Medical Licensing (MD/DO) · Independent exam preparation
MRCGP Applied Knowledge Test: Clinical Decisions and Evidence Guide Study Guide
Develop applied GP reasoning through 60 selective concepts, 20 explained questions and 20 flashcards covering clinical decisions, prescribing, evidence and professional responsibilities.
By CertMedbry · Updated 23 October 2026
Practise recognising urgent presentations, interpreting investigations, choosing and monitoring treatment, appraising evidence and making defensible professional decisions in UK general practice. These 60 concepts are selective. The official RCGP GP Curriculum and linked AKT Blueprint define the full scope, including clinical, professional and life-stage subjects beyond this guide. The questions and flashcards are independently authored learning materials.
Try 20 free practice questionsWhat is the exam format?
Check the question types, timing and outline before planning your revision.
How many questions are there, and how long is the examination?
From October 2025, the AKT has 160 questions answered in 2 hours 40 minutes: an average of one minute per question. The earlier format had 200 questions over 3 hours 10 minutes.
How are questions distributed across the domains?
Clinical knowledge accounts for 80%, Evidence-based practice for 10%, and Primary care organisation and management issues for 10%: 128, 16 and 16 questions respectively. The blueprint states that therapeutics is tested across clinical knowledge in approximately one third of the paper. This guide's 48 clinical, 6 evidence and 6 organisation concepts are a selective teaching allocation.
Introducing the AKT · MRCGP Applied Knowledge Test (AKT) Blueprint
Where and how is the AKT delivered?
It is a computer-based assessment delivered at Pearson test centres across the UK. The introduction describes examinations in January, April, July and October.
Which question styles should candidates prepare for?
The introduction describes single-best-answer style questions. The preparation page lists mainly single best answers, alongside multiple best answers, free text and extended matching questions. Use the official examples and platform tutorial to become familiar with the formats. The questions here are four-option single-best-answer drills.
Is a separate scored-versus-pretest question count published in the cited guidance?
The current introduction and blueprint specify 160 questions without a separate scored-versus-pretest breakdown.
Introducing the AKT · MRCGP Applied Knowledge Test (AKT) Blueprint
Which curriculum and format changes apply?
The RCGP GP Curriculum 2025 was implemented on 1 August 2025. The examination-format change took effect separately in October 2025. The current linked AKT Blueprint displays no publication date, version number or effective date.
GP curriculum · The RCGP Curriculum Topic Guides 2025 · MRCGP Applied Knowledge Test (AKT) Blueprint · Introducing the AKT
How should supplementary topic lists be used?
Use them to identify subjects for study while taking examination proportions from the current blueprint. The Data Interpretation document describes topics through September 2024 and retains the historical equation of 10% with 20 questions. The organisation list also describes historical examples, although it states 16 questions. Neither replaces the full curriculum and blueprint.
Data Interpretation · Primary care organisation and management issues · MRCGP Applied Knowledge Test (AKT) Blueprint
When can candidates take the examination?
Candidates may take the AKT during or after ST2 of GP training. Preparation should reflect applied knowledge for independent UK general practice within the NHS.
The AKT is a postgraduate assessment of knowledge supporting independent NHS general practice in the UK and forms one component of MRCGP. This guide addresses that component rather than the whole qualification.
Outline used: RCGP GP Curriculum 2025, implemented from 1 August 2025, together with the current linked MRCGP AKT Blueprint, which displays no publication or effective date. The current examination format took effect in October 2025. Verified on 10 October 2026. The workbook's expanded membership label maps to the Applied Knowledge Test component of MRCGP; the assigned canonical slug is preserved.
60 key concepts: understand, apply and avoid the traps
Work through the questions by exam domain. Explain the answer in your own words, try the example, then check the common pitfall.
Clinical knowledge80%
1.How is sustained hypertension distinguished from an isolated clinic elevation, and when does severe hypertension require a different pathway?
For routine confirmation when clinic systolic pressure is below 180 and diastolic pressure below 120 mmHg, clinic systolic ≥140 or diastolic ≥90 mmHg should be accompanied by daytime ambulatory blood pressure monitoring (ABPM) or structured home blood pressure monitoring (HBPM) averaging systolic ≥135 or diastolic ≥85 mmHg. Offer ABPM first; use HBPM if ABPM is unsuitable or not tolerated. Either component can meet its threshold. Clinic systolic ≥180 or diastolic ≥120 mmHg requires prompt assessment for target-organ damage. With retinal haemorrhage, papilloedema or life-threatening symptoms, arrange same-day specialist assessment. Without these referral features, investigate target-organ damage as soon as possible; if identified, consider immediate antihypertensive treatment without awaiting ABPM or HBPM. If no damage is identified, confirm through repeat clinic measurement within seven days, or ABPM/HBPM with clinical review within seven days.
Apply it
Clinic pressure of 146/92 mmHg and a valid home average of 137/87 mmHg meet the routine diagnostic criteria. A reading of 184/108 mmHg enters the severe pathway because the systolic component alone qualifies. Assess symptoms, examine the fundi, and investigate renal and cardiac damage using urine albumin:creatinine ratio, haematuria testing, creatinine/eGFR and ECG. Papilloedema requires same-day specialist assessment even if the person reports feeling well.
Common pitfall: Do not make out-of-office confirmation an absolute prerequisite for treating severe hypertension. Absence of symptoms does not exclude target-organ damage. Conversely, a severe reading without referral features or identified damage requires confirmation and timely review, rather than automatically establishing a hypertensive emergency. Use the daytime ABPM average for routine diagnosis; diagnostic thresholds differ from treatment targets.
Recommendations | Hypertension in adults: diagnosis and management | Guidance | NICE · hypertension-in-adults-diagnosis-and-management-pdf-66141722710213.pdf
2.What makes an out-of-office blood pressure average representative?
Diagnostic ABPM should take at least two measurements per hour during usual waking hours and use the average of at least 14 waking measurements. For HBPM, take two seated measurements at least one minute apart, morning and evening, for at least four days and ideally seven. Discard the first day's measurements and average the remainder. A few selected readings cannot substitute for this structured average.
Apply it
A patient brings seven days of morning and evening paired readings. Exclude day one and average all remaining readings rather than choosing the lowest measurements.
Common pitfall: A single reassuring home measurement does not invalidate repeated clinic elevation; technique, sampling and averaging determine the result's usefulness.
Recommendations | Hypertension in adults: diagnosis and management | Guidance | NICE
3.How is initial antihypertensive treatment selected?
When step 1 treatment is indicated, offer an ACE inhibitor or ARB to adults with type 2 diabetes of any age or family origin, and to adults under 55 who are not of Black African or African-Caribbean family origin. Offer a calcium-channel blocker to adults aged 55 or over without type 2 diabetes, or adults of Black African or African-Caribbean family origin without type 2 diabetes. Prefer an ARB over an ACE inhibitor when choosing renin–angiotensin treatment for Black African or African-Caribbean adults. Disease-specific indications and pregnancy can alter the choice.
Apply it
A 62-year-old without diabetes or a competing disease-specific indication starts a calcium-channel blocker. A troublesome ACE-inhibitor cough supports switching to an ARB.
Common pitfall: Do not combine an ACE inhibitor with an ARB for hypertension. Check diabetes, comorbidity and pregnancy circumstances before using age alone.
