MRCGP [INT]

🩺 MRCGP Exam
[INT] FREE Guide
MCQ GUIDE – AKT STYLEfor Family
QUESTIONS Medicine
BY CHAPTER

MRCGP [INT] Exam Guide for Family

Medicine

MRCGP [INT] Free MCQ Guide – AKT Style Questions by Chapter

Over 50 high-yield, guideline-based questions with explanationsCreated for

international Family Medicine candidates

ExamCure™ – Master the Exam, Ace the Practice

Part of the Prometric & Global Boards Series[Email address]
Welcome to the MRCGP [INT] Free MCQ Guide

This resource was created by ExamCure™ to support Family Medicine doctors preparing for
the MRCGP [INT] – Applied Knowledge Test (AKT). Inside, you'll find over 50 clinical,
scenario-based questions organized by chapter, all aligned with international guidelines like
NICE, BTS, and RCGP.

How to Use This Guide:

• Attempt questions chapter by chapter

• Review detailed answer explanations at the end
• Use this guide to complement your full exam preparation plan

Disclaimer:
This guide is for educational purposes only. While every effort has been made to ensure accuracy
and alignment with UK and international standards, it does not replace official board materials.
Always follow your exam board’s latest guidance.
 MRCGP [INT] Exam Guide for Family
Medicine
Membership of the Royal College of General Practitioners – International
Updated for 2025

1. What is MRCGP [INT]?

The MRCGP [INT] is the internationally recognized version of the UK’s Family Medicine
board certification — the Membership of the Royal College of General Practitioners (UK).

It is delivered in collaboration with regional institutions and is accepted across many countries in
the Middle East, South Asia, and Africa.

This exam aims to assess whether a doctor is competent to practice independently as a Family
Physician in their country — according to RCGP UK standards.

2. Who Can Take It?

MRCGP [INT] is offered in several regional tracks, such as:

• South Asia (India, Pakistan, Bangladesh, Nepal, Sri Lanka)

• Middle East (UAE, Kuwait, Bahrain, Oman, KSA)
• North Africa (Egypt, Sudan)
• Sub-Saharan Africa (Nigeria, Kenya, etc.)

To be eligible, candidates usually need:

• An MBBS/MD or equivalent
• Completion of local Family Medicine training or relevant postgraduate experience
• Registration with the local medical council

Each region may have additional requirements.

 3. Exam Structure
The MRCGP [INT] consists of two major components:

A. AKT – Applied Knowledge Test

• Format: 150 single-best-answer MCQs

• Duration: 3 hours
• Content: Evidence-based management, diagnostics, screening, ethical/legal scenarios
• Focus: Core topics in Family Medicine + guideline-aligned decision-making

B. SCA – Simulated Consultation Assessment (replacing CSA)

• Format: 12 simulated patient consultations (10 minutes each)

• Conducted face-to-face or via telehealth (varies by region)
• Tests: Communication, clinical reasoning, safe decision-making, and professionalism

Some regions may still conduct the CSA (Clinical Skills Assessment) until fully transitioned to
SCA.

4. Study Plan & Resources

Most candidates spend 4–6 months preparing with the following:

• AKT-style MCQ banks

• NICE & RCGP-aligned guideline summaries
• Recorded consultation practice
• Communication & ethics cases
• Peer or tutor-led practice for SCA

We recommend structuring your study as:

Phase Focus Area Duration

Phase 1 Core concepts review (clinical + ethical) 4 weeks
Phase 2 Practice MCQs + review answers 6–8 weeks
Phase 3 SCA prep + mock consultations 4–6 weeks
Final Mock test + exam revision 2 weeks
 5. Tips to Pass the MRCGP [INT]
• Focus on real-life consultation flow — not just textbook answers
• Use MCQs that mimic AKT logic, not just recall
• Practice timed mocks under exam conditions
• For SCA, work on building rapport, structuring consultations, and managing
uncertainty
• Always refer to current NICE/RCGP guidelines

6. Want Free Sample MCQs?

We've prepared a free MCQ PDF with 50 AKT-style questions + answer key to test your
knowledge.

[continue until the end of the guide]

Or join our study group below to access exclusive practice questions every week!

7. Join the Study Group

Connect with other MRCGP [INT] candidates across the globe.

• WhatsApp & Telegram groups

• Weekly MCQs + discussion
• OSCE practice sessions
• Shared resources + motivation

[Join WhatsApp Group]

[Join Telegram Group]

AKT-style MCQs

Chapter 1: Cardiovascular,

Perfect — I now understand that you want realistic, in-depth AKT-style MCQs with:
 Clinical vignette format
Best-of-five options
Detailed, guideline-based explanations (e.g., NICE)
Structured just like the real MRCGP [INT] AKT exam

Let’s begin with 2 high-quality sample MCQs from Chapter 1: Cardiovascular, fully
formatted to exam standards:

Chapter 1: Cardiovascular
Question 1

A 62-year-old male presents with central chest pain on exertion for the past 2 months. The pain
is relieved with rest and has not changed in character. He has a history of type 2 diabetes,
hypertension, and is an ex-smoker. Examination is unremarkable. His ECG shows sinus rhythm
with no acute changes. Blood pressure is 134/82 mmHg, pulse 78 bpm.

What is the most appropriate first-line investigation to confirm the diagnosis?

A. Exercise ECG
B. CT coronary angiography
C. Stress echocardiogram
D. Coronary angiography
E. Myocardial perfusion scan

Correct Answer: B. CT coronary angiography

Explanation:
This patient has typical angina symptoms (effort-induced chest pain relieved by rest), no ECG
abnormalities, and is clinically stable. According to the NICE NG185 (Chest pain of recent
onset: assessment and diagnosis), the recommended first-line test for suspected stable angina in
a patient with no known coronary artery disease and a normal resting ECG is CT coronary
angiography.

• Exercise ECG is no longer recommended for diagnosis.

• Stress echo and MPS are reserved for second-line functional imaging when CT is
inconclusive or not possible.
• Coronary angiography is invasive and usually reserved for high-risk or confirmed
cases.
 NICE Reference: NG185 – Chest pain of recent onset
Clinical takeaway: Use CTCA first in stable patients with no previous CAD and normal
ECG.

Question 2

A 70-year-old man presents for a routine check-up. He is found to have persistent atrial
fibrillation. He has a history of hypertension and had a TIA 2 years ago. His CHADS₂-VASc
score is calculated as 4. He is not currently on anticoagulation.

Which of the following is the most appropriate next step in his management?

A. Start aspirin 75 mg daily

B. Start rivaroxaban
C. Refer for cardioversion
D. Start amiodarone
E. Monitor and reassess in 3 months

Correct Answer: B. Start rivaroxaban

Explanation:
This patient has non-valvular atrial fibrillation and a CHADS₂-VASc score of 4 (TIA = 2,
HTN = 1, Age 70 = 1), indicating high stroke risk. According to NICE NG196 (Atrial
fibrillation: diagnosis and management), anticoagulation should be offered to all patients
with a score ≥2, unless contraindicated.

• DOACs (e.g., rivaroxaban, apixaban) are preferred over warfarin unless contraindicated.
• Aspirin is not recommended for stroke prevention in AF.
• Cardioversion may be considered but not before anticoagulation.
• Amiodarone is not first-line without rhythm control indication.
• Monitoring without action is inappropriate in high-risk cases.

NICE Reference: NG196 – Atrial fibrillation: diagnosis and management

Clinical takeaway: All high-risk AF patients should be anticoagulated, preferably with a
DOAC.
 Question 3

A 55-year-old woman with type 2 diabetes and hyperlipidemia presents for a routine check-up.
She has no history of cardiovascular disease. Her BP is 138/84 mmHg and her total cholesterol is
5.6 mmol/L. Her QRISK3 score is 14%. She is asymptomatic and non-smoking.

What is the most appropriate next step in her cardiovascular risk management?

A. Reassure and repeat QRISK3 in 1 year

B. Start atorvastatin 20 mg
C. Refer for exercise ECG
D. Start aspirin
E. Start lifestyle modification and recheck cholesterol in 3 months

Correct Answer: B. Start atorvastatin 20 mg

Explanation:
According to NICE CG181 (Cardiovascular disease: risk assessment and reduction), if a
patient has a QRISK3 score ≥10%, they should be offered atorvastatin 20 mg for primary
prevention. This patient has no prior CVD, but has diabetes and a 14% QRISK3 — which
qualifies her for statin therapy.

• Lifestyle changes are advised alongside statin therapy, not instead of.
• Aspirin is not indicated for primary prevention in asymptomatic patients.
• Repeating the score later without intervention misses the window to reduce risk.

NICE Reference: CG181 – Cardiovascular risk assessment and lipid modification

Clinical takeaway: Initiate statins when QRISK3 ≥10% in primary prevention.

Question 4

A 64-year-old man presents with shortness of breath and ankle swelling. On examination, he has
elevated JVP, bilateral basal crepitations, and pitting edema up to mid-shin. Echocardiography
confirms left ventricular ejection fraction (LVEF) of 35%.

Which of the following medications is proven to reduce mortality in this patient?

