Set 1: For each patient, select the most appropriate nutrition-related option.
A. Stop all nutrition until electrolytes normalise without monitoring
B. Start nutrition cautiously with thiamine, electrolyte replacement and close monitoring for refeeding syndrome
C. Start high-calorie feeding immediately at full requirements
D. Restrict all fluids and give no micronutrients
E. Insert a PEG tube immediately for all malnourished patients
F. Arrange dietetic assessment and oral nutrition support if intake remains inadequate
G. Reassure because malnutrition cannot occur if haemoglobin is normal
H. Start parenteral nutrition as first-line for all patients with poor appetite
1. An 82-year-old man with COPD has lost 8 kg over 4 months. His BMI is 18.2 kg/m² and he eats less than half of his meals because of breathlessness. He is still able to swallow safely and has no bowel obstruction.
Which option is most appropriate?
2. A 24-year-old woman with anorexia nervosa has had negligible intake for 10 days. Her BMI is 14.9 kg/m². Baseline blood tests show low phosphate, low potassium and low magnesium.
Which option is most appropriate?
Set 2: For each patient, select the most appropriate pharmacist action.
A. Crush all modified-release medicines and administer via the tube
B. Use parenteral nutrition because all enteral tubes are unsafe
C. Give all medicines intravenously regardless of suitability
D. Review the phenytoin–enteral feed interaction and separate administration or monitor levels as appropriate
E. Flush the tube only once weekly
F. Give high-osmolality medicines undiluted through the tube
G. Ignore tube position if the patient looks well
H. Confirm nasogastric tube position before first use according to local policy
3. A 76-year-old man has a nasogastric tube inserted after a stroke. The nurse asks whether the first feed can be started, but tube position has not yet been confirmed.
Which option is most appropriate?
4. A 41-year-old man receiving continuous enteral feed has worsening seizure control. He takes phenytoin suspension via his feeding tube. His phenytoin level is lower than expected despite adherence.
Which option is most appropriate?
Set 3: For each patient, select the most appropriate option.
A. Treat suspected vitamin B12 deficiency urgently, especially because neurological symptoms are present
B. Give folic acid alone and ignore neurological symptoms
C. Arrange appropriate suspected colorectal cancer investigation or referral pathway for unexplained iron-deficiency anaemia
D. Reassure because anaemia is expected with age
E. Start oral iron but do not investigate the cause
F. Give vitamin C only
G. Stop all medicines permanently
H. Transfuse all patients with mild anaemia
5. A 69-year-old man has new iron-deficiency anaemia, tiredness and a change in bowel habit. He has no history of heavy bleeding and is not vegetarian. His GP asks what further action is needed.
Which option is most appropriate?
6. A 58-year-old woman has macrocytic anaemia, glossitis, numbness in her feet and an unsteady gait. She has a history of autoimmune thyroid disease.
Which option is most appropriate?
Set 4: For each patient, select the most appropriate action.
A. Arrange routine blood tests in 4 weeks
B. Start oral iron and review later
C. Reassure because low blood counts are expected after chemotherapy
D. Supply paracetamol only
E. Urgent assessment for severe thrombocytopenia with bleeding risk
F. Start folic acid only
G. Immediate assessment for possible neutropenic sepsis
H. Give live vaccines to improve immunity
7. A 61-year-old woman received chemotherapy for lymphoma 8 days ago. She has a temperature of 38.3°C, chills and feels generally unwell. She has no obvious cough or urinary symptoms.
Which option is most appropriate?
8. A 47-year-old man with acute leukaemia has widespread petechiae, gum bleeding and a platelet count of 9 × 10⁹/L. He feels dizzy when standing.
Which option is most appropriate?
Set 5: For each patient, select the most appropriate management option.
A. Treat all sickle cell pain with oral iron
B. Rapid assessment and appropriate analgesia for acute painful sickle cell episode
C. Reassure because severe pain is expected and does not need treatment
D. Avoid fluids in all sickle cell crises
E. Delay analgesia until all blood results return
F. Urgent assessment for possible acute chest syndrome
G. Use NSAID monotherapy regardless of renal function
H. Treat with folic acid only during all acute episodes
9. A 22-year-old man with sickle cell disease presents with severe pain in his arms and legs. He has no chest pain, no breathlessness, oxygen saturation is 98% on air and temperature is 37.2°C.