Recommendations | Hypertension in adults: diagnosis and management | Guidance | NICE
4.How should suspected atrial fibrillation be investigated?
An irregular pulse raises suspicion but requires a 12-lead ECG for confirmation. A normal ECG between episodes does not exclude paroxysmal AF. Use a 24-hour ambulatory ECG if asymptomatic episodes are suspected or symptomatic episodes occur less than 24 hours apart. If symptomatic episodes are more than 24 hours apart, choose longer monitoring or an event recorder appropriate to their frequency. Match monitoring duration to the chance of capturing an episode.
Apply it
Palpitations occurring once a fortnight with a normal resting ECG are better investigated with a suitably prolonged recording than a single repeat ECG between episodes.
Common pitfall: Pulse irregularity is a detection clue, not sufficient evidence for a permanent rhythm diagnosis. A recording without an episode may leave intermittent disease unresolved.
Recommendations | Atrial fibrillation: diagnosis and management | Guidance | NICE
5.How does CHA2DS2-VASc guide an anticoagulation decision?
CHA2DS2-VASc assigns one point each for heart failure, hypertension, diabetes, vascular disease, age 65–74 and female sex; age at least 75 and previous stroke, TIA or systemic embolism score two each. Offer a DOAC at a score of at least 2 and consider one for men scoring 1, accounting for bleeding risk, drug suitability and preferences. Sex alone in someone under 65 does not justify anticoagulation. Rate or rhythm symptom control does not replace stroke prevention.
Apply it
A 67-year-old man with AF, hypertension and diabetes scores 3: age 1, hypertension 1 and diabetes 1. Offer anticoagulation after discussing benefits, bleeding risk, contraindications and practical medicine choice.
Common pitfall: Do not substitute aspirin monotherapy for AF stroke prevention or withhold anticoagulation solely because of age or falls risk.
Recommendations | Atrial fibrillation: diagnosis and management | Guidance | NICE
6.How should ORBIT and interacting medicines affect AF treatment?
Use ORBIT to assess bleeding risk when starting or reviewing anticoagulation. Its factors include older age, reduced haemoglobin or anaemia, bleeding history, impaired kidney function and antiplatelet treatment. The result supports shared decisions and risk reduction rather than an automatic treatment cutoff. Address uncontrolled pressure, reversible anaemia, harmful alcohol intake and concurrent medicines. NSAIDs and antiplatelets can add clinically important bleeding risk to anticoagulation.
Apply it
A patient eligible for a DOAC also takes regular ibuprofen. Review the need for the NSAID and safer pain management while discussing anticoagulation.
Common pitfall: A high bleeding score does not by itself prohibit anticoagulation, and a low score does not remove the need to review interacting medicines.
Recommendations | Atrial fibrillation: diagnosis and management | Guidance | NICE
7.How does NT-proBNP guide suspected chronic heart failure referral?
In suspected chronic heart failure, NT-proBNP above 2,000 ng/L warrants urgent specialist assessment and echocardiography within two weeks. A result from 400 to 2,000 ng/L warrants assessment within six weeks. The peptide helps prioritise investigation; it does not establish the underlying structural abnormality or distinguish reduced from preserved ejection fraction. Acute instability requires immediate assessment rather than waiting for an outpatient pathway.
Apply it
A stable patient with progressive breathlessness and NT-proBNP of 2,700 ng/L needs the two-week assessment pathway, including cardiac imaging and specialist assessment.
Common pitfall: A high biomarker is neither a complete diagnosis nor a reason to overlook current respiratory or circulatory deterioration.
Recommendations | Chronic heart failure in adults: diagnosis and management | Guidance | NICE
8.Which factors modify the interpretation of a low NT-proBNP?
Below 400 ng/L in an untreated person makes chronic heart failure less likely. Obesity and treatment with diuretics, ACE inhibitors, ARBs, ARNIs, beta-blockers or MRAs can lower peptide levels. Renal and other systemic disorders can raise them. Review alternative causes when the result is low, but discuss persistent credible suspicion with a heart failure specialist. The result changes probability rather than proving that the heart is normal.
Apply it
An obese patient taking a diuretic remains breathless despite NT-proBNP of 290 ng/L. Reassess the clinical evidence and alternative causes.
Common pitfall: Less likely is not impossible, and an elevated result cannot be translated directly into the severity of ventricular dysfunction.
Recommendations | Chronic heart failure in adults: diagnosis and management | Guidance | NICE
9.What treatment and monitoring principles apply to reduced-ejection-fraction heart failure?
Offer an ACE inhibitor, beta-blocker, MRA and SGLT2 inhibitor when suitable, tailoring introduction to symptoms, blood pressure, renal function, frailty and preferences. Before an ACE inhibitor, ARB, ARNI or MRA, measure renal function and electrolytes; repeat one to two weeks after starting and after each dose increase, then every three to six months once the maximum tolerated dose is established. Recheck whenever renal function may be compromised. A switch from an ACE inhibitor to an ARNI requires at least 36 hours between doses.
Apply it
After increasing ramipril for stable heart failure, arrange renal function and electrolytes in one to two weeks and assess blood pressure around titration.
Common pitfall: Symptomatic improvement does not replace biochemical monitoring. Avoid overlapping ACE-inhibitor and ARNI treatment.
Recommendations | Chronic heart failure in adults: diagnosis and management | Guidance | NICE
10.How is post-bronchodilator spirometry interpreted in suspected COPD?
In a compatible clinical context, post-bronchodilator FEV1/FVC below 0.7 supports persistent airflow obstruction and COPD. Consider symptoms and exposure, usually in someone over 35 with smoking or another relevant risk. A fixed ratio can misclassify age extremes: reconsider alternatives in older people below 0.7 without typical symptoms, and consider COPD in symptomatic younger people even above 0.7. FEV1 percentage predicted grades obstruction after the obstructive pattern is established.
Apply it
A 60-year-old smoker with chronic sputum and progressive breathlessness has post-bronchodilator FEV1/FVC 0.62 and FEV1 65% predicted: compatible with COPD and moderate airflow obstruction.
Common pitfall: Do not diagnose COPD from smoking alone or mistake FEV1 percentage predicted for the FEV1/FVC ratio.
11.Why can a chest radiograph help without confirming COPD?
Chest radiography helps exclude alternative pathology but does not directly measure airflow obstruction. At initial COPD evaluation, radiography, full blood count and BMI complement spirometry. A normal image does not exclude obstructive physiology. Chest pain or haemoptysis should prompt consideration of another diagnosis rather than automatic attribution to COPD. Incidental emphysema on imaging should prompt respiratory review and consideration of spirometry.
Apply it
A patient with chronic sputum and exertional breathlessness still needs post-bronchodilator spirometry after a normal radiograph; investigate additional symptoms according to their own clinical significance.
Common pitfall: Structural imaging and physiological testing answer different questions. Neither a normal image nor a smoking history supplies the missing measurement of airflow.
12.How do symptoms and steroid responsiveness guide COPD inhaler escalation?
For confirmed COPD with persistent breathlessness or exacerbations despite short-acting bronchodilation, smoking treatment and optimised non-drug care, offer LAMA plus LABA when asthmatic features are absent. Consider LABA plus ICS when asthmatic features or steroid responsiveness are present. ICS carries a pneumonia risk. Before triple therapy, check that continuing symptoms or exacerbations are actually due to COPD and that other management is optimised.
