Core Revision
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Core Tools · MSRA
MSRA Core Tools
Professional Dilemmas judgement, paediatric red flags and contraceptive eligibility (UKMEC) — the fast, principle-led decisions the MSRA’s two papers reward. Commit to an answer before you see the reasoning. That moment of commitment is what makes it stick.
Commit to an answer before the reasoning unlocks. You get why the right answer is right, why not the others — the trap each wrong option sets — and the rule to carry into the exam.
Professional Dilemmas
Six situational-judgement dilemmas reasoned from GMC Good Medical Practice 2024 and its four domains: name the governing principle, then pick the best first action. The real Professional Dilemmas paper uses ranking and multiple-choice questions — practise those formats in the Professional Dilemmas Reasoner.
Scenario 1 of 6
You are a foundation doctor on a busy ward. A colleague arrives for the night shift smelling of alcohol, slurring slightly and struggling to focus on the handover.
What is your best first action?
Choose one to unlock the reasoning.
Why
The governing principle is Colleagues, culture and safety — you must protect patients and raise a concern about a colleague who is not fit to work. Patient safety comes first, so you act now.
Why not the others
- Passive option — Doing nothing lets an impaired colleague treat patients, which ignores a clear safety risk.
- Straight to the GMC — Jumping to the regulator overreacts and skips raising the concern locally with your senior first.
- Beyond your competence — Silently covering a whole shift alone stretches you beyond safe practice and hides the real problem.
The rule
Patient safety comes first — raise the concern locally and now, do not ignore it and do not leap to the GMC.
Scenario 2 of 6
You realise you prescribed and gave a patient double the intended dose of a medication an hour ago. The patient currently appears well.
What is your best first action?
Choose one to unlock the reasoning.
Why
The governing principle is Patients, partnership and communication: GMP 2024 places the duty of candour under “Being open if things go wrong” (para 45) — be open and honest with the patient, apologise, explain what happened and report the incident. Hiding it would also breach Trust and professionalism.
Why not the others
- Passive option — Watchful waiting in silence delays honest disclosure and any needed action if harm develops.
- Hiding the error — Altering the chart is dishonest, breaches candour and is a serious integrity failure.
- Quiet cover-up — A private word asking a colleague to keep it secret still conceals the error from the patient and the system.
The rule
Candour means telling the patient and reporting — own the mistake, never disguise it.
Scenario 3 of 6
A senior asks you to perform a practical procedure you have never done and have not been trained or signed off to do. The patient is stable.
What is your best first action?
Choose one to unlock the reasoning.
Why
The governing principle is Knowledge, skills and development — work within your competence and keep learning. Asking for help or supervision is a strength, not a weakness.
Why not the others
- Beyond your competence — Attempting an untrained procedure risks harm and breaches the duty to work within your limits.
- Aggressive refusal — Walking off without explanation is unprofessional and leaves the task and patient unaddressed.
- Passive option — Hoping it is forgotten ignores the request and the patient’s need for the procedure.
The rule
Seeking supervision is a strength — stay within your competence and ask for help rather than guessing.
Scenario 4 of 6
A distressed teenage patient discloses information and asks you to keep it completely confidential, but what they describe suggests a risk of serious harm to them.
What is your best first action?
Choose one to unlock the reasoning.
Why
The governing principle is Patients, partnership and communication, balanced with maintaining trust: confidentiality is respected but has safety-based exceptions, and you are honest with the patient about those limits.
Why not the others
- False promise — Promising absolute secrecy is dishonest when a safety exception may require sharing information.
- Over-reaction — Breaking confidence without any explanation abandons the partnership and the patient’s autonomy.
- Passive option — Ending the consultation to avoid the issue ignores a possible risk of serious harm.
The rule
Respect confidentiality, but be honest that safety-based exceptions exist — never promise secrecy you cannot keep.
Scenario 5 of 6
During a ward round a senior colleague speaks rudely and dismissively to a junior in front of patients, and you are concerned about the behaviour.
What is your best first action?
Choose one to unlock the reasoning.
Why
The governing principle is Colleagues, culture and safety — address problems directly and proportionately, speaking to the person involved first before escalating.
Why not the others
- Public confrontation — Challenging a colleague loudly in front of patients is aggressive and undermines the team publicly.
- Passive option — Ignoring poor behaviour lets an unsafe or unkind culture continue unchecked.
