Emedica Stage2 Study Guide

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GP ST Entry Stage 2 Assessment
Study Guide 2013
7th Edition
Mahibur Rahman MB BCh MSc MRCGP

Published by
Emedica Publications
Birmingham
www.emedica.co.uk
0845 388 3402
Published 2010 in Great Britain
Mahibur Rahman, Emedica Ltd, 2012
The right of Mahibur Rahman to be identified as author of this work has been
asserted by him in accordance with the copyright, designs and patents act
1988.
All rights reserved.
Emedica 2012 www.emedica.co.uk 3

Foreword to the Seventh Edition
General Practice is the most popular of all the specialties, with more than a
quarter of all candidates ranking it as their top choice, and more than half
likely to apply for it as one of their choices.
Shortlisting for entry into GP Specialty Training (GP ST) is decided solely by
the scores candidates achieve in the Stage 2 assessments.
This National assessment will provide an objective means of ranking

candidates. The two papers are designed to give a broad picture of the
candidates knowledge and judgement, and their suitability for GP training.
In 2012, around 6000 doctors sat the Stage 2 exam, and it is anticipated that
the competition will be similar or even higher in 2013.
It is essential that you are familiar with the structure and content of both
papers (clinical problem solving and professional dilemma) that will determine
your overall ranking.
I hope that you will find this guide useful in your preparation for the
assessment, and I wish you every success in your chosen career.
Dr Mahibur Rahman MB BCh MSc MRCGP

Medical Director
Emedica
www.emedica.co.uk

Table of Contents
Introduction ......................................................................................................6
Stage 2 Assessment Basics 2013 application round ....................................7
Clinical Problem Solving paper ........................................................................8
Extended Matching questions...................................................................9
Single Best Answer questions ................................................................12
Preparing for the Clinical Problem Solving paper ...................................14
Professional Dilemma Paper / Situational Judgement Tests .........................15
Core criteria assessed by the SJT from National Person Specification ..16
Professional Dilemma paper Section 1...................................................16
Professional Dilemma paper Section 2...................................................19
Preparing for the Professional Dilemma Paper.......................................19
Extended Matching Questions examples.......................................................22
Single Best Answer Question Examples........................................................24
Extended Matching Questions Answers and Explanations.....................27
Single Best Answer questions Answers and explanations...................31
Professional Dilemma Paper Situational Judgement Test questions..........34
Summary .......................................................................................................38
GP ST Entry Preparation courses..39

Introduction
Shortlisting for GP ST entry is done SOLELY on the basis of your ranking

after the Stage 2 assessments. Your work experience, publications, audits
and references will NOT contribute at all to your score. There is no way to
have a good application (as they are not scored). You either meet the
eligibility criteria and are accepted to sit the exam, or you do not meet the
criteria and will be rejected. This differs to many other specialties where the
application or your CV may play a large part in shortlisting.
As long as you meet the basic eligibility criteria (including evidence of F2

competencies) and submit a completed application by noon on December 7th
2012, you should be invited to attend for the Stage 2 assessment between the
5th and 12th January 2013.
This date is not negotiable, and if you are unable to attend, then you
CANNOT be shortlisted for GP ST. The only exception to this is for doctors
unable to sit an examination on a Saturday for religious reasons alternative
arrangements will be made by the National GP Recruitment Office.
The exam will be done entirely on computer, and will consist of two sections
or papers lasting a total of 3 hours 5 minutes, and you will be ranked
according to your score. The highest ranked doctors in each deanery will be
shortlisted in 2012, 1.5 doctors were shortlisted for every job available in
each deanery.
This study guide will cover the two different papers the background, what
they are testing, what to read, sample questions for each section of each
paper, and advice on further reading and ways to prepare.
Section 1 covers the make up of the papers, with tips on how to prepare.
Section 2 has example questions for the Clinical Problem Solving paper.
Section 3 has example questions for the Professional Dilemma paper.

Stage 2 Assessment Basics 2013 application Round 1
Date: Saturday 5th January 2013 Saturday 12th January 2013
Venue: The assessment will be offered at various Pearson Vue testing

locations throughout the UK. You will be able to book a place at
the centre closest to your home address (not necessarily near
your first choice Deanery).
Papers: Professional Dilemma Paper 110 minutes
Clinical Problem Solving Paper 75 minutes
Time: 3 hours 5 minutes total
Booking: Online booking for the Stage 2 assessments will be offered to
doctors that submit complete applications and meet the basic
eligibility criteria. You will be able to book a place from the 10th
December 2012 onwards (in some cases earlier).
If there are any jobs outstanding after round 1, then there may be a second
round commencing in late April or early May 2013.
The two papers in the Stage 2 assessment are a Clinical Problem Solving
paper, and a Professional Dilemma paper.
Both papers are equally weighted, and you need to reach a minimum
standard in BOTH papers to be considered for shortlisting.
There are around 100 - 110 questions in the Clinical Problem Solving Paper.
There are around 55 - 60 questions in the Professional Dilemma Paper.