Apply it
A patient without asthmatic features remains breathless despite appropriate initial management: LAMA plus LABA is preferable to adding ICS automatically.
Common pitfall: Wheeze alone does not establish asthma, and escalating inhalers will not correct breathlessness caused mainly by heart failure or another condition.
13.What is the current adult asthma diagnostic sequence?
With a suggestive history, first measure blood eosinophils or FeNO: diagnose asthma if eosinophils exceed the laboratory reference range or FeNO is at least 50 ppb. If unconfirmed, use spirometry with bronchodilator reversibility: FEV1 must rise at least 12% and 200 mL from baseline, or at least 10% of predicted normal FEV1. If spirometry is delayed, twice-daily PEF for two weeks can support diagnosis when variability is at least 20%. Persistent uncertainty warrants consideration of bronchial challenge.
Apply it
An adult with variable nocturnal wheeze, normal eosinophils and FeNO 28 ppb has FEV1 increasing from 2.0 to 2.3 L: a 15% and 300 mL rise meets reversibility criteria.
Common pitfall: A normal examination or first test does not exclude variable asthma. ICS treatment can make FeNO and spirometry more likely to appear normal.
14.Why should inhaler technique and adherence be checked before escalation?
An inhaled medicine needs effective delivery to the airways. Observe the patient using each device and spacer, review prescription records and actual use, and address smoking, exposures and comorbidities before adjusting treatment. If the person cannot use the device correctly, choose a suitable alternative. A metered-dose inhaler usually requires a spacer. Review response eight to twelve weeks after starting or changing asthma medicines.
Apply it
A stable patient with worsening control repeatedly fails to coordinate actuation and inhalation. Correct delivery and reassess control before assuming a higher drug dose is needed.
Common pitfall: Collecting prescriptions establishes supply, not adherence or correct delivery. Verbal confidence is insufficient evidence of device competence.
15.How do AIR and MART guide asthma prescribing?
AIR uses a suitable low-dose ICS/formoterol inhaler as needed; MART uses a suitable ICS/formoterol inhaler for both scheduled maintenance and relief. For newly diagnosed asthma from age 12, offer as-needed AIR; start low-dose MART when presentation is highly symptomatic, such as regular nocturnal waking, or involves a severe exacerbation alongside acute treatment. Uncontrolled asthma on AIR supports low-dose MART after addressing technique and adherence. Check the product, dose, device and licensed indication.
Apply it
A newly diagnosed adult with infrequent symptoms can start suitable as-needed AIR; regular nocturnal symptoms support low-dose MART.
Common pitfall: Do not prescribe SABA without concomitant ICS or assume every ICS/LABA combination can serve as a reliever.
16.When is an asthma attack an emergency?
Assess adult attacks using objective measurements and clinical signs. Peak expiratory flow (PEF) of 33–50% of personal best, or predicted if recent best is unknown, or inability to complete sentences in one breath supports acute severe asthma. Life-threatening features include PEF below 33%, oxygen saturation below 92%, silent chest, poor respiratory effort, exhaustion or altered consciousness; cyanosis, arrhythmia and hypotension are additional warning signs. Any life-threatening feature requires immediate emergency escalation and treatment without waiting for investigations. In primary care, arrange emergency ambulance transfer while starting treatment. Immediate treatment includes oxygen targeting saturation of 94–98%, inhaled salbutamol and ipratropium, and systemic corticosteroids. Hospital management requires urgent senior and intensive-care involvement when life-threatening features are present. Obtain arterial blood gases alongside treatment when indicated; investigations must not postpone treatment.
Apply it
An adult with asthma appears calm and has little audible wheeze, but their PEF is 150 L/min against a personal best of 500 L/min and oxygen saturation is 91% on air. Their PEF is 30% of best, and both measurements independently indicate life-threatening features. Arrange emergency transfer and begin immediate treatment despite limited apparent distress. By comparison, PEF of 40% with inability to complete sentences indicates acute severe asthma requiring urgent hospital care, even without a life-threatening feature.
Common pitfall: Little apparent distress does not exclude a dangerous attack. A silent chest can reflect critically reduced airflow rather than improvement, while exhaustion can reduce respiratory effort. Judge severity by the worst feature present; do not require every abnormality or delay emergency care to obtain PEF from someone unable to perform it.
Asthma · GGC Medicines - Management of Acute Severe Asthma in Adults in Hospital
17.How should an adult's hypoglycaemia be treated when swallowing is safe?
For a fully conscious adult able to swallow safely, give 15–20 g of rapid-acting carbohydrate immediately. Recheck glucose after 10–15 minutes and repeat treatment if it remains below 4 mmol/L. Once glucose is above 4 mmol/L and the person has recovered, use the next meal or, if it is more than an hour away, a snack containing 15–20 g of slow-release carbohydrate. Persistent hypoglycaemia after repeated treatment needs medical help.
Apply it
An alert insulin user with glucose 3.2 mmol/L receives 15–20 g rapid carbohydrate, followed by a timed recheck and repeat treatment if still below 4 mmol/L.
Common pitfall: A slow-release snack alone may act too slowly; symptom improvement does not replace a glucose recheck.
How to treat hypoglycaemia | Kent Community Health NHS Foundation Trust
18.Why does reduced consciousness change hypoglycaemia treatment?
Reduced consciousness impairs swallowing and airway protection, making oral food, drinks and glucose unsafe. Call emergency services and give nothing by mouth. Available glucagon may be administered by someone who knows how to use it, alongside appropriate immediate care. Route safety depends on consciousness and swallowing rather than the glucose number alone. The usual oral carbohydrate sequence becomes appropriate only after recovery sufficient for safe swallowing.
Apply it
An unresponsive insulin user with a low glucose needs emergency assistance and airway-safe treatment; a trained relative can use the available glucagon kit.
Common pitfall: Oral glucose gel is not an airway-safe substitute when swallowing is impaired. Its consistency does not remove the risk associated with administering material by mouth.
19.What should be reviewed after recurrent hypoglycaemia?
Repeated episodes suggest a continuing mismatch between glucose-lowering treatment and food, activity or alcohol exposure. Review timing, missed meals, exercise, medicine use and awareness of warning symptoms. Episodes requiring help or loss of warning symptoms are particularly important. Establish what happened before each episode and how it was treated. Correcting each low glucose without reviewing its cause leaves the recurrence mechanism in place.
Apply it
Repeated pre-lunch episodes after increased morning exercise prompt review of breakfast, activity and diabetes treatment, including whether the person still recognises early symptoms.
Common pitfall: Do not assume recurrent events are simply dietary mistakes or a necessary cost of treatment. Successful rescue treatment does not demonstrate that the regimen remains suitable.
20.What does eGFR contribute to kidney assessment?
eGFR estimates filtration and must be interpreted with previous results, clinical state and urine findings. An eGFR of at least 60 mL/min/1.73 m² does not exclude CKD when persistent markers of kidney damage are present. G3a is 45–59, G3b 30–44 and G4 15–29. These categories describe stable kidney function; acute deterioration needs separate assessment. Classification therefore requires both the numerical category and evidence about duration and stability.