A. Furosemide
B. Digoxin
C. Amlodipine
D. Bisoprolol
E. Spironolactone

Correct Answer: D. Bisoprolol

Explanation:
In patients with heart failure with reduced ejection fraction (HFrEF), certain medications
improve mortality, including:

• ACE inhibitors (e.g., ramipril)

• Beta blockers (bisoprolol, carvedilol, nebivolol)
• Mineralocorticoid receptor antagonists (spironolactone)
• SGLT2 inhibitors (dapagliflozin)

While diuretics like furosemide relieve symptoms, they do not improve survival. Digoxin is
used for rate control or symptomatic benefit in atrial fibrillation with HF but also does not
improve mortality.

NICE Reference: NG106 – Chronic heart failure in adults

Clinical takeaway: Bisoprolol improves mortality in HFrEF and is first-line after ACEi.

Question 5

A 48-year-old male of South Asian descent presents with newly diagnosed hypertension. His BP
is consistently 148/92 mmHg. He has no diabetes, no proteinuria, and normal renal function. He
is otherwise healthy and on no medications.

What is the most appropriate first-line antihypertensive?

A. Amlodipine
B. Atenolol
C. Indapamide
D. Ramipril
E. Losartan

Correct Answer: A. Amlodipine

Explanation:
According to NICE NG136 (Hypertension in adults), for patients under 55 years and not of
Black African or Caribbean descent, an ACE inhibitor is first-line. However, in patients of
South Asian descent, especially with higher salt sensitivity, calcium channel blockers (like
amlodipine) are often more effective and may be preferred depending on regional adaptations.

In the UK, amlodipine is typically first-line for patients ≥55 or of Black heritage, but South
Asian populations may also benefit — practice varies slightly by local guidance, but CCBs
remain appropriate and often first-line.

NICE Reference: NG136 – Hypertension in adults

Clinical takeaway: Amlodipine is a safe and effective first-line agent in South Asian patients.

Question 6

A 65-year-old woman with type 2 diabetes presents with leg cramps at night. She recently started
simvastatin 40 mg. Her CK is mildly elevated at 450 U/L. She has no muscle weakness or
tenderness.

What is the most appropriate next step?

A. Stop statin and repeat CK in 2 weeks

B. Continue statin and reassure
C. Switch to rosuvastatin
D. Reduce dose and monitor symptoms
E. Check liver function and continue

Correct Answer: D. Reduce dose and monitor symptoms

Explanation:
According to NICE CG181, if a patient develops muscle symptoms while on statins, and CK is
raised but <5x upper limit of normal (ULN), the statin can be continued or dose reduced,
depending on clinical judgement. For CK <1000 U/L and mild symptoms, reducing the dose or
switching statins is appropriate.

Stopping statins is only necessary for CK >5x ULN or severe symptoms.

 NICE Reference: CG181 – Lipid modification
Clinical takeaway: For CK <5x ULN + tolerable symptoms, dose adjustment is appropriate.

Question 7

A 74-year-old man presents with dizziness and palpitations. ECG shows new-onset atrial
fibrillation with a ventricular rate of 140 bpm. He is hemodynamically stable. This is the first
episode and symptoms started 12 hours ago.

What is the most appropriate initial management?

A. Admit for immediate DC cardioversion

B. Start apixaban and refer for delayed cardioversion
C. Rate control with bisoprolol and start apixaban
D. Start aspirin and monitor
E. Refer to emergency department

Correct Answer: C. Rate control with bisoprolol and start apixaban

Explanation:
For new-onset AF (<48 hours) in a hemodynamically stable patient, NICE NG196
recommends rate control as first-line in most cases. Anticoagulation (DOAC preferred) should
be started if stroke risk is elevated (CHADS₂-VASc ≥2). Cardioversion can be considered after
rate control and appropriate risk stratification.

• Immediate cardioversion is reserved for life-threatening hemodynamic compromise.

• Aspirin is not recommended for stroke prevention in AF.

NICE Reference: NG196 – AF management

Clinical takeaway: Control rate and anticoagulate unless unstable or highly symptomatic.

Question 8

A 50-year-old man with stable angina has been taking bisoprolol 5 mg once daily. He still
experiences chest pain after moderate exertion. His ECG is normal. You consider adding a
second anti-anginal agent.

Which of the following is the most appropriate to add?

A. Ivabradine
B. Ranolazine
C. Amlodipine
D. GTN patch
E. Digoxin

Correct Answer: C. Amlodipine

Explanation:
NICE NG185 states that calcium channel blockers like amlodipine are suitable second-line
agents for angina in patients already on beta blockers. GTN is used for symptomatic relief but
not long-term control. Ranolazine and ivabradine are third-line options or for those intolerant to
CCBs and beta-blockers.

NICE Reference: NG185 – Chest pain: stable angina

Clinical takeaway: CCBs are appropriate add-ons to beta blockers in angina.

Question 9

A 61-year-old male smoker has persistent claudication of the right calf after walking 150 meters.
Ankle-brachial pressure index (ABPI) is 0.65.

What is the most appropriate next step in management?

A. Immediate vascular referral

B. Prescribe naftidrofuryl oxalate
C. Start statin and clopidogrel
D. Arrange Doppler ultrasound
E. Refer for angioplasty

Correct Answer: C. Start statin and clopidogrel

Explanation:
Peripheral arterial disease (PAD) with ABPI <0.9 requires secondary prevention. According to
NICE CG147, all PAD patients should receive:

• Antiplatelet therapy (clopidogrel preferred)

• Statin therapy
• Smoking cessation and supervised exercise
Naftidrofuryl can be added if symptoms persist after exercise therapy. Vascular referral is only
for critical limb ischemia or lifestyle-limiting claudication despite maximal therapy.

NICE Reference: CG147 – Peripheral arterial disease

Clinical takeaway: Start statin and clopidogrel as core PAD management.

Question 10

A 60-year-old woman on ramipril develops a persistent dry cough. BP is 138/86 mmHg. She
tolerates the medication otherwise.

What is the most appropriate next step?

A. Continue ramipril and monitor

B. Add a calcium channel blocker
C. Stop ramipril and switch to losartan
D. Add a diuretic
E. Check for asthma

Correct Answer: C. Stop ramipril and switch to losartan

Explanation:
ACE inhibitors commonly cause dry cough due to increased bradykinin. If intolerable, the
preferred alternative is an angiotensin II receptor blocker (ARB) like losartan, which has a
similar BP-lowering and cardio-protective profile but does not cause cough.

NICE Reference: NG136 – Hypertension in adults

Clinical takeaway: Replace ACEi with ARB if cough develops.

Chapter 2: Respiratory
Question 1
A 29-year-old woman presents to the GP surgery with a history of wheezing, chest tightness, and
breathlessness that worsens at night and during exercise. She reports using her salbutamol inhaler
3–4 times per week. She is not currently on any regular preventer therapy.

What is the most appropriate next step in her management?

A. Continue salbutamol and monitor

B. Start inhaled corticosteroid (ICS)
C. Add long-acting beta-agonist (LABA)
D. Prescribe leukotriene receptor antagonist
E. Refer to respiratory clinic

Correct Answer: B. Start inhaled corticosteroid (ICS)

Explanation:
This patient has symptomatic asthma that is not controlled with as-needed salbutamol.
According to NICE NG80 (Asthma: diagnosis, monitoring and chronic asthma
management), patients who use a short-acting beta-agonist (SABA) more than twice a week or
have night symptoms should be stepped up to low-dose ICS as a preventer.

• LABAs are added after initiating ICS if control remains poor.

• Referrals are not needed unless red flags or diagnostic uncertainty exist.

NICE Reference: NG80 – Asthma management

Clinical takeaway: ICS is first-line preventer therapy in persistent asthma.

Question 2

A 64-year-old man with COPD presents with increased dyspnea and purulent sputum. He has no
signs of pneumonia and oxygen saturation is 94% on room air. His last exacerbation was 7
months ago. He uses a salbutamol inhaler and tiotropium regularly.

What is the most appropriate management?

A. Refer to hospital for IV antibiotics

B. Prescribe oral corticosteroids and oral antibiotics
C. Increase salbutamol dose and review in 2 weeks
D. Add inhaled corticosteroids
E. Prescribe mucolytics and monitor
 Correct Answer: B. Prescribe oral corticosteroids and oral antibiotics

Explanation:
This is an acute exacerbation of COPD with increased dyspnea and sputum purulence,
qualifying for treatment with a 5-day course of oral prednisolone (30 mg) and empirical
antibiotics (e.g. doxycycline or amoxicillin).

NICE NG115 recommends this approach for moderate exacerbations managed in primary care,
in the absence of hypoxia or red flag features.

NICE Reference: NG115 – COPD in over 16s: diagnosis and management

Clinical takeaway: Treat moderate COPD exacerbations with steroids + antibiotics.

Question 3

A 38-year-old man with no prior history presents with a 4-week history of chronic cough and
occasional hemoptysis. He reports weight loss, night sweats, and low-grade fever. He is
originally from India and recently returned from a trip there.

On examination, there are coarse crepitations in the upper zone of the right lung. What is the
most appropriate next investigation?