Clinical Problem Solving paper
This is a 75 minute paper assessing your clinical knowledge and ability to

apply it in the diagnosis and management of patients. This paper is set at the
level of knowledge expected for a Pre-registration House Officer or
Foundation 1 doctor at the END of their first year. The paper is very broad,
covering almost all the medical and surgical specialties. It does NOT require
any specific knowledge of General Practice. The full subject list includes:
Medical Surgical
General Medicine General Surgery
Cardiovascular Orthopaedics and Trauma
Respiratory Obstetrics / Gynaecology
Renal medicine Urology
Endocrinology / Metabolic Ophthalmology
Gastroenterology / Nutrition ENT
Infectious disease
Haematology
Pharmacology / Therapeutics
Rheumatology
Dermatology
Neurology
Psychiatry
Paediatrics
Genetics
Immunology / Allergies

Each question provides a clinical scenario and then asks a question relating
to:
Disease factors e.g. risk factors, exacerbating factors, prognosis

Making a diagnosis diagnostic criteria, signs and symptoms, red
flag symptoms etc.
Investigations choice of test, need for testing, most appropriate
modality, urgent vs routine investigation, sensitivity and specificity,
interpreting blood results / ECGs etc.
Management plans immediate and long term management,
supportive or drug treatment, conservative / surgical management,
risks and side effects etc.
Prescribing choice of drug, side effects, contraindications, dosages,
controlled drugs, analgesia etc.
Emergency care ABC, immediate management of common
emergencies Myocardial infarction, rupture / dissection of AAA, acute
severe asthma, pancreatitis, diabetic ketoacidosis etc.
There are two main types of questions Extended Matching questions, and
Single Best answers.
Extended Matching questions
Most of you will be familiar with this type of question as it is common in

medical finals and membership exams for most specialties. You are
presented with a range of possible options, and then given 3 scenarios. For
each scenario, you have to select the most suitable option from the list. The
list may consist of different investigations, diagnoses, drugs, actions or
statements. Each option can be used once, more than once, or not at all.
This sometimes catches people out if they have used an option to answer a
question, they tend to assume that the same answer could not be used again.

Extended Matching Question example:
Investigations for back pain
A X-ray of the lumbar spine F Urgent MRI scan lumbar spine

B X-Ray of sacro-iliac joints G DEXA scan
C Routine CT scan lumbar spine H No investigations needed
D Urgent CT scan lumbar spine
E Routine MRI scan lumbar spine
For each of the following patients, select the MOST suitable

investigation from the list above.
You can use each answer once, more than once or not at all.
1. A 25 year-old man involved in a road traffic accident. He was on a bike and

hit from the side. He did not want to attend the hospital, and was taken home
by his friends. He now complains of severe pain in his lower back and cannot
pass water. He has tingling in his legs below the knee.
A B C D E F G H
2. A 68 year-old woman with known osteoporosis. She has had a fractured

neck of femur in the past after a fall in her garden. She now complains of pain
in her lower back, but does not have much muscular tenderness. She has no
bowel or bladder symptoms. She has no neurological symptoms.
A B C D E F G H
3. A 40 year-old labourer who attends complaining of severe low back pain

after finishing his shift. He does not have any bowel or bladder problems, and
on examination has a straight leg raise of 90 degrees in both legs. He has no
other significant medical history.
A B C D E F G H

Answers:
A X-ray of the lumbar spine F Urgent MRI scan lumbar spine

B X-Ray of sacro-iliac joints G DEXA scan
C Routine CT scan lumbar spine H No investigations needed
D Urgent CT scan lumbar spine
E Routine MRI scan lumbar spine
1. A 25 year-old man involved in a road traffic accident. He was on a bike and

hit from the side. He did not want to attend the hospital, and was taken home
by his friends. He now complains of severe pain in his lower back and cannot
pass water. He has tingling in his legs below the knee.
A B C D E F G H
The correct answer is F: Urgent MRI Scan. In cases where there is any
suspicion of cord compression, urgent MRI is the investigation of
choice, and these patients should be referred to the neurosurgeons or
orthopaedic surgeons. A Computed tomography (CT) scan is not
commonly used except where MRI is not available.
2. A 68 year-old woman with known osteoporosis. She has had a fractured

neck of femur in the past after a fall in her garden. She now complains of pain
in her lower back, but does not have much muscular tenderness. She has no
bowel or bladder symptoms. She has no neurological symptoms.
A B C D E F G H
The correct answer is A: X Ray lumbar spine. In a case of known

osteoporosis like this woman, a plain x-ray of the lumbar spine may
identify collapse fractures. Doing a DEXA scan is of no benefit as we
already have a diagnosis of osteoporosis.