Apply it
Persistent albuminuria remains significant with eGFR 78; eGFR 50 falls in G3a if the abnormality is chronic.
Common pitfall: A single estimate neither proves chronicity nor captures every dimension of kidney health. Review the trajectory before interpreting a category as stable disease.
21.How does ACR complement eGFR?
Urine albumin-to-creatinine ratio measures albumin leakage while accounting for urine concentration. A1 is below 3, A2 is 3–30 and A3 is above 30 mg/mmol. Combining filtration and albuminuria improves classification and risk assessment because leakage and clearance describe different abnormalities. The four-variable Kidney Failure Risk Equation uses age, sex, eGFR and ACR in CKD G3a–G5.
Apply it
Persistent eGFR 50 with ACR 35 mg/mmol is G3aA3, rather than a classification based on filtration alone.
Common pitfall: Do not interchange ACR and eGFR thresholds or assume identical eGFR means identical renal risk. ACR also contributes information relevant to treatment and referral.
Chronic kidney disease — Diagnosis · CKD staging | UK Kidney Association
22.How is chronic kidney disease separated from acute deterioration?
CKD requires abnormalities of kidney function or structure lasting more than three months. An eGFR below 60 on at least two occasions 90 days apart can establish chronic reduced filtration. A first abnormal result in a well patient without worrying features generally needs repeat testing within 14 days to establish stability. Acute illness, rapidly falling function, hyperkalaemia or possible obstruction requires faster assessment. Review potentially nephrotoxic and over-the-counter medicines, especially NSAIDs.
Apply it
A dehydrated patient with a first low eGFR needs assessment for acute kidney dysfunction and comparison with prior results.
Common pitfall: The three-month chronicity requirement is not permission to postpone assessment of an acute abnormality.
23.What gluten exposure is needed before coeliac testing?
Tests depend on gluten-driven immune and intestinal changes. Advise someone eating a normal diet to consume some gluten in more than one meal every day for at least six weeks before testing, and continue gluten during the diagnostic process until specialist confirmation. If someone cannot or will not reintroduce gluten, refer for specialist assessment and explain that confirming the diagnosis may be difficult.
Apply it
A patient planning a gluten-free diet before serology should understand that restriction can make blood tests and biopsy falsely reassuring, potentially complicating later confirmation.
Common pitfall: Improvement on gluten avoidance does not independently diagnose coeliac disease. A positive antibody result also does not justify abandoning the planned specialist diagnostic assessment.
Recommendations | Coeliac disease: recognition, assessment and management | Guidance | NICE
24.Which antibody tests should be requested initially for suspected coeliac disease?
Request total IgA and IgA tissue transglutaminase as the initial tests. If IgA tTG is weakly positive, use IgA endomysial antibodies. If total IgA is deficient, consider IgG EMA, IgG deamidated gliadin peptide or IgG tTG. Measuring total IgA identifies patients in whom an IgA-based result may be misleading. Antibody interpretation also depends on adequate gluten exposure throughout the diagnostic process.
Apply it
A patient with negative IgA tTG and very low total IgA needs appropriate IgG-based testing rather than interpretation of the IgA result alone.
Common pitfall: Negative IgA tTG cannot provide its usual reassurance when the patient is IgA deficient. Repeating only the same IgA test does not correct that limitation.
Recommendations | Coeliac disease: recognition, assessment and management | Guidance | NICE
25.When should negative coeliac serology fail to end investigation?
Check whether the patient had adequate gluten exposure and whether IgA deficiency affected testing. Even valid negative serology does not end assessment when clinical suspicion persists: refer to a gastrointestinal specialist. Persistent unexplained diarrhoea, weight loss or nutrient deficiency can sustain concern. A negative test reduces probability under appropriate conditions; it does not establish another diagnosis or explain continuing abnormalities.
Apply it
Persistent diarrhoea and iron deficiency despite negative IgA tTG warrant review of diet, total IgA and specialist referral when suspicion remains.
Common pitfall: Do not diagnose a functional bowel disorder solely because a coeliac screening result is negative. The unresolved clinical findings still need a coherent explanation.
Recommendations | Coeliac disease: recognition, assessment and management | Guidance | NICE
26.How do presentation and biopsy contribute to coeliac diagnosis?
Coeliac disease can present with unexplained iron, B12 or folate deficiency, fatigue or other extraintestinal features without dramatic diarrhoea. Serology detects an associated immune response; intestinal biopsy assesses tissue changes. NICE recommends specialist referral for young people and adults with positive serology for endoscopic intestinal biopsy to confirm or exclude disease. Maintain gluten during that pathway so that dietary restriction does not undermine interpretation.
Apply it
An adult with iron deficiency and positive tTG still needs specialist diagnostic assessment rather than cancelling referral after starting a gluten-free diet.
Common pitfall: Neither absent bowel symptoms nor symptomatic dietary improvement should replace a valid diagnostic pathway. Different tests assess related but distinct features of disease.
Recommendations | Coeliac disease: recognition, assessment and management | Guidance | NICE
27.When does persistent synovitis require urgent referral?
Refer any adult with suspected persistent synovitis of undetermined cause for specialist opinion. Refer urgently if small hand or foot joints are affected, more than one joint is affected, or at least three months elapsed between symptom onset and seeking advice. Normal inflammatory markers, negative rheumatoid factor or negative anti-CCP must not delay referral. Investigations may accompany referral but must not precede it as a requirement.
Apply it
Several swollen small hand joints and prolonged morning stiffness require urgent rheumatology referral despite negative rheumatoid factor.
Common pitfall: Waiting for positive antibodies or radiographs can delay treatment of seronegative inflammatory arthritis. Clinical swelling remains significant when supporting blood tests are normal.
Recommendations | Rheumatoid arthritis in adults: management | Guidance | NICE
28.How do disease-modifying treatment and symptom treatment differ in rheumatoid arthritis?
Early specialist treatment aims for remission or low disease activity, using conventional DMARDs such as methotrexate, leflunomide or sulfasalazine. NSAIDs can reduce pain and stiffness but do not replace this strategy. If an oral NSAID is used, choose the lowest effective dose for the shortest time, offer a PPI and review gastrointestinal, cardiovascular and renal risks. Short-term glucocorticoids can provide bridging or flare treatment rather than indefinite sole therapy.
Apply it
Pain improvement on an NSAID does not justify postponing urgent referral or disease-modifying treatment.
Common pitfall: Symptom relief is not evidence that joint damage risk has been controlled. Treatment goals include sustained disease control and preservation of function.
Recommendations | Rheumatoid arthritis in adults: management | Guidance | NICE
29.How does functional assessment improve rheumatoid arthritis care?
Ask about dressing, gripping, walking, work and other valued activities. Functional ability supplies a baseline for treatment response and can reveal disability missed by pain ratings or inflammatory markers. At annual review, assess activity, damage, function and comorbidity. Occupational therapy is relevant when hand function or everyday activities are impaired. A structured measure such as the Health Assessment Questionnaire can support comparison over time.
Apply it
A patient reporting modest pain but inability to fasten buttons has a meaningful functional deficit that needs recording and support.
Common pitfall: A low pain score or normal blood result cannot establish that daily functioning is satisfactory. Ask what the patient can actually do.