A. Chest X-ray
B. Sputum culture and sensitivity
C. Full blood count and CRP
D. High-resolution CT chest
E. Spirometry

Correct Answer: A. Chest X-ray

Explanation:
This presentation raises suspicion of pulmonary tuberculosis. A chest X-ray is the first-line
investigation to evaluate cavitary lesions or infiltrates, especially in the upper lobes. If
suggestive, further testing (e.g., sputum AFB, GeneXpert MTB/RIF) would follow.

• HRCT is not the first step.

• FBC and CRP are supportive, not diagnostic.
• Spirometry has no role here.

NICE Reference: NG33 – Tuberculosis

Clinical takeaway: TB suspicion warrants urgent chest imaging.
 Question 4

A 50-year-old man presents with progressive dyspnea and dry cough. He is a non-smoker and
has no history of asthma or COPD. On examination, he has finger clubbing and fine inspiratory
crackles at both lung bases.

Which of the following is the most likely diagnosis?

A. Bronchiectasis
B. Idiopathic pulmonary fibrosis
C. Chronic bronchitis
D. Lung cancer
E. Pneumonia

Correct Answer: B. Idiopathic pulmonary fibrosis

Explanation:
IPF presents with:

• Progressive exertional dyspnea

• Dry cough
• Bibasal “velcro” crackles
• Clubbing
• Restrictive pattern on spirometry

Diagnosis is confirmed with HRCT, showing honeycombing and reticulation. Smoking is a risk
factor but not essential. Clubbing + basal crackles are classic.

NICE Reference: NG163 – Pulmonary fibrosis in adults

Clinical takeaway: Think IPF with dry cough + clubbing + bibasal crackles.

Question 5

A 25-year-old female with known asthma presents with sudden onset wheeze, chest tightness,
and difficulty speaking. Her respiratory rate is 36/min, SpO₂ is 91% on room air, and she is using
accessory muscles. She can only speak in short phrases.

How would you classify the severity of her asthma attack?

A. Mild
B. Moderate
C. Severe
D. Life-threatening
E. Near-fatal

Correct Answer: C. Severe

Explanation:
According to BTS/SIGN guidelines (often referenced in NICE), features of severe asthma
include:

• RR ≥ 25
• HR ≥ 110
• Inability to complete sentences in one breath
• SpO₂ 92–94%

This patient meets these criteria. Life-threatening would involve silent chest, cyanosis, poor
respiratory effort, SpO₂ <92%, or exhaustion.

Guideline Reference: BTS/SIGN 158 – Asthma

Clinical takeaway: Use objective signs to classify severity; this case = severe.

Chapter 3: Endocrinology
Question 1

A 54-year-old man with type 2 diabetes attends for review. His most recent HbA1c is 71
mmol/mol despite being on maximum tolerated doses of metformin and gliclazide. His BMI is
33 kg/m² and he has no significant comorbidities. His renal function is normal.

What is the most appropriate next step in his management?

A. Add sitagliptin
B. Add empagliflozin
C. Add basal insulin
D. Increase gliclazide dose
E. Switch to pioglitazone

Correct Answer: B. Add empagliflozin

Explanation:
In patients with poor glycaemic control on dual therapy, and especially those who are
overweight (BMI ≥30), NICE NG28 recommends considering a triple therapy including an
SGLT2 inhibitor like empagliflozin. These agents offer both glucose-lowering and
cardiovascular protection benefits.

• Sitagliptin is an option, but SGLT2 inhibitors are preferred in overweight patients and
those at cardiovascular risk.
• Insulin is not yet indicated as oral options haven’t been exhausted.

NICE Reference: NG28 – Type 2 diabetes in adults

Clinical takeaway: Add SGLT2 inhibitors in overweight patients not controlled on dual
therapy.

Question 2

A 43-year-old woman presents with weight gain, facial puffiness, easy bruising, and irregular
periods. She is hypertensive and on amlodipine. On examination, she has a round face,
supraclavicular fat pads, and thin skin with purple striae on the abdomen.

What is the most appropriate first investigation?

A. Random serum cortisol

B. ACTH stimulation test
C. Overnight dexamethasone suppression test
D. 24-hour urinary free cortisol
E. MRI pituitary

Correct Answer: C. Overnight dexamethasone suppression test

Explanation:
This patient has classic features of Cushing’s syndrome. The initial screening test of choice is
the overnight dexamethasone suppression test (ONDST) or 24-hour urinary cortisol.
 • ONDST involves 1 mg dexamethasone at night with cortisol measured the next morning.
• Only after diagnosis is confirmed are localisation tests (e.g. ACTH level, pituitary MRI)
performed.

NICE Reference: CKS – Cushing's syndrome

Clinical takeaway: Use ONDST as a first-line test in suspected Cushing’s.

Question 3

A 68-year-old woman presents with fatigue, weight gain, and cold intolerance. Examination
reveals dry skin, bradycardia, and delayed reflexes. Blood tests show:

• TSH: 18 mU/L (high)

• Free T4: 8 pmol/L (low)
• Anti-TPO antibodies: positive

What is the most appropriate next step in management?

A. Start levothyroxine 25 mcg daily

B. Refer to endocrinology
C. Repeat thyroid function in 6 weeks
D. Prescribe liothyronine
E. Start levothyroxine 100 mcg daily

Correct Answer: A. Start levothyroxine 25 mcg daily

Explanation:
This is overt primary hypothyroidism with elevated TSH and low T4. Levothyroxine is the
treatment of choice. In elderly patients, or those with cardiac risk, start low (25–50 mcg) and
titrate up.

• 100 mcg is too high as a starting dose in this age group.

• Liothyronine is not routinely recommended due to cardiovascular risk.

NICE Reference: CKS – Hypothyroidism

Clinical takeaway: Start low-dose thyroxine in elderly with overt hypothyroidism.

Question 4
A 60-year-old man is found to have corrected calcium of 2.9 mmol/L during routine blood tests.
He reports increased thirst and fatigue. PTH is elevated, phosphate is low, and 25-OH vitamin D
is normal. His eGFR is 72.

What is the most likely diagnosis?

A. Primary hyperparathyroidism
B. Secondary hyperparathyroidism
C. Tertiary hyperparathyroidism
D. Familial hypocalciuric hypercalcemia
E. Hypervitaminosis D

Correct Answer: A. Primary hyperparathyroidism

Explanation:
Primary hyperparathyroidism is characterised by:

• High calcium
• High or inappropriately normal PTH
• Low phosphate
• Normal/low vitamin D
• Normal or mildly reduced renal function

Secondary hyperparathyroidism typically occurs in CKD or vitamin D deficiency and presents

with low or normal calcium.

NICE Reference: CKS – Hypercalcaemia

Clinical takeaway: Elevated calcium + high PTH = primary hyperparathyroidism.

Question 5

A 32-year-old woman with known type 1 diabetes is planning pregnancy. Her current HbA1c is
66 mmol/mol. She uses a basal-bolus insulin regimen and has no complications.

What is the most appropriate advice?

A. Continue current plan and try to conceive

B. Switch to metformin
C. Delay pregnancy and optimize HbA1c <48 mmol/mol
D. Refer for bariatric surgery
E. Add a GLP-1 agonist
 Correct Answer: C. Delay pregnancy and optimize HbA1c <48 mmol/mol

Explanation:
Preconception counseling for women with type 1 diabetes is essential. NICE NG3 recommends
achieving HbA1c <48 mmol/mol (6.5%) before conception to minimize risk of congenital
malformations.

• GLP-1 agonists and metformin are not appropriate in T1DM.

• Current control is not safe enough for pregnancy.

NICE Reference: NG3 – Diabetes in pregnancy

Clinical takeaway: HbA1c <48 mmol/mol is the preconception target for T1DM.

Excellent! Let's now begin Chapter 4: Gastroenterology of your MRCGP [INT] Free MCQ
PDF, continuing the high-quality AKT-style format with the first 5 detailed clinical vignette
MCQs, each with best-of-five options and NICE-aligned explanations.

Chapter 4: Gastroenterology

Question 1

A 45-year-old man presents with a 6-month history of heartburn, regurgitation, and occasional
epigastric pain. He has been self-medicating with antacids with partial relief. He denies
dysphagia, weight loss, or vomiting. Examination is unremarkable.

What is the most appropriate next step in management?

A. Refer for upper GI endoscopy

B. Prescribe omeprazole and test for H. pylori
C. Start metoclopramide
D. Advise lifestyle changes and observe
E. Prescribe ranitidine and refer to gastroenterology

Correct Answer: B. Prescribe omeprazole and test for H. pylori

Explanation:
This presentation is consistent with GORD or dyspepsia without alarm symptoms. NICE
CG184 recommends testing and treating H. pylori in patients with persistent dyspepsia and
offering a trial of PPI for 4 weeks.

• No red flags → no immediate need for endoscopy.

• Ranitidine is no longer recommended due to availability issues and PPI superiority.

NICE Reference: CG184 – Dyspepsia and GORD

Clinical takeaway: For chronic dyspepsia without alarm signs, test for H. pylori and offer a
PPI.