3. A 40 year-old labourer who attends complaining of severe low back pain
after finishing his shift. He does not have any bowel or bladder problems, and
on examination has a straight leg raise of 90 degrees in both legs. He has no
other significant medical history.
A B C D E F G H
The correct answer is H: no investigations needed. This is a description

of mechanical back pain. Simple mechanical low back pain can typically
be managed with non-steroidal anti-inflammatory drugs (NSAIDs) and
analgesics, without need for referral or further investigation.
There are more examples of EMQs for you to practice in Section 2.
Single Best Answer questions
This type of question offers a scenario and five possible answers. You have
to select the SINGLE most appropriate response. This type of question made
up the remainder of the questions in the 2012 exam.
Single Best Answer example:
A 35 year old man has a severe allergic reaction while in hospital. He has no
history of past allergic reactions. Which ONE of the following commonly
causes a reaction WITHOUT prior exposure or sensitization?
Select ONE answer only.
a. Peanuts
b. Hymenoptera stings
c. IV Penicillin
d. IV Contrast media
e. Latex

The correct answer is D: IV Contrast Media. IV contrast media causes a
reaction in 1-2% of cases, although it only causes death in about 0.9 per
100,000 cases. It can cause an anaphylactoid reaction, and does not require
previous exposure to sensitise the individual.
There are more examples of SBAs for you to practice in Section 2.
Other question types
Other question types which have been used in the past, and may be used
again include algorithm questions, questions where you have to fill in the
blanks from a paragraph with the most suitable word, data interpretation
questions, and multiple best answer questions. It is likely that these questions
will only make up a small part of the paper (usually less than 10%).

Preparing for the Clinical Problem Solving paper
This section covers a broad rage of subjects across both medical and surgical
specialties. As the level is set at PRHO / F1 level, it is better to cover a broad
range of subjects briefly than to bog yourself down with any one specialty at
Membership level.
Useful books include:
Oxford Handbook of Clinical Medicine you should all be familiar with this,
so reading it quickly will be good revision.
Oxford Handbook of Clinical Specialties this handbook is well written,

and covers most of the specialties in the CPS paper in enough depth at this
level.
BNF reading the introductory chapter on pain management, prescribing in

palliative care, and then revising the introduction to each chapter (covering all
the disease areas) is a useful way to prepare for the therapeutics questions in
the exam.
Another way to revise is to practise questions. Use the True / False questions
and explanations in the online revision service to quickly revise the different
subject areas and assess which areas you need to work on most. After doing
your reading, you can then use the Extended Matching questions and Single
Best Answer questions to practise questions at the same level and in the
same format as the real exam.
We recommend you do not attempt the Mock Exams until you are near the
end of your revision. The mock exam will allow you to gauge your readiness
for the exam by providing a timed exam in the same format as the real exam.

Professional Dilemma Paper / Situational Judgement Tests
The second paper in the Stage 2 assessment is the Professional Dilemma

paper. This paper uses Situational Judgement questions, and is also known
as the Situational Judgement Test. You will have 110 minutes to complete
this part of the computerised test.
Background to situational judgement tests (SJTs)
SJTs have been used for decades by employers, usually as part of multiple
recruitment assessments. They date back to the 1940s, and have evolved to
become a popular tool in various industries. They are used by the Canadian
Civil Service, the Federal Bureau of Investigations (FBI), the Department of
Works and Pensions, the NHS Graduate Management Training Scheme
amongst others.
They are used to assess soft skills, and non-academic, practical intelligence.
They have been adopted by many organisations because they are seen to be
better predictors of actual job performance and offer a way to test candidates
more broadly than knowledge based exams. They are machine markable so
are much easier to administer and mark, and more cost effective than essay
based assessments. This is one of the key reasons they have been adopted
for GP ST entry selection the short timescales between the assessment
date and shortlisting make it impractical to mark thousands of essays.
The SJT / Professional Dilemma paper will test you against some of the
criteria in the National Person Specification for GP ST entry:

Core criteria assessed by the SJT from National Person Specification
Empathy & Sensitivity Capacity & motivation to take in others

perspectives & to treat others with understanding
Communication Skills Capacity to adjust behaviour & language as
appropriate to needs of differing situations
Conceptual Thinking Capacity to think beyond the obvious, with an
& Problem Solving analytical and flexible mind
Coping with Pressure Capacity to recognise own limitations and develop
appropriate coping mechanisms
Organisation & Capacity to organise information/time effectively in
Planning a planned manner
Managing Others & Capacity to work effectively in partnership with
Team Involvement others
Professional Integrity Capacity & motivation to take responsibility for own
actions and demonstrate respect for all
Learning & Personal Capacity & motivation to learn from experience and
Development: constantly update skills/knowledge
It also tests your capacity to apply the guidelines in the GMCs Good Medical
Practice.
There are two sections to this paper. Both present you with a scenario that a
junior doctor might face. The scenario could be related to an ethical dilemma,
a difficult patient, teamwork, or involve prioritising demands on your time.
Professional Dilemma paper Section 1
This section offers a scenario with 4 or 5 possible actions or options. You

have to rank the options from 1 to 4 (or 1 to 5). The option ranked 1 is the
most effective or best option, and 5 the least effective, or worst option. You
cannot have tied ranks (i.e. joint second or joint last).