Recommendations | Rheumatoid arthritis in adults: management | Guidance | NICE
30.Which symptom cluster suggests giant cell arteritis?
In an older adult, new headache, scalp tenderness and jaw pain during chewing raise concern for giant cell arteritis. Arterial inflammation can compromise ocular blood supply. Ask directly about blurred vision, double vision and sight loss; shoulder and hip girdle stiffness may suggest associated polymyalgia rheumatica. The potential harm depends on vascular compromise rather than headache intensity, so a relatively modest headache does not remove the need for urgent assessment.
Apply it
A new temporal headache with pain when brushing the hair and chewing warrants urgent assessment and explicit questioning about current or recent visual disturbance.
Common pitfall: Do not require every classic feature or severe headache before considering this diagnosis. Associated stiffness should strengthen the overall assessment rather than distract from visual risk.
31.Why may giant cell arteritis treatment precede confirmation?
Strong clinical suspicion warrants prompt steroid treatment because delayed control of arterial inflammation can cause irreversible visual injury. Biopsy or imaging remains important, but arranging confirmation must not create a harmful delay. The decision combines the credibility of the symptom pattern with the consequences of waiting. It does not require that visual loss has already occurred before treatment and specialist assessment begin.
Apply it
An older patient with new temporal headache, scalp tenderness and jaw claudication needs urgent assessment and prompt treatment even if confirmatory testing is unavailable that day.
Common pitfall: Diagnostic certainty should not be pursued at the cost of preventable loss of sight. Symptomatic headache relief does not treat the underlying arterial inflammation.
32.What do visual symptoms add to suspected giant cell arteritis?
Blurred vision, double vision or loss of sight in suspected giant cell arteritis can indicate threatened ocular blood supply. These symptoms require immediate attention and same-day specialist eye assessment, alongside prompt steroid treatment through the urgent arteritis pathway. A transient episode remains significant even when vision appears normal during consultation because recovery does not establish that arterial inflammation or the threat to sight has resolved.
Apply it
An older patient with jaw claudication reports blurred vision earlier that morning. Record its timing and nature, and arrange same-day urgent assessment without waiting for biopsy confirmation.
Common pitfall: Do not downgrade urgency because the visual disturbance was brief, painless or has recovered. The purpose of immediate action is to prevent irreversible visual injury.
33.How are transient focal neurological symptoms distinguished from active stroke?
Sudden facial weakness, unilateral limb weakness or speech disturbance suggests a vascular neurological event. Fully resolved symptoms can represent TIA; ongoing or recurrent deficits require emergency stroke action. Exclude hypoglycaemia as a potential mimic without delaying urgent care. Establish the onset, duration, recovery and any recurrence because these details determine the immediate pathway. A normal examination after recovery does not invalidate a convincing history.
Apply it
Resolved unilateral weakness needs urgent TIA management; weakness recurring during the consultation requires immediate emergency escalation and communication of the symptom timeline.
Common pitfall: Do not equate a normal current examination with absence of a significant earlier event. A short episode still requires urgent assessment rather than reassurance alone.
34.What immediate management is required for suspected TIA?
Start aspirin 300 mg daily immediately unless contraindicated, and refer immediately for specialist assessment and investigation within 24 hours of symptom onset. Do not use ABCD2 or similar scores to determine referral urgency. These initial TIA measures apply to resolved symptoms; active suspected stroke follows the emergency pathway, where antiplatelet treatment depends on assessment and exclusion of intracranial haemorrhage.
Apply it
After a fully resolved episode of focal weakness three hours ago, give aspirin 300 mg if suitable and arrange assessment within 24 hours of onset.
Common pitfall: A low ABCD2 score must not justify delayed referral, and routine imaging should not delay initial suspected-TIA care.
35.How does investigation refine prevention after TIA?
Assessment seeks the mechanism, including AF, carotid disease and other vascular risk factors. Do not routinely request CT brain imaging for suspected TIA unless an alternative diagnosis detectable by CT is suspected. After specialist assessment, MRI may clarify ischaemic territory or alternative pathology; potential carotid endarterectomy candidates need urgent carotid imaging. Prevention then addresses the findings as well as blood pressure, lipids and lifestyle.
Apply it
A recovered patient needs cause-directed assessment rather than assuming smoking cessation alone completes prevention. ECG findings or carotid imaging may identify additional treatment priorities.
Common pitfall: A TIA is an event description, not proof that every patient has the same underlying vascular mechanism.
Recommendations | Stroke and transient ischaemic attack in over 16s: diagnosis and initial management | Guidance | NICE · Transient ischaemic attack (TIA) - Diagnosis - NHS
36.When should ectopic pregnancy be considered without a positive test?
Possible pregnancy with unilateral lower abdominal pain, vaginal bleeding or a missed period should raise concern for ectopic pregnancy. Symptoms can develop before someone knows they are pregnant. A previously positive home test is not required before seeking assessment. Bleeding may be mistaken for an unusual period, so establish its timing and character alongside pregnancy possibility and pain. Assess urgency from the whole presentation, including faintness or severe pain.
Apply it
A late period, one-sided pelvic pain and spotting need assessment for a pregnancy complication even when no home test has been taken.
Common pitfall: Unknown pregnancy status should prompt assessment rather than exclude pregnancy-related disease. Apparent menstrual bleeding does not reliably settle the diagnosis.
37.Which features suggest ruptured ectopic pregnancy?
Sudden severe abdominal pain, faintness, collapse or marked pallor in someone who could be pregnant can indicate rupture and internal bleeding. Arrange emergency assistance. Visible vaginal bleeding may be slight because major blood loss can occur internally. Do not delay escalation for a home test or routine outpatient confirmation. Shoulder-tip pain adds concern because blood in the abdomen can irritate the diaphragm.
Apply it
Severe pain and collapse after a missed period and light spotting require emergency hospital care, even when the person has not previously confirmed pregnancy.
Common pitfall: The volume of visible bleeding cannot be used to estimate internal haemorrhage. A routine early-pregnancy appointment does not address suspected current rupture.
38.Why is shoulder-tip pain relevant to possible ectopic pregnancy?
Blood leaking into the abdomen can irritate the diaphragm and produce referred shoulder-tip pain. In a possible pregnancy, especially with abdominal pain or faintness, this can indicate internal bleeding. Its significance comes from the reproductive and systemic context rather than a local shoulder abnormality. Assess accompanying pain, bleeding, missed periods and collapse symptoms to recognise the urgent abdominal problem.
Apply it
A patient with pelvic pain and a late period mentions new shoulder-tip pain without injury. Escalate assessment for a pregnancy complication, with emergency assistance if severe pain or faintness suggests rupture.
Common pitfall: A normal shoulder examination does not exclude referred pain from abdominal pathology. Do not let the location of discomfort distract from the associated reproductive symptoms.
39.Which infant fever thresholds require urgent assessment?
A temperature of at least 38°C in an infant under three months requires urgent medical advice or assessment. At three to six months, at least 39°C is an important urgent threshold. These supplement assessment of breathing, consciousness, hydration and appearance; danger signs require action at any temperature. Establish the baby's exact age because applying the older-infant threshold to a younger baby can delay care.
Apply it
A seven-week-old with temperature 38.1°C needs urgent assessment despite preserved feeding and absence of a rash.
