of the phrase *'often leads to overdiagnosis and increased healthcare costs'* and the quote *'We are not doctors; we are insurance assessors,'* which suggests clinical decisions are influenced by fear of litigation rather than patient needs. Option A is incorrect because the passage does not claim patient safety is the *only* priority. Option C is wrong because the writer criticizes the approach, not endorses it. Option D is unsupported by the passage.
Recent debates about screening thresholds for breast cancer have sparked controversy among healthcare professionals. Critics argue that lowering the age for mammograms may lead to overdiagnosis, where small, slow-growing tumors are detected and treated unnecessarily. A study cited in *The Lancet* suggested that for every life saved by early screening, three women may be overdiagnosed. However, advocates counter that early detection saves lives and reduces mortality rates. The tension lies in balancing the benefits of screening against its risks. As one radiologist noted, *'We must not confuse detection with cure.'* This distinction is crucial in guiding evidence-based practice.
2. What does the radiologist’s quote imply about the limitations of screening programs?
Answer: B. The quote *'We must not confuse detection with cure'* implies that detecting a tumor (especially small or slow-growing ones) does not mean it will necessarily be harmful or require treatment. Option A is incorrect because the passage does not claim screening is ineffective. Option C is wrong because the writer acknowledges risks and does not advocate prioritizing detection *regardless* of risks. Option D is unsupported, as the passage highlights potential harms of overdiagnosis.
The rise of overdiagnosis in modern healthcare is not merely an academic concern but a tangible threat to patient well-being. Studies show that many conditions detected through screening are indolent or asymptomatic, yet they are treated as if they were clinically significant. This practice inflates morbidity statistics without improving mortality outcomes. For instance, low-dose CT scans for lung cancer have led to overdiagnosis rates of up to 20 percent, exposing patients to unnecessary interventions like surgery or chemotherapy. The ethical dilemma here is clear: we must balance the psychological harm of false positives with the potential benefits of early detection. However, current guidelines often prioritise reducing false negatives over minimising overdiagnosis, a trade-off that risks doing more harm than good in the long run.
3. What does the writer suggest about the current guidelines for screening programs?
Answer: B. The writer explicitly states that 'current guidelines often prioritise reducing false negatives over minimising overdiagnosis.' This is the key phrase showing the writer’s attitude toward the imbalance in screening priorities. Option A is incorrect because the passage does not mention eliminating false positives entirely. Option C is wrong as the passage acknowledges overdiagnosis persists. Option D is incorrect as the passage does not suggest guidelines encourage unnecessary interventions.
Attending a morbidity and mortality (M&M) meeting can be a humbling experience for any clinician. The focus is not on blame but on learning, yet the tension in the room is often palpable. Colleagues dissect cases with surgical precision, highlighting where systems failed or where individual judgement erred. What strikes me most is the way these meetings reveal the fragility of even the most routine clinical decisions. A small oversight in documentation, a misinterpreted lab result, or an unrecognised patient allergy can spiral into catastrophic outcomes. The best M&M meetings, however, transform this vulnerability into collective growth. They create a culture where mistakes are dissected not to assign fault, but to refine practice. Yet, not all meetings achieve this balance. Some devolve into defensive posturing, where participants justify actions rather than reflect on them.
4. What does the writer imply about the purpose of a well-conducted morbidity and mortality meeting?
Answer: B. The writer states that 'the focus is not on blame but on learning' and highlights that 'mistakes are dissected not to assign fault, but to refine practice.' This indicates the writer’s view that the purpose is learning and improvement, not blame. Option A contradicts this directly. Option C is incorrect as the passage acknowledges the inevitability of errors. Option D is wrong because the passage does not suggest perfection is required.
The much-cited Framingham Heart Study has been a cornerstone of cardiovascular research for decades. Its findings on risk factors like cholesterol levels and blood pressure have shaped global guidelines. Yet, recent critiques question whether its results are universally applicable. The study’s participants were predominantly white, middle-class Americans in the mid-20th century—a demographic that bears little resemblance to modern, diverse patient populations. Moreover, the study’s reliance on self-reported data introduces significant bias. When applied to global populations without adjustment, the Framingham risk scores may overestimate or underestimate actual risk. This raises a critical question: how much confidence can we place in guidelines derived from a study that was never intended to be representative? The answer, it seems, is that we must approach these tools with caution and recognise their limitations.
5. What does the writer imply about the reliability of the Framingham risk scores in contemporary clinical practice?
Answer: C. The writer states that the study's participants were 'predominantly white, middle-class Americans' and that the scores may 'overestimate or underestimate actual risk' when applied globally. The phrase 'how much confidence can we place in guidelines derived from a study that was never intended to be representative?' underscores the need for caution. Option A is too absolute, and Option B contradicts the passage. Option D is incorrect as the passage does not limit the scores to specific ethnic groups.
Defensive medicine is often framed as a necessary evil in today’s litigious healthcare environment. Clinicians order unnecessary tests or avoid high-risk procedures to protect themselves from malpractice claims. While this behaviour may reduce legal risk, it contributes to rising healthcare costs and exposes patients to avoidable harm. The irony is that defensive practices rarely prevent lawsuits—they merely shift the financial burden to patients and insurers. What concerns me most is the normalisation of this culture. When a junior doctor hesitates to prescribe a potentially life-saving treatment because of fear of litigation, we have crossed a dangerous threshold. The solution lies not in more fear, but in systemic reforms that address the root causes of malpractice claims—such as clearer guidelines, better communication, and stronger patient advocacy. Until then, defensive medicine will continue to erode trust in our profession.
6. What does the writer suggest about the effectiveness of defensive practices in reducing malpractice claims?
Answer: B. The writer explicitly states that 'defensive practices rarely prevent lawsuits—they merely shift the financial burden to patients and insurers.' This phrase directly addresses the ineffectiveness of defensive practices in reducing claims while highlighting their downsides. Option A contradicts this, and Option C is incorrect as the writer criticises the encouragement of such practices. Option D is not supported by the passage.
Dr. Daniel Nguyen, an infectious disease specialist, critiques a widely cited meta-analysis on antibiotic stewardship programs. He argues that while the study suggested significant reductions in antibiotic resistance, the data were heavily influenced by observational biases. ‘The study’s conclusions were drawn from correlational data rather than controlled experiments,’ he says. ‘We can’t assume causation where only correlation exists,’ he emphasizes. Dr. Nguyen points out that many of the programs included in the analysis were implemented after resistance rates were already rising, creating a flawed temporal relationship. ‘This is like trying to prove a cause-and-effect relationship by looking at two things that happened to be happening at the same time,’ he says. He argues that the study’s findings should be interpreted with caution, especially in the context of complex healthcare systems where multiple factors influence outcomes.
7. What does Dr. Nguyen imply about the reliability of the meta-analysis’s conclusions regarding antibiotic stewardship?
Answer: B. The phrase ‘we can’t assume causation where only correlation exists’ directly signals Dr. Nguyen’s skepticism about the meta-analysis’s conclusions, making option B the correct interpretation of his argument.
In recent years I have watched the rise of ‘protocol‑driven’ care in our department with a mixture of admiration and unease. While standardised pathways have undoubtedly reduced variation in treatment, they also risk turning clinicians into mere technicians. I recall a junior colleague who, when faced with a patient whose presentation did not fit the algorithm, felt compelled to document a ‘protocol deviation’ rather than trust his clinical judgment. This culture of conformity, I fear, may erode the very art of medicine that allows us to tailor care to individual needs. The challenge, therefore, is to balance the safety of evidence‑based protocols with the flexibility required for nuanced decision‑making.
8. What attitude does the writer express towards protocol‑driven care?
Answer: B. The writer says the pathways have "undoubtedly reduced variation" (positive) but also "risk turning clinicians into mere technicians" and "may erode the very art of medicine" (negative). This shows a mixed attitude: beneficial but potentially restrictive.
The recent publication of the XYZ trial, which claimed a 30 per cent reduction in mortality with early aggressive screening, has been widely heralded. Yet, a closer look reveals that the absolute risk reduction was merely 0.8 per cent, and the number needed to screen to prevent one death exceeded 120. Moreover, the trial excluded patients over 75, a group that accounts for the majority of deaths from this condition. Consequently, the enthusiasm surrounding the study may be more reflective of a desire for a simple solution than of robust evidence. Clinicians should therefore interpret the findings with caution and consider the broader context before changing practice.
9. What does the writer suggest about the enthusiasm for the XYZ trial?
Answer: C. The writer states the enthusiasm "may be more reflective of a desire for a simple solution than of robust evidence," indicating it reflects a wish for an easy answer.
During our last morbidity and mortality meeting, the discussion centred on a case of postoperative sepsis that could have been prevented with earlier antibiotic administration. While the team acknowledged the lapse, the senior consultant remarked, "We must not let this become a blame game; the focus should be on system improvements, not individual fault." This comment, however, glosses over the fact that the primary surgeon had documented a clear deviation from the hospital's antibiotic protocol. By framing the issue as purely systemic, the consultant sidesteps accountability and risks perpetuating similar oversights in the future.
10. What does the writer imply about the senior consultant's comment?
Answer: A. The writer says the comment "glosses over the fact" and "sidesteps accountability," indicating it downplays individual responsibility.
A recent editorial argued that the proliferation of point‑of‑care ultrasound (POCUS) in primary care will democratise diagnostics and reduce unnecessary referrals. While the premise is appealing, the authors overlook the steep learning curve and the risk of false‑positive findings that can lead to over‑investigation. In my practice, I have observed that junior doctors, eager to use POCUS, sometimes misinterpret artefacts as pathology, prompting costly imaging that ultimately proves unnecessary. Therefore, the claim that POCUS will automatically curtail referrals is overly optimistic and fails to account for the need for rigorous training and quality assurance.
11. What attitude does the writer convey towards the editorial's claim about POCUS?
Answer: A. The writer calls the claim "overly optimistic" and points out "steep learning curve" and "risk of false‑positive findings," showing a skeptical attitude.
During our recent morbidity and mortality meeting I noted that many of the cases discussed involved patients who had been discharged with a ‘watchful waiting’ plan for early-stage prostate cancer. The team’s consensus was that the initial decision to defer treatment was appropriate, yet the subsequent rapid progression in several patients highlighted a potential gap in our risk stratification. I am concerned that our reliance on PSA thresholds alone may be insufficient, and that we should incorporate genomic testing earlier in the pathway. This would allow us to identify those men who truly benefit from immediate intervention rather than subjecting them to unnecessary anxiety and delayed care.
12. What attitude does the writer express towards the current use of PSA thresholds alone?
Answer: C. The writer states ‘I am concerned that our reliance on PSA thresholds alone may be insufficient’, directly expressing doubt about its adequacy.
A recent systematic review claimed that routine screening for abdominal aortic aneurysm (AAA) in men over 65 reduces mortality by 30%. While the data are compelling on paper, I question whether the study accounted for the high rate of incidental findings that lead to unnecessary interventions. In my practice, I have seen several patients undergo endovascular repair for aneurysms that would have remained stable, exposing them to procedural risks without clear benefit. The authors’ enthusiasm seems to overlook the balance between early detection and over-treatment.
13. What attitude does the writer convey towards the authors’ enthusiasm?
Answer: A. The writer says ‘I question whether the study accounted… The authors’ enthusiasm seems to overlook…’, indicating scepticism.
I was recently asked to comment on the landmark trial that demonstrated a 20% reduction in cardiovascular events with a new antihypertensive drug. The trial’s methodology was rigorous, yet the patient population was predominantly white and middle-aged, limiting generalisability. Moreover, the trial’s primary endpoint was a composite of non-fatal myocardial infarction, stroke, and cardiovascular death, which may mask differential effects on each component. While the authors celebrate the drug’s efficacy, I remain unconvinced that the results apply to the diverse patients I see daily.
14. What attitude does the writer have towards the trial’s applicability to diverse patients?
Answer: A. The writer states ‘I remain unconvinced that the results apply to the diverse patients I see daily’, showing scepticism about generalisability.
In our latest audit of antibiotic stewardship, we found that 18% of patients prescribed broad-spectrum antibiotics for uncomplicated urinary tract infections were later switched to narrow-spectrum agents after culture results. The audit report praised the stewardship team for achieving a 15% reduction in broad-spectrum use over the past year. While I applaud the effort, I am concerned that the audit’s metrics may overstate success by not accounting for the 5% of patients who received inappropriate broad-spectrum therapy for longer than 48 hours. The narrative of progress may therefore be somewhat misleading.
15. What attitude does the writer express towards the audit report’s claim of progress?
Answer: B. The writer says ‘The narrative of progress may therefore be somewhat misleading’, indicating a cautious or critical attitude.
The recent push for universal genetic screening in primary care has been hailed as a triumph of proactive medicine. Advocates argue that early identification of actionable mutations empowers patients and slashes long-term morbidity. Yet this uncritical enthusiasm ignores the reality of variants of unknown significance that inevitably plague broad panels. When a laboratory report returns a novel missense variant in a hereditary cancer gene, the primary care physician is left stranded between clinical uncertainty and patient anxiety. Rather than providing clarity, the test frequently initiates a cascade of redundant surveillance and specialist referrals that swamp our outpatient clinics. The true burden is not merely financial; it is the psychological toll exacted on healthy individuals who are suddenly recategorized as patients-in-waiting. We are mistaking the generation of genomic data for genuine health creation, blind to the downstream friction our eagerness introduces into an already buckling system.
16. What attitude does the writer express towards the current push for universal genetic screening?
Answer: B. The writer views the push skeptically, noting that it creates redundant surveillance and psychological tolls, which matches option B. Option A is an advocate view the writer critiques. Option C misrepresents the writer as praising psychological benefits and dismissing costs, whereas the writer highlights psychological tolls and financial burdens. Option D reflects the advocate view mentioned in the second sentence rather than the writer's own stance.
During the morbidity and mortality conference last Tuesday, the department spent an hour dissecting the missed diagnosis of an aortic dissection in the emergency department. The consensus in the room swiftly settled on human error, specifically the attending physician's failure to order an immediate computed tomography angiogram. While individual accountability has its place, this ritualistic focus on the singular mistake serves primarily as a comforting psychological shield for the institution. By framing the adverse event as an isolated cognitive lapse, leadership avoids confronting the systemic fractures that actually compromise care. The chronically understaffed triage bay, the broken sign-out software, and the crushing shift lengths are airbrushed out of the narrative. We sacrifice institutional learning on the altar of personal blame, ensuring that the exact same catastrophe remains fully primed to recur next month.
17. What does the writer suggest about the department's focus on individual human error during the conference?
Answer: B. The writer states that focusing on the singular mistake serves as a comforting psychological shield that lets leadership avoid systemic fractures, which aligns with option B. Option A is the opposite of the writer's claim that systemic issues are ignored. Option C is incorrect because the writer explicitly criticizes the focus as ritualistic and unbalanced. Option D is contradicted by the final sentence warning that the catastrophe will recur.