Sample question
You have just started a job as a medical F2 in a new hospital. Your wife has a
chest infection, and is not yet registered with a GP and has asked you to
prescribe antibiotics.
Rank the following options 1-5, 1 being the most effective / best option, 5
being the least effective / worst option:
A. Prescribe the medication as a private prescription, and arrange for her

to register with a GP the following week.
B. Tell her to register with a GP locally.
C. Prescribe the medication on a hospital take home prescription with her
details on it.
D. Prescribe the medication on a hospital take home prescription with one
of your patients details on it. Collect the medication from the hospital
pharmacy.
E. Ask one of your work colleagues to write a prescription on a hospital
take home script without seeing your wife.

Answers:
1. B. Tell her to register with a GP locally.
Your wife could be seen as a temporary resident and register with a local GP.
The GMC Good Medical Practice guidance states that Wherever possible,
you should avoid providing medical care to anyone with whom you have a
close personal relationship.
2. A. Prescribe the medication as a private prescription, and arrange for

her to register with a GP the following week.
The GMC guidance does allow for you to prescribe for those close to you if
absolutely necessary, or in an emergency, but your wife still needs to register
with a GP for her future care. This is not an emergency, but this is option is
better than C, D, or E.
3. C. Prescribe the medication on a hospital take home prescription with

her details on it.
Take home prescriptions are for patients being seen in the hospital only. You
should not abuse your position of responsibility.
4. E. Ask one of your work colleagues to write a prescription on a

hospital take home script without seeing your wife.
This is unfair to your colleague he has not seen the patient, yet he would be
responsible for any adverse events.
5. D. Prescribe the medication on a hospital take home prescription with

one of your patient's details on it. Collect the medication from the
hospital pharmacy.
This is fraudulent, and dishonest. This could lead to you losing your job, and
potentially your GMC registration.

Professional Dilemma paper Section 2
This section offers scenarios similar to Section 1, but with more possible
options. There may be 7 or 8 options for each scenario, and you must choose
the 2 or 3 options which combined make the most appropriate response. This
is very different to Section 1 as you are not being asked to assign ranks to all
the options, nor are you being asked to just select 2 or 3 options that seem
sensible. The options you choose have to be looked at together to make up
the most appropriate overall response.
Sample question Section 2:
You are an F2 in Orthopaedics. An 80 year old lady has an intracapsular

fracture of her right neck of femur. You have been asked to consent her prior
to surgery but on talking to her she seems confused. Her daughter tells you
she has dementia and this is confirmed in the notes. She is first on the
morning list. Do you:
A. Ask her daughter to sign the consent form and state that she is the
daughter.
B. Inform your consultant she has dementia and ask him to complete
the consent form.
C. Encourage the patient to sign the form as the procedure is in her
best interests.
D. Exclude any acute causes that could be worsening her confusion.
E. Discharge the patient as she will be unable to have surgery without
consent.
F. Cancel the patients operation.
G. Ring the theatre to rearrange the list so this lady is lower down on
the list.
Underline the three options that make the most appropriate combined
response. (Answers are on the next page)

Answers:
The most appropriate combined response is:
D. Exclude any acute causes for her confusion.

G. Ring the theatre to rearrange the list so this lady is lower down on
the list.
B. Inform your consultant she has dementia and ask him to complete the
consent form.
If the patient is confused and cannot understand the risks and

benefits of the procedure, then she does not have capacity to
consent for the procedure. No other adult can consent on her
behalf. Treatment is lawful if it is in her best interests and this
decision should be made by someone senior (ideally the
consultant) who should also sign the consent form. Often two
senior doctors will discuss this. This lady may have an infection,
or pain making her confusion worse. There is no mention of the
severity of her dementia in the scenario someone with mild
dementia may be able to consent if you deal with any other
problems. Rescheduling this patient will allow time for the
consultant to discuss the case and sign the consent form without
rushing. It will also ensure that another patient can be properly
prepared for surgery.

Preparing for the Professional Dilemma Paper
The best way to prepare for this paper is to make sure you are familiar with all
of the competencies in the National Person Specification for GP ST entry.
This will help you understand the attributes being tested. Another useful
publication to read is the General Medical Councils Good Medical Practice.
This provides the material and concepts that are assessed in many of the
questions (there is some overlap with the National Person Specification).
Use the SJT section of the online revision service to practise answering
Professional Dilemma questions.
One of the key things to remember in the exam is to keep an eye on the clock
many doctors were unable to finish this paper in the allotted time last year.
You have to answer around 60 questions in 110 minutes this is less than 2
minutes a question to read the scenario, assess the options, decide on an
answer and check the relevant boxes on screen!