Which option is most appropriate?
10. A 19-year-old woman with sickle cell disease has chest pain, fever, cough and oxygen saturation of 91% on air. She is more breathless than usual.
Which option is most appropriate?
Set 6: For each patient, select the most appropriate immediate action.
A. Stop the transfusion immediately, maintain IV access, assess the patient and inform the blood bank
B. Speed up the transfusion to finish the unit
C. Ignore a new rash if observations are normal
D. Start oral iron and continue the transfusion
E. No observations are needed once blood has started
F. Repeat the same unit after a short pause
G. Give the next unit without checking patient identity
H. Suspect transfusion-associated circulatory overload and seek urgent assessment/support
11. A 64-year-old woman develops fever, rigors, loin pain and hypotension 20 minutes after a red cell transfusion is started.
Which option is most appropriate?
12. An 86-year-old man with heart failure becomes acutely breathless during a red cell transfusion. He is hypertensive, has raised JVP and new basal crackles.
Which option is most appropriate?
Set 7: For each patient, select the most appropriate pharmacist action.
A. Continue anticoagulation unchanged
B. Give oral iron only and review in 3 months
C. Avoid all anticoagulants permanently
D. Double the next anticoagulant dose
E. Arrange urgent assessment for suspected major bleeding
F. Treat as uncomplicated haemorrhoids
G. Withhold warfarin and follow local high-INR protocol
H. Give vitamin C to reverse anticoagulation
13. A 77-year-old woman taking apixaban reports black stools, dizziness and shortness of breath. Her blood pressure is 90/58 mmHg and she recently started naproxen.
Which option is most appropriate?
14. A 72-year-old man taking warfarin has an INR of 8.1 after starting metronidazole. He has no bleeding, no recent fall and is clinically stable.
Which option is most appropriate?
Set 8: For each patient, select the most appropriate nutrition or medicines action.
A. Continue normal fluids and tablets despite coughing during swallowing
B. Crush all modified-release tablets for ease of swallowing
C. Consider parenteral nutrition when the gastrointestinal tract cannot be used and specialist assessment supports it
D. Refer for swallowing assessment; use safe texture/fluid plan and review medicine formulations
E. Stop all nutrition support until weight normalises
F. Treat aspiration risk with oral antibiotics only
G. Insert a PEG tube immediately for all short-term swallowing problems
H. Ignore medicine formulation issues in dysphagia
15. A 79-year-old woman has a new stroke. She coughs when drinking thin fluids and has a wet voice after swallowing. Her tablets include modified-release diltiazem and alendronate.
Which option is most appropriate?
16. A 56-year-old man has severe postoperative ileus and cannot tolerate enteral feeding. He is malnourished and is expected to be unable to use his gastrointestinal tract for several more days.
Which option is most appropriate?
Set 9: For each patient, select the most appropriate option.
A. Lifelong micronutrient monitoring and supplementation after bariatric surgery
B. Advise a reliable vitamin B12 source or supplementation for a vegan diet and test if symptomatic
C. No supplements are ever needed if weight loss is successful
D. Start high-dose vitamin A in pregnancy without review
E. Avoid all vitamin K-containing foods permanently
F. Take iron tablets with tea to improve absorption
G. Use paracetamol to correct micronutrient deficiency
H. Stop all prescribed vitamins once symptoms improve
17. A 45-year-old woman had Roux-en-Y gastric bypass 2 years ago. She stopped her supplements because she felt well. She now has fatigue, hair loss and tingling in her feet.
Which option is most appropriate?
18. A 28-year-old man follows a strict vegan diet. He has tiredness and intermittent paraesthesia. He does not take fortified foods or supplements.
Which option is most appropriate?
Set 10: For each patient, select the most appropriate management option.
A. Ignore diarrhoea because enteral feeding always causes it
B. Increase feed rate immediately
C. Stop all oral and enteral fluids
D. Start regular NSAIDs
E. Give potassium replacement without checking blood tests
F. Assess causes of diarrhoea, hydration, medicines and infection risk, and review feed regimen
G. Urgent review and correction of severe electrolyte disturbance during refeeding risk
H. Treat all tube-feed diarrhoea with loperamide only
19. A 68-year-old man receiving enteral feed develops diarrhoea after recent antibiotics. He also takes liquid medicines containing sorbitol. He is increasingly thirsty and has reduced urine output.
