Membership of the Royal College of General Practitioners (MRCGP) Applied Knowledge Test (AKT): Clinical Medicine Flashcards

24 sample cards from the Applied Knowledge Test (AKT): Clinical Medicine deck

Sampled from the end of the deck, so these are different cards from the ones shown on the syllabus page.

1. Interpret a predominantly raised ALT/AST versus a raised ALP/GGT pattern on LFTs.

   A predominant ALT/AST rise indicates a hepatocellular pattern (e.g. viral hepatitis, NAFLD, drugs). A predominant ALP rise with raised GGT indicates a cholestatic/obstructive pattern (e.g. biliary obstruction, PBC); raised GGT confirms a hepatic source for the ALP.

2. What non-invasive score helps assess advanced fibrosis in non-alcoholic fatty liver disease, and what does a low result indicate?

   The FIB-4 score (using age, AST, ALT, and platelets). A low score (e.g. $< 1.3$) makes advanced fibrosis unlikely; higher values prompt enhanced liver fibrosis (ELF) testing or specialist referral.

3. What first-line antibiotic and duration does NICE recommend for an uncomplicated lower UTI in a non-pregnant woman?

   Nitrofurantoin (if eGFR $\geq 45$) for 3 days, or trimethoprim 3 days if local resistance is low. Antimicrobial stewardship: use the shortest effective course and review local resistance patterns.

4. What is the CURB-65 score, and what total score suggests hospital assessment for community-acquired pneumonia?

   One point each for: Confusion, Urea $> 7\ \text{mmol/L}$, Respiratory rate $\geq 30$, Blood pressure ($\text{systolic} < 90$ or $\text{diastolic} \leq 60$), Age $\geq 65$. A score of $\geq 2$ suggests hospital assessment; $0\text{--}1$ can often be managed at home.

5. How do you distinguish iron-deficiency anaemia from anaemia of chronic disease on a blood film and iron studies?

   Iron deficiency: microcytic, hypochromic (low MCV/MCH), low ferritin, low transferrin saturation, raised total iron-binding capacity (TIBC). Anaemia of chronic disease: normocytic or mildly microcytic with normal/raised ferritin and low TIBC.

6. What two vitamin deficiencies cause a macrocytic megaloblastic anaemia, and which antibody confirms pernicious anaemia?

   Vitamin B$_{12}$ and folate deficiency. Pernicious anaemia is confirmed by intrinsic factor antibodies (and may show anti-parietal cell antibodies).

7. Give the diagnostic features distinguishing migraine from tension-type headache.

   Migraine: moderate-severe, often unilateral, pulsating, $4\text{--}72$ hours, with nausea/vomiting and/or photophobia and phonophobia, worse with activity, $\pm$ aura. Tension-type: bilateral, pressing/tightening, mild-moderate, not aggravated by routine activity, no significant nausea.

8. List four red-flag headache features that warrant urgent investigation.

   Thunderclap (sudden, maximal within seconds-minutes), new headache with focal neurology or papilloedema, headache worse on standing/lying or with Valsalva, new headache in over-50s (consider GCA), fever/neck stiffness, or progressive headache with morning vomiting.

9. What is first-line acute treatment for migraine, and what defines medication-overuse headache risk?

   A triptan (e.g. sumatriptan) plus an NSAID or paracetamol. Medication-overuse headache risk: triptans/opioids/combination analgesics on $\geq 10$ days/month, or simple analgesics on $\geq 15$ days/month, for $> 3$ months.

10. What is the cardinal triad of Parkinson's disease, and how does Parkinsonian tremor differ from essential tremor?

    Bradykinesia, rigidity, and a resting tremor (plus postural instability). Parkinsonian tremor is a 4–6 Hz resting "pill-rolling" tremor, asymmetrical, worse at rest. Essential tremor is a postural/action tremor, often symmetrical, improved by alcohol, and worse on sustained posture.

11. After a first unprovoked seizure, what investigations are recommended and when is anti-epileptic drug treatment usually started?

    Refer to a specialist; arrange an EEG and brain MRI. AEDs are generally started after a second seizure, or after a first seizure if there is a structural lesion, an unequivocal epileptiform EEG, or the patient/clinician deems the risk of recurrence unacceptable.

12. Which first-line anti-epileptic drugs are used for focal versus generalised tonic-clonic seizures (and a key caution in pregnancy)?