Extended Matching Questions examples
Endocrine emergencies:
A Diabetic ketoacidosis (DKA) F Hypophosphataemia
B Hypoglycaemic coma G Thyrotoxic crisis
C Addisonian crisis H Phaeochromocytoma
D Acute hypocalcaemia
E Acute hypercalcaemia
For each of the following scenarios, select the SINGLE most likely
diagnosis. You can use each option ONCE, more than once, or NOT at
all.
1. A 14 year-old boy presents with nausea, vomiting and night sweats. He

feels faint on standing. On examination he has right basal crackles, and
deeply tanned skin. His blood pressure is 90/55 mm Hg.
A B C D E F G H
2. A 10 year-old boy presents with a two-day history of vomiting, abdominal

pain, headache, thirst and polyuria. On examination he is hyperventilating,
drowsy and has a capillary refill time of three seconds.
A B C D E F G H
3. A 35 year-old woman presents with headache that has persisted for three
days. She has recently had an endoscopy to investigate her dyspepsia. She
has been vomiting, become very sweaty and is having palpitations. She
describes feelings of intense fear and anxiety. On examination she has a
pulse of 120 beats per minute, BP is 180/108 mm Hg, she has a tremor and a
temperature of 38.4C. You also notice several brown cutaneous macules over
her body.
A B C D E F G H

Drug side effects:
A Ramipril F Isotretinoin
B Prednisolone G Dermovate
C Methotrexate H Oxytetracycline
D Celecoxib
E Simvastatin
For each of the following patients, select the drug most likely to be causing
the side effects mentioned.
You may use each option ONCE, MORE than ONCE, or not at all.
4. A 19 year-old girl with severe acne presents to accident and emergency

after taking an overdose of alcohol. She says she does not want to live and
has been feeling this way for the last two weeks.
A B C D E F G H
5. A 55 year-old man with known heart disease presents with severe muscle
pains. He reports feeling "weak". Creatine kinase (CK) is 1,000 U/L.
A B C D E F G H
6. A 40 year-old patient with systemic lupus erythematosus (SLE) presents

with severe upper abdominal pain radiating to the back. Her medication was
recently increased after a flare up of her Lupus (SLE).
A B C D E F G H

Single Best Answer Question Examples
1. A 54 year old woman is admitted with extensive bruising and bleeding

gums. She is on Warfarin and various other drugs. Her INR is raised. Which
ONE of the following is most likely to have contributed to her raised INR?
Select ONE answer only
A. Carbamazepine
B. Orange juice
C. Azathioprine
D. Cranberry juice
E. Nystatin
2. A 44 year-old woman presents with sudden onset of shortness of breath

and palpitations. On examination she has a tanned appearance to her skin,
white nails and extensive bruising. She also has an irregularly irregular pulse
and swollen ankles. Her blood glucose is 13.8.
Which ONE of the following is the most likely diagnosis?
a. Primary sclerosing cholangitis

b. Haemochromatosis
c. Hepatocellular carcinoma
d. Viral hepatitis
e. Primary biliary cirrhosis

3. A 26 year old man attends A and E on the weekend. He has just returned
from a safari holiday in Africa. He complains of diarrhea, vomiting, and
abdominal pains for the last 2 days. It started shortly after his last meal on
holiday. Which ONE of the following is the most likely cause of his
symptoms?
a. Campylobacter
b. Escherichia coli
c. Clostridium difficile
d. Salmonella
e. Shigella species
4. You see a patient in clinic in General Medicine. A 55 year-old man with

ischaemic heart disease attends for review. His chest pains are well
controlled but he is complaining of severe constipation. He says this has been
going on for several months, but he was too embarrassed to seek treatment
before. He is taking Verapamil, which commonly causes constipation. Which
ONE of the following is a stimulant laxative suitable for this patient?
a. Isphagula husk
b. Senna
c. Lactulose
d. Movicol
e. Co-danthramer

5. A 31 year-old manager complains of upper abdominal pain. It is worse after
food or when lying down. He has no haematemesis or malaena, and has not
had any treatment in the past. Examination is unremarkable. Which ONE of
the following is the most suitable initial management option?
a. Routine endoscopy
b. 13C urea breath testing
c. Admission to hospital.
d. Triple therapy (amoxicillin + clarithromycin + lansoprazole) for one week
e. Urgent endoscopy
6. A 60 year old man complains of a gradual loss of his central vision. Which
ONE of the following is the leading cause of visual loss in patients over 65 in
the Western world?
a. Glaucoma
b. Diabetic eye disease
c. Cataract
d. Age related macular degeneration (AMD)
e. Retinal detachment

Extended Matching Questions Answers and Explanations
Endocrine emergencies:
A Diabetic ketoacidosis (DKA) F Hypophosphataemia