Common pitfall: Do not apply the older-infant threshold to a baby under three months. Apparent comfort or a fall in temperature after medicine does not cancel the age-specific concern.
40.Which findings in a febrile child require emergency action?
Difficulty breathing, difficulty waking, a non-blanching rash, abnormal colour or a first seizure are emergency warning features. Compromised breathing or consciousness matters more than the height of the fever. Do not wait to see whether an antipyretic improves the temperature before responding to these signs. A rash that does not fade under pressure is concerning in this context, but assessment should also consider the child's overall state.
Apply it
A difficult-to-wake child with a rash that does not fade under pressure needs emergency help even with only a moderate fever.
Common pitfall: A lower temperature cannot make dangerous accompanying signs reassuring. Waiting for a complete collection of warning features risks delaying action on an already serious finding.
41.What is the purpose of antipyretics in children?
Use suitable paracetamol or ibuprofen for distress or discomfort, following age-appropriate instructions. The purpose is comfort rather than forcing temperature into a normal range. Do not give aspirin to children under 16. A response to fever medicine does not establish that the underlying illness is harmless. Continue to assess behaviour, breathing, fluid intake and other warning features independently of the thermometer reading.
Apply it
A comfortable child with continuing fever does not need repeated additional medicines solely to normalise the thermometer; provide fluids and watch for changes in clinical condition.
Common pitfall: A falling temperature is not a test that excludes serious illness. Medication must not postpone assessment when age thresholds or emergency signs are present.
42.How does hydration assessment change fever advice?
Assess fluid intake and urine output over time. Offer regular fluids and continue breastfeeding when applicable. Fewer wet nappies, sunken eyes or absent tears may indicate dehydration and warrant medical advice. Appetite for solids is less informative than the ability to maintain fluids and urine output. Ask about the pattern across the illness rather than relying on what the child drinks during a brief consultation.
Apply it
A febrile toddler drinking very little with markedly fewer wet nappies needs assessment for dehydration, even if they accept a small drink while being observed.
Common pitfall: Accepting one drink does not establish adequate hydration over the preceding day. Fever advice should include observable changes in intake and output that require reassessment.
43.How does the weighted seven-point checklist determine melanoma referral?
For a suspicious pigmented lesion, refer through a suspected cancer pathway at a weighted checklist score of at least 3. Major features score 2 each: change in size, irregular shape and irregular colour. Minor features score 1 each: largest diameter at least 7 mm, inflammation, oozing and change in sensation. Refer if dermoscopy suggests melanoma regardless of the checklist total.
Apply it
A 4 mm lesion with irregular shape and irregular colour scores 4 and requires a suspected cancer pathway referral, even without pain or bleeding.
Common pitfall: Small diameter does not negate points for major suspicious features. Calculate the weighted score rather than simply counting the number of features.
44.Which melanoma presentations challenge a diameter-only rule?
Melanoma can be smaller than familiar size thresholds and can occur beneath a nail. Evaluate a small evolving lesion or persistent unexplained nail pigmentation using its history and appearance. For pigmented skin lesions, apply the weighted checklist and dermoscopic findings where appropriate rather than using diameter as an exclusion rule. Change, irregularity and an appearance different from the person's other lesions can be important.
Apply it
A changing small lesion or new persistent nail streak without an adequate explanation needs assessment; neither can be dismissed by size or site.
Common pitfall: Do not automatically attribute persistent nail pigment to unnoticed trauma. Size is one observation within assessment, not a guarantee that a lesion is benign.
Symptoms of melanoma skin cancer · Recommendations organised by site of cancer | Suspected cancer: recognition and referral | Guidance | NICE
45.How can nodular or amelanotic melanoma present?
Melanoma may have little pigment and appear pink, red or skin-coloured. Nodular melanoma may lack conventional ABCD features; elevation, firmness and sustained growth are useful warning cues. Consider a suspected cancer pathway referral for a pigmented or non-pigmented lesion suggesting nodular melanoma. A low pigmented-lesion checklist score must not dismiss this different presentation, especially when the lesion continues to grow.
Apply it
A firm pink nodule showing sustained growth and bleeding warrants urgent melanoma consideration despite lacking dark pigment or an irregular flat outline.
Common pitfall: Colour alone cannot establish benignity, and a nodular lesion need not resemble a flat irregular mole. Ask about growth and palpate the lesion's consistency.
Melanoma · Recommendations organised by site of cancer | Suspected cancer: recognition and referral | Guidance | NICE
46.Which symptoms distinguish kidney infection from uncomplicated cystitis?
Fever, flank or back pain, systemic illness and nausea or vomiting suggest upper urinary tract involvement. Dysuria and frequency may coexist but do not localise infection to the bladder. Recognising the systemic pattern changes assessment of severity and treatment setting. Ask whether fluids and medicines can be retained, whether the person is pregnant and whether their condition is deteriorating, because these findings affect the immediate management plan.
Apply it
Dysuria followed by fever, vomiting and pain beneath the ribs at the back should prompt assessment for kidney infection.
Common pitfall: Do not apply a simple lower-UTI model when systemic symptoms and flank pain are present. A familiar urinary symptom should not obscure a more serious accompanying pattern.
47.When does suspected kidney infection need more urgent assessment?
Pregnancy, significant systemic illness or inability to keep fluids and medicines down increases concern about complications or failure of oral treatment. Arrange urgent assessment and consider hospital care. Immediate deterioration requires escalation according to the patient's clinical state rather than waiting for urine results. The decision about setting must account for whether the proposed treatment can actually be taken and whether adequate hydration can be maintained.
Apply it
A pregnant patient with fever, flank pain and repeated vomiting needs urgent assessment and consideration of hospital treatment rather than an uncomplicated-cystitis pathway.
Common pitfall: A positive urine result identifies part of the problem but does not determine a safe care setting. Culture collection must not delay necessary escalation.
48.How should suspected mania change primary care management?
Markedly increased energy, reduced need for sleep, rapid speech, overconfidence and risky behaviour with functional impairment suggest mania. Arrange urgent specialist mental health assessment and assess self-harm, harm to others, neglect, spending, exploitation and driving risk; imminent danger requires emergency escalation. Review substances, medicines and physical differentials. In depressive presentations, ask about previous overactivity or disinhibition lasting at least four days. Stable intervals do not remove the need for relapse prevention, medication review and physical health monitoring.
Apply it
Eight days of little sleep without fatigue, escalating spending and inability to work require urgent specialist assessment, including review of recent antidepressant or substance exposure.
Common pitfall: Subjectively feeling well does not exclude serious impairment. Do not postpone referral until routine tests are completed or start lithium for the first time outside shared-care arrangements.
Recommendations | Bipolar disorder: assessment and management | Guidance | NICE
Evidence-based practice10%
49.How do study designs answer different clinical questions?
A randomised trial allocates an intervention and compares subsequent outcomes, supporting causal treatment inference when well conducted. A cohort starts with exposure groups and follows outcomes, allowing incidence and risk comparisons but remaining vulnerable to confounding. A case-control study starts with outcome status and compares prior exposures, useful for rare outcomes but not direct incidence estimation. A cross-sectional study measures exposure and outcome at a point in time, estimating prevalence with limited temporal inference.