The publication of the ADVANCE-HF trial was greeted with rapturous applause across cardiology symposiums, heralded as a definitive turning point in the management of refractory heart failure. The investigators concluded that their novel neurohormonal antagonist reduced combined hospitalizations and cardiovascular mortality by a statistically significant margin. A closer inspection of the supplementary appendix, however, reveals a fragility index that should temper our collective jubilation. The entire positive finding rests on a handful of end-point events in a subgroup that was not pre-specified in the primary analysis plan. When pharmaceutical enthusiasm outpaces methodological rigor, we risk adopting expensive therapies that offer marginal, highly selected benefits while straining hospital formularies. It is time to pause our celebrations and subject the data to the rigorous scrutiny it should have received before making its way into the clinical guidelines.
18. What attitude does the writer convey towards the initial reception of the ADVANCE-HF trial?
Answer: B. The writer contrasts the rapturous applause with the fragility index and unprespecified subgroup, indicating concern that the celebration is unwarranted due to methodological flaws, matching option B. Option A is incorrect because the writer criticizes the rapid adoption without scrutiny. Option C is wrong as the writer points out that the subgroup details were buried in the appendix, not transparently heralded. Option D assumes the findings apply broadly, which the writer disputes by calling the benefits highly selected.
Clinical guidelines have increasingly evolved into rigid algorithmic checklists, marketed as the ultimate safeguard against substandard care. We are told that adherence to these rigid protocols ensures quality and protects practitioners from liability. Yet this mechanical approach strips the clinician of professional autonomy and discounts the nuanced judgment required for complex, multimorbid patients. Medicine is not an assembly line where a single protocol fits all presentations. When a physician overrides a guideline because an elderly patient's unique physiological baseline demands a tailored strategy, they are frequently penalized by institutional audit committees. We are sleepwalking into a regime of defensive box-ticking that prioritizes administrative compliance over the actual welfare of the human being lying on the examination table.
19. What does the writer imply about the impact of protocol-driven care on modern medical practice?
Answer: B. The writer argues that protocol-driven care results in defensive box-ticking prioritizing administrative compliance over human welfare and stripping nuanced judgment, matching option B. Option A reflects the marketing claim of the guidelines, which the writer opposes. Option C is incorrect because the writer notes the approach strips autonomy rather than empowering clinicians. Option D is wrong because the writer explicitly states that clinical judgment and patient welfare are negatively affected.
The new departmental guideline on preoperative fasting arrived by email last Tuesday, nested between a pharmacy bulletin and a reminder about parking permits. I read it twice, not because the evidence behind it was new, but because I wanted to be sure I had correctly identified the small concessions to clinical judgement buried in the flowchart. There were two. The rest of the document assumes we are all the same kind of anaesthetist, looking after the same kind of patient, on the same kind of list. I have signed the form acknowledging receipt. I have not, I should confess, changed what I do at the bedside. For routine lists the protocol is harmless enough; for the diabetic patient booked second on a half-day emergency slot, it is a straightjacket. Compliance, in my experience, is the new competence.
20. What attitude does the writer express towards the new departmental guideline?
Answer: A. The attitude signal is the contrast between the formal compliance (signed the form, read it twice) and the quiet admission that he has not changed practice ('I have not... changed what I do at the bedside'). Candidates who pick B anchor on 'read it twice' and 'signed the form' and miss the tongue-in-cheek 'I should confess'. Those who pick C seize on the two concessions, but the writer calls them 'small' and 'buried', and they did not persuade him. D ignores the overall measured tone; the parking-permit comparison is dry wit, not hostility.
The editorial in last week's Lancet Rheumatology argues that we should abandon the term 'early rheumatoid arthritis' altogether and replace it with a window-of-opportunity framing that emphasises months rather than weeks. The argument is clean and the metaphors are persuasive, but the underlying trial evidence is the same ten-year-old cohort that has been re-analysed more times than a Shakespeare sonnet. Re-analysing data does not create new biology. The authors are not wrong that clinicians overinterpret the word 'early', but the proposed alternative is itself a rhetorical move dressed as a conceptual one, and I am not convinced that patients presenting at three months versus three weeks experience meaningfully different trajectories in the real-world clinic. The terminology debate, frankly, has been more useful to journal editors than to my Tuesday-morning list.
21. What does the writer imply about the proposed change in terminology?
Answer: D. The key signals are 're-analysing data does not create new biology', 'rhetorical move dressed as a conceptual one' and 'more useful to journal editors than to my Tuesday-morning list'. Together these mark the proposal as a relabelling exercise rather than a genuine clinical step forward. A is the trap for candidates who answer from the topic (terminology matters) rather than the wording (the writer explicitly says it does not affect his real-world clinic). C is too strong: 'not wrong' and 'rhetorical' are criticism, not alarm. D collapses into acceptance, which the final line directly contradicts.
Our mortality meeting last Thursday considered the death of a 74-year-old two days after an elective colectomy. The presentation was thorough, the slides were well-cited, and the chair closed the session by thanking the team for 'such a rich discussion'. Rich is a word I used to associate with learning. In this meeting it described twenty-five minutes spent establishing that the operation note was complete, the antibiotic timing was correct, and the venous thromboembolism prophylaxis was given. Every box on the trust checklist was ticked. The patient, who bled from an artery nobody could have predicted, was almost incidental. We have built a system in which a checklist can pass and a person can still die, and in which our response to that fact is to refine the checklist. I left the room earlier than I usually do.
22. What does the writer suggest about the department's focus during the conference?
Answer: A. The wording 'Every box on the trust checklist was ticked' followed by 'The patient... was almost incidental' is the writer's evidence that the discussion dwelt on compliance rather than the clinical story. 'We have built a system in which a checklist can pass and a person can still die' makes the same complaint. A is the classic 'agree with the topic, not the text' trap: human factors were exactly what was missing. C contradicts 'almost incidental' and the chair's tidy closure. D is unsupported; the writer describes the bleed as 'nobody could have predicted', removing the grounds for a judgement error.
The ADVANCE-HF trial has now been cited in 412 subsequent papers, by my last rough count, and almost every discussion of heart-failure with preserved ejection fraction begins with a deferential nod to its findings. The trial was well-funded, well-powered, and recruited seventeen thousand patients across thirty-one countries. What it did not do, despite the assertions of its discussants, is settle the question it claimed to settle. The primary endpoint was a composite that lumped together hospitalisation and cardiovascular death in a way that made a modest reduction in admissions look like a mortality win. Anyone who has sat with a patient on a loop diuretic adjustment will appreciate the gap between a hazard ratio on a forest plot and the decision in front of them. The trial deserves its place in the canon; its conclusions do not deserve their immunity from criticism.
23. What attitude does the writer convey towards the trial’s conclusions?
Answer: B. The attitude lives in the final sentence: 'deserves its place in the canon; its conclusions do not deserve their immunity from criticism'. That is a precise formula for qualified respect plus objection to unthinking acceptance. The middle paragraph supplies the specific objection (the composite endpoint made admissions look like mortality). A ignores the criticism entirely; the recruitment figures are background, not endorsement. C overreads: 'deserves its place' rules out complete rejection. D is wrong because the writer engages seriously with the bedside decision rather than dismissing the trial.
The latest guidelines on antibiotic stewardship are often hailed as a breakthrough in reducing resistance, yet their implementation remains patchy. In my unit, we’ve seen compliance rates hover around 60 percent at best. The problem isn’t a lack of awareness—most clinicians understand the risks—but the sheer inertia of entrenched habits. When I asked junior doctors why they still default to broad-spectrum antibiotics, the response was telling: ‘It’s what we’ve always done.’ This isn’t just about education; it’s about breaking cycles of convenience. The guidelines themselves are sound, but without systemic changes—like automated alerts or mandatory audits—they’ll remain just another layer of bureaucracy.
24. What attitude does the writer express towards the effectiveness of current antibiotic stewardship guidelines?
Answer: B. The writer’s attitude is conveyed through phrases like ‘their implementation remains patchy’ and ‘without systemic changes—they’ll remain just another layer of bureaucracy.’ The key is the contrast between ‘sound’ guidelines and the need for ‘systemic changes,’ not just education. Option A is wrong because the writer does not blame the lack of education alone; option C is wrong because the writer does not argue for abandonment; option D is wrong because the writer explicitly states compliance is low.
The Morbidity and Mortality (M&M) conference is often framed as a forum for learning, but in practice, it can feel like a blame game. Last week, a case involving a missed diagnosis was dissected with surgical precision—literally. The consultant leading the discussion zeroed in on the resident’s ‘failure to follow protocol,’ ignoring the systemic issues that contributed to the error. When I raised the point about workflow bottlenecks, I was met with silence. It’s not that we don’t learn; it’s that we learn the wrong lessons. The focus on individual error distracts from the real opportunity to improve processes.
25. What does the writer suggest about the department's focus during the conference?
Answer: B. The writer’s attitude is clear in phrases like ‘blame game,’ ‘failure to follow protocol,’ and ‘the consultant leading the discussion zeroed in on the resident’s.’ The key is the contrast between ‘individual error’ and ‘systemic issues,’ which the writer highlights as misplaced priorities. Option A is wrong because the writer criticizes the lack of focus on systemic improvements; option C is wrong because the writer explicitly mentions errors being discussed; option D is wrong because the writer does not mention celebrating successes.
The recent meta-analysis on statin therapy for primary prevention was widely celebrated, but its applicability to real-world practice is questionable. The study’s inclusion criteria excluded patients over 75, yet cardiovascular events peak in older adults. The authors justified this by citing ‘logistical challenges,’ but that’s a weak excuse. We can’t ignore the fact that the data may not reflect the populations we treat daily. Until trials include older adults and those with comorbidities, we’re prescribing based on incomplete evidence. It’s time to demand better.
26. What attitude does the writer convey towards the trial’s applicability to diverse patients?
Answer: B. The writer’s scepticism is evident in phrases like ‘its applicability to real-world practice is questionable,’ ‘the data may not reflect the populations we treat daily,’ and ‘prescribing based on incomplete evidence.’ The key is the contrast between the trial’s limitations and clinical reality. Option A is wrong because the writer explicitly questions applicability; option C is wrong because the writer calls the justification ‘a weak excuse’; option D is wrong because the writer does not advocate for excluding younger patients.
Defensive medicine is often dismissed as a frivolous concern, but the reality is far more insidious. A recent survey found that 40 percent of physicians order unnecessary tests to avoid malpractice claims, yet the same physicians admit it increases patient anxiety and healthcare costs. The irony is that this ‘protection’ strategy actually harms patients. What’s worse, it distorts clinical judgment, turning doctors into risk-averse administrators rather than healers. Until we address the root causes of fear—like the punitive nature of liability systems—we’ll continue to see this cycle of overdiagnosis and overtreatment.
27. What attitude does the writer express towards the current practice of defensive medicine?
Answer: C. The writer’s critical attitude is clear in phrases like ‘far more insidious,’ ‘actually harms patients,’ and ‘turning doctors into risk-averse administrators.’ The key is the contrast between the perceived ‘protection’ and its harmful effects. Option A is wrong because the writer does not dismiss it as minor; option B is wrong because the writer criticizes the practice; option D is wrong because the writer does not advocate for encouraging it.
The rise of defensive medicine is often framed as a necessary response to litigation risks, but in my experience, it distorts clinical priorities far more than it protects patients. During my time as a consultant in internal medicine, I’ve seen colleagues order unnecessary tests and treatments not because they were medically indicated, but because they feared potential malpractice claims. The phrase ‘better safe than sorry’ has become a mantra, yet it often leads to overdiagnosis and unnecessary interventions. For instance, a patient presenting with non-specific abdominal pain might undergo a full battery of imaging and lab tests, all to avoid the risk of missing a rare condition. This approach not only increases healthcare costs but also exposes patients to the harms of invasive procedures. What concerns me most is how this culture undermines trust between clinicians and patients. When decisions are driven by fear rather than evidence, the patient-doctor relationship suffers, and the focus shifts away from what truly matters: improving health outcomes.
28. What attitude does the writer express towards the practice of defensive medicine?
Answer: B. The writer’s attitude is conveyed through phrases like ‘distorts clinical priorities far more than it protects patients’ and ‘undermines trust between clinicians and patients.’ The key words ‘concerns me most’ and ‘fear rather than evidence’ show disapproval of defensive medicine’s impact on clinical decision-making and patient relationships. Option A is incorrect because the writer does not view it as acceptable; option C is wrong because the writer does not justify unnecessary tests for non-specific symptoms; option D is incorrect as the writer does not support precautionary measures driven by fear.
The recent push for universal genetic screening in newborns has been met with cautious optimism, but I remain sceptical about its practical benefits. While early detection of genetic disorders can be life-saving, the reality is that many conditions identified through screening remain untreatable or only manageable with uncertain outcomes. For example, screening for conditions like spinal muscular atrophy (SMA) has led to increased parental anxiety and resource allocation to families who may not benefit from early intervention. The statement that ‘early detection is always better’ ignores the psychological and logistical burdens placed on families and healthcare systems. Additionally, the cost-effectiveness of such programmes is often overstated, as the financial burden of managing asymptomatic conditions can outweigh the benefits. My concern is that we are screening for conditions not because they can be treated, but because we can now detect them.
29. What does the writer suggest about the current push for universal genetic screening?
Answer: C. The writer’s scepticism is evident in phrases like ‘the reality is that many conditions identified through screening remain untreatable’ and ‘we are screening for conditions not because they can be treated, but because we can now detect them.’ The key phrase ‘technological capability’ in the explanation reinforces the idea that screening is driven by what is possible rather than what is medically necessary. Option A is incorrect because the writer does not view it as cost-effective; option B is partially true but does not capture the writer’s broader critique; option D is too narrow as it ignores the writer’s concern about the broader implications of screening beyond treatable conditions.
Attending the recent morbidity and mortality (M&M) conference, I was struck by how the discussion repeatedly circled back to individual clinician error as the root cause of adverse events. While it is true that human factors play a role, the focus on individual blame risks overshadowing systemic issues that contribute far more significantly to patient safety problems. For instance, during the case review of a postoperative complication, the discussion centred on the surgeon’s failure to double-check equipment, yet the operating room’s workflow and staffing shortages were never addressed. The phrase ‘lessons learned’ often became a euphemism for assigning responsibility rather than implementing change. This approach not only creates a culture of fear among staff but also fails to tackle the underlying structural issues that compromise patient safety. If we truly want to improve outcomes, we must shift the conversation from individual accountability to systemic solutions.
30. What does the writer suggest about the department's focus during the M&M conference?
Answer: B. The writer’s suggestion is conveyed through phrases like ‘risks overshadowing systemic issues’ and ‘assigning responsibility rather than implementing change.’ The key phrase ‘lessons learned’ is used ironically to highlight the failure to address structural problems. Option A is incorrect because the writer does not justify the focus on individual error; option C is wrong as the writer does not believe the conference effectively balances both factors; option D is incorrect because the writer argues that focusing on individual error prevents addressing systemic issues, not that it is a prerequisite.