- Straight to the GMC — Going to the regulator first skips the proportionate step of speaking to the person directly.
The rule
Deal with people directly and proportionately — a private word first, escalate only if it continues.
Scenario 6 of 6
A patient with capacity declines a treatment you believe is clearly in their best interest, after you have explained the risks and benefits.
What is your best first action?
Choose one to unlock the reasoning.
Why
The governing principle is Patients, partnership and communication — work with patients and respect autonomy: a patient with capacity may decline treatment after being properly informed.
Why not the others
- Overriding autonomy — Treating against a capacitous refusal disregards the patient’s right to decide.
- Coercion — Pressuring the patient until they relent undermines genuine informed consent.
- Aggressive dismissal — Discharging a patient for refusing is punitive and abandons the partnership.
The rule
A patient with capacity may say no — explain, respect autonomy, and document the conversation.
Paediatric red flags
Six developmental and fever scenarios distinguishing normal variants from referral lines, using NICE NG143 and standard UK developmental teaching.
Scenario 1 of 6
A 15-month-old is brought in because they are not yet walking unaided. They cruise around furniture, sit well and are otherwise developing normally.
How should you classify this finding?
Choose one to unlock the reasoning.
Why
Median walking is around 12 months but the limit age — the referral line — is 18 months. At 15 months with normal cruising and sitting, this is within normal limits.
Why not the others
- Median-as-limit — Twelve months is the median, not the referral line; using it as a cut-off refers normal children.
- Over-investigation — There is no abnormal tone or regression described to justify a cerebral palsy work-up.
- Wrong red flag — Not walking at 15 months is a normal variant, not a safeguarding issue.
The rule
Median is when half can; the limit age is the referral line — walking’s limit age is 18 months.
Scenario 2 of 6
A parent reports their 2-year-old could previously say several clear words and wave, but over recent weeks has stopped doing these things.
What is the most appropriate response?
Choose one to unlock the reasoning.
Why
Regression — “used to be able to, now can’t” — is never a normal variant. It warrants urgent referral for possible neurodevelopmental or metabolic disease.
Why not the others
- Reassurance trap — Losing established skills is never a normal phase and must not be reassured away.
- Routine not urgent — A slow routine pathway underplays regression, which needs urgent referral.
- Watchful waiting — Delaying to age 3 misses the always-red flag of skill loss.
The rule
“Used to be able to, now can’t” is regression — always red, refer urgently.
Scenario 3 of 6
A 5-month-old baby who is not yet crawling or rolling independently is noted to have several unexplained bruises on the trunk.
What is the correct interpretation?
Choose one to unlock the reasoning.
Why
Bruising in a baby who cannot yet move is a safeguarding emergency until proven otherwise — a non-mobile baby cannot cause such injuries themselves.
Why not the others
- Age-softens-it — Calling bruises normal handling ignores that a non-mobile baby should not have unexplained bruising.
- Wrong pathway — Framing it as mere developmental delay misses the urgent safeguarding dimension.
- Misread as milestone — Bruising is not evidence of emerging mobility and must not be reassured away.
The rule
A baby who can’t yet move but is bruised is a safeguarding emergency until proven otherwise.
Scenario 4 of 6
A 4-month-old is brought in with a new persistent squint. The parents say the eyes have been turning inward for several weeks.
What is the most appropriate action?
Choose one to unlock the reasoning.
Why
Squints that come and go are common before 3 months; a squint persisting beyond 3 months needs assessment (NHS). Check the red reflex: NICE NG12 (1.7.6) advises considering a suspected cancer pathway referral for retinoblastoma when the red reflex is absent.
Why not the others
- Age-softens-it — Squints can be transient early on, but persistence after 3 months is a referral line, not normal.
- Watch and wait — Reviewing in three months delays assessment of a squint already past the age at which it should settle, and of the red reflex.
- Wrong concept — A squint is not hand preference; conflating the two misses the eye red flag.
The rule
A squint persisting after 3 months needs ophthalmology assessment; an absent red reflex is a suspected cancer pathway referral for retinoblastoma (NICE NG12).
Scenario 5 of 6
A 2-month-old presents with a temperature of 38.2 degrees, is pale and mottled, has grunting respirations and does not respond normally to social cues.
How should you triage this child on the NG143 traffic light?
Choose one to unlock the reasoning.
