Passing the MRCGP AKT is necessary to successfully progress through General Practice training and achieve your goal of becoming a General Practitioner.
The AKT is a computer based examination comprising mainly single best answer questions and extended matching questions. It tests the fundamental knowledge base required to work in general practice in the UK. It is a summative assessment of the knowledge base that underpins independent general practice in the United Kingdom within the context of the National Health Service.
The AKT is three hours and ten minutes long and comprises separate 200 questions. It is sat three times a year at 150 Pearson VUE professional testing centres across the UK. 80% of question items will be on clinical medicine, 10% on critical appraisal and evidence based clinical practice and 10% on health informatics and administrative issues.
All questions address important issues relating to UK general practice and focus mainly on higher order problem solving rather than just the simple recall of basic facts.
Sitting practice questions is a great way to prepare for the MRCGP AKT. Here are a few to get you started.
1. A 25-year-old comes to see you with a painful right elbow. He is right handed and enjoys various sports. When you examine him you note tenderness over his medial epicondyle and his pain increases with resisted pronation at the wrist. Which of the following would be the MOST likely diagnosis?
A. Golfer’s elbow
B. Ulnar neuritis
C. Tennis elbow
D. De Quervain’s tenosynovitis
E. Olecranon bursitis
Answer: A. Golfer’s elbow
This history and examination in this case are classical for golfer’s elbow (medial epicondylitis). It is caused by repetitive strain on the extensor tendons inserting at the medial epicondyle, leading to inflammation and pain. One of the most common causes is playing golf, hence its name.
Tennis elbow (lateral epidondylitis) is when the same occurs but at the lateral epicondyle. Pain can be reproduced or exacerbated by resisted wrist extension.
Treatment of both involves avoiding the triggering factors and the use of non-steroidal anti-inflammatories for flare-ups. Steroid injections can be utilised in refractory conditions.
Ulnar neuritis presents with clumsiness in the hand and can progress to weakness and wasting of muscles supplied by the ulnar nerve. There may be parasthesia or numbness in the little finger and medial half of the ring finger. It is caused by narrowing of the ulnar groove. Risk factors include osteoarthritis, trauma and rheumatoid arthritis. Patients can be referred for nerve conduction studies and may need surgical decompression.
De Quervain’s tenosynovitis occurs when there is inflammation of the thumb extensor and abductor tendon sheaths. This results in pain over the radial styloid, which becomes worse on forced adduction and flexion of the thumb. Treatments include anti-inflammatories, thumb splints and steroid injections.
Repeated pressure at the olecranon may result in a bursitis. There may be dramatic swelling and some pain over the olecranon. Fluid can be aspirated to exclude gout or sepsis. If these have been excluded it often settles spontaneously.
2. A 65 year-old man presents to your surgery 1 week after a triple vessel coronary artery bypass graft (CABG). He is now entirely well and asymptomatic. He wishes to have a discussion with you when about when he can return to driving. According to the DVLA guidance, which of the following would be the most appropriate advice to give him?
A. He may resume driving immediately
B. He must have a further 3 weeks off driving
C. He must have 2 months off driving from the date of the CABG
D. He must have 4 months off driving from the date of the CABG
E. He must inform the DVLA and await their guidance
Answer: B. He must have a further 3 weeks off driving
According to the DVLA guidance driving must cease for at least 4 weeks after CABG. Driving may recommence thereafter provided there is no other disqualifying condition. The DVLA need not be notified.
Please refer to the DVLA ‘at a glance’ guide for the current medical guidelines:
3. You perform a medication review on a 62-year-old woman with a history of angina. She currently takes 10 mg bisoprolol OD and GTN spray as required. Despite this she is still symptomatic. Which of the following drugs should be avoided?
A. Isosorbide mononitrate
Answer: C. Verapamil
Beta-blockers, such as bisoprolol, and verapamil are both highly negatively inotropic and when given together can depress ventricular contraction and cause marked bradycardia as well as increase the risk of AV block. In some circumstances this combination can cause severe hypotension or even asystole and the combination should be avoided.
4. You go on a home visit to perform a neonatal examination on a baby girl that was born by home birth two days earlier. On examination you find a unilateral left sided swelling in the groin. The swelling appears to extend downwards into the labia on the same side. It is difficult to clinically define the upper margin of the swelling. The swelling reduces easily and disappears with gentle pressure. Which is the SINGLE most appropriate management option?
A. Refer urgently for immediate assessment today
B. Refer for urgent surgical repair within 1-2 weeks
C. Refer non-urgently to paediatric surgeons
D. Review in 12-18 months and refer for surgical review if still present
E. No referral or follow-up required
Answer: B. Refer for urgent surgical repair within 1-2 weeks
This baby girl has an inguinal hernia. Inguinal hernias are the most common surgical problem of childhood affecting 1-2% of all children. They can occur in either sex but are much commoner in the male sex. They are more common in premature infants.
Congenital inguinal hernias are the ‘indirect’ type that occur secondary to the persistence of a wide processus vaginalis. This type of hernia makes up about 75-80% of all inguinal hernias. They originate lateral to the inferior epigastric vessels and follow the path of the spermatic cord or round ligament through the internal inguinal ring and along the inguinal canal.
Typical clinical findings include:
- Swelling in the groin in the inguinal area
- Can extend into scrotum in males and labia in females
- Usually reducible
- May transilluminate
Congenital inguinal hernias all need urgent outpatient referral for surgical repair and this is generally performed within 2-3 weeks of detection.
The incidence of incarceration in children is 10-20% and half of these occur in the first 6 months of life. If incarcerated they should be referred urgently for immediate assessment the same day.
5. A 28-year-old welder presents with a history of intermittent wheezing. He feels his symptoms improve on the weekends and when he is on holiday. He also experiences symptoms of rhinitis and conjunctivitis.
Which of the following is the most appropriate initial management plan?
A. Refer to an occupational health physician
B. Organise a chest X-ray
C. Organise local spirometry
D. Advise him to leave his job
E. Advise the wearing of a mask and protective equipment at work
Answer: A. Refer to an occupational health physician
This patient has a history consistent with a diagnosis of occupational asthma. Occupational factors are thought to account for 1 in 6 cases of adult asthma.
High-risk professions include:
- Pastry making
- Spray painting
- Laboratory animal work
- Healthcare and dental-care
- Food processing
- Chemical processing
- Textile, plastics and rubber manufacture
- Jobs with exposure to dusts and fumes
A diagnosis of occupational asthma should be suspected in anyone with asthma symptoms that improve whilst away from work and deteriorate whilst working. Symptoms of rhinitis and conjunctivitis are also common and should be asked about during the history.
The British Occupational Health Research Foundation (BOHRF) advise that patients with possible work-related asthma should be referred quickly to a chest physician or occupational physician and serial peak flow measurements should be organised. Referral should be made rapidly as the prognosis of occupational asthma is improved by early identification and avoidance of further exposure.
It would not be appropriate to tell him to leave his job at this stage as the diagnosis has yet to be confirmed and they may well be other options available to him in his workplace.
The BOHRF guidance on occupational asthma and rhinitis can be reviewed here:
Thank you to the joint editorial team of MRCGP Exam Prep for this ‘Exam Tips’ blog post.