Apply it
Following smokers and non-smokers for incident disease is a cohort; selecting people with disease and controls before comparing smoking histories is case-control.
Common pitfall: A large observational association does not gain the protection of randomisation merely because many participants were included.
50.How can selection bias inflate apparent diagnostic accuracy?
A diagnostic study comparing only severe disease with exceptionally healthy controls omits the borderline and competing presentations encountered in practice. This spectrum selection can exaggerate accuracy when the test is later used in an unselected symptomatic population. Increasing the sample size reduces random uncertainty but does not remove the systematic selection problem. Assess the intended-use population and whether all relevant patients received an appropriate reference standard.
Apply it
A test evaluated in advanced cancer versus healthy volunteers may perform less impressively among patients with mild symptoms and benign mimics.
Common pitfall: A narrow confidence interval around a biased estimate does not make the estimate valid for routine primary care.
51.How are sensitivity and specificity calculated?
Sensitivity is true positives divided by true positives plus false negatives: the proportion with disease who test positive. Specificity is true negatives divided by true negatives plus false positives: the proportion without disease who test negative. These calculations require an appropriate reference standard. Agreement with another imperfect test is not automatically diagnostic accuracy.
Apply it
If 90 of 100 diseased participants test positive and 180 of 200 disease-free participants test negative, sensitivity and specificity are both 90%, using different denominators.
Common pitfall: True positives divided by everyone testing positive is PPV, not sensitivity. Identify whether the denominator is defined by disease status or by the test result before calculating.
Statistical Guidance on Reporting Results from Studies Evaluating Diagnostic Tests - Guidance for Industry and FDA Staff | FDA · Principles of Epidemiology — Lesson 5, Appendix A
52.Why does prevalence affect positive predictive value?
PPV is true positives divided by all positive results. When prevalence is low, the large disease-free group can contribute many false positives even with reasonably high specificity. Thus the same sensitivity and specificity can produce different predictive values in different populations. A positive result may need confirmation rather than being treated as a definitive diagnosis.
Apply it
Among 1,000 people at 1% prevalence, 90% sensitivity and 90% specificity produce 9 true positives and 99 false positives: PPV is 9/108, approximately 8.3%.
Common pitfall: High sensitivity does not answer the patient's question about the probability of disease after a positive result. Keep the population's prior disease probability in view.
53.How should treatment effects, NNT and uncertainty be communicated?
Absolute risk reduction is control risk minus treatment risk; relative risk is treatment risk divided by control risk, and relative risk reduction is one minus that ratio. NNT is the reciprocal of absolute reduction expressed as a proportion and needs an outcome, comparator and time horizon. Confidence intervals show uncertainty: a risk-ratio interval of 0.60–1.20 includes benefit and harm because the null is 1. Crossing the null does not prove equivalence.
Apply it
Risk falling from 12% to 8% over two years gives ARR 4 percentage points, RR about 0.67, RRR about 33% and NNT 25 over two years.
Common pitfall: Do not take the reciprocal of a relative reduction or compare NNTs with different outcomes and follow-up periods as if they were interchangeable.
Cochrane Handbook — Chapter 15: Interpreting results and drawing conclusions
54.How should practice charts and audit results be interpreted?
Read the axis, units, denominator and time period before comparing bars or trends. If timely monitoring increases from 60/100 patients to 90/150, the count rises but the proportion remains 60%. Against an 80% audit standard, both periods fall short. A truncated vertical axis may magnify a small visual difference. A before-and-after change alone cannot establish that an intervention caused improvement because case mix and other changes may differ.
Apply it
A chart showing 60 then 90 completed reviews does not show a higher completion rate when the eligible population grew from 100 to 150.
Common pitfall: Do not confuse counts with rates, a target with an observed result, or temporal association with causation.
Primary care organisation and management issues10%
55.How should capacity, communication support and refusal be assessed together?
Assess capacity for the particular decision at the relevant time, using the applicable UK jurisdiction's law. Support communication first, then assess understanding, retention, use or weighing of information and communication of a decision. A diagnosis or an unwise outcome does not itself establish incapacity. A capacitous adult making a voluntary informed refusal can decline even life-preserving treatment; explore alternatives and document the discussion.
Apply it
After hearing support and an accessible explanation, a patient understands the consequences and declines according to their values. A relative's disagreement does not replace that decision.
Common pitfall: Do not infer incapacity from a communication barrier, a cognitive diagnosis or refusal of professional advice.
Decision making and consent — Circumstances that affect the decision-making process, part 3 · Decision making and consent — Circumstances that affect the decision-making process, part 2
56.How can relatives contribute information without gaining access to confidential records?
Listening to a relative's concerns differs from disclosing a patient's information. When a capacitous patient has refused family disclosure and no other justification applies, receive relevant concerns without providing a confidential update. Explain that information affecting care may need discussion with the patient; do not promise absolute secrecy. Family relationship alone does not establish access.
Apply it
A sibling can describe behavioural changes even when the patient has refused updates to that sibling. Maintain the disclosure boundary while considering how the information affects assessment.
Common pitfall: Confidentiality does not require refusing to listen, and accepting information does not imply permission to disclose. Even confirming a diagnosis can disclose confidential information.
Confidentiality — Using and disclosing patient information for direct care
57.How should a safeguarding concern change assessment of a household affected by bipolar disorder?
Identify children, young people and adults at risk of abuse or neglect who depend on, live with or care for the person. Assess actual care arrangements and unmet needs rather than inferring safety from the adult's presentation alone. Review the need for assessment through the relevant child or adult safeguarding procedures and offer psychological and social support. The concern is the dependent person's welfare, not the diagnostic label itself.
Apply it
During a manic episode, a parent cannot describe who is feeding or supervising a dependent child. Establish the child's current care and initiate safeguarding assessment through the relevant pathway.
Common pitfall: A mental health referral for the adult does not by itself establish that dependants' care needs have been assessed.
Recommendations | Bipolar disorder: assessment and management | Guidance | NICE
58.What service response is needed when a patient cannot use standard appointment information?
NHS organisations in England must follow the Accessible Information Standard for people with relevant disability or sensory communication needs. Identify the communication barrier and arrange information and support the person can use. Reasonable adjustments can include accessible documents, communication support, appointment length or physical access. An administrative process should enable informed participation rather than make standard print or digital access a condition of care.
Apply it
A patient with significant visual impairment repeatedly misses monitoring because standard appointment letters are inaccessible. Record the need and arrange a usable communication method and suitable support.
Common pitfall: Sending the same inaccessible letter again does not address the access failure. Do not assume this England-specific standard is one identical statutory scheme across the UK.
59.How does an audit become a quality-improvement cycle?
Define an explicit criterion, eligible population and standard; measure baseline performance; examine why care falls short; implement a targeted change; then repeat measurement using comparable definitions. Add a balancing measure when improvement could create another problem. For missed medicine monitoring, a recall system needs named responsibility and follow-up of non-response, not merely production of another patient list.
Apply it
An illustrative audit finds 60% timely monitoring against an agreed 80% standard. Introduce a named recall process, re-audit the same criterion and check whether extra urgent appointments displace other necessary care.
Common pitfall: Measuring performance once identifies a gap but does not demonstrate that care improved or that the change was sustained.
Primary care organisation and management issues · The RCGP Curriculum Topic Guides 2025
60.What responsibilities must be explicit when specialist treatment moves into primary care?