Listening Part A — consultation notes 25 questions

Part A is note completion while a patient talks.

Patient: ‘My dad had a heart attack when he was in his 50s, and my mom had high blood pressure, but she didn’t know it until she was diagnosed later.’ Doctor: ‘Do you have any family history of diabetes or thyroid issues?’ Patient: ‘No, but my uncle had a stroke when he was in his 60s. I’m just worried about my own health.’
1. Which detail about the patient’s family history should the doctor record?
Answer: C. The patient mentions a heart attack in a family member (dad) and a stroke in an uncle. The vague phrasing about ‘high blood pressure’ and ‘diabetes’ is not specific enough to record. The correct clinical detail is the presence of both cardiovascular events.
Patient: ‘I’ve been having a lot of trouble sleeping lately. It’s been going on for about three months now, and I’ve been taking some medication for it. I’ve been taking 50 milligrams of melatonin every night, but I think I’ve been taking it three times a week instead of every night.’ Doctor: ‘How did you first find out about this medication?’
2. What should the doctor record about the patient’s melatonin dose?
Answer: D. The patient states they are taking 50 milligrams of melatonin but admits they have been taking it incorrectly—three times a week instead of every night. The notes must reflect the patient’s self-reported incorrect dose, not the prescribed one.
Patient: ‘I’ve been feeling really dizzy and lightheaded, especially when I’m standing up too quickly. It started about a month ago, and I’ve been feeling a bit nauseous too. I’ve been taking some medication for my blood pressure, but I think I’ve been taking too much.’ Doctor: ‘What medication are you taking for your blood pressure?’ Patient: ‘I’m taking lisinopril, but I’ve been taking two tablets a day instead of one.’ Patient: ‘Actually, it started about two weeks ago, not a month.’
3. Which detail about the patient’s symptoms should the doctor record?
Answer: C. The patient initially states the symptoms have lasted a month but corrects herself to two weeks. The notes must reflect the corrected duration, not the first incorrect figure provided. The patient’s own words are not clinically precise.
Doctor: "When did you first notice the swelling in your ankle?" Patient: "It started about the 5th of March, actually the 15th, sorry I meant the 15th. It’s a sort of puffiness, like a balloon. I’ve been taking my blood pressure tablets, but I only take half a tablet each day instead of the full dose prescribed. Also, I’ve been using a topical cream called 'Dermacare' that I bought at the pharmacy on Main Street. My mother had some joint problems, but I’m not sure what exactly she had."
4. What should the doctor record in the notes?
Answer: D. The correct detail is the corrected date the patient gave – 15 March. An unwary candidate might record the initial, incorrect 5 March. The clinical term for "puffiness" is swelling, so the note should use the corrected date and the clinical description, not the lay word. This training mirrors Listening Part A where you must capture the accurate information despite corrections.
Doctor: "How often have you been feeling short of breath?" Patient: "I’ve been getting wheezy, especially when I climb the stairs – that started about two weeks ago, I think it was the 3rd of April, actually the 13th, sorry." Patient: "I also take my inhaler, Salbutamol, but I only use two puffs instead of the prescribed four. My aunt on my father's side had a heart problem, I think it was a blockage, but I'm not certain."
5. What information is required in the note?
Answer: D. The patient corrected the date to the 13th, so the note must reflect that. The dose error (two puffs) is also noted, but the question asks for the date detail; the wrong option uses the initial 3 April. Candidates often record the first figure. This exercise trains the candidate to listen for corrections.
Doctor: "Can you tell me about the pain in your chest?" Patient: "It’s a sharp, stabbing feeling, like a knife, that started on the 22nd of May, actually the 12th – I misspoke earlier. I’ve been taking my cholesterol tablets, but I take one tablet every other day instead of daily as prescribed. I bought the medication from a pharmacy on Oak Road. My brother had some sort of cardiovascular disease, but I don’t know the exact diagnosis."
6. Which detail should be entered in the patient's record?
Answer: B. The corrected date is 12 May, so that is the accurate information to note. The other options are plausible but either reflect the initial wrong date or add unverified specifics about the brother's condition. Listening Part A requires capturing the corrected information, not the initial error.
Doctor: "When did your rash appear?" Patient: "It showed up around the 1st of June, actually the 11th, sorry – I meant the 11th. I would describe it as 'itchy spots' that look like tiny red dots. I’ve been applying a cream called 'HydroClear' that I bought at the chemist on River Avenue. I also take my antihistamine, but I only take half the prescribed dose each night. My paternal grandmother had some skin condition, maybe psoriasis, but I’m not sure."
7. What is the correct entry for the onset date of the rash?
Answer: B. The patient corrected the onset to the 11th of June, so the note must record that date. An inattentive candidate might write the initial 1st of June. The other options either repeat the lay description or assume a diagnosis not confirmed. This exercise reflects the note‑completion task in Listening Part A, training candidates to focus on corrections.
Doctor: "Your rash started on 12th March, not April, as you first said." Patient: "Yes, 12th March." Doctor: "You describe the rash as a hot‑pepper burn." Patient: "Exactly." Doctor: "You’ve been taking 10 mg of amlodipine daily, but the prescription is 5 mg." Patient: "I doubled it because I thought it was better." Doctor: "Your mother had hypertension, but she was never diagnosed with it." Doctor: "The rash is on your left forearm, near the elbow." Doctor: "You live in Manchester, correct?" Patient: "Yes, in Manchester."
8. What should the doctor record about the onset date of the rash?
Answer: D. The patient corrects the date to 12th March; the note must reflect the accurate date, not the earlier mistaken one.
Doctor: "Your rash started on 12th March, not April, as you first said." Patient: "Yes, 12th March." Doctor: "You describe the rash as a hot‑pepper burn." Patient: "Exactly." Doctor: "You’ve been taking 10 mg of amlodipine daily, but the prescription is 5 mg." Patient: "I doubled it because I thought it was better." Doctor: "Your mother had hypertension, but she was never diagnosed with it." Doctor: "The rash is on your left forearm, near the elbow." Doctor: "You live in Manchester, correct?" Patient: "Yes, in Manchester."
9. What should the doctor record about the patient’s family history?
Answer: B. The patient states the mother had hypertension but was never diagnosed; that is the precise information to record.
Doctor: So how long have you had this chest tightness, Mr Evans? Patient: Well, it started on the twelfth of March, oh wait, my mistake, it was actually the fourteenth, two days later. Doctor: Right, the fourteenth. And how would you describe it? Patient: It feels like an elephant is sitting right on my chest. Doctor: I see, so retrosternal pressure. And are you taking any heart medication? Patient: Just the aspirin as prescribed, one tablet daily.
10. What should the doctor record as the onset date of the symptom?
Answer: C. Listening Part A tests your ability to catch self-corrections in real time. The patient initially says the twelfth, but immediately corrects himself to the fourteenth. Unwary candidates write down the first date they hear, but the notes must reflect the final confirmed information.
Doctor: Have you had any odd sensations in your legs recently? Patient: Yes, my legs have been jumping about by themselves every night when I try to sleep. Doctor: That sounds like restless legs. And any family history of circulation issues? Patient: My father had some kind of heart trouble when he was older, but I do not know the details. Doctor: Heart trouble is too vague to note down specifically. Patient: Right, and I take my blood pressure pills, ramipril, spelled R-A-M-I-P-R-I-L, twice a day instead of once.
11. What clinical term should the doctor record for the leg symptoms?
Answer: D. Listening Part A requires you to translate lay descriptions into appropriate clinical terms while listening to the consultation. The patient describes his legs jumping about, which the doctor labels as restless legs. Candidates who simply write down the patient exact words will fail to score.
Doctor: Let us check your medication routine for your sleep problems. You were given zopiclone. Patient: Yes, but the prescription says half a tablet nightly, but I have been taking two whole tablets every night because half did nothing. Doctor: That is four times the prescribed dose. We must address that. Now, about your rash, when did it appear? Patient: It began on the morning of Monday the fifth of April.
12. What dosage of zopiclone should be recorded in the patient medication notes?
Answer: D. In OET Listening Part A, notes must record what the patient is actually taking, not merely what was prescribed, so that the clinician has an accurate pharmacological picture. Unwary candidates record the intended prescription rather than the real drug intake revealed during the talk.
Doctor: Do you have any known allergies to medications or foods? Patient: None to drugs, but I do get a bad reaction whenever I visit my sister in O-A-K-V-I-L-L-E. Doctor: Oakville, got it. And regarding your past medical history, have you had any major surgeries? Patient: Just my appendix out back in nineteen ninety five. Doctor: Appendectomy in 1995. And how is your breathing during the day? Patient: I get breathless walking up hills, my wife says I have a bit of a wheeze.
13. What location should the doctor record in relation to the patient allergies?
Answer: C. Listening Part A frequently tests spelling when speakers spell out unusual names or places letter by letter. The patient explicitly spells out O-A-K-V-I-L-L-E, so candidates must transcribe the exact letters provided rather than guessing a phonetic equivalent.
Doctor: So, when did these dizzy spells begin? Patient: It was last Tuesday, no wait, let me think, it was actually Thursday of last week, the fourteenth. Doctor: Right, Thursday the fourteenth. Patient: Yes, exactly. Doctor: And how would you describe the feeling? Patient: The room just keeps spinning around me whenever I stand up too fast. Doctor: I see, so true vertigo rather than lightheadedness. Patient: Exactly that.
14. What should the doctor record as the onset date of the dizzy spells?
Answer: B. The patient initially mentions Tuesday but immediately corrects herself to Thursday of last week, the fourteenth. Listening Part A frequently uses self-correction traps where the first uttered detail is incorrect. Option A captures the abandoned date, while C and D are distractor dates mentioned nowhere in the dialogue. Training this in reading requires treating the dialogue transcript like an audio script where early statements are frequently revised.
Patient: I have been taking my thyroxine, one tablet every morning as prescribed, but I also started having these terrible pins and needles in both feet. Doctor: Paresthesia in the lower extremities, understood. And what about your blood pressure medication? Patient: I take the lisinopril twice daily, even though the bottle says once a day, because I felt my blood pressure was still too high. Doctor: You must stick to the prescribed once-daily dose. Let us record that discrepancy.
15. What dosing frequency of lisinopril should be documented in the medication notes?
Answer: B. The patient admits she takes the lisinopril twice daily against the official prescription instructions. OET Listening PartA often tests patient adherence versus prescription instructions, requiring candidates to record what the patient is actually doing or the discrepancy itself. Option A reflects the prescription rather than the patient's actual reported intake, while C and D introduce unmentioned behaviors.
Doctor: Now, regarding your family history, is there any heart trouble? Patient: My father had some kind of heart condition when he was older, maybe a blockage or something similar, and my mother had high blood pressure. Doctor: Let us note paternal cardiac disease and maternal hypertension. Patient: My brother also had a bad skin reaction to penicillin, so we avoid that. Doctor: Right, penicillin allergy in the sibling.
16. What should the doctor record regarding the patient paternal family history?
Answer: B. The patient describes a vague father's heart condition and the doctor explicitly reformulates this into the clinical note as paternal cardiac disease. Option C is too specific since myocardial infarction was not stated, Option A is overly dismissive of the clinical translation, and Option D contradicts the transcript. Training this involves matching vague patient narratives to concise professional summaries.
Doctor: Let us check your medical history. Have you ever had surgery? Patient: Yes, I had an appendectomy back in nineteen ninety eight at St Jude Hospital. Doctor: Could you spell that hospital name for my records? Patient: Certainly, it is S-T space J-U-D-E. Doctor: Perfect. And any other operations? Patient: Just a tonsillectomy as a child in the local clinic.
17. What hospital name should the doctor record for the previous surgery?
Answer: B. The patient explicitly spells the hospital name as S-T space J-U-D-E, which abbreviates to St Jude. Option A spells out Saint, which was not dictated. Options C and D introduce a spelling error in the saint's name. Listening Part A spelling checks penalize deviations from the exact spelling provided in the audio or transcript.
Doctor: So, how long have you had this cough now? Patient: Oh, it's been about ten days, I suppose. No, wait — a fortnight. Yes, two weeks. Started right after I came back from Penrhyn — no, Penrith, in the Lake District. P-E-N-R-I-T-H. Doctor: And any sputum? Patient: Some yellow stuff coming up. Bit thick. Not like water. Doctor: Is there blood in it? Patient: Touch of red a couple of mornings, yes. Doctor: Anyone in the family with lung trouble? Patient: My dad had something with his chest — he had a cough for years, then they said it was emphysema. That was years back. Doctor: And your salbutamol inhaler — how often are you using it? Patient: The label says twice a day, but honestly I've been doing it three or four times most days lately. It's not touching it.
18. Which clinical term should replace the patient's lay description of the sputum?
Answer: B. The patient says 'yellow stuff coming up, bit thick, not like water' (so mucoid/purulent and yellow, not frothy or white) and 'touch of red a couple of mornings' (so streaking, not the large-volume bleeding implied by 'frank haemoptysis'). The notes record what is clinically understood from the lay words — colour, consistency and the qualifier on the blood — not the patient's own phrases. Writing 'purulent sputum, frank haemoptysis' overstates both findings; writing 'froth, no blood' contradicts what the patient said.
Doctor: So, how long have you had this cough now? Patient: Oh, it's been about ten days, I suppose. No, wait — a fortnight. Yes, two weeks. Started right after I came back from Penrhyn — no, Penrith, in the Lake District. P-E-N-R-I-T-H. Doctor: And any sputum? Patient: Some yellow stuff coming up. Bit thick. Not like water. Doctor: Is there blood in it? Patient: Touch of red a couple of mornings, yes. Doctor: Anyone in the family with lung trouble? Patient: My dad had something with his chest — he had a cough for years, then they said it was emphysema. That was years back. Doctor: And your salbutamol inhaler — how often are you using it? Patient: The label says twice a day, but honestly I've been doing it three or four times most days lately. It's not touching it.
19. What should the doctor record about the patient's paternal family history?
Answer: C. The patient offers a vague two-part history: 'something with his chest' and 'a cough for years' (long-standing, not recent), then 'they said it was emphysema' (a diagnosis, but the patient does not give a date or a treating clinician, so do not infer recency). The notes record the chronicity the patient gave and the diagnosis as stated, without filling in the gap of when it was diagnosed. Option A drops the diagnosis; option B adds 'last year', which the patient never said; option D wrongly implies it is current and active.
Doctor: How would you describe the rash, Mrs. Patel? Patient: It’s red and bumpy, like little bumps all over my arms. It’s really itchy, and sometimes it feels hot too. Doctor: Any other symptoms? Patient: Yes, my legs feel weak sometimes, like I can’t stand up straight properly.
20. Which clinical term should the doctor record for the patient’s description of the leg symptoms?
Answer: C. The patient describes their legs as feeling 'weak' and unable to stand up straight properly. While 'numbness' and 'paralysis' are possible clinical terms, the patient’s description aligns most closely with 'weakness.' 'Muscle cramps' does not fit the description of an inability to stand. Training for this requires translating lay terms into clinical language accurately.
Patient: I’ve been taking these pills for my blood pressure, but I think I might have been taking them wrong. The bottle says to take one in the morning, but I’ve been taking two at night. I’ve also been taking some extra pills when I feel really stressed. Doctor: Which medication is that? Patient: It’s called Lisinopril. And my uncle had heart problems, but I’m not sure if it was because of his lifestyle or something else.
21. What should the doctor record about the patient’s medication adherence and frequency?
Answer: B. The patient explicitly states they have been taking two tablets at night instead of one in the morning and has been taking extra pills during stress. This is a clear deviation from the prescribed regimen. Option B accurately reflects the patient’s self-reported behavior, while the others either ignore the incorrect dosing or are vague.
Patient: I’ve been having these dizzy spells, doctor. It started after I moved to New Zealand from India last year. It’s really bad when I stand up quickly. My mother also had problems with her heart, but I’m not sure if it’s hereditary or just because of her age. Doctor: Any other symptoms? Patient: Yes, I’ve been taking some sleeping pills called Zopicon, but I can’t remember the dose.
22. What should the doctor record regarding the patient’s family history of heart problems?
Answer: B. The patient mentions their mother had heart problems but is unsure if it is hereditary or due to her age. This vague description requires the doctor to record the information without assuming certainty. Option B correctly reflects the uncertainty, while the other options either assume hereditary causes or introduce incorrect family members.
Doctor: When did the episodes of dizziness start? Patient: I think it was around the 12th of March, no wait—actually the 15th of March. Doctor: Got it. And how often do you take your amlodipine? Patient: I take one tablet every day, but I’ve been taking 5 mg instead of the 10 mg prescribed. Doctor: Any other symptoms? Patient: My chest feels like a tight band around it. Doctor: Any family history of heart disease? Patient: My mother had some heart issues, not sure exactly what.
23. What should be recorded in the notes for the onset date of the dizziness?
Answer: C. The patient corrects the date to the 15th of March; the correct note is the corrected date. Candidates may pick the first, incorrect figure (12 March).
Doctor: How would you describe the pain in your leg? Patient: It feels like a burning sensation, like when I touch a hot stove. Doctor: And the medication you are on for hypertension? Patient: I'm supposed to take Lisinopril 20 mg once daily, but I’ve been taking it twice a day at 10 mg each time. Doctor: Any relevant family history? Patient: My dad had a stroke sometime ago.
24. What clinical term should replace the patient’s description of the leg pain?
Answer: B. The lay description 'burning sensation' corresponds to the clinical term 'neuropathic pain'. An unwary candidate might write the exact words used by the patient. This training uses a transcript instead of audio.
Doctor: Where did you have your previous gallbladder surgery? Patient: At St. Mary's Hospital in London. Doctor: And the dose of your metformin? Patient: I was told 500 mg twice daily, but I’ve been taking 250 mg three times a day. Doctor: Any family history of diabetes? Patient: My grandparents on both sides had diabetes, but I don’t know which side exactly.
25. What medication dosage should be recorded for metformin?
Answer: B. The patient states the actual regimen they are following: 250 mg three times a day. Candidates often record the prescribed dose (500 mg twice daily) instead of the patient’s actual use.

Listening Parts B and C — briefings and talks 29 questions

Part B is short workplace extracts (a handover, a board round, an instruction from a consultant, a phone referral); Part C is longer presentations and interviews — a grand round, a journal club, an interview with a researcher.