B Hypoglycaemic coma G Thyrotoxic crisis
C Addisonian crisis H Phaeochromocytoma
D Acute hypocalcaemia
E Acute hypercalcaemia
For each of the following scenarios, select the SINGLE most likely
diagnosis. You can use each option ONCE, more than once, or NOT at
all.
1. A 14 year-old boy presents with nausea, vomiting and night sweats. He

feels faint on standing. On examination he has right basal crackles, and
deeply tanned skin. His blood pressure is 90/55 mm Hg.
A B C D E F G H
The correct answer is C. Addison's disease results from destruction of

the adrenal cortex. Patients may present with symptoms of nausea,
vomiting and feeling faint on standing. Acute crises are often triggered
by an infection or other stress on the body. Clinical findings include
hypotension and deep pigmentation of the skin.
2. A 10 year-old boy presents with a two-day history of vomiting, abdominal

pain, headache, thirst and polyuria. On examination he is hyperventilating,
drowsy and has a capillary refill time of three seconds.
A B C D E F G H

The correct answer is A. This is a classic presentation of DKA. DKA is a
common and potentially fatal condition that ALWAYS needs urgent
assessment and management.
3. A 35 year-old woman presents with headache that has persisted for three
days. She has recently had an endoscopy to investigate her dyspepsia. She
has been vomiting, become very sweaty and is having palpitations. She
describes feelings of intense fear and anxiety. On examination she has a
pulse of 120 beats per minute, BP is 180/108 mm Hg, she has a tremor and a
temperature of 38.4C. You also notice several brown cutaneous macules over
her body.
A B C D E F G H
The correct answer is H. Phaeochromocytomas are functional tumours

that arise from chromaffin cells in the adrenal medulla. They are a rare
cause of hypertension, but should be considered in any hypertensive
patient, within any hypertensive with orthostatic hypotension and
tachycardia, or with 'cafe au lait' spots. They often present with
hypertensive crisis, with symptoms as mentioned.

Drug side effects:
A Ramipril F Isotretinoin
B Prednisolone G Dermovate
C Methotrexate H Oxytetracycline
D Celecoxib
E Simvastatin
For each of the following patients, select the drug most likely to be causing
the side effects mentioned.
You may use each option ONCE, MORE than ONCE, or not at all.
4. A 19 year-old girl with severe acne presents to accident and emergency

after taking an overdose of alcohol. She says she does not want to live and
has been feeling this way for the last two weeks.
A B C D E F G H
The correct answer is F: Isotretinoin. Although is an uncommon side

effect, suicidal ideation is a well recognised side effect of Isotretinoin,
which is used for treating severe acne. Patients who develop suicidal
tendencies on Isotretinoin may need follow up even after the medication
is stopped.
5. A 55 year-old man with known heart disease presents with severe muscle
pains. He reports feeling "weak". Creatine kinase (CK) is 1,000 U/L.
A B C D E F G H
The correct answer is E: Simvastatin. Rhabdomyolysis/myositis is a

well known potentially serious side effect of most statins. Many patients
are started on a statin after a myocardial infarction (MI) or if at risk of
heart disease. Patients often improve once the drug is stopped, and this
can be monitored using CK levels.

6. A 40 year-old patient with systemic lupus erythematosus (SLE) presents
with severe upper abdominal pain radiating to the back. Her medication was
recently increased after a flare up of her Lupus (SLE).
A B C D E F G H
The correct answer is B: Prednisolone. This presentation is in keeping

with acute pancreatitis, which can be caused by steroid treatment.
Prednisolone is a commonly used treatment for flares in SLE.

Single Best Answer questions Answers and explanations
1. A 54 year old woman is admitted with extensive bruising and bleeding

gums. She is on Warfarin and various other drugs. Her INR is raised. Which
ONE of the following is most likely to have contributed to her raised INR?
Select ONE answer only
A. Carbamazepine
B. Orange juice
C. Azathioprine
D. Cranberry juice
E. Nystatin
The correct answer is D: Cranberry juice. Warfarin interacts with many

drugs, but be careful of no drug interactions!
2. A 44 year-old woman presents with sudden onset of shortness of breath

and palpitations. On examination she has a tanned appearance to her skin,
white nails and extensive bruising. She also has an irregularly irregular pulse
and swollen ankles. Her blood glucose is 13.8.
Which ONE of the following is the most likely diagnosis?
a. Primary sclerosing cholangitis

b. Haemochromatosis
c. Hepatocellular carcinoma
d. Viral hepatitis
e. Primary biliary cirrhosis
The correct answer is B. Haemochromatosis is a condition in which

excessive iron is deposited into organs. It can be inherited in an
autosomal recessive manner or acquired. In the hereditary form
symptoms usually occur after the age of 40. Symptoms include skin
pigmentation, shortness of breath and palpitations, swollen ankles,
bruising and white nails. Treatment is by regular venesection.