Question 2

A 62-year-old woman presents with a 3-month history of intermittent rectal bleeding mixed with
stool and a recent change in bowel habit to loose stools. She reports unintentional weight loss
and fatigue. Her haemoglobin is 98 g/L.

What is the most appropriate next step?

A. Treat empirically for haemorrhoids

B. Refer urgently for colonoscopy
C. Arrange a faecal occult blood test
D. Prescribe iron and review in 1 month
E. Order a CT abdomen

Correct Answer: B. Refer urgently for colonoscopy

Explanation:
This patient meets NICE NG12 criteria for an urgent 2-week wait referral for suspected
colorectal cancer, due to:

• Rectal bleeding
• Change in bowel habit
• Unintentional weight loss
• Iron deficiency anaemia (Hb <110 g/L in women)

NICE Reference: NG12 – Suspected cancer recognition and referral

Clinical takeaway: Red flags = urgent 2WW referral for colorectal cancer.
 Question 3

A 34-year-old woman presents with recurrent upper abdominal pain, bloating, and loose stools
for the past 4 months. She reports the symptoms are worse after meals and when stressed. There
is no weight loss, blood in stool, or night pain. Examination is normal.

What is the most likely diagnosis?

A. Inflammatory bowel disease

B. Coeliac disease
C. Peptic ulcer disease
D. Irritable bowel syndrome
E. Gallbladder disease

Correct Answer: D. Irritable bowel syndrome

Explanation:
This presentation fits Rome IV criteria for IBS: recurrent abdominal discomfort with a change
in bowel habit, worsened by food/stress, and no alarm features. Red flag features such as
weight loss, rectal bleeding, or nocturnal symptoms are absent.

• IBS is a clinical diagnosis after excluding red flags.

NICE Reference: CG61 – Irritable bowel syndrome in adults

Clinical takeaway: In absence of red flags, consider IBS as a diagnosis of exclusion.

Question 4

A 70-year-old man with a history of hypertension presents with sudden severe epigastric pain
radiating to the back. He appears unwell and hypotensive. He has a 40-pack-year smoking
history. On examination, there is a pulsatile abdominal mass.

What is the most likely diagnosis?

A. Acute pancreatitis
B. Aortic dissection
C. Perforated peptic ulcer
D. Ruptured abdominal aortic aneurysm
E. Mesenteric ischaemia
 Correct Answer: D. Ruptured abdominal aortic aneurysm

Explanation:
This patient has classic signs of a ruptured AAA: elderly male, smoker, sudden epigastric/back
pain, hypotension, and a pulsatile abdominal mass.

• Immediate emergency referral is needed.

• Pancreatitis and perforated ulcer are in the differential but less likely with hypotension
and pulsatile mass.

NICE Reference: NG156 – Abdominal aortic aneurysm

Clinical takeaway: In elderly males with back/epigastric pain and hypotension, think AAA.

Question 5

A 25-year-old man presents with jaundice, dark urine, and fatigue for 1 week. He recently
returned from a trip to India. He has no significant past medical history and is not on
medications. On examination, he is icteric but alert and afebrile.

What is the most likely diagnosis?

A. Hepatitis B
B. Hepatitis C
C. Hepatitis A
D. Autoimmune hepatitis
E. Drug-induced liver injury

Correct Answer: C. Hepatitis A

Explanation:
Hepatitis A presents acutely with jaundice, malaise, dark urine, and raised ALT, especially in
returning travellers from endemic regions (e.g., India). It is self-limiting and spreads via the
faeco-oral route.

• Hepatitis B and C tend to present more subacutely or chronically.

• No drug history or autoimmune risk.

NICE Reference: CKS – Hepatitis A

Clinical takeaway: In travellers with acute hepatitis symptoms, suspect Hep A.
 Chapter 5: Musculoskeletal

Question 1

A 66-year-old woman presents with bilateral shoulder and hip stiffness, especially in the
morning. It lasts for over an hour and affects her ability to get out of bed. She denies joint
swelling. ESR is 68 mm/hr. She has difficulty lifting her arms but has full passive range of
motion.

What is the most likely diagnosis?

A. Rheumatoid arthritis
B. Osteoarthritis
C. Polymyalgia rheumatica
D. Fibromyalgia
E. Rotator cuff tear

Correct Answer: C. Polymyalgia rheumatica

Explanation:
PMR commonly affects older adults, especially women, and presents with:

• Bilateral proximal muscle stiffness (shoulders, hips)

• Elevated ESR/CRP
• No true muscle weakness, just stiffness and pain

It typically responds well to low-dose corticosteroids (e.g. 15 mg prednisolone). RA tends to

involve smaller joints and swelling; fibromyalgia doesn't raise ESR.

NICE Reference: CKS – Polymyalgia rheumatica

Clinical takeaway: Think PMR in elderly with bilateral shoulder/hip stiffness and raised
inflammatory markers.

Question 2
A 42-year-old man presents with back pain and stiffness that improves with exercise and
worsens with rest. He reports morning stiffness lasting over 45 minutes. On examination, there is
reduced lumbar flexion and tenderness over the sacroiliac joints.

What is the most likely diagnosis?

A. Osteoarthritis of the spine

B. Mechanical back pain
C. Ankylosing spondylitis
D. Spinal stenosis
E. Rheumatoid arthritis

Correct Answer: C. Ankylosing spondylitis

Explanation:
Ankylosing spondylitis is a seronegative spondyloarthropathy that affects young males and
presents with:

• Inflammatory back pain

• Improvement with activity
• Sacroiliac tenderness and reduced spine mobility

Diagnosis is supported by HLA-B27 and MRI sacroiliac joints.

NICE Reference: CKS – Ankylosing spondylitis

Clinical takeaway: Inflammatory back pain in young male = consider AS.

Question 3

A 72-year-old woman presents after a low-trauma wrist fracture. She has a history of
hypertension and hypothyroidism. A DEXA scan reveals a T-score of –2.8.

What is the most appropriate next step?

A. Start calcium supplements only

B. Reassure and repeat DEXA in 2 years
C. Start alendronate and vitamin D/calcium
D. Refer to endocrinology
E. Prescribe hormone replacement therapy
 Correct Answer: C. Start alendronate and vitamin D/calcium

Explanation:
A T-score ≤ –2.5 with a fragility fracture confirms osteoporosis, and NICE CG146
recommends starting bisphosphonates (e.g., alendronate) + calcium and vitamin D unless
contraindicated.

HRT is not first-line for osteoporosis in older women. Endocrine referral is unnecessary unless
there's secondary osteoporosis.

NICE Reference: CG146 – Osteoporosis

Clinical takeaway: Treat fragility fractures with osteoporosis medication even without
DEXA.

Question 4

A 60-year-old man presents with sudden onset of severe pain, redness, and swelling in his right
first metatarsophalangeal (MTP) joint. He drinks alcohol regularly and has hypertension. The
joint is warm and very tender. His temperature is 37.9°C.

What is the most likely diagnosis?

A. Septic arthritis
B. Pseudogout
C. Cellulitis
D. Gout
E. Osteoarthritis

Correct Answer: D. Gout

Explanation:
Acute monoarthritis of the first MTP joint (podagra) is classic for gout, especially in men
with alcohol use, hypertension, and metabolic syndrome.

Septic arthritis is a differential but usually involves fever and systemic signs. Definitive
diagnosis requires joint aspiration if uncertain.

NICE Reference: CKS – Gout

Clinical takeaway: First MTP inflammation in older male = gout until proven otherwise.
 Question 5

A 38-year-old woman presents with widespread body pain, fatigue, poor sleep, and difficulty
concentrating (“brain fog”) for over 6 months. Physical examination is normal. Bloods including
TSH, CRP, and FBC are normal.

What is the most likely diagnosis?

A. Hypothyroidism
B. Fibromyalgia
C. Chronic fatigue syndrome
D. Polymyalgia rheumatica
E. Depression

Correct Answer: B. Fibromyalgia

Explanation:
Fibromyalgia is a diagnosis of exclusion characterized by:

• Widespread musculoskeletal pain

• Fatigue, non-restorative sleep, and cognitive fog
• Normal inflammatory markers

It is more common in women and can be triggered by stress or illness. TSH and CRP help
exclude hypothyroidism and inflammatory causes.

NICE Reference: CKS – Fibromyalgia

Clinical takeaway: Consider fibromyalgia in patients with chronic pain + fatigue and normal
labs.

Chapter 6: Women’s Health

Question 1

A 26-year-old woman presents requesting contraception. She is otherwise healthy, a non-smoker,

and has no family history of thrombosis. BMI is 31 kg/m². Blood pressure is 122/78 mmHg.
Which is the most appropriate first-line contraceptive option?

A. Combined oral contraceptive pill (COCP)

B. Progestogen-only pill (POP)
C. Copper intrauterine device (IUD)
D. Combined hormonal patch
E. Depot medroxyprogesterone acetate (DMPA)

Correct Answer: A. Combined oral contraceptive pill (COCP)

Explanation:
According to UKMEC guidelines, a BMI of 31 does not contraindicate the COCP if there are
no other risk factors (smoking, hypertension, history of VTE). COCP remains appropriate in
non-smoking women under 35 with normal BP.