"During the handover, the senior nurse said: ‘The patient’s blood pressure has been consistently above 140/90 for the past 48 hours. We need to start a low‑dose antihypertensive and monitor for side effects. The junior doctor should check the ECG before any medication. If the BP remains uncontrolled, we will consider a specialist review.’
1. What is the main purpose of the senior nurse’s statement?
Answer: C. The nurse is summarising the patient’s current blood pressure status and the plan for monitoring and escalation. The other options focus on specific actions rather than the overall purpose.
"In today’s grand round, Dr. Patel will discuss the latest evidence on anticoagulation in atrial fibrillation. The guideline states that patients with CHA2DS2‑VASc score of 2 or more should receive anticoagulation. However, a recent audit showed that 30% of eligible patients were not prescribed a direct oral anticoagulant. Dr. Patel will present the audit results and propose a quality improvement project to increase adherence."
2. Which statement best reflects Dr. Patel’s attitude toward the guideline?
Answer: C. Dr. Patel acknowledges the guideline and uses audit data to suggest improvement, showing acceptance and a proactive stance.
"During the interview with the researcher, Dr. Lee explained: ‘The current consensus is that early mobilisation improves postoperative recovery. Our study challenges this by showing no significant difference in length of stay between early and delayed mobilisation groups. The guideline has always assumed early mobilisation is beneficial, and that assumption is exactly what our audit challenged.’"
3. What does Dr. Lee report as the guideline’s assumption?
Answer: D. Dr. Lee explicitly states the guideline assumes early mobilisation improves recovery. The other options are not mentioned.
"In the board round, the consultant said: ‘The patient’s chest X‑ray shows a right lower lobe infiltrate. We have started ceftriaxone and azithromycin. The guideline recommends a 7‑day course for community‑acquired pneumonia, but we are considering a shorter course because the patient is improving rapidly. I will discuss this with the pharmacy team to adjust the duration.’"
4. What is the consultant’s main concern in this statement?
Answer: C. The consultant focuses on whether to shorten the antibiotic course, indicating concern about duration rather than drug choice or other aspects.
Dr Vance: Right team, before we start the morning ward round, I want to flag bed twelve. The patient was admitted overnight with acute severe asthma and hasn't responded fully to the initial nebulised salbutamol and oral prednisolone. Nursing staff note he is still tachypneic at twenty-eight breaths per minute. Now, his peak flow has improved slightly from thirty to forty percent of predicted, but his latest blood gas shows a rising PaCO2. My main worry is that despite our standard therapy, he is tiring out and heading toward acute respiratory failure if we don't escalate his care promptly.
5. What does the consultant identify as the primary indication for escalating care?
Answer: C. While options A, B, and D mention clinical findings stated in the text, the consultant explicitly specifies that his main worry is the rising PaCO2 showing the patient is tiring out, which makes option C the correct answer for the primary indication of escalation.
Dr Thorne: We reviewed our hospital mortality data following the introduction of the new sepsis bundle. The historical literature maintained that protocol-driven compliance alone would universally drop intensive care admissions. However, our local audit data revealed that while time to antibiotics improved significantly, intensive care admission rates actually remained completely unchanged across all three of our medical wards.
6. According to the speaker, what did the hospital audit data demonstrate regarding the new sepsis bundle?
Answer: A. The speaker contrasts the historical literature assumption with their actual audit findings. The audit showed that while time to antibiotics improved, intensive care admission rates remained unchanged, matching option A.
Nurse Manager: I need to update everyone regarding the upcoming CQC inspection next Tuesday. The inspectors will be focusing heavily on medication reconciliation records on admission. While some staff feel that our current electronic system makes this process foolproof, our internal spot checks showed that reconciliation is still frequently delayed beyond the mandatory twenty-four-hour window on the acute assessment unit.
7. What is the nurse manager's primary message regarding the medication reconciliation records?
Answer: B. The nurse manager contrasts what staff believe about the electronic system with the reality found in internal spot checks, which showed delays beyond the mandatory window, making option B correct.
Dr Kenneth: During today's journal club, we are looking at the landmark trial on carotid endarterectomy. The authors concluded that surgical intervention is definitively indicated for all patients with symptomatic stenosis exceeding seventy percent. However, our local vascular MDT has consistently noted that elderly comorbid patients rarely achieve the same risk-benefit ratio seen in that trial's highly selected cohort.
8. What does the speaker's vascular MDT believe about the application of the trial's conclusion?
Answer: C. The speaker reports the trial authors' conclusion but contrasts it with their local MDT's observation that elderly comorbid patients rarely achieve the same risk-benefit ratio, meaning those patients may not experience the same benefits. This makes option C correct.
Consultant: 'Right, team, let’s go over the case of Mr. Thompson. The patient presented with persistent chest pain and elevated troponins. The ECG showed ST-segment depression, but the initial troponin levels were only mildly elevated. The question is whether we proceed with an invasive strategy or start with medical therapy. Given the low-risk score on the TIMI model, I’d like to hold off on angioplasty for now. We’ll monitor his symptoms and repeat troponins in six hours. If there’s any change, we’ll escalate. Does anyone have concerns?'
9. What is the consultant’s primary recommendation regarding Mr. Thompson’s management?
Answer: A. The consultant explicitly states they want to 'hold off on angioplasty for now' and 'monitor his symptoms and repeat troponins in six hours.' This indicates a cautious, observation-based approach rather than immediate invasive or purely medical intervention. The TIMI risk score being low further supports this recommendation.
Researcher: 'Our recent study on the efficacy of telemedicine for chronic disease management has shown promising results. However, the guideline we followed during the trial assumed that patients would have reliable access to technology. Our audit found that nearly 30 percent of participants lacked consistent internet access or a smartphone. This discrepancy between the guideline’s assumption and our real-world data suggests that telemedicine may not be universally applicable. We’re now revisiting how we design these programs to ensure inclusivity.'
10. What does the researcher conclude about the guideline’s assumption regarding telemedicine?
Answer: C. The researcher explicitly states that the guideline assumed 'patients would have reliable access to technology,' but the audit revealed 'nearly 30 percent of participants lacked consistent internet access or a smartphone.' This contradiction leads the researcher to conclude the assumption was flawed. The speaker does not attribute this conclusion to the guideline itself but to their own analysis.
Nurse Educator: 'Alright, let’s talk about the new sepsis protocol rollout. The hospital board is pushing for full compliance by the end of the month. I’ve noticed some resistance from the wards, particularly around the fluid resuscitation phase. Many nurses feel overwhelmed by the additional documentation required. While I understand the urgency, we need to ensure that our teams are trained and supported. If we rush this, we risk compromising patient care. Let’s focus on small, manageable steps to build confidence first.'
11. What is the nurse educator’s primary concern regarding the sepsis protocol implementation?
Answer: B. The nurse educator highlights 'resistance from the wards, particularly around the fluid resuscitation phase' and explicitly mentions 'many nurses feel overwhelmed by the additional documentation required.' They emphasize the need for 'training and support,' indicating their concern is centered on the staff’s preparedness rather than the protocol’s validity or administrative burdens alone.
Clinical Pharmacist: 'During our recent review of medication reconciliation records, we identified a critical gap: 47 percent of patients admitted from home had discrepancies in their medication lists. This is not just an administrative issue—it directly impacts patient safety. For instance, we found that 12 percent of these discrepancies led to either missed doses or incorrect dosages upon admission. The guideline recommends reconciling medications within 24 hours of admission, but our data shows that only 38 percent of our team adheres to this. To address this, we’re proposing a structured handover checklist and mandatory pharmacist involvement in the first 12 hours of admission.'
12. What does the clinical pharmacist attribute the high rate of medication discrepancies to?
Answer: C. The pharmacist states that 'only 38 percent of our team adheres to the guideline’s recommendation' of reconciling medications within 24 hours, and they directly link this non-compliance to the 'critical gap' in medication lists. While they acknowledge the impact on patient safety, the root cause they imply is the absence of adherence to the guideline’s protocol, not patient behavior or vague guidelines. The solution they propose (checklist and pharmacist involvement) further supports this.
Consultant: 'Right, team, we’ve got a case of acute pancreatitis here that’s not responding as expected. The patient’s amylase levels are still elevated at 800 units per liter after 72 hours, and their pain hasn’t improved despite maximal medical therapy. I’m particularly concerned about the possibility of necrotizing pancreatitis. We need to discuss whether we should escalate to interventional radiology for drainage or if we can safely continue conservative management. Let’s review the imaging again.'
13. What is the consultant’s main concern in this statement?
Answer: A. The consultant explicitly mentions 'possibility of necrotizing pancreatitis' and the need to 'discuss whether we should escalate to interventional radiology for drainage.' This indicates their concern is about the progression of the condition and the need for further intervention, not just the amylase levels or pain management alone.
Researcher: 'Our recent study on telemedicine consultations for chronic obstructive pulmonary disease (COPD) patients revealed some interesting findings. The guideline we followed assumed that telemedicine would reduce hospital readmissions by improving patient adherence to medication. However, our audit showed that while telemedicine did improve patient satisfaction and reduce clinic visits, it did not significantly lower readmission rates. This suggests that adherence alone isn’t the sole driver of readmission outcomes.'
14. What does the researcher conclude about the guideline’s assumption regarding telemedicine?
Answer: B. The researcher states that the guideline assumed telemedicine would reduce readmissions 'by improving patient adherence to medication,' but the audit showed that while telemedicine improved adherence and satisfaction, it did not significantly lower readmissions. This implies the assumption was partially correct but not sufficient on its own.
Nurse Educator: 'I’ve been reviewing the sepsis protocol implementation across our wards, and the data is concerning. While the early recognition of sepsis has improved, there are still significant delays in administering the first dose of antibiotics. Our audit found that in 30 percent of cases, the delay was due to missing or incomplete medication reconciliation records. This is a critical gap, as timely antibiotic administration is a cornerstone of sepsis management. We need to address this systematically.'
15. What is the nurse educator’s primary concern regarding the sepsis protocol implementation?
Answer: C. The nurse educator highlights that 'there are still significant delays in administering the first dose of antibiotics' and directly attributes this to 'missing or incomplete medication reconciliation records' in 30 percent of cases. This is the primary concern they raise, as it directly impacts patient care.
Vascular Surgeon: 'The recent clinical trial on endovascular aneurysm repair (EVAR) showed promising results, particularly in high-risk patients. However, we must be cautious in applying these conclusions to our local population. The trial participants were predominantly younger and had fewer comorbidities than our average patient. Our vascular MDT believes that while EVAR is beneficial, the trial’s success may not translate directly to our patients with more complex conditions. We need to consider individual risk factors before recommending this procedure.'
16. What does the vascular MDT believe about the application of the trial’s conclusion?
Answer: C. The surgeon states that the trial participants were 'predominantly younger and had fewer comorbidities' than their local population, and the MDT believes the trial’s success 'may not translate directly to our patients with more complex conditions.' This indicates a cautious stance about direct application of the trial’s conclusions.
Dr. Patel is presenting at a journal club meeting about a recent study on the efficacy of low-dose aspirin in preventing cardiovascular events in high-risk patients. She begins by summarizing the study’s key findings: "The trial showed that patients who took low-dose aspirin had a 20% reduction in major cardiovascular events compared to those who did not. However, there was a significant increase in bleeding complications, particularly gastrointestinal bleeding." She then explains the study’s limitations, stating: "The guideline we follow has always assumed that the benefits of aspirin outweigh the risks in all high-risk patients, but this trial suggests that the risk of bleeding may not be justified for every individual." Dr. Patel concludes by emphasizing the need for personalized medicine in aspirin prescription, "We must reconsider our approach and tailor treatment based on individual patient risk profiles."
17. What does Dr. Patel’s presentation primarily suggest about the guideline’s assumption regarding aspirin use?
Answer: C. Dr. Patel explicitly states that the guideline has always assumed the benefits of aspirin outweigh risks in all high-risk patients, but the trial’s results challenge this assumption. The correct option reflects her conclusion that the guideline’s approach needs revision based on new evidence.
Dr. Chen is leading a board round discussing a patient with suspected deep vein thrombosis (DVT). She starts by summarizing the patient’s clinical presentation: "The patient presents with swelling, pain, and a positive Homan’s sign. However, their D-dimer level is negative, which is unusual for DVT." She then explains the differential diagnosis: "Given the negative D-dimer, we need to consider alternative diagnoses such as cellulitis, pulmonary embolism, or even a deep vein thrombosis mimicker like a tumor or infection. The key here is to rule out these conditions thoroughly." Dr. Chen emphasizes the importance of imaging studies like ultrasound or CT angiography to confirm or rule out DVT. She concludes by stating: "We must avoid missing this diagnosis because delayed treatment can lead to serious complications like pulmonary embolism."
18. What is Dr. Chen’s main concern in this board round discussion?
Answer: A. Dr. Chen’s primary concern is accurately diagnosing DVT despite the negative D-dimer result and ensuring thorough evaluation to rule out alternative diagnoses. The correct option highlights the necessity of careful differential diagnosis and imaging to avoid missing critical conditions.
Dr. Martinez is presenting at a grand round about a new telemedicine initiative aimed at improving access to primary care for rural patients. She begins by outlining the initiative’s goals: "Our goal is to provide same-day consultations for patients in remote areas who might otherwise have to travel long distances for care." She then discusses the challenges: "The guideline we follow traditionally assumes that in-person consultations are essential for accurate diagnosis and treatment planning. However, our pilot study shows that telemedicine can be effective for many routine consultations, particularly for chronic conditions like hypertension and diabetes." Dr. Martinez concludes by saying: "We need to rethink our approach and integrate telemedicine more widely, but we must ensure patient safety and data security are prioritized."
19. What does Dr. Martinez attribute to the pilot study’s success in demonstrating the feasibility of telemedicine for primary care?
Answer: B. Dr. Martinez explicitly states that the pilot study challenged the guideline’s assumption that in-person consultations are essential. The correct option reflects her conclusion that telemedicine can be effective for many routine consultations, thereby questioning the guideline’s traditional stance.
Dr. Thompson is discussing a case with a research team during a grand round. The patient, a 68-year-old male with a history of hypertension and coronary artery disease, presented with chest pain. Initial ECG and troponin levels were normal, but the patient’s symptoms persisted. Dr. Thompson explains: "We started him on a beta-blocker and monitored him closely. However, his symptoms worsened, and we decided to perform a cardiac catheterization. The results showed significant coronary artery stenosis, and we proceeded with a percutaneous coronary intervention (PCI)." Dr. Thompson then shares the patient’s outcome: "The patient’s symptoms improved significantly after the PCI, and he was discharged on aspirin and a statin. However, we noticed that his blood pressure remained elevated, and we adjusted his antihypertensive medication accordingly." Dr. Thompson concludes by saying: "This case highlights the importance of a multidisciplinary approach in managing complex cardiovascular cases, especially when initial diagnostic tests are inconclusive."
20. What is Dr. Thompson’s main point about managing complex cardiovascular cases, based on this case presentation?
Answer: D. Dr. Thompson emphasizes the necessity of a multidisciplinary approach and the importance of adjusting medications based on ongoing symptoms and test results. The correct option captures his conclusion that complex cases demand thorough, adaptive management.
Good morning everyone, just a quick handover on Mr. Ahmed, a 68‑year‑old with COPD exacerbation. He's been on nebulised salbutamol q4h and oral steroids. We need to ensure his inhaler technique is reviewed before discharge and that his follow‑up appointment with respiratory services is booked for next week.
21. What is the primary instruction given in this handover?
Answer: A. The speaker explicitly says the inhaler technique must be reviewed before discharge. The other options are not mentioned; a candidate might pick B thinking steroids need adjustment, but the passage only mentions reviewing technique.
During today's grand round I will outline the recent audit of our sepsis bundle compliance. Historically, the protocol assumes that early broad‑spectrum antibiotics improve outcomes, but our data show no significant mortality difference when the bundle is initiated within the first hour versus the second hour. This suggests the timing assumption may need revisiting.
22. What does the speaker attribute to the audit findings?
Answer: A. The speaker says the audit challenges the assumption about timing. Option B reflects the original assumption, a common trap. Options C and D misrepresent the speaker's conclusion.
In this interview, the researcher explains that the national guideline has long held that tele‑rehabilitation is only suitable for patients with mild stroke. Our recent multicentre trial, however, demonstrated comparable functional gains in moderate‑severity cases, contradicting that guideline premise.
23. According to the researcher, what does the recent trial demonstrate?
Answer: A. The researcher states the trial showed comparable gains in moderate cases, directly opposing the guideline. Option B repeats the outdated guideline, a distractor. Options C and D are not mentioned.
Dr. Liu, thank you for presenting the audit on postoperative pain management. You noted that the current protocol assumes patient‑controlled analgesia (PCA) reduces opioid consumption, yet your data indicate a 15% increase in total morphine use when PCA is employed compared with scheduled dosing. This challenges the protocol's underlying assumption.
24. What is the speaker's overall assessment of the protocol's assumption?
Answer: A. The speaker explicitly says the data challenge the assumption that PCA reduces opioid use. Option B is an over‑statement, C is opposite, and D is irrelevant, though a candidate might mistakenly choose D if they recall a positive comment elsewhere.
"During the morning handover, Dr. Singh said: ‘The junior doctors have been reporting a higher incidence of postoperative nausea in patients who received ondansetron pre‑operatively. Our audit shows that 27% of those patients still had nausea, which is higher than the 15% we expect. I think we need to review the dosing schedule.’
25. What is the main point Dr. Singh is making in this handover?
Answer: A. Dr. Singh explicitly states that the audit shows a higher incidence and that he thinks the dosing schedule should be reviewed. The other options misinterpret his intent.
"In the grand round today, Professor Lee presented the latest evidence on atrial fibrillation management. She noted that the 2021 guideline recommends a target INR of 2.0–3.0 for most patients. She added that the guideline has always assumed that patients can maintain that range with standard warfarin therapy. However, our recent audit of 120 patients showed that only 48% achieved the target INR, suggesting that the assumption may not hold in real‑world practice."
26. Which statement reflects Professor Lee’s own view?
Answer: A. Professor Lee reports the audit finding herself; the other statements are what the guideline states, not her personal opinion.
"During the board round, Dr. Patel explained the case of a 68‑year‑old man with COPD exacerbation. He said, ‘We have been using the standard 30 mg dose of prednisolone for all exacerbations, but the latest meta‑analysis suggests that a lower dose of 20 mg may be equally effective with fewer side effects. Our audit of 200 patients showed that the 20 mg group had a 12% lower incidence of hyperglycaemia.’"
27. What is Dr. Patel’s main concern in this statement?
Answer: A. Dr. Patel highlights that a lower dose may be as effective, indicating concern that the current standard dose might be unnecessarily high.
Doctor, before you finalise the discharge summary for bed four, I need to flag that pharmacy called to query the loading dose of the direct oral anticoagulant given yesterday. They noted the creatinine clearance is sitting right on the thirty millilitres per minute threshold, and while the chart says the standard dose is appropriate for renal function above that, they want us to formally document our justification for not reducing it given the patient's advanced age and concurrent mild thrombocytopenia.
28. What is the primary purpose of the pharmacist's call as reported by the ward clerk?
Answer: B. The speaker states that pharmacy called to query the loading dose and wants formal documentation justifying why it was not reduced, given the age and thrombocytopenia. Option B accurately captures this. Option A is incorrect because cessation is not requested. Option C is wrong because the pharmacist is querying the dose relative to the threshold and patient factors, not demanding an automatic reduction. Option D is incorrect as thrombocytopenia is a patient factor cited in the justification query, not a reported drug interaction.
In reviewing our intensive care unit outcomes for post-operative sepsis, the preliminary guidelines have traditionally assumed that aggressive early fluid resuscitation alone is sufficient to stabilise hemodynamic parameters within the first six hours. However, our recent multi-centre audit challenges this foundational premise, demonstrating that routine administration without continuous stroke volume variation monitoring frequently precipitates sub-clinical pulmonary oedema. While the national committee maintains that their historical data supports broad fluid administration, our empirical findings indicate a pressing need for individualised titration protocols rather than blanket volume targets.
29. Which statement reflects Dr. Davies's own view regarding early fluid resuscitation in post-operative sepsis?
Answer: C. Dr. Davies contrasts the traditional guideline assumption with the audit findings, explicitly stating that empirical findings indicate a pressing need for individualised titration protocols rather than blanket targets, because routine administration precipitates pulmonary oedema. Therefore, option C reflects the speaker's own view. Option A and Option B represent the positions of the national committee and the traditional guideline assumption that the speaker's audit actually challenges. Option D is incorrect because the speaker advocates for monitoring rather than dismissing it.