Why
On the NG143 traffic light, age under 3 months with a temperature of 38 or more, pale/mottled colour, grunting and no response to social cues are all red features needing urgent paediatric assessment.
Why not the others
- Under-triage — Calling this amber ignores multiple red features including age under 3 months with fever.
- Temp-only thinking — Judging by the number alone misses the ashen colour, grunting and poor responsiveness.
- Splitting the flags — Isolating mottling as amber ignores the other clear red features present.
The rule
Under 3 months with temp 38 or more, mottling, grunting or no social response is red — urgent assessment.
Scenario 6 of 6
A 9-month-old with a fever of 38.5 has normal colour, responds normally to you, smiles, is content and has moist mucous membranes.
What does the NG143 traffic light indicate here?
Choose one to unlock the reasoning.
Why
Normal colour, responding normally, content and smiling with moist mucous membranes are all green features, so the child can go home with a safety-net.
Why not the others
- Fever-equals-red — The temperature alone does not make a well-looking child red; the traffic-light features are green.
- Over-triage — Calling a green-feature child amber escalates a reassuring picture unnecessarily.
- Age over-caution — A well 9-month-old with green features does not need admission for the fever itself.
The rule
Normal colour, responsive, content and moist membranes are green — home with a safety-net.
UKMEC eligibility
Six contraception scenarios assigning the UKMEC category or the safe alternative method, based on CoSRH UKMEC 2025.
Scenario 1 of 6
A 28-year-old woman with migraine with aura asks to start the combined oral contraceptive pill.
What is the UKMEC category for combined hormonal contraception here?
Choose one to unlock the reasoning.
Why
Migraine with aura is CHC Category 4 at any age: aura signals a raised ischaemic stroke risk and oestrogen compounds it. Progestogen-only methods (POP, implant, injectable and LNG-IUS) are Category 2, so benefits generally outweigh risks; only the copper IUD is Category 1.
Why not the others
- Aura-as-no-aura — Migraine without aura is generally Cat 2 to start, but aura raises it to Cat 4.
- Under-categorising — Cat 3 understates the risk; aura makes CHC an unacceptable, not merely cautioned, risk.
- No-restriction error — Cat 1 ignores the ischaemic stroke risk that aura carries with oestrogen.
The rule
Migraine with aura plus oestrogen is Category 4 at any age — progestogen-only methods (Category 2) and the copper IUD (Category 1) are the alternatives.
Scenario 2 of 6
A 32-year-old woman with a past provoked VTE, no longer on anticoagulation, wants effective contraception.
Which option is safe under UKMEC?
Choose one to unlock the reasoning.
Why
Past VTE, whether provoked or not and whether anticoagulated or not, makes CHC Category 4. The copper IUD is unrestricted and the LNG-IUS is also suitable, so an oestrogen-free method is the safe choice.
Why not the others
- Provoked-is-fine — A provoked clot still makes CHC Cat 4; the provocation does not lower the category.
- Off-anticoagulant myth — Being off anticoagulation does not change the Cat 4 status of CHC after VTE.
- Any-CHC error — All combined hormonal methods are Cat 4 here, including the patch.
The rule
Past VTE makes all CHC Category 4 regardless of provocation or anticoagulation — the copper IUD is Category 1; the LNG-IUS, implant and POP are Category 2; DMPA is Category 3 (UKMEC 2025).
Scenario 3 of 6
A woman who is 3 weeks postpartum and fully breastfeeding asks about starting the combined pill.
What is the UKMEC category for CHC at this point?
Choose one to unlock the reasoning.
Why
Breastfeeding with under 6 weeks postpartum is CHC Category 4. From 6 weeks to 6 months it is Cat 2, and from 6 months Cat 1. POP and implant are Cat 1 immediately postpartum.
Why not the others
- Wrong window — Cat 2 applies from 6 weeks to 6 months, not in the first 6 weeks.
- No-restriction error — Cat 1 for CHC only applies from 6 months of breastfeeding, not at 3 weeks.
- Under-categorising — Cat 3 understates the risk; under 6 weeks and breastfeeding is Cat 4.
The rule
Breastfeeding under 6 weeks postpartum is CHC Category 4 — POP and implant are Cat 1 immediately.
Scenario 4 of 6
A woman on treatment for hypertension has an adequately controlled blood pressure and wants to continue her combined pill.