• POP is a good option too but not necessary in this case.

• IUDs and DMPA are long-acting options but not first-line unless preferred.

NICE Reference: CKS – Contraception – assessment

Clinical takeaway: COCP is safe and effective in healthy women with BMI <35.

Question 2

A 45-year-old woman presents with irregular, heavy periods. She reports flooding and clots,
especially during the first two days of her cycle. There are no intermenstrual bleeds or postcoital
bleeding. Examination is normal and pregnancy test is negative.

What is the most appropriate first-line management?

A. Refer for hysteroscopy

B. Prescribe tranexamic acid
C. Start norethisterone
D. Start combined oral contraceptive pill
E. Fit levonorgestrel intrauterine system (LNG-IUS)

Correct Answer: E. Fit levonorgestrel intrauterine system (LNG-IUS)

Explanation:
NICE NG88 recommends the LNG-IUS (e.g. Mirena) as first-line for heavy menstrual bleeding
(HMB) without structural abnormalities or red flags. It provides both bleed control and
contraception.

• Tranexamic acid is useful short-term but not preferred first-line.

• Norethisterone is less effective and has more side effects long term.

NICE Reference: NG88 – Heavy menstrual bleeding

Clinical takeaway: LNG-IUS is first-line for HMB with normal exam.

Question 3

A 30-year-old woman presents with severe dysmenorrhoea and deep dyspareunia. She has been
trying to conceive for 1 year. Pelvic examination reveals a tender, retroverted uterus and adnexal
tenderness. TVUS shows an ovarian endometrioma.

What is the most likely diagnosis?

A. Pelvic inflammatory disease

B. Uterine fibroids
C. Endometriosis
D. Polycystic ovary syndrome
E. Ovarian cancer

Correct Answer: C. Endometriosis

Explanation:
Classic triad: dysmenorrhoea, dyspareunia, and subfertility. Ovarian endometriomas on
imaging strongly suggest endometriosis.

• Fibroids rarely cause deep dyspareunia.

• PID tends to present more acutely with fever and discharge.

NICE Reference: NG73 – Endometriosis

Clinical takeaway: Suspect endometriosis with chronic pelvic pain + infertility +
endometrioma.

Question 4
A 56-year-old woman presents with vaginal dryness, itching, and dyspareunia. She had her last
menstrual period 3 years ago. She has no hot flushes and no systemic symptoms. Examination
confirms signs of vulvovaginal atrophy.

What is the most appropriate treatment?

A. Systemic HRT patches

B. Vaginal lubricants only
C. Vaginal oestrogen cream
D. Vaginal progesterone
E. Refer to gynaecology

Correct Answer: C. Vaginal oestrogen cream

Explanation:
For urogenital symptoms of menopause (e.g., vaginal dryness, atrophy), local oestrogen
therapy is first-line. Systemic HRT is unnecessary if vasomotor symptoms are absent.

• Vaginal oestrogen is safe and effective long-term even in older women.

• Vaginal progesterone is not needed unless systemic oestrogen is used.

NICE Reference: NG23 – Menopause diagnosis and management

Clinical takeaway: Local oestrogen is first-line for vaginal atrophy in postmenopausal
women.

Question 5

A 35-year-old woman presents with a missed period and lower abdominal pain. A pregnancy test
is positive. She is unsure of her dates. On transvaginal ultrasound, the uterus appears empty.
Serum beta-hCG is 2100 IU/L.

What is the most appropriate next step?

A. Reassure and repeat scan in 1 week

B. Refer urgently for laparoscopy
C. Repeat beta-hCG in 48 hours
D. Start methotrexate
E. Admit for medical evacuation
 Correct Answer: C. Repeat beta-hCG in 48 hours

Explanation:
This is a pregnancy of unknown location (PUL). At hCG >1500 IU/L, you would expect to see
an intrauterine pregnancy. The absence of a gestational sac raises concern for ectopic
pregnancy, but diagnosis is not confirmed.

• The next step is to repeat hCG in 48 hours:

o If it doubles → likely viable pregnancy
o If it plateaus or falls → likely ectopic or failing pregnancy

NICE Reference: NG126 – Ectopic pregnancy and miscarriage

Clinical takeaway: In suspected ectopic with PUL, repeat hCG in 48 hours is key to triage.

Chapter 7: Psychiatry & Mental Health

Question 1

A 32-year-old woman presents with a 2-month history of low mood, early morning wakening,
poor appetite, and feelings of guilt and hopelessness. She denies suicidal thoughts. This is her
first episode. There is no history of mania or psychosis. She is not on any medications and
prefers non-drug options.

What is the most appropriate first-line management?

A. Start sertraline
B. Refer to psychiatry
C. Offer guided self-help and CBT-based intervention
D. Prescribe diazepam
E. Recommend St. John's Wort

Correct Answer: C. Offer guided self-help and CBT-based intervention

Explanation:
According to NICE NG222 (Depression in adults), low to moderate depression without
suicidal risk is first managed with low-intensity psychological interventions, such as:
 • CBT-based guided self-help
• Computerized CBT
• Group CBT

Antidepressants are reserved for more severe or persistent cases or patient preference.

NICE Reference: NG222 – Depression in adults

Clinical takeaway: For first mild/moderate depressive episodes, offer psychological therapy
first.

Question 2

A 22-year-old man presents with a 6-month history of feeling constantly “on edge,” with
difficulty sleeping, muscle tension, and frequent worry about daily tasks. There are no panic
attacks or depressive symptoms.

What is the most likely diagnosis?

A. Panic disorder
B. Generalised anxiety disorder (GAD)
C. Adjustment disorder
D. Acute stress reaction
E. Obsessive-compulsive disorder

Correct Answer: B. Generalised anxiety disorder (GAD)

Explanation:
GAD is characterized by persistent, excessive worry about everyday things, often for >6
months, with physical symptoms such as:

• Restlessness
• Muscle tension
• Sleep disturbance

Unlike panic disorder, GAD lacks discrete attacks.

NICE Reference: CG113 – Generalised anxiety disorder and panic disorder

Clinical takeaway: Chronic, widespread worry + somatic symptoms = GAD.
 Question 3

A 45-year-old man with a history of schizophrenia presents for routine review. He has been
stable on risperidone for 1 year. He reports recent weight gain and increased thirst. Bloods show
fasting glucose of 8.4 mmol/L.

What is the most appropriate next step?

A. Stop risperidone immediately

B. Start metformin and continue antipsychotic
C. Refer urgently to endocrinology
D. Switch to clozapine
E. Repeat fasting glucose in 1 week

Correct Answer: B. Start metformin and continue antipsychotic

Explanation:
Antipsychotics like risperidone can cause metabolic syndrome, including diabetes. NICE
recommends:

• Regular metabolic monitoring

• Managing diabetes without necessarily stopping antipsychotics if stable

Clozapine has higher metabolic risk. Stopping antipsychotics abruptly may destabilize mental
health.

NICE Reference: CG178 – Psychosis and schizophrenia in adults

Clinical takeaway: Manage side effects (e.g., hyperglycemia) without disrupting psychiatric
stability.

Question 4

A 29-year-old woman reports repetitive hand-washing for hours each day due to fear of
contamination. She knows the behaviour is excessive but cannot resist the urge. It’s affecting her
work and relationships.

What is the most appropriate first-line treatment?

A. Start sertraline and refer for CBT

B. Refer for family therapy
C. Prescribe benzodiazepines
D. Recommend mindfulness techniques
E. Prescribe amitriptyline

Correct Answer: A. Start sertraline and refer for CBT

Explanation:
OCD should be treated with:

• CBT with exposure and response prevention (ERP)

• AND/OR SSRIs, with sertraline being first-line per NICE

Benzodiazepines and amitriptyline are not recommended. Family therapy has limited role
unless children are involved.

NICE Reference: CG31 – Obsessive-compulsive disorder and BDD

Clinical takeaway: Combine CBT + SSRI for moderate/severe OCD.

Question 5

A 65-year-old woman is brought by her daughter with increasing forgetfulness and confusion
over the past year. She often repeats herself, forgets names, and recently got lost in her own
neighbourhood. There are no hallucinations or motor symptoms.

What is the most appropriate next step in assessment?

A. Start donepezil
B. Refer for urgent MRI brain
C. Perform a cognitive assessment in clinic
D. Refer directly to memory clinic
E. Start memantine

Correct Answer: C. Perform a cognitive assessment in clinic

Explanation:
Before referral or treatment for dementia, NICE NG97 recommends:

• History from patient and carer

• Cognitive testing (e.g., GPCOG, MMSE, 6CIT)
• Rule out delirium or depression
Referral to memory services follows positive screening or red flags. Starting treatment requires
confirmed diagnosis.

NICE Reference: NG97 – Dementia: assessment, management and support

Clinical takeaway: Always assess cognition in primary care before referring.

Chapter 8: Pediatrics

Question 1

A 5-year-old boy is brought to the clinic with a 3-day history of fever, sore throat, and difficulty
swallowing. On examination, he is febrile (38.5°C), has a muffled voice, trismus, and tender
cervical lymphadenopathy. His uvula is deviated to the right, and there is a unilateral swelling of
the soft palate.