Writing — the referral letter 19 questions

The hardest sub-test to pass and the one that decides most resits, so it gets the most items.

CASE NOTES Patient: Ms Briony Cassar, 54 years Diagnosis: Acute biliary sepsis with ascending cholangitis History: Known gallstone disease, awaiting elective cholecystectomy. Presented to ED with 48 hours of rigors, RUQ pain and jaundice. Temperature 39.1, BP 92/60, HR 118, WCC 18. On admission: bilirubin 92, ALP 340, ALT 210, INR 1.4. Committed on fluids and IV antibiotics. ERCP scheduled for tomorrow morning. Medications: IV ceftriaxone 2 g daily, IV fluid resuscitation. No regular medications. NKDA. Allergies: NKDA. Social: Works part-time as a school librarian. Mother of three adult children. Non-smoker, no alcohol. Task: Write a letter of referral to the gastroenterology registrar for urgent ERCP and ongoing biliary care.
1. Ms Cassar is being referred urgently for ERCP. Which opening sentence states the clinical request at the right level of directness?
Answer: B. Purpose decides this, with Conciseness and Genre supporting. The notes describe acute biliary sepsis with hypotension, tachycardia and deranged LFTs in a patient already booked for ERCP tomorrow — this is an urgent, indicated procedure, not a discretionary opinion. The correct opening therefore uses a direct request: 'Please could you arrange an urgent ERCP', followed by a one-line clinical justification. Option A understates the need with 'consider performing', which hedging rule flags as wrong when the procedure is clinically indicated. Option C layers three softeners ('most grateful', 'kindly', 'at your convenience') onto a request that is not optional. Option D is the most hedged, with three layers of conditionality ('whether you might', 'with a view to', 'if deemed clinically appropriate') for a patient who is septic and booked on a list. The signal in the notes is the combination of 'ascending cholangitis', haemodynamic instability and an ERCP already scheduled.
Case Notes: Patient name: Master Leo Vance, DOB: 14/09/2015. Clinical situation: Brought in by mother with acute epiglottitis, stridor, drooling, and rapid respiratory deterioration. Immediate transfer required to the paediatric intensive care unit.
2. The referral is to the on-call PICU registrar for an immediate emergency transfer. Which sentence correctly states the clinical request?
Answer: B. Criterion: Language and Tone. Urgency outranks politeness; hedging understates real clinical danger. Quote: acute epiglottitis, stridor, drooling, and rapid respiratory deterioration requires a direct, imperative request (Please accept this child immediately...).
Case Notes: Patient name: Mr George Rix, DOB: 22/07/1944. Referring to: Dr Marcus Thorne, Consultant Gastroenterologist. The patient was diagnosed with an obstructing sigmoid colon adenocarcinoma on CT scan yesterday. He is suitable for surgical resection. His past medical history includes well-controlled hypertension managed on amlodipine, and an appendectomy in 1990. He plays golf twice a week.
3. Which detail from the case notes is essential to include in the opening line of the referral letter?
Answer: B. Criterion: Organisation and Layout. The opening line must immediately state the core clinical problem and purpose of the referral. Quote: diagnosed with an obstructing sigmoid colon adenocarcinoma on CT scan yesterday.
You are Dr Aisha Khan, GP, writing a referral letter for your patient. Patient: Mr David Okafor, age 71 Diagnosis: New-onset atrial fibrillation, rate 120 bpm at rest, confirmed on 12-lead ECG today. BP 134/82. No chest pain. No syncope. Past history: Hypertension (on amlodipine 5 mg). Mild osteoarthritis of knees. Medications: Amlodipine 5 mg OD. Social: Retired civil servant. Lives with wife. Non-smoker for 20 years; 30 pack-year history prior. Family history: Father had stroke aged 78. Current issue: Symptomatic on minimal exertion; unable to climb stairs without breathlessness. Commenced on bisoprolol 2.5 mg OD yesterday; resting rate now 92. Recipient: Dr Meera Joshi, Consultant Cardiologist, Electrophysiology Clinic, Royal Infirmary. Reason for referral: Request for consideration of rhythm management, likely ablation.
4. You need to include the reason for referral in the opening line. Which sentence is correct?
Answer: B. The criterion is Content, and specifically how the opening line states the clinical reason for referral. A real reader — a cardiologist receiving a referral for ablation — needs three things up front: the patient identifier, the presenting diagnosis, and the specific request. Option B contains all three: the name and age, the diagnosis (new atrial fibrillation), and the precise request (rhythm management, likely ablation). The distractors fail on Content. A hedges the request ('if you could kindly consider') — hedging is appropriate only for discretionary opinions, not for an assessment where the GP has already made the diagnosis and started treatment; it understates the clinical need. C frames the referral around hypertension, which is a long-standing, well-controlled background issue, not the reason for this referral — the cardiologist does not need to take over hypertension care. D replaces clinical content with biographical softening ('retired gentleman', 'expert opinion') and again uses the discretionary 'expert opinion' phrasing for what is in fact a specific procedural request. Quote from the notes that decides it: 'Request for consideration of rhythm management, likely ablation.' That request must appear in the opening line, and it must be stated directly, not softened into a request for an opinion.
You are Dr Aisha Khan, GP, writing a referral letter for your patient. Patient: Ms Priya Sharma, age 34 Diagnosis: Acute onset right-sided weakness and expressive dysphasia, onset 4 hours ago. GCS 14. NIHSS 7. Right arm 2/5, right leg 3/5. Past history: Migraine. Combined oral contraceptive pill (Microgynon), last dose taken this morning. Medications: Microgynon 1 OD. Social: Receptionist. Husband at bedside. BP: 156/92. Glucose: 6.8. ECG: sinus rhythm 88. Recipient: On-call stroke registrar, Royal Infirmary. Reason for referral: Thrombolysis/thrombectomy assessment.
5. Which opening sentence correctly states the urgency and clinical request for this referral?
Answer: C. The criterion is Purpose — stating the request against the urgency in the notes. This is a hyperacute stroke presentation with a clear time window; the receiver is an on-call stroke registrar who must be able to mobilise the thrombolysis pathway from the first sentence. Option C does this: names the patient, states the onset, gives the NIHSS, and ends with a direct, urgent request — 'Please assess urgently … for thrombolysis.' The distractors fail on Purpose and on the urgency rule. A is wrong twice — it uses the discretionary hedging ('kindly consider', 'at your earliest convenience') that is appropriate for a non-urgent opinion but is dangerous here because it weakens an urgent clinical request, and it omits the stroke scale and onset time that the registrar needs to decide eligibility. B is wrong for the same reason: 'expert opinion' frames an urgent thrombectomy assessment as a discretionary second view, and 'mild stroke' understates an NIHSS 7 presentation with 2/5 arm weakness. D omits both the urgency and the thrombolysis request entirely, and uses the wrong tone for an acute transfer. Quote from the notes that decides it: 'Acute onset right-sided weakness and expressive dysphasia, onset 4 hours ago. … Reason for referral: Thrombolysis/thrombectomy assessment.' The opening must state that urgency directly.
Patient: Ms Aisha Khan, 45 years old, presents with a 2‑week history of severe headache, visual blurring and vomiting. She reports a sudden onset of a throbbing headache that is worse in the morning. She has a history of migraine but no prior neurological disease. Blood pressure 190/110 mmHg, heart rate 78 bpm. CT scan shows a sub‑arachnoid haemorrhage. She is referred urgently to the neurosurgery team for possible endovascular coiling.
6. Which opening salutation is correct for the referral letter to the on‑call neurosurgery registrar?
Answer: D. The recipient is an on‑call registrar whose name is not specified. The correct opening is the generic "Dear Sir/Madam" as per the Genre and Style criterion. Using a named salutation would be a genre error. The case note states "She is referred urgently to the neurosurgery team for possible endovascular coiling."
Patient: Mr Carlos Ruiz, 55 years old, presents with a 3‑month history of progressive fatigue, weight loss of 5 kg, night sweats and a palpable left supraclavicular lymph node. He is a former smoker (quit 10 years ago, 20 pack‑year history). Blood tests show a haemoglobin of 9.5 g/dL, white cell count 14 000 /µL, platelets 400 000 /µL. He is referred to the oncology team for a biopsy of the lymph node and staging work‑up.
7. Which detail is essential to include in the referral letter to the oncology team?
Answer: B. The oncology specialist requires the patient’s smoking history to assess risk factors and guide staging. This is a safety issue under Purpose and Content. The case note states "He is a former smoker (quit 10 years ago, 20 pack‑year history)."
Patient: Mrs Ellen Park, 62 years old, presents with a 1‑month history of lower abdominal pain and dysuria. Urine dipstick shows leukocytes and nitrites. She is referred to the urology team for a possible urinary tract infection and consideration of a cystoscopy. She is currently on amoxicillin 500 mg three times daily for 7 days.
8. Which sentence should be included in the opening line of the referral letter?
Answer: C. The referral is urgent and the request should be direct. The correct sentence is "Please investigate her urinary symptoms urgently." This follows the Urgency outranks politeness criterion. The case note indicates an urgent investigation is required. The other options use hedging or lack urgency.
Case Notes: Patient name: Arthur Pendelton. Age: 78. Social history: Retired carpenter, lives alone in a first-floor flat with a stairlift. Wife passed away in 2014. Clinical background: T2DM well-controlled on metformin, hypertension. Current presentation: Brought to Emergency Department by ambulance following a collapse at home. Found to be in complete heart block with a ventricular rate of 34 bpm. Received atropine 0.5 mg IV with transient response. Currently stable on temporary transvenous pacing wire inserted in ED. Plan: Urgent transfer to cardiology for permanent pacemaker insertion.
9. Which of the following clinical details from the case notes is essential to include in the referral letter to the cardiology team?
Answer: D. Criterion: Content. The cardiology team receiving an urgent transfer for pacing requires the acute life-saving interventions and current rhythm disturbance. Distractors A, C, and D are inert biography or stable chronic conditions that do not alter the immediate procedural management for complete heart block.
Case Notes: Patient name: David Chen. Age: 55. Presentation: Acute severe asthma attack refractory to nebulised salbutamol and ipratropium, plus IV hydrocortisone given over the last hour in the urgent care centre. Current observations: RR 28, SpO2 88 percent on oxygen 15L via non-rebreather mask, PEF 35 percent of predicted. Arterial blood gases show rising PaCO2. Plan: Immediate emergency transfer to the intensive care unit for intubation and ventilation.
10. Which sentence correctly states the urgency and clinical request for this ICU transfer letter?
Answer: B. Criterion: Language and Purpose. Urgency outranks politeness, and hedging understates a critical clinical need. The patient is failing medical therapy with rising PaCO2 requiring immediate ventilation, making the direct imperative in option B correct. Options A, C, and D use inappropriate hedging or minimisation for an emergency transfer.
Case Notes: Patient name: Eleanor Vance. Age: 68. Background: Presented to her general practitioner with a two-month history of progressive dysphagia for solids and significant unintentional weight loss of 7 kg. Urgent upper gastrointestinal endoscopy performed yesterday revealed an ulcerated mass at the lower third of the oesophagus. Biopsy results are pending. Referral destination: Upper Gastrointestinal Surgery and Oncology Multidisciplinary Team.
11. Which detail is essential to include in the opening line of this urgent referral letter?
Answer: B. Criterion: Organisation and Content. The opening line of a cancer referral must immediately state the core clinical reason for referral and key objective finding. Option B correctly includes the structural lesion and primary symptom. Options A, C, and D contain either secondary details or irrelevant background history that do not belong in the primary opening sentence.
Ms Priya Devi, 34, 32+4 weeks gestation, G1P0, known HbS-beta thalassaemia on hydroxyurea (stopped at 28 weeks), regular transfusions every 4 weeks, last transfusion 12 days ago, Hb 78 g/L today. She presents with sudden severe right upper quadrant pain, vomiting, BP 95/60, HR 118, temp 38.1°C. Urinalysis: protein +++, blood +. Obstetric review notes a tense tender uterus and a non-reassuring CTG with baseline 165, reduced variability, late decelerations. She is allergic to penicillin (rash). PMH: cholecystectomy 2017, hypothyroidism on levothyroxine 75 mcg. The midwife has contacted the on-call obstetric registrar for an urgent review and possible emergency delivery.
12. Which sentence most correctly states the urgency and clinical request for this referral?
Answer: C. Genre and Style — directness matched to urgency. Rule 3: hedging understates a real clinical need. The notes describe a haemoglobinopathy patient with sepsis, pre-eclampsia features, and a non-reassuring CTG at 32+4 weeks — this is an obstetric emergency and the request is for immediate senior review, not an opinion. Direct phrasing ('Please attend urgently') is required because the situation is not discretionary. Options A, B and D soften a request that the clinical picture demands be made firmly. Quote from the notes: 'non-reassuring CTG with baseline 165, reduced variability, late decelerations'.
Mr Owen Halloran, 71, retired electrician, attends with his daughter. Six-month history of forgetfulness, getting lost on familiar walks, and a recent incident where he left the gas hob on. Past medical history: well-controlled atrial fibrillation on apixaban 5 mg BD, hypertension on ramipril 5 mg, hypercholesterolaemia on atorvastatin 20 mg, osteoarthritis of the right knee, cataract surgery 2019, lifelong chess enthusiast. MSE today: MMSE 21/30, lost points on orientation, recall and language. BP 142/86, otherwise examination unremarkable. Bloods normal. The GP is referring Mr Halloran to the older-adult memory clinic for assessment of suspected dementia.
13. Which single detail from the case notes is essential to include in this referral letter?
Answer: C. Content — what this reader must have. Rule 1: the question asks what is essential. The recipient is a memory clinic psychiatrist who will need to plan investigations and consider any treatable contributors, but more importantly will need to know whether the patient is anticoagulated because cognitive testing, possible future interventions, and any decisions about driving, capacity and consent turn on bleeding risk. The distractors are biography: chess (option A) and his occupation (option D) are inert personal details, and a resolved cataract operation two years earlier (option B) is not load-bearing for a memory clinic. Quote from the notes: 'atrial fibrillation on apixaban 5 mg BD'.
Aisha Karim, 8 years old, known severe asthma on salbutamol PRN, beclomethasone 100 mcg BD and montelukast 5 mg nocte. Presented to the GP by her father after a third acute exacerbation in 6 weeks despite adherence. Two required oral prednisolone bursts; the third, this morning, did not respond to 10 puffs of salbutamol at home, lasted over 90 minutes, and Aisha was visibly exhausted with saturations of 91% on air, widespread wheeze, and a silent chest on the right. She was given nebulised salbutamol and ipratropium, oral prednisolone 30 mg, and oxygen at the surgery, with improvement to SpO2 96%. She has no known drug allergies, is up to date with immunisations, enjoys netball and reading, and the family have a cat. The GP is writing to Dr Faisal Rahman, consultant paediatrician with an interest in respiratory medicine, requesting urgent review.
14. Which sentence correctly states the opening line of this referral letter?
Answer: C. Content and Conciseness and Clarity. Rule 1 (essential detail) and rule 5 (right level of detail, not a transcript). The named recipient (Dr Rahman) means the salutation is fine in the next sentence, but the opening line must tell a respiratory paediatrician what is actually going on. Option A is too thin — it omits the acuity and the failure of current therapy, which is the reason for the referral. Option B is too colloquial ('tough week', 'kindly see'). Option D is flattering and adds nothing clinical. Option C states the diagnosis, the failure of current therapy, the frequency of exacerbations and today's red-flag finding (silent chest) at the right level of detail for a specialist reader. Quote from the notes: 'third acute exacerbation in 6 weeks despite adherence' and 'silent chest on the right'.
Case Notes: Patient is a 72-year-old male with a history of chronic obstructive pulmonary disease (COPD) and coronary artery disease. He presents with acute dyspnea, oxygen saturation of 88% on room air, and a respiratory rate of 32 breaths per minute. His peak flow is 30% of predicted. He is currently on salbutamol nebulizers and prednisolone 40mg daily. The patient is anxious and requests immediate admission.
15. Which sentence correctly states the urgency and clinical request for this referral to the emergency department?
Answer: B. The correct sentence is 'Please admit this patient urgently for acute respiratory failure and initiate oxygen therapy.' (Purpose: Urgency outranks politeness). The patient’s clinical status (oxygen saturation 88%, respiratory rate 32) and request for immediate admission justify a direct and urgent request. Hedging phrases like 'consider' (A) or 'could you review' (D) are inappropriate given the urgency. Option C is incorrect as it does not reflect the patient’s clinical need for admission.
Patient: Ms L. Nguyen, 45, presenting with severe abdominal pain and vomiting. Labs: serum amylase 620 U/L, lipase 780 U/L. Ultrasound shows gallstones. Diagnosis: acute biliary pancreatitis. Request: urgent surgical review for possible cholecystectomy. The on‑call surgical registrar is the addressee.
16. How should the salutation be written in this referral letter?
Answer: B. Criterion: Genre and Style – when the recipient is given only as a role, the correct opening is the role title. The case notes specify “the on‑call surgical registrar is the addressee”, so “Dear On‑call Surgical Registrar” is required.
Patient: Mrs S. Ahmed, 30, pregnant at 28 weeks, presenting with severe hypertension (BP 180/110) and proteinuria. Diagnosis: pre‑eclampsia. Immediate transfer to tertiary obstetric unit required. The receiving unit is the on‑call obstetrician, Dr. Hassan.
17. Which detail is essential to include in the opening line of the referral letter?
Answer: B. Criterion: Conciseness and Clarity – the opening line must convey the critical clinical information. The case note quotes “blood pressure reading of 180/110 mmHg”, which is essential for the obstetrician to know immediately.
Case Notes: Patient name Mr Arthur Pendelton, DOB 12 March 1945. Presented to general practice with acute chest tightness and diaphoresis. ECG shows ST elevation in leads V2 to V4. History: retired accountant, lives with wife, mild osteoarthritis managed with paracetamol, non-smoker. Action: Calling ambulance for emergency transfer to cardiology. Referral recipient: On-call cardiologist at City General Hospital. No named clinician provided in notes.
18. Which opening salutation is correct for this urgent referral letter?
Answer: D. This tests Genre and Style regarding recipient naming. Rule 2 states that if the notes give only a role and no named addressee, the correct opening is Dear Sir or Madam. Quoted from the case notes: Referral recipient: On-call cardiologist at City General Hospital. No named clinician provided in notes.
Case Notes: Patient name Master Leo Briggs, DOB 22 July 2018. Brought by mother with acute severe asthma exacerbation. Peak flow 40 percent of predicted, intercostal recession, speaking in single words. Action: Immediate emergency department transfer required. Recipient: Emergency Department Triage Nurse, St Jude Childrens Hospital. No named clinician.
19. Which sentence correctly states the urgency and clinical request for this emergency transfer letter?
Answer: B. This tests Language and Tone regarding urgency versus hedging. Rule 3 states that urgency outranks politeness and hedging understates real clinical need. A severe asthma attack requires a direct, urgent request. Quoted from the case notes: Action: Immediate emergency department transfer required.