What is the UKMEC category for CHC?
Choose one to unlock the reasoning.
Why
Adequately controlled hypertension on treatment is CHC Category 3, as is a systolic of 140-159 or diastolic of 90-99. The POP, implant and both IUDs are Category 1 at these blood pressures; DMPA is Category 2 (UKMEC 2025).
Why not the others
- Controlled-equals-safe — Good control does not drop CHC to Cat 1; treated hypertension is still Cat 3.
- Under-categorising — Cat 2 understates it; controlled hypertension on treatment is Cat 3 for CHC.
- Over-escalation — Cat 4 and stopping applies at 160/100 or above, not to adequately controlled BP.
The rule
Treated, controlled hypertension is CHC Category 3 — but 160/100 or above is Cat 4, so check the BP.
Scenario 5 of 6
A 37-year-old woman who smokes 20 cigarettes a day requests the combined oral contraceptive pill.
What is the UKMEC category for CHC?
Choose one to unlock the reasoning.
Why
Age 35 or over and smoking 15 or more a day is CHC Category 4. If she smoked under 15 a day it would be Cat 3, and under 35 any smoking is Cat 2.
Why not the others
- Under-15 confusion — Cat 3 applies at 35 or over smoking under 15 a day; at 15 or more it is Cat 4.
- Minimising smoking — At her age and smoking level this is Cat 4, not a minor Cat 2 factor.
- No-restriction error — Cat 1 ignores that heavy smoking at 35 or over is an unacceptable CHC risk.
The rule
Age 35 or over and 15 or more cigarettes a day is CHC Category 4 — ask the number and the age.
Scenario 6 of 6
A 38-year-old woman who stopped smoking 18 months ago, with no other risk factors, asks about the combined pill.
What is the UKMEC category for CHC?
Choose one to unlock the reasoning.
Why
Having stopped smoking more than a year ago is CHC Category 2 — you must ask WHEN they stopped, not just whether they used to smoke.
Why not the others
- History-as-current — Treating a past smoker as a current one wrongly pushes her to Cat 4.
- Over-categorising — Stopping over a year ago is Cat 2, not Cat 3.
- No-restriction error — Cat 1 overlooks that a recent ex-smoker over 35 sits at Cat 2.
The rule
Ask WHEN they stopped — stopped more than a year ago is Category 2, not the Category 4 of a current heavy smoker.
Twenty cards on the highest-yield MSRA facts. Grade yourself honestly; the spacing does the rest.
What are the four domains of GMC Good Medical Practice 2024?
Knowledge, skills and development; Patients, partnership and communication; Colleagues, culture and safety; Trust and professionalism.
- Knowledge, skills and development — work within your competence and keep learning.
- Patients, partnership and communication — explain, listen, respect autonomy.
- Colleagues, culture and safety — protect patients and raise concerns.
- Trust and professionalism — be honest, keep boundaries, act with integrity.
What is a useful “when unsure” order of priorities for Professional Dilemmas questions (a teaching heuristic, not an official rule)?
Patient safety comes first — act to prevent harm before anything else.
- Then be honest and open, including candour about your own mistakes.
- Then stay within your competence.
- Then address things directly and proportionately.
- Then maintain trust — boundaries, conflicts, confidentiality.
What does the duty of candour require after a mistake?
Tell the patient and report it — do not hide it.
Owning your mistakes is honesty in action, not weakness.
Which two option types are almost never the SJT answer?
The passive option and the aggressive option.
- Almost never the passive option — ignore it or do nothing.
- Rarely the aggressive one — straight to the GMC or confront publicly.
- Speak to the person directly first, then escalate if needed.
What should you do when asked to act beyond your competence?
Ask for help or supervision rather than guessing.
Seeking supervision is a strength, not a failing.
When two options feel equally close, how do you choose?
Pick the one that puts the patient first, is honest, and deals with people directly and kindly before escalating.
Name the governing principle first and the best first action almost chooses itself.
What does GMP 2024 say about the doctor’s own health?
Try to take care of your own health and wellbeing, recognising if you may not be fit for work (para 78).
If a condition or its treatment could affect your judgement or performance, consult a suitably qualified professional and follow their advice (para 79). A doctor unfit to work safely is itself a patient-safety issue.
What is the difference between median age and limit age?
Median age = when half of children can do something; limit age = when nearly all should, and it is the referral line.