What is the most likely diagnosis?

A. Streptococcal tonsillitis
B. Infectious mononucleosis
C. Peritonsillar abscess (quinsy)
D. Epiglottitis
E. Retropharyngeal abscess

Correct Answer: C. Peritonsillar abscess (quinsy)

Explanation:
Quinsy presents with:

• Unilateral sore throat

• Uvular deviation
• Trismus (jaw stiffness)
• “Hot potato” voice
It is a complication of tonsillitis, often in older children and adolescents.

NICE Reference: CKS – Sore throat

Clinical takeaway: Uvula deviation and trismus point to peritonsillar abscess.
 Question 2

A 3-year-old girl is brought in with a barking cough, hoarseness, and inspiratory stridor that
worsens at night. She has no drooling, is afebrile, and is well-appearing.

What is the most likely diagnosis?

A. Epiglottitis
B. Croup (laryngotracheobronchitis)
C. Foreign body aspiration
D. Bronchiolitis
E. Acute asthma

Correct Answer: B. Croup (laryngotracheobronchitis)

Explanation:
Croup commonly affects children aged 6 months to 6 years, with:

• Barking cough
• Inspiratory stridor
• Worse at night
• Viral cause (often parainfluenza)

Absence of drooling or toxicity helps exclude epiglottitis.

NICE Reference: CKS – Croup

Clinical takeaway: Barking cough + stridor = croup in well-appearing young child.

Question 3

A 9-month-old boy presents with 2 days of cough, wheezing, and difficulty feeding. He is
afebrile and has fine crackles and wheeze on auscultation. Oxygen saturation is 91% on room air.

What is the most likely diagnosis?

A. Asthma
B. Viral pneumonia
C. Bronchiolitis
D. Croup
E. Pertussis

Correct Answer: C. Bronchiolitis

Explanation:
Bronchiolitis is common in children <1 year and presents with:

• Cough
• Wheeze
• Crackles
• Feeding difficulty
• Low-grade fever or afebrile

Asthma is rare <1 year. Oxygen support may be needed if saturations drop.

NICE Reference: NG9 – Bronchiolitis in children

Clinical takeaway: Wheezy baby <12 months = bronchiolitis.

Question 4

A 2-month-old baby is brought with persistent vomiting after every feed. The vomit is forceful
and non-bilious. The baby has lost weight and appears dehydrated. On examination, there is a
palpable olive-shaped mass in the upper abdomen.

What is the most likely diagnosis?

A. Gastroesophageal reflux
B. Pyloric stenosis
C. Intussusception
D. Milk protein allergy
E. Duodenal atresia

Correct Answer: B. Pyloric stenosis

Explanation:
Pyloric stenosis presents at 2–8 weeks with:

• Projectile non-bilious vomiting

 • Palpable pyloric “olive”
• Dehydration and weight loss
• Hypochloraemic metabolic alkalosis

NICE Reference: CKS – Vomiting in children

Clinical takeaway: In young infant with projectile vomiting and olive mass → think pyloric
stenosis.

Question 5

A 14-year-old boy is brought in with left knee pain, fever, and refusal to bear weight. The knee is
warm and swollen. He has a temperature of 38.7°C and elevated CRP. He has no significant
trauma or history of autoimmune disease.

What is the most likely diagnosis?

A. Reactive arthritis
B. Juvenile idiopathic arthritis
C. Septic arthritis
D. Osgood-Schlatter disease
E. Transient synovitis

Correct Answer: C. Septic arthritis

Explanation:
Septic arthritis in children presents with:

• Fever
• Painful, swollen joint
• Refusal to weight bear
It is a medical emergency requiring immediate hospital referral for IV antibiotics and
joint aspiration.

NICE Reference: CKS – Limping child

Clinical takeaway: Febrile child with painful joint + no trauma = septic arthritis until proven
otherwise.
 Chapter 9: Ethics & Communication

Question 1

A 17-year-old girl attends alone and asks for the oral contraceptive pill. She does not want her
parents to know. She understands the risks and benefits and is able to explain them clearly. She
is not being coerced or exploited.

What is the most appropriate action?

A. Refuse to prescribe unless a parent is present

B. Encourage her to return with a guardian
C. Prescribe the pill and document assessment of capacity
D. Inform safeguarding team immediately
E. Delay the decision until a follow-up visit

Correct Answer: C. Prescribe the pill and document assessment of capacity

Explanation:
This scenario meets the Fraser guidelines — a legal framework for providing contraceptive
advice to under-16s (also applies for mature 16–17-year-olds) if:

• The young person understands the advice

• The advice is in their best interest
• They are likely to continue sexual activity regardless
• Parents cannot be persuaded to be involved

NICE & GMC guidance – Apply Gillick competence and Fraser criteria
Clinical takeaway: If a minor demonstrates capacity and it's in their best interest, care can be
provided confidentially.

Question 2

You are seeing a patient who has been newly diagnosed with terminal pancreatic cancer. His
family asks you not to disclose the diagnosis to him, stating that it would “destroy him.”

What is the most appropriate next step?

A. Respect the family’s wishes
B. Tell the patient only if he asks directly
C. Explain your duty and discuss with the patient sensitively
D. Delay disclosure until a multidisciplinary meeting is held
E. Document their request and do nothing further

Correct Answer: C. Explain your duty and discuss with the patient
sensitively

Explanation:
The GMC and ethical best practice state that doctors must be honest and open with patients
about their condition unless the patient has clearly stated they do not wish to know. Family
requests do not override patient autonomy.

GMC: Good Medical Practice – Communication and Consent

Clinical takeaway: Always aim to involve the patient directly unless they’ve opted out of
knowing.

Question 3

A 40-year-old man with schizophrenia refuses to take his antipsychotic medication and is
refusing to allow blood pressure or blood tests. He appears calm and states he does not wish to
engage further.

What is the best next step?

A. Administer medication covertly

B. Detain under the Mental Health Act immediately
C. Assess mental capacity to make this decision
D. Seek consent from next of kin
E. Call police for forced treatment

Correct Answer: C. Assess mental capacity to make this decision

Explanation:
Before any decision is made, you must assess whether the patient has capacity to refuse
treatment — under the Mental Capacity Act (MCA). If capacity is confirmed, his decision
must be respected, even if unwise.
 GMC & Mental Capacity Act 2005
Clinical takeaway: Capacity must be assessed before considering detention or forced
treatment.

Question 4

A GP receives a court order to release the full medical records of a patient involved in a criminal
investigation. The patient has previously refused permission for their records to be shared.

What is the most appropriate response?

A. Refuse to release the records due to lack of consent

B. Release only selected information
C. Release the full records as ordered
D. Ask the police to seek consent again
E. Refer to the practice manager

Correct Answer: C. Release the full records as ordered

Explanation:
A court order overrides patient consent and must be complied with. However, disclosure
should still be limited to what the order specifies. Always document the legal basis for
disclosure.

GMC – Confidentiality: good practice in handling patient information

Clinical takeaway: Court orders must be obeyed, even if the patient objects.

Question 5

During a consultation, a patient becomes agitated and starts shouting aggressively. He refuses to
calm down despite verbal de-escalation. Other patients in the waiting room appear distressed.

What is the most appropriate immediate response?

A. Continue the consultation and try to calm him down

B. Call his family to help de-escalate
C. Ask the patient to leave and end the consultation
D. Prioritise safety and activate the practice's security/emergency protocol
E. Refer to mental health crisis team immediately
 Correct Answer: D. Prioritise safety and activate the practice's
security/emergency protocol

Explanation:
In any situation involving aggression or violence, safety comes first — for staff, the patient,
and others. De-escalation is attempted first, but if the situation becomes threatening, follow your
local emergency protocol.

NICE: Violence and aggression – short-term management

Clinical takeaway: Always follow safety-first approach before clinical interventions.

Chapter 10: Public Health & Preventive Care

Question 1

A 58-year-old man attends for an NHS Health Check. He is a smoker with a BMI of 29 kg/m².
His QRISK3 score is calculated at 12%. He has no history of cardiovascular disease. Bloods
show total cholesterol 6.1 mmol/L.

What is the most appropriate next step?

A. Prescribe atorvastatin 20 mg
B. Start aspirin 75 mg daily
C. Refer to a dietitian
D. Repeat QRISK3 in 6 months
E. Prescribe ezetimibe

Correct Answer: A. Prescribe atorvastatin 20 mg

Explanation:
According to NICE CG181, a QRISK3 score ≥10% warrants statin therapy for primary
prevention. The first-line choice is atorvastatin 20 mg daily, regardless of baseline cholesterol
level. Lifestyle advice should be given concurrently but not instead of pharmacological
prevention.

NICE Reference: CG181 – Cardiovascular risk assessment and lipid modification

Clinical takeaway: Start statin in patients with QRISK3 ≥10% even in primary prevention.

Question 2

A 62-year-old woman asks whether she needs bowel cancer screening. She has no symptoms and
no family history. She last had a stool test 2 years ago.

What is the most appropriate next step?