Speaking — the two role-plays 29 questions

Two profession-specific role-plays where the doctor must handle a patient or relative who is anxious, angry, sceptical, grieving, or has not understood.

1. A 42 year old man presents with acute bronchitis. He insists on receiving a prescription for broad spectrum antibiotics, stating his previous doctor always gave them and that is the only way his chest infections clear up. Which statement best demonstrates effective relationship-building and management of this request?
Answer: B. Option B earns the higher grade by demonstrating the Clinical Communication criterion of relationship-building. It acknowledges the patient's past experience and distress about the cough before gently correcting the misconception about antibiotics and offering a constructive alternative. Option A is dismissive of the patient's view. Option C capitulates inappropriately to inappropriate prescribing. Option D is clinically accurate but completely ignores the patient's perspective, making it interpersonally deaf.
2. A 58 year old woman is attending a follow-up appointment after routine blood tests reveal a new diagnosis of type 2 diabetes. She looks shocked, tears up, and says she thought she was just tired from working long hours. Which response best prioritizes the patient's perspective?
Answer: A. Option A excels under the Clinical Communication criterion of understanding the patient's perspective and managing emotions. It explicitly validates her emotional reaction to the unexpected news and offers control by suggesting a manageable pace. Option B minimizes her genuine distress with false reassurance. Option C jumps straight into clinical management and targets without acknowledging her emotional state. Option D generalizes her feelings rather than directly addressing her specific reaction.
3. A 65 year old man with essential hypertension and previous myocardial infarction admits during a medication review that he stopped taking his statin three months ago because he read online that it causes severe muscle wasting. Which response best negotiates adherence?
Answer: B. Option B satisfies the Clinical Communication criterion of information-gathering and relationship-building in a difficult scenario. It respects the patient's agency and acknowledges his fear without validating misinformation, inviting a collaborative review of evidence. Option A uses a paternalistic approach focused entirely on clinical risk without exploring his perspective. Option C capitulates without addressing the underlying cardiovascular risk. Option D is confrontational and alienates the patient by dismissing his information source.
4. A 29‑year‑old woman with newly diagnosed type 2 diabetes is upset because she feels the diagnosis means she will have to take many pills forever. Which response best demonstrates the communication skills needed for a higher grade?
Answer: A. This response shows relationship‑building by acknowledging the patient’s fear, and it invites shared decision‑making – the key criterion is acknowledging the concern before answering.
5. A 55‑year‑old man with chronic back pain asks for an MRI, believing it will reveal a serious problem. He is frustrated after several previous negative scans. Which reply best meets the OET communication criteria?
Answer: D. The doctor acknowledges the patient’s perspective, provides structure by signposting three steps, and gives information in a patient‑centred way – the criterion is providing structure (signposting).
6. A 68‑year‑old woman with advanced ovarian cancer asks if there is any chance of cure after you explain that treatment is palliative. She becomes tearful and says she feels abandoned. Which statement is most appropriate for a higher grade?
Answer: D. The response shows empathy (relationship‑building), acknowledges the patient’s emotional state, and offers information about the next steps – the criterion is understanding the patient’s perspective.
7. A 45‑year‑old man with hypertension stopped his medication because he believes it caused his recent headaches. He says, “I don’t want to be dependent on pills.” Which reply best demonstrates the required communication skill?
Answer: D. The doctor acknowledges the patient’s concern (relationship‑building) and then provides a balanced plan that includes lifestyle measures and a possible medication adjustment – the criterion is relationship‑building and understanding the patient’s perspective.
You are a GP. A 52‑year‑old man with a history of hypertension and type 2 diabetes presents for a routine check‑up. He has stopped his antihypertensive medication for the last three months because he believes it caused his recent severe headaches. He is now anxious and says he will not take the medication again unless you prescribe a different drug. You need to discuss adherence and reassure him.
8. Which of the following statements is most likely to earn the highest grade?
Answer: B. Option B demonstrates relationship‑building by acknowledging the patient’s fear, shows understanding of the patient’s perspective, provides structure by offering to explain and then discuss alternatives, and gives information pitched at the patient’s level. Option A is clinically correct but lacks empathy. Option C is accurate but dismissive of the patient’s concerns. Option D is warm but offers no concrete plan.
You are a specialist in a community clinic. A 30‑year‑old woman has just been diagnosed with early‑stage breast cancer. She is visibly upset and asks you if the cancer will spread quickly. She wants to know if surgery is the only option. She is anxious about the future and wants reassurance.
9. Which response is likely to earn the highest grade?
Answer: B. Option B shows relationship‑building by acknowledging anxiety, demonstrates understanding of the patient’s perspective, provides a clear structure for the discussion, and gives information at an appropriate level. Option A is clinically correct but lacks empathy. Option C is reassuring but overly simplistic and dismissive. Option D is warm but offers no information.
You are a consultant in a hospital. A 70‑year‑old man with a recent hip fracture has just been informed that a complication has occurred during surgery. He is angry and says the hospital is at fault. He demands an apology and wants to know what will happen next.
10. Which statement is most likely to earn the highest grade?
Answer: A. Option A demonstrates relationship‑building by offering a sincere apology, shows understanding of the patient’s anger, provides a clear structure for explaining the complication and future steps, and gives information pitched to the patient. Option B is empathetic but vague. Option C is clinically accurate but dismissive of the patient’s feelings. Option D is warm but avoids addressing the patient’s concerns.
You are a GP. A 45‑year‑old man with a history of asthma presents with a new cough. He insists on a chest X‑ray to rule out pneumonia, despite no fever or shortness of breath. He is anxious about the possibility of a serious condition.
11. Which response is most likely to earn the highest grade?
Answer: C. Option C shows relationship‑building by acknowledging anxiety, demonstrates understanding of the patient’s perspective, provides a clear structure for explaining the condition, and gives information at an appropriate level. Option A is empathetic but does not outline the plan. Option B is clinically correct but lacks empathy. Option D is warm but offers no explanation.
12. A 62-year-old woman is attending a follow-up consultation after routine blood tests confirm a new diagnosis of chronic kidney disease stage 3. She looks shocked and states that her uncle died on dialysis, so her life is effectively over. Which response is most likely to earn the highest grade?
Answer: C. Option C earns the highest grade by directly addressing the patient's emotional perspective and validating her fears linked to her family history before attempting to educate her. Option A offers reassurance that is clinically accurate but emotionally tone-deaf, Option B borders on arguing with her feelings, and Option D provides structure too abruptly without acknowledging the acute distress.
13. A 72-year-old woman is accompanied by her daughter to discuss recent biopsy results that confirm metastatic pancreatic cancer. The patient asks if she has only a few weeks left to live. Which response is most likely to earn the highest grade?
Answer: B. Option B successfully demonstrates the criterion of understanding the patient's perspective and relationship-building by holding space for the emotional weight of the question and validating the fear before navigating the uncertainty. Option A is overly blunt, Option C offers false or generalized prognostic comfort, and Option D introduces a rigid structural framework that ignores the immediate emotional crisis.
14. A 58-year-old man with long-standing osteoarthritis of the knees presents for review. He has been using a walking stick for the past year and reports that his pain is now keeping him awake at night. He mentions that a friend had a knee replacement and is asking when he can have one done. His examination shows crepitus and reduced range of motion bilaterally, with X-rays confirming significant joint space narrowing. He is otherwise well. Which of the following statements is most likely to earn the highest grade?
Answer: B. Option B scores highest because it combines two Clinical Communication criteria: relationship-building and understanding the patient's perspective. It opens by acknowledging the impact of the pain on sleep and daily life before moving on, which validates the patient's concern rather than dismissing it. It then signposts the consultation by saying 'I'd like to find out a little more… before we talk about surgery', which is the structuring criterion. It also gathers information about the patient's own goals and prior treatment, which is the information-gathering criterion. Option A is clinically safe but interpersonally blunt — it closes the discussion before the patient has been heard. Option C is pitched in jargon ('refractory to non-operative management') and ignores the patient's stated request. Option D is warm and acknowledges the patient but does not invite further input or structure what comes next, so it is correct in tone but empty in direction.
15. A 25-year-old man with type 1 diabetes attends for review. His HbA1c has risen from 58 mmol/mol to 86 mmol/mol over the past six months. He admits he has been missing insulin doses because he finds them inconvenient while at university. He becomes quiet when you raise the HbA1c result. Which of the following statements is most likely to earn the highest grade?
Answer: B. Option B scores highest because it acknowledges the patient's non-verbal cue ('I can see this is a difficult conversation for you'), which is relationship-building, and then opens with an information-gathering question about the underlying reason for missing doses, which is understanding the patient's perspective. It does not lecture, jump to a solution or pretend the problem is not there. Option A is the classic clinically accurate but interpersonally deaf response — it issues an instruction over the top of a patient who has visibly become quiet. Option C generalises ('young people often…') and proposes a solution before the problem has been explored. Option D sounds empathetic but deliberately avoids the HbA1c result and therefore avoids the issue the patient actually raised; warm but empty, moving nothing forward.
16. A 50-year-old woman is admitted with a swollen, erythematous right lower leg. Doppler ultrasound confirms a deep vein thrombosis. She has no significant past medical history and is not pregnant. You recommend rivaroxaban. She hesitates and tells you that a close friend recently suffered a pulmonary embolism while on a direct oral anticoagulant, and she is now frightened of taking it. Which response is most likely to earn the highest grade?
Answer: A. Option A is the strongest response because it acknowledges the fear (relationship-building), explicitly invites the patient to share more about her perspective on her friend's experience (understanding the patient's perspective), and signals a structured conversation before giving information ('I would like to address it'). It also gathers information that will allow the explanation to be pitched to her specific worry. Option B is the textbook interpersonally deaf response: it delivers a risk–benefit argument over the top of a stated fear. Option C minimises the patient's experience ('almost certainly different') and tells her to trust the evidence rather than engaging with it. Option D is warm and offers an alternative, but switching to injections without first understanding the concern concedes to an unexamined fear and is not good information-giving.
17. A 34-year-old woman with a history of severe asthma attacks requests a repeat prescription for a bronchodilator despite being asymptomatic. She says, 'I don’t want to take any more pills—I just want to be able to breathe normally again.' Which response earns the highest grade?
Answer: A. The correct response acknowledges the patient’s concern (relationship-building) and provides structured information about managing symptoms without dismissing their request (signposting). It also gathers understanding by validating their feelings and offering a collaborative approach. Option B is clinically correct but doesn’t address the patient’s emotional state or offer a structured plan. Option C is clinically correct but lacks empathy and fails to acknowledge the patient’s desire for a solution. Option D is abrupt and dismissive, failing to build rapport or address the patient’s immediate need.
18. A 70-year-old man with a new diagnosis of chronic heart failure is visibly distressed. He says, 'I thought I was just getting older, but this is worse than I imagined. Can’t you just tell me to stop worrying?' Which response earns the highest grade?
Answer: A. The correct response validates the patient’s emotions (understanding the patient’s perspective), acknowledges their concern (relationship-building), and provides structured information about the next steps (signposting). It avoids dismissing their feelings while offering hope and a collaborative approach. Option B is overly reassuring and dismissive of the patient’s emotional state. Option C is clinically correct but lacks empathy and fails to acknowledge the patient’s fear. Option D is dismissive and lacks a structured plan for managing the condition.
19. A 28-year-old woman with a recent diagnosis of multiple sclerosis (MS) is visibly upset and says, 'I can’t believe this is happening to me. I thought I was healthy.' She asks, 'Can’t you just find a cure?' Which response earns the highest grade?
Answer: A. The correct response acknowledges the patient’s emotions (relationship-building), validates their perspective (understanding the patient’s perspective), and provides structured information about the next steps (signposting). It avoids jargon and offers hope while addressing their immediate concerns. Option B is clinically correct but lacks empathy and fails to acknowledge the patient’s emotional distress. Option C is abrupt and dismissive, failing to build rapport or address the patient’s emotional needs. Option D is overly directive and lacks emotional support.
20. A 45‑year‑old man with chronic low back pain returns for a review. He insists on getting an MRI scan, saying he is worried the pain might be due to a tumour. Which response is most likely to earn the highest grade?
Answer: B. This answer demonstrates relationship‑building (acknowledging the concern), understanding the patient’s perspective, provides structure (discuss causes then explain why MRI isn’t needed) and gives information in lay terms. It meets the relationship‑building criterion.
21. A 62‑year‑old woman has just been diagnosed with type 2 diabetes. She looks upset and says, “I don’t want to be a diabetic for the rest of my life.” Which statement would most likely achieve the highest grade?
Answer: D. The response builds rapport by acknowledging her upset feelings, shows understanding, provides a clear structure (review, management, questions) and gives information at an appropriate level – fulfilling the relationship‑building criterion.
22. A 28‑year‑old woman with newly diagnosed multiple sclerosis says, “I can’t believe this is happening; I’m scared I’ll never work again.” Which reply is most likely to earn the highest grade?
Answer: B. This answer acknowledges the patient’s fear, shows understanding, provides a structured plan (explain disease, treatment, work support) and gives information in plain language, meeting the relationship‑building criterion.
23. A 70‑year‑old man with chronic heart failure says, “I stopped taking my diuretics because they make me feel dizzy.” Which response would most likely receive the highest grade?
Answer: A. The doctor acknowledges the patient’s concern (relationship‑building), shows understanding, structures the consultation (review benefits, discuss adjustments, check BP) and gives information in understandable terms – satisfying the relationship‑building criterion.
A 30‑year‑old woman presents with a sore throat and fever. She asks for antibiotics, but the doctor believes she has viral pharyngitis.
24. Which response would earn the highest grade?
Answer: B. Option B shows relationship‑building by acknowledging concern, understanding perspective, providing structure (pain reliever and rest) and giving information in a patient‑friendly way. Option A dismisses the fear, C is clinically correct but interpersonally deaf, and D is warm but empty.
A 55‑year‑old man has just been diagnosed with type 2 diabetes. He is anxious about diet changes and medication.
25. Which statement would earn the highest grade?
Answer: B. Option B demonstrates relationship‑building, understanding the patient’s perspective, providing structure (talk about steps and goals), and giving information at the right level. Option A is clinically correct but lacks empathy, C is too technical, and D is vague.
A 48‑year‑old woman stopped her antihypertensive medication because it caused dizziness. She now feels anxious about her blood pressure.
26. Which response would earn the highest grade?
Answer: A. Option A shows relationship‑building, understanding perspective, providing structure (discuss alternatives), and giving information in a patient‑appropriate way. Option B is clinically correct but dismisses fear, C is empty, and D is abrupt.
27. You are a general practitioner. A 55-year-old man attends a follow-up consultation and you need to inform him that his routine blood tests show early chronic kidney disease. He looks anxious and asks if he is going to need dialysis soon. Which response would earn the highest grade?
Answer: C. Option C demonstrates relationship-building by explicitly acknowledging the patient's immediate fear of dialysis before addressing the clinical reality of his early-stage chronic kidney disease. Option A is interpersonally deaf, giving accurate numbers without addressing the fear. Option B is reassuring but prematurely dismissive. Option D uses structure, but addressing the emotional concern directly comes before signposting in this context.
28. You are a hospital doctor. A 40-year-old woman with persistent migraine requests a brain MRI scan, stating she is convinced she has a brain tumour. A neurological examination is completely normal. Which response would earn the highest grade?
Answer: B. Option B successfully balances relationship-building and understanding the patient's perspective by acknowledging the terror of the suspected tumour before exploring her concerns, while appropriately holding the clinical line on resource use. Option A is blunt and dismissive of her fear. Option C ignores the stated fear of a tumour. Option D caves to an unnecessary investigation without exploring the underlying anxiety first.
29. You are a hospital doctor. A 55-year-old man was admitted overnight with acute cholecystitis and is being discharged this morning. He says to you, 'I just want to go home and forget about this — please don't make me take any long-term medication, I feel fine now.' His observations are stable and he is pain-free, but an abdominal ultrasound shows multiple small gallstones and a thickened gallbladder wall. He has no drug allergies. The discharge plan should include lifestyle advice, a review appointment and a discussion about elective cholecystectomy. Four possible openings are listed. Which would earn the highest grade on the OET Medicine Speaking role-play?
Answer: A. The clinical communication criteria being tested here are relationship-building, understanding the patient's perspective and providing structure through signposting. Option A opens by acknowledging the patient's wish ('I can see you're keen to get back home'), then signposts the consultation ('I'd like to check how you are feeling this morning and what your understanding is') and invites his perspective before giving information. Option B is a one-way information dump with no acknowledgement of what the patient has just said and no signposting — it scores poorly on relationship-building. Option C is the classic 'clinically correct but interpersonally deaf' answer: it dismisses the patient's stated preference ('you don't really have a choice') rather than exploring why he feels that way, and uses a fear-based argument before listening. Option D is warm but empty — it agrees with the patient and moves nothing forward, omitting the lifestyle advice, follow-up and surgical discussion that the case notes require. The correct answer earns the higher grade because it leads with empathy and structure before moving into information-giving.