3. A 26 year old man attends A and E on the weekend. He has just returned
from a safari holiday in Africa. He complains of diarrhea, vomiting, and
abdominal pains for the last 2 days. It started shortly after his last meal on
holiday. Which ONE of the following is the most likely cause of his
symptoms?
a. Campylobacter
b. Escherichia coli
c. Clostridium difficile
d. Salmonella
e. Shigella species
The correct answer is B. Travellers diarrhoea is transmitted via

contaminated food or water and usually presents with diarrhoea
vomiting and abdominal symptoms. E. coli species are the most
common cause, and the symptoms typically begin shortly after
ingestion of the contaminated food.
4. You see a patient in clinic in General Medicine. A 55 year-old man with

ischaemic heart disease attends for review. His chest pains are well
controlled but he is complaining of severe constipation. He says this has been
going on for several months, but he was too embarrassed to seek treatment
before. He is taking Verapamil, which commonly causes constipation. Which
ONE of the following is a stimulant laxative suitable for this patient?
a. Isphagula husk
b. Senna
c. Lactulose
d. Movicol
e. Co-danthramer
The correct answer is B: Senna. Constipation is the most common side

effect of verapamil leading to it being stopped. Patients started on
verapamil should be warned about this, and a laxative considered.

Senna and co-danthramer are the only 2 stimulant laxatives on the list,
and co-danthramer should only be used in terminally ill patients.
5. A 31 year-old manager complains of upper abdominal pain. It is worse after

food or when lying down. He has no haematemesis or malaena, and has not
had any treatment in the past. Examination is unremarkable. Which ONE of
the following is the most suitable initial management option?
a. Routine endoscopy
b. 13C urea breath testing
c. Admission to hospital.
d. Triple therapy (amoxicillin + clarithromycin + lansoprazole) for one week
e. Urgent endoscopy
The correct answer is B: 13C urea breath testing. The NICE guidance on
management of dyspepsia recommends empirical treatment with a
proton pump inhibitor (PPI) or testing for H. pylori as options for initial
management in patients with no alarm signs. Routine endoscopy is not
recommended for these patients. Triple therapy is only recommended
once H. pylori has been confirmed.
6. A 60 year old man complains of a gradual loss of his central vision. Which
ONE of the following is the leading cause of visual loss in patients over 65 in
the Western world?
a. Glaucoma
b. Diabetic eye disease
c. Cataract
d. Age related macular degeneration (AMD)
e. Retinal detachment
The correct answer is D. AMD usually has an insidious onset, and

affects central vision. There are two main types - 'wet' AMD and 'dry'
AMD. There are no treatments available for dry AMD. Photodynamic
therapy (PDT) has been shown to be useful in the treatment of wet AMD.

Professional Dilemma Paper Situational Judgement Test questions
You have just started an F2 job in Otolaryngology (ENT). You are asked by
one of the staff nurses to consent a patient for Stage II cholesteatoma surgery.
You are not sure how this operation is performed or of all the risks involved.
The patient is about to be wheeled off the ward to theatre as they are next on
the list.
Rank the following options 1-5 (1 being the best, and 5 being the worst)
Should you:
A. Explain what you can and consent the patient quickly before they leave
the ward.
B. Contact the registrar to explain the situation. Ask him to consent the
patient.
C. Leave the consent form unsigned and continue with the rest of the
ward jobs.
D. Ask to go to theatre to watch the operation at a later date.
E. Tell the patient to sign the form as he cant have his operation without it.
Answers are on the next page

Answers:
1. B. The patient needs to be consented. For the patient to make up his mind
and give informed consent, he needs to know the risks and benefits, and what
will happen. The registrar will be able to provide this information, and even if
this delays the list a little, this is the best option.
2. D. It would be useful to see the operation in due course. This episode has
shown a learning need, and this would allow you to learn about the procedure
and ask about the risks and side effects.
3. C. Not very constructive. If you are not happy to consent the patient you
need to contact the surgeon/registrar to inform them of the situation. However,
the operation wont be able to proceed without consent, so the patient will
either be cancelled or consented by the surgeon.
4. A. You need to provide the patient with adequate information about the
procedure in order to be able to consent them. If the patient is not aware of
the risks and benefits, he cannot make an informed decision.
5. E. Consent is only valid if it is informed. The patient may find this
threatening. They are in a vulnerable position and may feel unable to refuse.