Correct for prematurity up to age 2.
What are the three always-red developmental flags?
Regression, hand preference before 12 months, and bruising in a non-mobile baby.
- Regression — losing a skill once gained — urgent referral.
- Hand preference before 12 months — suggests hemiplegia on the weaker side.
- Bruising in a non-mobile baby — safeguarding emergency until proven otherwise.
What are the median ages for social smile, sitting, walking and first words?
Smile ~6 weeks; sitting unsupported ~6-7 months; walking unaided ~12 months; first words ~12 months.
- Two-word phrases ~2 years.
- Pincer grip ~9-10 months.
What are the referral limit ages for walking, words and two-word phrases?
Not walking by 18 months; no clear words by 18 months; no two-word phrases by 2 years.
- Not smiling by 6–8 weeks; not sitting by 8 months (NICE NG62, corrected for prematurity).
- Not walking by 18 months in boys — check CK for Duchenne.
- No two-word phrases by 2 years — test hearing.
Which eye findings in an infant need referral, and how fast?
An absent red reflex: suspected cancer pathway referral for retinoblastoma (NICE NG12). A squint persisting after 3 months: ophthalmology assessment.
Cataract is the other important cause of an absent red reflex.
Name some NG143 red features in a febrile child.
Pale/mottled/ashen/blue, no response to social cues, grunting, RR over 60, age under 3 months with temp 38 or more.
- Non-blanching rash, bulging fontanelle, neck stiffness.
- Status epilepticus, focal signs, reduced skin turgor.
- Red means urgent paediatric assessment, 999 if life-threatening.
What are the green (low-risk) features on the NG143 traffic light?
Normal colour, responds normally, content and smiling, moist mucous membranes.
Green means home with a safety-net.
What do UKMEC categories 1 to 4 mean?
1 no restriction; 2 advantages generally outweigh risks; 3 risks usually outweigh advantages; 4 unacceptable health risk.
Cat 3 means not recommended unless other methods are unavailable or unacceptable; Cat 4 means do not use.
What is the CHC category for migraine with aura?
Category 4 at any age.
Aura raises ischaemic stroke risk and oestrogen compounds it; progestogen-only methods are Category 2 and the copper IUD Category 1 (UKMEC 2025). Migraine without aura is generally Cat 2 to start.
What is the CHC category after a past VTE?
Category 4, whether provoked or not and whether anticoagulated or not.
Cu-IUD Cat 1; LNG-IUS, implant and POP Cat 2; DMPA Cat 3 (UKMEC 2025). Known thrombophilia such as Factor V Leiden is also Cat 4.
How does breastfeeding and postpartum timing affect CHC?
Under 6 weeks postpartum Cat 4; 6 weeks to 6 months Cat 2; from 6 months Cat 1.
POP and implant are Cat 1 immediately postpartum.
How does blood pressure change the CHC category?
Systolic 140-159 or diastolic 90-99 is Cat 3; controlled hypertension on treatment is also Cat 3; 160/100 or above is Cat 4.
The POP, implant and both IUDs are Cat 1 at any of these levels; DMPA is Cat 2 (UKMEC 2025). Checking the BP is the key step.
How do age and smoking affect the CHC category?
Age 35 or over and 15 or more a day is Cat 4; 35 or over and under 15 a day is Cat 3; under 35 any smoking is Cat 2.
Stopped smoking more than a year ago is Cat 2 — ask WHEN they stopped.
All caught up
Nothing is due right now. Come back later — spacing is the point.
Now practise it against the clock
Reasoning builds the framework. The Clinical Problem Solving paper allows about 52 seconds an item (86 items in 75 minutes); Professional Dilemmas allows nearly two minutes a question (50 in 95 minutes) — take these principles into timed practice.
Build an MSRA mock in Core CompassTake this further
This tool is free. If you are preparing for the MSRA, the full course puts the same reasoning into exam-style questions: a question bank with Core Lens and Deep Dive explanations, a Core Calendar revision plan built around your exam date, and Core Compass to show you which topics need you next.
Core Revision is an independent revision resource, not affiliated with the RCGP or the bodies that administer the MSRA.
Professional-dilemma reasoning is based on GMC Good Medical Practice 2024; clinical content reflects NICE guidance and CoSRH (formerly FSRH) UKMEC 2025. Sources last checked October 2026. A revision aid, not an official answer key.