Clinical and lay register 33 questions

The specific bilingual skill OET actually tests: saying the same clinical thing two ways and knowing which room you are in.

1. A patient says to you: 'I feel like my stomach is always full, even after eating very little.' How would you record this in the patient’s notes?
Answer: D. The correct option uses precise clinical terminology ('abdominal distension') and avoids ambiguity ('even after eating small meals' is clearer than 'very little'). Option A is grammatically correct but less specific. Option B incorrectly suggests overeating and uses 'bloating' which is less formal. Option C is vague ('possibly due to overeating') and less professional.
2. You explain to a patient that their recent blood test showed a false-positive result for a certain condition. Which of the following is the most appropriate way to phrase this for the patient?
Answer: B. Option B uses lay-friendly language ('false alarm') and avoids technical jargon while keeping it reassuring. Option A is too casual ('mistake' and 'numbers were off'). Option C is overly clinical ('we’ll need to repeat it') and less reassuring. Option D is correct but slightly less approachable ('it might be a false positive' is more clinical than necessary).
3. A patient says to you: 'My legs feel like they’re giving way sometimes.' How would you record this in the notes?
Answer: B. Option B uses precise clinical terms ('episodes of leg buckling or collapse') and is concise. Option A is too vague ('leg weakness and instability'). Option C introduces an unnecessary assumption ('possibly due to fatigue'). Option D is grammatically correct but less specific ('which may indicate instability' is speculative).
4. You are explaining to a patient that they will need to be nil by mouth before their procedure. Which of the following is the most appropriate lay explanation?
Answer: B. Option B is clear, reassuring, and avoids jargon ('keep things safe' is more approachable than 'fast'). Option A is too blunt ('won’t be able to' sounds restrictive). Option C is overly specific ('24 hours' is not always the case) and clinical. Option D uses 'fast,' which may confuse some patients.
5. A patient tells you, 'I’ve been having terrible headaches that wake me up at night.' How would you record this in the patient’s notes?
Answer: A. The correct option uses concise, professional clinical language ('reports') and avoids unnecessary qualifiers like 'terrible' or 'disturbing' which are more conversational. Option B is overly wordy and uses 'complains of' in a way that sounds less natural in formal notes. Option C uses 'suffering from' which is less common in clinical notes, and 'which' introduces unnecessary complexity. Option D uses 'causing insomnia' which is incorrect—headaches may disrupt sleep but do not necessarily cause insomnia. The correct phrasing is direct and avoids lay language.
6. You are explaining to a patient that they have been diagnosed with a mild case of gastroenteritis. Which of the following is the most appropriate way to phrase this for the patient?
Answer: B. Option B is the most accurate and professional way to explain the condition to a patient without using overly simplistic or lay terms. Option A is too vague and informal, while Option C incorrectly assumes the cause is food poisoning. Option D is dismissive and lacks clinical precision. The correct phrasing balances clarity with professionalism.
7. A patient says to you, 'I’ve been feeling really dizzy when I stand up.' How would you record this in the note?
Answer: A. Option A uses the correct clinical term 'orthostatic' to describe dizziness upon standing, which is the most precise and professional way to record this symptom. Option B is vague and includes an unnecessary qualifier ('which is concerning'). Option C incorrectly uses 'vertigo'—dizziness upon standing is typically orthostatic dizziness, not vertigo. Option D is less specific, as 'lightheadedness' is a broader term and does not specify the trigger (standing).
8. You are explaining to a patient that they will need to take antibiotics for a bacterial infection. Which of the following is the most appropriate way to phrase this?
Answer: A. Option A is the most concise and professional way to explain the treatment plan. Option B is overly wordy and less formal. Option C uses 'put on antibiotics,' which is less common in clinical notes. Option D is overly simplistic and does not use the correct collocation ('commenced ON antibiotics'). The correct phrasing is direct and avoids lay language while maintaining professionalism.
A patient says: 'I’ve noticed my skin is itchy and I keep scratching, especially at night. It’s driving me crazy.'
9. How would you explain this to a doctor in clinical terms?
Answer: A. The correct option uses precise clinical terms: pruritus (itching) and specifies the exacerbation at night. Option B is too vague and lacks specificity. Option C introduces unnecessary admission and a non-specific allergic reaction without evidence. Option D does not match the patient’s description of itching and scratching.
10. You are explaining to a patient who has been diagnosed with a mild case of gastroenteritis: 'We will monitor your hydration status closely and review you if symptoms worsen.' Which option best captures this explanation?
Answer: D. The correct option accurately reflects the clinical instruction to monitor and review the patient’s condition. Option A introduces unnecessary intervention (IV fluids), Option B implies starting treatment (oral rehydration) without evidence, and Option C incorrectly suggests nil-by-mouth, which is not standard for gastroenteritis unless vomiting is severe.
11. A patient says: 'I’ve been feeling very light-headed and sometimes faint when I stand up.' How would you document this in the notes?
Answer: B. The correct option uses precise clinical phrasing: dizziness and presyncope (a near-fainting episode) when standing. Option A incorrectly combines syncope (fainting) and vertigo, which are distinct symptoms. Option C introduces hypotension and nausea without evidence from the patient’s description, and Option D is too dismissive and lacks specificity.
12. A patient says, "My heart feels like a hammer pounding in my chest." How would you record this symptom in the clinical note?
Answer: A. The lay description of a hammer‑like sensation in the chest corresponds to palpitations. 'Palpitations' is the standard term used in notes. The other options describe different symptoms that a candidate might mistakenly choose if they misinterpret the metaphor.
13. Explain to a patient why they will be kept nil by mouth before their endoscopy, using language they can understand without medical jargon.
Answer: A. The correct lay explanation tells the patient that no food or drink is allowed for a short time so the stomach is empty, allowing clear view. Options B, C and D use clinical terms (aspiration, nil by mouth, gastric secretions) that are not appropriate for a lay explanation.
14. A patient says, "I’ve been feeling a bit light‑headed and sometimes I almost faint when I stand up quickly." Which of the following is the most accurate clinical documentation?
Answer: C. The lay description matches presyncope – a feeling of faintness without loss of consciousness, especially on standing. 'Orthostatic dizziness' and 'vertigo' are different phenomena, and 'imbalance' does not capture the faintness.
15. You need to write a referral note for a patient with an ongoing, unexplained chest pain that could be cardiac in origin, but you have not yet ruled out other causes. Which sentence best reflects the appropriate clinical language?
Answer: A. Option A uses correct clinical collocations: 'presents with', 'of uncertain aetiology', 'remains in the differential', and 'further assessment is required'. The other options are either too informal, lack proper structure, or omit key clinical phrasing.
16. A patient tells you, 'I feel like my heart is racing and pounding like a drum.' How would you record this symptom in the clinical note?
Answer: A. In a clinical note the phrase "heart racing and pounding" is a concise, accurate description. Option B uses a metaphor that is not standard clinical language. Options C and D are less specific and omit the word "heart."
17. You are explaining to a patient that they will need to be nil by mouth before their colonoscopy. Which of the following best conveys this in lay terms?
Answer: A. Option A uses simple, clear language and specifies the time frame. The other options are either too vague (B, C) or use medical jargon such as "fast" (D).
18. A patient says, 'My legs feel like they’re going to give way sometimes.' Which clinical phrase best records this?
Answer: A. Option A uses the collocation "intermittent" and "weakness" which are typical in notes. Options B and D are colloquial and less formal; option C lacks the clinical term "weakness."
19. A patient tells you during a morning ward round, 'The room keeps spinning around whenever I turn my head quickly.' How should this symptom be documented in the clinical notes?
Answer: B. The patient describes a specific spinning sensation, which is clinically defined as vertigo rather than generalized dizziness or lightheadedness. Option B uses accurate clinical terminology and standard collocation present with and acute episodes, whereas the other options dilute the specific symptom into vague descriptions like lightheadedness or dizzy spells.
20. You are preparing to explain an incidental finding of a benign renal cyst on an ultrasound scan to an anxious patient. Which phrasing best communicates this clearly without causing undue alarm?
Answer: C. Explaining an incidental finding requires acknowledging the unexpected nature of the discovery while reassuring the patient through watchful waiting without dismissing their concerns entirely. Option C uses clear lay terms fluid-filled sac, frames the finding neutrally, and explains the clinical plan to watch it. Option A uses irrelevant which sounds dismissive, B says ignore which is poor practice, and D uses zero risk which is overly absolute.
21. A patient presents to the emergency department describing an episode where pressure built up centrally in their chest and radiated down their left arm during exertion. How should this clinical presentation be recorded in the medical admission notes?
Answer: A. The clinical notes must document the exact history provided by the patient without prematurely locking in a specific diagnosis before investigations are complete. Option A accurately records the presentation as admitted with central chest tightness using descriptive terminology. Options B, C, and D make definitive diagnostic leaps angina pectoris, myocardial infarction, acute coronary syndrome that are inappropriate for an initial presentation before ECG and cardiac biomarker results are known.
22. You are discussing a management plan with a patient whose diagnostic test results remain inconclusive and whose symptoms persist. How should you explain the strategy of watchful waiting in accessible lay terms?
Answer: B. Translating clinical management strategies requires balancing reassurance with transparency. Option B explains watchful waiting using plain terms monitor your symptoms closely over time without treatment yet, which is easily understood and reassuring. Options A and D sound neglectful or overly aggressive by using terms like deteriorates or withhold, while option C uses passive observation which sounds cold and non-collaborative.
23. A patient tells you, 'I get these sharp, shooting pains down the back of my leg when I bend over to pick things up.' Which clinical phrase best records this symptom?
Answer: C. This is a lay-to-clinical item. The patient describes pain that is sharp, shooting, runs down the back of the leg, and is brought on by bending. The standard clinical documentation pattern is 'Patient reports/complains of [symptom] [character] [location] [timing/precipitant]'. Option C follows that pattern directly. Option A is wrong because 'paraesthesia' means an abnormal sensation such as tingling or numbness, not pain, and 'on forward flexion' is awkward. Option B is wrong because 'radicular pain' is a diagnostic interpretation the clinician should not commit to in the notes at this stage, and 'presents with' is reserved for the presenting complaint as a whole. Option D is wrong because 'sciatica-type symptoms' is non-specific and the word 'sciatica' is again an interpretation, not a description; 'aggravated by' is also less precise than 'precipitated by' for a movement that triggers the symptom.
24. A patient says, 'I’ve been having this terrible burning sensation in my chest that spreads to my arm and jaw.' Which clinical phrase best records this symptom?
Answer: A. The correct answer uses precise clinical terminology: 'retrosternal' (behind the breastbone), 'radiating' (indicating spread), and correctly identifies the left arm and mandible (jaw) as classic areas for angina or myocardial infarction pain. Option B incorrectly uses 'sharp, stabbing' (more typical of pleuritic pain) and the wrong side (right arm). Option C uses 'tightness' and 'shoulder/neck,' which is vague and less specific. Option D uses 'dull ache' and 'mouth,' which is inaccurate for cardiac symptoms.
25. You are writing in the notes about a patient who has been admitted with a suspected pulmonary embolism. Which of the following phrases best describes the patient's current condition?
Answer: C. The correct answer uses the proper collocation 'admitted WITH' for a suspected condition and specifies 'commenced ON low-molecular-weight heparin,' which is a common initial treatment for suspected pulmonary embolism. Option A incorrectly pairs the patient's admission with deep vein thrombosis instead of pulmonary embolism. Option B uses 'commenced ON anticoagulant medication,' which is too vague. Option D incorrectly links the admission to deep vein thrombosis and specifies warfarin, which is typically used later in treatment, not as an initial therapy.
26. You are explaining to a patient that their recent blood test showed an elevated troponin level. Which of the following is the most appropriate lay explanation?
Answer: A. The correct answer uses clear, lay-friendly language to explain elevated troponin levels, which are specific markers for heart muscle damage, commonly associated with myocardial infarction (heart attack). Option B is vague and non-specific, which could cause unnecessary anxiety without clarity. Option C incorrectly suggests the heart is working harder, which is not accurate for troponin results. Option D uses overly technical language ('chemicals linked to heart disease') and is less precise than the correct answer.
27. A patient says, 'I’ve been feeling really dizzy and unsteady, especially when I stand up quickly, and sometimes I feel like I’m going to pass out.' Which clinical phrase best records this symptom?
Answer: A. The correct answer uses precise clinical terminology: 'orthostatic hypotension' (drop in blood pressure on standing) and 'syncope' (fainting), which are accurate for the described symptoms. Option B incorrectly uses 'vertigo' (a spinning sensation, often related to inner ear issues) instead of orthostatic symptoms. Option C is vague and does not specify the underlying cause. Option D is partially correct but less precise than option A, as it does not specify the exact nature of the blood pressure changes or the term for fainting.
28. You are explaining to a patient that their recent MRI scan showed a small, non-cancerous growth on their liver. Which of the following is the best way to phrase this for the patient?
Answer: B. Option B is the most natural and reassuring for a lay audience, using simple language ('small, harmless lump') and avoiding overly technical terms ('adenoma' or 'incidental'). Option A is too dismissive ('nothing to worry about'), Option C is overly specific and potentially alarming ('benign tumour'), and Option D uses clinical jargon ('non-malignant hepatic nodule') that may confuse the patient.
29. A patient says, 'I’ve been having this awful pressure in my chest, and it feels like my heart is racing sometimes.' Which clinical phrase best captures both symptoms in the notes?
Answer: B. Option B uses lay-friendly language ('central chest pressure' and 'a pounding sensation') that aligns with the patient’s description, avoiding unnecessary clinical terms like 'ischemia' or 'tachycardia.' Option A introduces diagnostic speculation ('suggestive of cardiac ischemia'), Option C is overly technical ('substernal discomfort' and 'tachycardia'), and Option D incorrectly uses 'precordial pain' (which implies a specific location) and 'possibly indicative of arrhythmia' (which is speculative).
30. A patient says, 'I’ve had this persistent cough for weeks, and it’s been worse at night. I’ve also been wheezing and feeling short of breath.' How would you document this in the notes?
Answer: A. The correct option translates the clinical description of symptoms (cough, wheezing, shortness of breath) into a professional note using the phrase 'presents with'. Option B incorrectly shifts focus to tiredness and productivity, which are not mentioned. Option C introduces unnecessary medical intervention (admission, antibiotics) and is not supported by the patient’s description. Option D contradicts the patient’s reported symptoms.
31. You are explaining to a patient who has been diagnosed with type 2 diabetes that they will need to monitor their blood sugar levels closely. Which statement best captures this explanation?
Answer: A. The correct option uses the phrase 'monitor and review' to indicate ongoing clinical assessment, which is appropriate for diabetes management. Option B introduces an immediate intervention (insulin) that isn’t mentioned in the question. Option C is irrelevant to the explanation of monitoring and does not reflect the patient’s current status. Option D dismisses the seriousness of diabetes symptoms.
32. A patient reports, 'I’ve been experiencing sudden, severe headaches that come on very quickly, and they’re accompanied by nausea and vomiting.' How would you document this in the notes?
Answer: B. The correct option uses 'presents with' to document the patient’s symptoms accurately, including the sudden onset and associated nausea/vomiting. Option A incorrectly assumes a diagnosis of migraine without further context. Option C contradicts the patient’s reported symptoms and is irrelevant. Option D suggests discharge without proper clinical assessment, which is inappropriate for sudden severe symptoms.
33. You are writing in the notes about a patient who has been admitted with a suspected deep vein thrombosis (DVT). The patient says, 'I’ve noticed swelling in my leg and it’s been getting worse over the past few days.' Which option best captures the clinical-to-lay translation of this symptom?
Answer: A. The correct option translates the clinical symptom of swelling and worsening leg pain into lay terms using 'complains of'. Option B introduces irrelevant information (trauma, allergy) and is not supported by the patient’s description. Option C suggests immediate intervention without confirmation of the diagnosis. Option D implies discharge without addressing the suspected DVT, which is premature.