    Focal: lamotrigine or levetiracetam. Generalised tonic-clonic: sodium valproate (men) or lamotrigine/levetiracetam. Valproate must be avoided in women of childbearing potential due to teratogenicity unless conditions of the pregnancy prevention programme are met.

13. What tool stratifies early stroke risk after a TIA, and what is the immediate antiplatelet management?

    The ABCD$^2$ score historically estimated risk, but current UK practice treats all suspected TIAs urgently. Give aspirin 300 mg immediately (unless contraindicated) and refer for specialist assessment within 24 hours.

14. What is the time window for thrombolysis with alteplase in acute ischaemic stroke, and what must be excluded first?

    Within $4.5$ hours of symptom onset. A CT/MRI brain must first exclude haemorrhage. Mechanical thrombectomy may be offered up to 6 hours (or later in selected patients with favourable imaging) for large-vessel occlusion.

15. What is the long-term antiplatelet regimen after a non-cardioembolic ischaemic stroke or TIA?

    Clopidogrel 75 mg once daily long-term (first-line). If clopidogrel is unsuitable, use aspirin plus modified-release dipyridamole. High-intensity statin and blood pressure control are also indicated.

16. What clinical features distinguish mechanical low back pain from cauda equina syndrome (a red flag)?

    Cauda equina red flags: bilateral sciatica, saddle (perianal) anaesthesia, bladder/bowel dysfunction (urinary retention/incontinence, faecal incontinence), and reduced anal tone — these require emergency MRI and surgical referral.

17. What is the typical history and examination finding in lateral epicondylitis (tennis elbow)?

    Pain over the lateral epicondyle radiating down the forearm, worsened by resisted wrist extension and gripping. Tenderness over the common extensor origin; provoked by resisted middle-finger extension.

18. What antibody is most specific for rheumatoid arthritis, and which joints are characteristically involved?

    Anti-cyclic citrullinated peptide (anti-CCP) antibody is most specific (rheumatoid factor is also used). It causes a symmetrical polyarthritis affecting the small joints — MCPs, PIPs, and wrists — with early-morning stiffness lasting $> 30$ minutes.

19. What is first-line treatment to control synovitis in newly diagnosed rheumatoid arthritis?

    A conventional DMARD as monotherapy (methotrexate first-line, or leflunomide/sulfasalazine), ideally started within 3 months, with a short-term bridging glucocorticoid. Treat-to-target aiming for remission/low disease activity.

20. What crystal and joint fluid finding confirm gout, and what is the first-line acute treatment?

    Negatively birefringent, needle-shaped monosodium urate crystals on polarised microscopy. First-line acute treatment: an NSAID or colchicine (or a short course of oral corticosteroid). Serum urate target for prophylaxis is $< 360\ \mu\text{mol/L}$ (or $< 300$ in tophaceous/severe disease).

21. What are the classic clinical and laboratory features of polymyalgia rheumatica, and its first-line treatment?

    Bilateral shoulder and pelvic girdle pain and stiffness (worse in the morning) in over-50s, with a raised ESR/CRP. First-line treatment is oral prednisolone (typically 15 mg daily) with a dramatic response within days; be alert for coexisting giant cell arteritis.

22. What is the first-line management of mild-to-moderate plaque psoriasis in primary care?

    A potent topical corticosteroid plus a topical vitamin D analogue (e.g. calcipotriol) applied separately (one in the morning, one in the evening), or as a combined product, for up to 4 weeks initially.

23. How do you distinguish the typical lesion of basal cell carcinoma from a malignant melanoma?

    BCC: a slow-growing, pearly, rolled-edge papule with telangiectasia, often with central ulceration (rodent ulcer), rarely metastasises. Melanoma: a pigmented lesion meeting ABCDE criteria — Asymmetry, irregular Border, Colour variation, Diameter $> 6\ \text{mm}$, Evolving — warranting urgent 2-week-wait referral.

24. What is the first-line treatment for moderate acne vulgaris, and which agent is teratogenic and prescriber-restricted?

    A topical combination (e.g. a topical retinoid with benzoyl peroxide, or with a topical antibiotic), or a fixed combination; an oral antibiotic (e.g. lymecycline/doxycycline) for up to 12 weeks if widespread. Oral isotretinoin (specialist-only) is highly teratogenic and requires a pregnancy prevention programme.

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Applied Knowledge Test (AKT): Clinical Medicine flashcards FAQ