A. Recommend colonoscopy every 10 years

B. Advise she will receive a faecal immunochemical test (FIT) by post at age 65
C. Reassure and no further action
D. Recommend annual faecal occult blood test
E. Advise she should already be receiving FIT screening every 2 years

Correct Answer: E. Advise she should already be receiving FIT screening

every 2 years

Explanation:
According to UK bowel cancer screening guidelines, adults aged 60–74 are automatically
invited every 2 years to complete a faecal immunochemical test (FIT) at home.

NHS Bowel Cancer Screening Programme

Clinical takeaway: FIT every 2 years for 60–74 year olds is standard UK screening.

Question 3

A 70-year-old man with COPD is concerned about influenza. He has never had the flu vaccine.
He is otherwise stable and on inhalers.

What is the most appropriate recommendation?

A. Annual inactivated influenza vaccine

B. One-time live intranasal influenza vaccine
C. No vaccine if asymptomatic
D. Recommend pneumococcal vaccine only
E. Advise vaccination only if hospitalised

Correct Answer: A. Annual inactivated influenza vaccine

Explanation:
NICE and Green Book guidance recommend annual inactivated influenza vaccination for all
patients with chronic respiratory conditions (e.g., asthma, COPD), as well as those over 65.

• The intranasal vaccine is for children only.

Green Book – Influenza chapter

Clinical takeaway: COPD and age ≥65 = annual flu jab is essential.

Question 4

A 27-year-old woman has recently moved to the UK. She has never had a cervical smear. She is
sexually active, and her last period was 3 weeks ago.

What is the most appropriate advice?

A. Offer cervical screening immediately

B. Wait until she turns 30
C. Only offer screening if she is symptomatic
D. Schedule a smear 6 months from now
E. Reassure that screening is not necessary yet

Correct Answer: A. Offer cervical screening immediately

Explanation:
In the UK Cervical Screening Programme, all women aged 25–64 are eligible. Since she is 27,
never screened, and is sexually active, she should be offered cervical screening immediately.

NHS Cervical Screening Programme

Clinical takeaway: Women aged 25–49 are invited every 3 years.
 Question 5

A 14-year-old boy presents for routine check-up. His immunisation record shows that he missed
the second dose of the HPV vaccine at school last year. What should you do?

A. Restart the HPV vaccination course

B. Give only one dose now
C. Administer the second dose now
D. No need to catch up after 14
E. Refer to sexual health clinic

Correct Answer: C. Administer the second dose now

Explanation:
The HPV vaccine is offered to boys and girls aged 12–13, usually as a 2-dose schedule (6–24
months apart). If the first dose was given, the second dose can still be administered within the
24-month window.

Green Book – HPV vaccination chapter

Clinical takeaway: Give second HPV dose if within timing window — don’t restart.

Chapter 11: Emergency Medicine & Red Flags

Question 1

A 65-year-old man presents with sudden-onset tearing chest pain radiating to the back. He is
hypertensive, has unequal arm pulses, and his BP is 190/100 mmHg. ECG shows sinus rhythm
with no ST changes. Troponin is normal.

What is the most likely diagnosis?

A. ST-elevation myocardial infarction

B. Pulmonary embolism
C. Acute aortic dissection
D. Tension pneumothorax
E. Pericarditis

Correct Answer: C. Acute aortic dissection

Explanation:
Red flags for aortic dissection:

• Sudden tearing/ripping chest or back pain

• Hypertension, pulse deficits
• Normal troponin and ECG despite severe pain
This is a life-threatening emergency needing immediate CT angiography.

NICE CKS – Chest pain & Aortic dissection

Clinical takeaway: Always consider dissection in severe chest pain + pulse differences.

Question 2

A 24-year-old man is brought in after collapsing at a party. He is unconscious, breathing

spontaneously, and has pinpoint pupils. His respiratory rate is 6/min and oxygen saturation is
88% on room air.

What is the most appropriate immediate management?

A. Administer naloxone
B. Start IV fluids
C. Perform CT head
D. Intubate immediately
E. Observe and reassess in 15 minutes

Correct Answer: A. Administer naloxone

Explanation:
This presentation is classic for opioid overdose:

• Pinpoint pupils, respiratory depression

• Altered consciousness
Naloxone reverses opioid effects rapidly and is life-saving.
 NICE CKS – Opioid overdose
Clinical takeaway: Respiratory depression + pinpoint pupils = opioid OD → naloxone.

Question 3

A 4-week-old baby presents with poor feeding, lethargy, vomiting, and a bulging fontanelle.
Rectal temperature is 38.5°C. He appears floppy and irritable.

What is the most appropriate next step?

A. Treat with oral antibiotics and review

B. Refer for urgent lumbar puncture and IV antibiotics
C. Start oral paracetamol and monitor
D. Arrange outpatient ultrasound brain
E. Send urine sample and wait for results

Correct Answer: B. Refer for urgent lumbar puncture and IV antibiotics

Explanation:
This baby has red flags for meningitis/sepsis:

• Bulging fontanelle
• High fever
• Lethargy and poor feeding
NICE NG51 recommends urgent hospital transfer for full septic workup and IV
antibiotics in any baby under 3 months with serious infection signs.

NICE Reference: NG51 – Fever in under 5s

Clinical takeaway: Sick neonates with red flags = hospital admission and IV treatment.

Question 4

A 45-year-old woman presents with severe abdominal pain that began suddenly and is
disproportionate to clinical findings. Her abdomen is soft with minimal tenderness. She has a
history of atrial fibrillation and is on no anticoagulation.

What is the most likely diagnosis?

A. Perforated peptic ulcer
B. Acute pancreatitis
C. Mesenteric ischaemia
D. Gastroenteritis
E. Small bowel obstruction

Correct Answer: C. Mesenteric ischaemia

Explanation:
Classically presents as:

• Sudden severe pain out of proportion to exam findings

• Often in patients with AF or cardiovascular risk
• Can lead to rapid deterioration
Immediate surgical referral and CT angiography is required.

NICE CKS – Acute abdomen

Clinical takeaway: Think mesenteric ischaemia in AF patients with sudden severe abdominal
pain.

Question 5

A 52-year-old man presents with a severe headache of sudden onset (“worst headache of my
life”), nausea, photophobia, and neck stiffness. He has a GCS of 15. BP is 165/95 mmHg.

What is the most appropriate next investigation?

A. CT brain without contrast

B. MRI brain with contrast
C. Lumbar puncture
D. Blood cultures and ESR
E. CT angiogram of head and neck

Correct Answer: A. CT brain without contrast

Explanation:
In suspected subarachnoid haemorrhage (SAH):

• First investigation = non-contrast CT brain

 • If CT is normal, LP after 12 hours is used to confirm xanthochromia

Urgent imaging is essential before LP.

NICE CKS – Headache (sudden onset)

Clinical takeaway: Sudden severe headache = rule out SAH with urgent CT head.

Chapter 12: Dermatology

Question 1

A 23-year-old woman presents with a red, itchy rash in the flexures of both elbows and behind
her knees. The rash is dry, with areas of excoriation and lichenification. She reports that it
worsens in winter and with stress. She has a history of asthma and allergic rhinitis.

What is the most likely diagnosis?

A. Psoriasis
B. Contact dermatitis
C. Atopic eczema
D. Seborrhoeic dermatitis
E. Tinea corporis

Correct Answer: C. Atopic eczema

Explanation:
Atopic eczema is common in young adults with atopic history (asthma, hay fever) and
typically affects flexural surfaces with dry, itchy, inflamed skin.

• Chronic scratching → lichenification

• Seasonal flares common (cold, stress, allergens)

NICE CKS – Atopic eczema

Clinical takeaway: Flexural rash in atopic patient = atopic eczema.
 Question 2

A 32-year-old man presents with well-demarcated, erythematous plaques with silvery scale on
his elbows and knees. He also has pitting of his fingernails. He denies itching but is embarrassed
by the appearance.

What is the most likely diagnosis?

A. Psoriasis vulgaris
B. Seborrhoeic dermatitis
C. Tinea corporis
D. Lichen planus
E. Eczema

Correct Answer: A. Psoriasis vulgaris

Explanation:
Plaque psoriasis is characterised by:

• Symmetrical plaques with silvery scale

• Common on extensor surfaces
• Nail pitting is a classic feature
• No significant itch in many patients

NICE NG190 – Psoriasis

Clinical takeaway: Extensor plaques + nail changes = psoriasis.

Question 3

A 19-year-old student presents with sudden onset of multiple small, scaly, salmon-pink lesions
over the trunk and upper limbs. A larger “herald patch” preceded the eruption by about a week.
He is otherwise well.

What is the most likely diagnosis?

A. Guttate psoriasis
B. Pityriasis rosea
C. Tinea versicolor
D. Viral exanthem
E. Lichen planus
 Correct Answer: B. Pityriasis rosea

Explanation:
Pityriasis rosea typically begins with a herald patch, followed by a Christmas tree pattern
rash on the trunk. It is:

• Self-limiting
• Seen in adolescents/young adults
• Often triggered by a viral illness

PCDS – Pityriasis rosea

Clinical takeaway: Herald patch + diffuse trunk rash in young person = pityriasis rosea.