A care plan should specify the diagnosis, medicines, monitoring, review arrangements and how to regain specialist advice. In bipolar disorder, do not start lithium for the first time except under shared-care arrangements and do not start valproate in primary care. When physical health monitoring transfers, undertake the agreed checks, communicate results to the care coordinator and psychiatrist, and maintain review. A discharge letter alone does not describe every operational responsibility.
Apply it
Before taking over bipolar follow-up, establish who monitors medicines, who reviews abnormal results and how relapse triggers specialist reassessment.
Common pitfall: Shared care needs an actionable division of tasks; assuming another team will respond to an abnormal result creates a preventable gap.
Recommendations | Bipolar disorder: assessment and management | Guidance | NICE · Recommendations | Chronic heart failure in adults: diagnosis and management | Guidance | NICE
What to focus on during revision
The following are CertMedbry study suggestions. Use the official outline to check the full scope of your examination.
- Use the official GP Curriculum and AKT Blueprint as the full scope; this guide selectively develops decisions within that wider outline.
- Connect diagnosis with prescribing choice, contraindications, interactions, monitoring and review.
- Practise urgent boundaries involving active stroke, suspected TIA, threatened vision, internal bleeding, severe hypoglycaemia and seriously unwell children.
- Interpret tests using the correct measurement setting, dietary exposure, treatment context and disease probability.
- Compare study designs, identify selection problems and interpret practice data using valid denominators.
- Apply capacity and confidentiality principles alongside safeguarding, accessible administration, quality improvement and shared-care responsibilities.
- Extend study to omitted curriculum subjects, including benefits, death certification, fitness to drive or work, immunisations and the remaining clinical and life-stage topics.
A practical preparation plan
1. Map the full curriculum
Build a coverage map from the official curriculum and blueprint. Mark these concepts as selected starting points and identify omitted clinical, life-stage and professional subjects.
2. Make each clinical decision explicit
State the discriminating findings, most useful investigation, treatment purpose and urgency. Explain why the closest competing action is less appropriate at that point.
3. Attach a prescribing plan
For each medicine decision, specify suitability, relevant interactions, baseline checks, monitoring and review. Distinguish symptom treatment from prevention of future harm.
4. Work through evidence
Draw diagnostic tables, compare study designs and calculate absolute effects. Read chart axes and denominators before interpreting a trend, then express the conclusion in a patient-relevant sentence.
5. Practise professional cases
Identify the decision-maker, communication support, confidentiality boundary, safeguarding concern and applicable jurisdiction. For organisational cases, state who must act and how completion will be checked.
6. Review errors by mechanism
Classify errors as missed cues, wrong thresholds, incorrect denominators, inappropriate prescribing or mistaken authority assumptions. Revisit the relevant principle and test it in a different case.
Use your sample score as a starting point
The free set contains 20 original practice questions. It is a small learning sample, not an official examination or a validated pass prediction. Review each explanation and its source before moving to another topic.
Start the free sampleOfficial sources and updates
- MRCGP: Applied Knowledge Test (AKT)
- Introducing the AKT
- Preparing for the AKT
- MRCGP Applied Knowledge Test (AKT) Blueprint
- GP curriculum
- The RCGP Curriculum Topic Guides 2025
- The Clinical Topic Guides
- Data Interpretation
- Primary care organisation and management issues
- High blood pressure
- Atrial fibrillation
- NT-proBNP
- Chronic obstructive pulmonary disease (COPD) — Diagnosis
- Asthma
- Low blood sugar (hypoglycaemia)
- Chronic kidney disease — Diagnosis
- Coeliac disease — Diagnosis
- Rheumatoid arthritis — Diagnosis
- Temporal arteritis
- Transient ischaemic attack (TIA)
- Ectopic pregnancy — Symptoms
- High temperature (fever) in children
- Symptoms of melanoma skin cancer
- Kidney infection
- Bipolar disorder
- Principles of Epidemiology — Lesson 5, Appendix A
- Cochrane Handbook — Chapter 15: Interpreting results and drawing conclusions
- Decision making and consent — Circumstances that affect the decision-making process, part 3
- Decision making and consent — Circumstances that affect the decision-making process, part 2
- Confidentiality — Using and disclosing patient information for direct care
- AKT-blueprint.pdf
- hypertension-in-adults-diagnosis-and-management-pdf-66141722710213.pdf
- CG049-Chronic%20Asthma%20Prescribing%20guidelines%20for%20Adults.pdf
- Out on a limb – prioritising clinical suspicion and early referral in rheumatoid arthritis diagnosis - Manchester University NHS Foundation Trust
- Ectopic pregnancy
- Recommendations | Atrial fibrillation: diagnosis and management | Guidance | NICE
- January-2026-AKT-feedback-report.pdf
- Melanoma
- nice-guidance-bipolar-affective-disorder-assessment-and-management.pdf
- Primary-care-organisation-and-management-topics-AKT_300926.pdf
- How to treat hypoglycaemia | Kent Community Health NHS Foundation Trust
- Recommendations | Chronic obstructive pulmonary disease in over 16s: diagnosis and management | Guidance | NICE
- Recommendations | Bipolar disorder: assessment and management | Guidance | NICE
- 4.2.3.1 Treatment of the acute phase of mania | NI Formulary
- topic-guides-2025.pdf
- CKD staging | UK Kidney Association
- Tissue transglutaminase (TTG) | University Hospitals of North Midlands
- Transient ischaemic attack (TIA) - Diagnosis - NHS
- Statistical Guidance on Reporting Results from Studies Evaluating Diagnostic Tests - Guidance for Industry and FDA Staff | FDA
- Recommendations | Coeliac disease: recognition, assessment and management | Guidance | NICE
- Recommendations | Hypertension in adults: diagnosis and management | Guidance | NICE
- Recommendations | Chronic heart failure in adults: diagnosis and management | Guidance | NICE
- Recommendations | Chronic obstructive pulmonary disease in over 16s: diagnosis and management | Guidance | NICE
- Recommendations | Asthma: diagnosis, monitoring and chronic asthma management (BTS, NICE, SIGN) | Guidance | NICE
- Recommendations | Rheumatoid arthritis in adults: management | Guidance | NICE
- Recommendations | Stroke and transient ischaemic attack in over 16s: diagnosis and initial management | Guidance | NICE
- Rationale and impact | Asthma: diagnosis, monitoring and chronic asthma management (BTS, NICE, SIGN) | Guidance | NICE
- Recommendations | Bipolar disorder: assessment and management | Guidance | NICE
- impact-on-nhs-workforce-and-resources-pdf-14506576287685
- Recommendations organised by site of cancer | Suspected cancer: recognition and referral | Guidance | NICE
- Recommendations | Chronic heart failure in adults: diagnosis and management | Guidance | NICE
- NICE-NG136-Hypertension-Management-Guideline-.pdf
- GGC Medicines - Management of Acute Severe Asthma in Adults in Hospital
- Principles of Epidemiology | Lesson 1 - Section 7
- NHS England » Accessible Information Standard – requirements (DAPB1605)
Confirm current eligibility, fees, scheduling and policies directly with the examination provider. CertMedbry is independent and is not endorsed by these organisations. How we handle content and corrections.