Which option is most appropriate?
20. A severely malnourished patient starts nutrition support and develops weakness, confusion and palpitations after 48 hours. Blood tests show severe hypophosphataemia, hypokalaemia and hypomagnesaemia.
Which option is most appropriate?
Answers and Rationale
1. F
Weight loss, low BMI and poor intake suggest malnutrition risk. Because he can swallow and the gut works, oral nutritional support and dietetic assessment are appropriate before invasive feeding options.
2. B
Very low BMI, negligible intake and low phosphate, potassium and magnesium indicate high refeeding risk. Nutrition should be restarted cautiously with thiamine, electrolyte replacement and close monitoring.
3. H
Nasogastric tube position must be confirmed before first use to reduce the risk of feeding into the lungs. Feeding should not start until correct position is confirmed according to local policy.
4. D
Enteral feeds can reduce phenytoin absorption, causing subtherapeutic levels and breakthrough seizures. Administration timing, feed interruption where appropriate, flushing and level monitoring should be reviewed.
5. C
New unexplained iron-deficiency anaemia in an older man, especially with bowel habit change, needs investigation for gastrointestinal blood loss and possible colorectal cancer.
6. A
Macrocytosis with neuropathy and gait disturbance suggests vitamin B12 deficiency. Neurological symptoms make prompt treatment important; folate alone could mask haematological signs while neurological damage progresses.
7. G
Fever after chemotherapy should be treated as possible neutropenic sepsis until proven otherwise. This is an oncology emergency even when there are no localising infection symptoms.
8. E
Platelets of 9 × 10⁹/L with mucosal bleeding and petechiae indicate severe thrombocytopenia with significant bleeding risk. Urgent haematology/clinical assessment is required.
9. B
This presentation is consistent with an acute painful sickle cell episode without clear acute chest features. Rapid assessment and timely analgesia are essential.
10. F
Chest pain, fever, cough, breathlessness and hypoxia in sickle cell disease suggest acute chest syndrome. This is a medical emergency requiring urgent assessment.
11. A
Fever, rigors, loin pain and hypotension during transfusion suggest a potentially serious transfusion reaction. The transfusion should be stopped immediately, IV access maintained and the blood bank informed.
12. H
Acute breathlessness, hypertension, raised JVP and crackles during transfusion suggest transfusion-associated circulatory overload. The transfusion should be stopped and urgent assessment/support arranged.
13. E
Black stools, dizziness, breathlessness and hypotension suggest major gastrointestinal bleeding. Apixaban plus naproxen increases bleeding risk, so urgent assessment is needed.
14. G
An INR of 8.1 after metronidazole suggests excessive anticoagulation. Warfarin should be withheld and local high-INR protocol followed, including vitamin K if indicated.
15. D
Coughing on thin fluids and wet voice after swallowing suggest aspiration risk. Swallowing assessment, safe texture/fluid planning and medicine formulation review are needed.
16. C
When the gastrointestinal tract cannot be used and inadequate intake is expected to continue, parenteral nutrition may be needed following specialist nutrition assessment.
17. A
Bariatric surgery can cause long-term deficiencies including iron, B12, folate, calcium, vitamin D and fat-soluble vitamins. Lifelong supplementation and monitoring are usually required.
18. B
A strict vegan diet without fortified foods or supplementation increases B12 deficiency risk. Neurological symptoms such as paraesthesia warrant testing and appropriate supplementation or treatment.
19. F
Diarrhoea during enteral feeding can be due to antibiotics, C. difficile, medicines such as sorbitol-containing liquids, feed rate or intolerance. Hydration, medicines, infection risk and feed regimen should be reviewed.
20. G
Severe phosphate, potassium and magnesium depletion after starting nutrition suggests refeeding syndrome. This needs urgent electrolyte correction, monitoring and nutrition regimen review.
Here are 20 extended matching questions designed to mimic the GPHC exam itself. At the bottom of the page you will find answers and rationale for each question.