Grammar that costs a Grade B 23 questions

The written-accuracy errors that pull a doctor from 350 to 300 in Writing, each in a sentence a real doctor would write in a letter or say in a consultation.

1. In the discharge letter you write: "The patient was referred ___ cardiology and ___ cardiac surgery for further assessment."
Answer: A. The verb 'referred' takes the preposition 'to' for both specialties. 'Referred to cardiology and to cardiac surgery' is correct. Options B, C and D misuse 'for' which is a common error.
2. You note in the referral: "He has had two admissions last year for pneumonia, he was treated with antibiotics."
Answer: B. The history requires past simple ('had') for completed events, and the two independent clauses need a semicolon or a period, not a comma splice. Option B uses a semicolon and correct past tense.
3. Select the option that correctly completes the sentence for a discharge summary: Mr Davis was commenced ___ aspirin 75 milligrams daily following his transient ischemic attack.
Answer: B. The correct preposition following the clinical verb commence when describing starting a patient on a medication is on. Option A is a common error stemming from the phrase presented with, while options C and D are grammatically incorrect collocations in this context.
4. Select the option that correctly completes the referral letter: Mrs Higgins presented ___ acute breathlessness and a productive cough lasting four days.
Answer: C. Standard clinical English requires the preposition with following the verb present when detailing a patient's presenting complaints or symptoms. Options A, B, and D are incorrect prepositions that disrupt the established medical collocation.
5. Select the option that correctly completes the outpatient clinic letter: The patient reported that she ___ experienced similar chest discomfort twice in the preceding month.
Answer: B. In reported speech referencing a past time frame prior to the consultation, the past simple or past perfect is required to sequence the events accurately. Option B maintains the correct tense shift from the direct statement, whereas options A, C, and D create grammatical or tense incongruity.
6. Select the option that correctly completes the transfer note: A series of diagnostic investigations ___ performed to determine the underlying cause of the persistent anemia.
Answer: B. Subject-verb agreement requires a plural verb because the head noun investigations is plural, despite the intervening prepositional phrase. Option A uses a singular verb incorrectly matched to a plural subject, while options C and D alter the required past passive tense of the clinical narrative.
7. In the referral to the vascular surgeon you write: "She was admitted ___ the medical unit ___ a four-day history of intermittent claudication." Choose the option that correctly completes the sentence.
Answer: A. Two clinical prepositions have to be right at once. The verb admit takes the preposition TO when the destination is a ward, team or hospital — 'admitted to the medical unit', 'admitted to ICU'. It is not admitted UNDER or admitted IN as a default. The second slot is the reason for admission, and the verb presents or admits a reason WITH — 'admitted with chest pain', 'presented with breathlessness'. 'For a four-day history' is grammatical but means the history itself was the reason for taking her in, which is awkward in English. The clinical signal is the pairing admit TO plus reason WITH, which is why B and D are wrong even though 'admitted under Dr X' is sometimes heard, and D pairs a wrong first preposition with an almost-right second one. Answer: A.
8. In the letter to the GP you write: "The dose ___ increased on day three because the blood pressure remained above target despite treatment." Choose the option that correctly completes the sentence.
Answer: C. This sentence is past-time narrative, anchored by 'on day three' and 'remained', so it needs past simple, not present perfect or past perfect. 'The dose is increased' would only work in a standing instruction or protocol; 'has been increased' would suggest the action still matters now and is not anchored to day three; 'had been increased' would require an earlier past reference point, which the sentence does not have. The clinical writing habit is to use the simple passive — 'the dose was increased', 'the wound was reviewed', 'the patient was referred' — to keep the focus on the clinical action rather than the doctor as the agent. The signal is the dated past event 'on day three'. Answer: C.
9. In the discharge summary you write: "If the wound ___ signs of infection at review, the sutures will be removed and oral antibiotics commenced." Choose the option that correctly completes the sentence.
Answer: A. This is a first conditional — a real, clinically plausible future possibility, not a remote or counterfactual one. The structure is IF + present simple, WILL + bare infinitive. 'If the wound will show' mixes the tenses and is the commonest spoken mistake in clinical handovers; 'showed' turns it into a past conditional that no longer fits a future clinic review; 'would show' would make it a second conditional about something unlikely, which is the wrong register for a discharge plan that genuinely expects to act on the finding. The signal is the 'will be removed' in the main clause, which locks the IF-clause into present simple. Answer: A.
10. Select the correct sentence to complete the discharge summary:
Answer: A. The correct choice is A because it is concise and correctly uses the passive voice ('was commenced') for clinical writing. The other options add unnecessary detail or repetition. Option B adds a time frame ('within a week') that is not justified by the context. Option C introduces an unnecessary clause ('which was confirmed by her follow-up visit'), and Option D repeats information ('as she reported during her discharge consultation') that is not needed for clarity.
11. Select the correct sentence to complete the outpatient clinic letter:
Answer: A. The correct choice is A because it uses the past perfect tense ('had been experiencing') to indicate that the chest pain started before the consultation and continued up to the point of reporting. Option B adds unnecessary detail ('which she thought might be related to stress'), which is not required for clarity. Option C incorrectly uses the present simple ('experiences') instead of past perfect, and Option D incorrectly uses present simple and adds speculative reasoning ('which she believed was due to anxiety').
12. Select the correct sentence to complete the transfer note:
Answer: B. The correct choice is B because it uses the past simple tense ('were conducted') to describe completed actions in the past. The subject ('a series of diagnostic investigations') is plural, so the verb must also be plural ('were'). Option A incorrectly uses the present perfect ('have been conducted') for completed past actions. Option C incorrectly uses singular ('it') to refer to a plural subject. Option D adds unnecessary detail ('which required immediate surgical intervention') and incorrectly uses present perfect ('have been conducted').
13. In the referral letter to the dermatologist, you write: 'The patient has a history of ___ eczema since childhood, which has been managed with topical steroids. However, the current flare-up is unresponsive to standard treatment and requires specialist assessment.'
Answer: A. The correct phrase is 'long-standing' as it is a fixed adjective meaning 'existing for a long time,' commonly used in clinical contexts to describe chronic conditions. 'Long stand' (B) is incorrect as it is not a standard phrase. 'Long time' (C) is grammatically incorrect here. 'Long term' (D) is incorrect because it implies a planned duration rather than a description of the condition's duration.
14. You note in the patient’s case notes: 'If the patient’s temperature ___ above 38 degrees Celsius for more than 24 hours, she should be readmitted for further evaluation.'
Answer: B. The correct choice is 'rises' because the sentence describes a hypothetical condition using a present tense in a first conditional structure. 'Will rise' (A) is incorrect because it is future tense and does not fit the conditional structure. 'Has risen' (C) is present perfect, which is incorrect here. 'Had risen' (D) is past perfect, which is also incorrect as it does not fit the conditional structure.
15. Select the option that correctly reports the patient’s statement in a discharge summary: "She said she ___ feeling dizzy when standing up this morning."
Answer: C. When reporting a past event the verb should be in simple past. The patient’s dizziness occurred this morning, so 'felt' is correct. Option C uses simple past without extra auxiliary verbs.
16. Select the sentence that uses the correct conditional for a plan contingent on a test result in a transfer note:
Answer: A. A real‑time plan uses a first‑type conditional: present simple in the if‑clause and will + base verb in the main clause. Option A follows this pattern; the others misuse past tense or would.
17. In a referral letter to a cardiologist you write: "The patient was admitted ___ a 48‑hour observation period ___ a suspected arrhythmia."
Answer: C. The correct prepositions are "for" a period of time and "with" a condition. "Admitted for a 48‑hour observation period with a suspected arrhythmia."
18. In a discharge summary you write: "If the patient’s blood pressure ___ above 140/90 mmHg at the next visit, the antihypertensive dose will be increased."
Answer: C. The conditional requires present simple for a future condition: "If the blood pressure is above 140/90 mmHg..."
19. A patient says, "I have been taking the medication for three months, but I still feel nauseous." In the notes you record: "The patient ___ that she has been taking the medication for three months, but she still feels nauseous."
Answer: A. Reported speech of a past statement uses the past simple: "The patient reported that she has been taking the medication for three months..."
20. Select the correct sentence for the outpatient clinic letter regarding the patient's medication history.
Answer: C. The correct preposition following the passive verb commenced in clinical contexts is on, indicating the start of a drug regimen. Prepositions such as in, by, and of are incorrect collocations for this verb.
21. Select the correct sentence for the discharge summary regarding the patient's past medical history.
Answer: C. The past simple tense is required for a completed action with a specified past time (in 2021). The second clause describes a state continuing from that past point up to the present, which requires the present perfect continuous or simple (has been stable), making option C correct.
22. Select the correct sentence for the referral letter describing the clinical presentation.
Answer: A. The verb present in the context of clinical presentation takes an active form when describing what the patient exhibited upon arrival (presented with), rather than a passive or incorrect tense. Option A correctly uses the simple past active voice.
23. Select the correct sentence for the multidisciplinary team handover note detailing the monitoring plan.
Answer: D. In inverted conditional structures denoting a future possibility in clinical directives, Should replaces If (Should the potassium level drop...). The other conjunctions either create false semantic conditions or require incorrect verb forms.