2. You are called by medical staffing at home. They ask if you can cover a
night shift as a colleague has called in sick. You are unable to accept as you
have made plans to go to the theatre. While waiting to go in, you see the
doctor who has called in sick in the line ahead of you.
Rank the following 1-5, 1 being the MOST effective / best option, 5 being the
LEAST effective / worst option:
A. Inform your consultant of the incident the next day

B. Discuss the situation with other junior doctors in your department the
next day
C. Do nothing - it is not your problem.
D. Tell your colleague that you will cover for him if he pays for your ticket.
E. Inform your co-worker that this is irresponsible and unethical, and that
were it to happen again, you would be obliged to inform your
consultant.
Enter your options next to the corresponding rank below:
Answers are on the next page

Answers
1. E - You are making your colleague aware that his actions are wrong, and
allowing him a chance to explain himself / make amends.
2. B - someone else may have a useful suggestion as to how to approach this

problem. The problem affects everyone on the rota so it makes sense to
discuss it together.
3. A - If you feel unable to tackle the situation yourself, by informing someone

in a position of responsibility, it allows the problem to be addressed.
4. C - this does not address the situation at all. As his action affects you and
all of your colleagues, it IS your responsibility to do something about it.
5. D - This is unethical - not only are you condoning his behaviour, you are
asking for a bribe as well.
This question tackles 2 of the competencies: Managing Others & Team

Involvement, and Professional Integrity.

Summary
The GP ST entry assessment provides an objective way to rank applicants

and shortlist them accordingly. I hope that this guide has been useful in
providing you with an introduction to the types of question that are likely to
appear in your assessment in January 2013.
Remember that this is a competitive exam, so the higher your overall score,
the greater your chance of being shortlisted. Now that you know what to
expect, please do make sure that you dedicate enough time to prepare
effectively.
I wish you all the best in your preparation, and every success in securing a
place on a GP ST programme.
Dr Mahibur Rahman MB BCh MSc MRCGP
Medical Director
Emedica
www.emedica.co.uk

Emedica Stage2 Study Guide

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Mahibur Rahman MB BCh MSc MRCGP

0845 388 3402

Published 2010 in Great Britain

Mahibur Rahman, Emedica Ltd, 2012

All rights reserved.

Emedica 2012 www.emedica.co.uk 3

This National assessment will provide an objective means of ranking

Dr Mahibur Rahman MB BCh MSc MRCGP

Emedica 2012 www.emedica.co.uk 4

Stage 2 Assessment Basics 2013 application round ....................................7

Clinical Problem Solving paper ........................................................................8

Extended Matching questions...................................................................9

Single Best Answer questions ................................................................12

Preparing for the Clinical Problem Solving paper ...................................14

Professional Dilemma Paper / Situational Judgement Tests .........................15

Professional Dilemma paper Section 1...................................................16

Professional Dilemma paper Section 2...................................................19

Preparing for the Professional Dilemma Paper.......................................19

Extended Matching Questions examples.......................................................22

Single Best Answer Question Examples........................................................24

Extended Matching Questions Answers and Explanations.....................27

Single Best Answer questions Answers and explanations...................31

Professional Dilemma Paper Situational Judgement Test questions..........34

GP ST Entry Preparation courses..39

Emedica 2012 www.emedica.co.uk 5

Shortlisting for GP ST entry is done SOLELY on the basis of your ranking

As long as you meet the basic eligibility criteria (including evidence of F2

Emedica 2012 www.emedica.co.uk 6

Date: Saturday 5th January 2013 Saturday 12th January 2013

Venue: The assessment will be offered at various Pearson Vue testing

There are around 55 - 60 questions in the Professional Dilemma Paper.

Emedica 2012 www.emedica.co.uk 7

This is a 75 minute paper assessing your clinical knowledge and ability to

Emedica 2012 www.emedica.co.uk 8

Disease factors e.g. risk factors, exacerbating factors, prognosis

Extended Matching questions

Most of you will be familiar with this type of question as it is common in

Emedica 2012 www.emedica.co.uk 9

Investigations for back pain

A X-ray of the lumbar spine F Urgent MRI scan lumbar spine

For each of the following patients, select the MOST suitable

1. A 25 year-old man involved in a road traffic accident. He was on a bike and

2. A 68 year-old woman with known osteoporosis. She has had a fractured

3. A 40 year-old labourer who attends complaining of severe low back pain

Emedica 2012 www.emedica.co.uk 10

A X-ray of the lumbar spine F Urgent MRI scan lumbar spine

1. A 25 year-old man involved in a road traffic accident. He was on a bike and

2. A 68 year-old woman with known osteoporosis. She has had a fractured

The correct answer is A: X Ray lumbar spine. In a case of known

Emedica 2012 www.emedica.co.uk 11

The correct answer is H: no investigations needed. This is a description

There are more examples of EMQs for you to practice in Section 2.

Single Best Answer questions

Single Best Answer example:

Select ONE answer only.

Emedica 2012 www.emedica.co.uk 12

There are more examples of SBAs for you to practice in Section 2.

Other question types

Emedica 2012 www.emedica.co.uk 13

Useful books include:

Oxford Handbook of Clinical Specialties this handbook is well written,

BNF reading the introductory chapter on pain management, prescribing in

Emedica 2012 www.emedica.co.uk 14