Question 4

A 48-year-old woman presents with a painful, red, swollen area on her lower left leg. It is warm
and tender to touch. She has a fever of 38.3°C. There is no pus or abscess. She has no trauma,
but had a recent fungal toe infection.

What is the most likely diagnosis?

A. Erythema nodosum
B. Cellulitis
C. Necrotising fasciitis
D. Deep vein thrombosis
E. Lipodermatosclerosis

Correct Answer: B. Cellulitis

Explanation:
Cellulitis presents with:

• Localised red, hot, swollen skin

• Often unilateral
• Fever, systemic signs
• Entry point (e.g., tinea pedis, skin breaks)

Necrotising fasciitis involves rapid progression, disproportionate pain, and systemic shock.
 NICE CKS – Cellulitis
Clinical takeaway: Unilateral red leg + fever = cellulitis until proven otherwise.

Question 5

A 65-year-old farmer presents with a rough, scaly patch on his bald scalp that has not healed for
several months. The area is erythematous, slightly raised, and occasionally bleeds. There is no
pain or lymphadenopathy.

What is the most appropriate next step?

A. Reassure and apply emollients

B. Prescribe topical steroid
C. Refer under 2-week rule for suspected skin cancer
D. Perform cryotherapy
E. Treat for actinic keratosis

Correct Answer: C. Refer under 2-week rule for suspected skin cancer

Explanation:
This lesion could be a squamous cell carcinoma (SCC) — especially given:

• Chronicity
• Sun exposure
• Bleeding or non-healing nature
All suspicious lesions require urgent dermatology review.

NICE NG12 – Skin cancer referral

Clinical takeaway: Non-healing scaly/bleeding lesion in sun-exposed area = urgent referral.

Chapter 13: Urology & Men’s Health

 Question 1

A 68-year-old man presents with increased urinary frequency, nocturia, and a weak stream. He
denies hematuria or pain. His PSA is 3.6 ng/mL. Digital rectal exam reveals a smooth, enlarged
prostate.

What is the most appropriate initial management?

A. Refer under 2-week wait pathway

B. Prescribe tamsulosin
C. Order a prostate biopsy
D. Start finasteride
E. Arrange MRI prostate

Correct Answer: B. Prescribe tamsulosin

Explanation:
This is benign prostatic hyperplasia (BPH) with lower urinary tract symptoms (LUTS). NICE
NG97 recommends starting with alpha-blockers (e.g. tamsulosin) as first-line for symptom
relief.

• PSA is within age-appropriate range (normal <4 ng/mL at age 60–69).

• No red flag signs → no urgent referral needed.
• Finasteride (5-alpha reductase inhibitor) is considered after 6+ months or if prostate is
very large.

NICE NG97 – LUTS in men

Clinical takeaway: LUTS + smooth prostate → alpha-blocker trial before investigations.

Question 2

A 55-year-old man reports visible hematuria for 2 days. He denies pain, fever, or trauma. This is
the first episode. His urine dipstick is positive for blood, and there is no evidence of infection.
BP and renal function are normal.

What is the most appropriate next step?

A. Reassure and observe

B. Treat for UTI empirically
C. Refer urgently to urology via 2-week wait
D. Order renal ultrasound
E. Check urine cytology

Correct Answer: C. Refer urgently to urology via 2-week wait

Explanation:
Visible (macroscopic) hematuria in patients aged ≥45 years with no UTI or trauma warrants
urgent urology referral for suspected bladder or renal cancer under NICE NG12.

NICE NG12 – Suspected cancer: recognition and referral

Clinical takeaway: First visible hematuria = red flag → 2WW referral.

Question 3

A 40-year-old man presents with sudden onset scrotal pain and swelling on the left side. He is
febrile and reports dysuria. On examination, the scrotum is swollen and tender, and Prehn’s sign
is positive (pain improves on elevation).

What is the most likely diagnosis?

A. Testicular torsion
B. Epididymo-orchitis
C. Inguinal hernia
D. Hydrocele
E. Varicocele

Correct Answer: B. Epididymo-orchitis

Explanation:
Prehn’s sign (pain relief on elevation of the scrotum) is classically seen in epididymo-orchitis,
not torsion. Torsion usually causes:

• Sudden severe pain

• High-riding testis
• No relief with elevation
This patient also has signs of infection.
 NICE CKS – Epididymo-orchitis
Clinical takeaway: Pain + fever + positive Prehn’s = epididymo-orchitis → antibiotics and
STI screen if <35.

Question 4

A 15-year-old boy presents with acute onset of severe left testicular pain and vomiting. The
testicle is high-riding and tender to palpation. On lifting the testicle, the pain worsens. The onset
was <6 hours ago.

What is the most appropriate next step?

A. Start antibiotics and monitor

B. Perform scrotal ultrasound
C. Refer immediately for surgical exploration
D. Prescribe NSAIDs and review
E. Check urine dip and delay referral

Correct Answer: C. Refer immediately for surgical exploration

Explanation:
This is testicular torsion, a urological emergency. Key signs:

• Sudden onset pain

• High-riding testicle
• Absent cremasteric reflex
• Negative Prehn’s sign (pain not relieved)

Do not delay for imaging — referral must be immediate.

NICE CKS – Acute scrotal pain

Clinical takeaway: Torsion = surgical emergency → explore within 6 hours.

Question 5

A 64-year-old man with type 2 diabetes complains of erectile dysfunction for the past 8 months.
He is on ramipril, simvastatin, and metformin. He has normal testosterone and normal BP. He
requests treatment.
What is the most appropriate first-line option?

A. Switch simvastatin to another statin

B. Prescribe sildenafil
C. Start testosterone replacement
D. Refer to urology
E. Recommend vacuum erection device

Correct Answer: B. Prescribe sildenafil

Explanation:
For erectile dysfunction (ED) in men with:

• Normal testosterone
• No contraindications
• Desire for treatment

→ NICE recommends a PDE5 inhibitor (e.g., sildenafil) as first-line. ED is common in diabetes

and should be addressed proactively.

NICE CKS – Erectile dysfunction

Clinical takeaway: Sildenafil is first-line for ED in stable diabetic patients.

Chapter 14: ENT & Ophthalmology

Question 1 – ENT

A 7-year-old boy presents with unilateral ear pain and fever for 2 days. He has no discharge, but
on otoscopy, the tympanic membrane is red and bulging. He is otherwise well and has no
comorbidities.

What is the most appropriate management?

A. Immediate antibiotics
B. Delayed prescription of amoxicillin
C. Topical antibiotics
D. Refer to ENT
E. Reassure and observe

Correct Answer: B. Delayed prescription of amoxicillin

Explanation:
In acute otitis media (AOM):

• For children over 2 years without systemic illness, NICE recommends no immediate
antibiotics
• Offer safety-netting or delayed prescription if symptoms worsen or persist after 3 days

NICE NG91 – Otitis media

Clinical takeaway: Most uncomplicated AOM in children can be managed with delayed or
no antibiotics.

Question 2 – ENT

A 42-year-old woman reports recurrent nasal obstruction, facial pressure, and anosmia lasting
>12 weeks. Examination reveals bilateral pale nasal swellings.

What is the most likely diagnosis?

A. Allergic rhinitis
B. Deviated nasal septum
C. Chronic sinusitis
D. Nasal polyps
E. Acute sinusitis

Correct Answer: D. Nasal polyps

Explanation:
Nasal polyps are:

• Painless, pale, bilateral swellings

• Often associated with anosmia, asthma, aspirin sensitivity
 • Typically chronic (>12 weeks)

Anosmia + nasal blockage = consider polyps.

NICE CKS – Chronic rhinosinusitis with nasal polyps

Clinical takeaway: Bilateral pale swellings = nasal polyps → consider intranasal steroids.

Question 3 – ENT

A 16-year-old male presents with a sore throat, fatigue, and fever for 5 days. On examination, he
has tonsillar exudate, palatal petechiae, and posterior cervical lymphadenopathy. Splenomegaly
is noted.

What is the most appropriate next step?

A. Prescribe amoxicillin
B. Refer for urgent ENT assessment
C. Do Monospot test (heterophile antibody)
D. Start acyclovir
E. Prescribe erythromycin

Correct Answer: C. Do Monospot test (heterophile antibody)

Explanation:
This is classic infectious mononucleosis (EBV):

• Fatigue + pharyngitis + posterior lymphadenopathy

• Avoid amoxicillin — causes rash in IM

Confirm with Monospot (or EBV serology).

NICE CKS – Infectious mononucleosis

Clinical takeaway: EBV suspected → confirm with Monospot before treating.

Question 4 – Ophthalmology

A 70-year-old woman complains of gradual, painless loss of central vision in both eyes. She
struggles with reading and recognizing faces. There is no pain or redness.
What is the most likely diagnosis?

A. Cataract
B. Glaucoma
C. Diabetic retinopathy
D. Macular degeneration
E. Retinal detachment

Correct Answer: D. Macular degeneration

Explanation:
Age-related macular degeneration (ARMD) typically presents with:

• Gradual central vision loss

• Bilateral, painless
• Loss of visual acuity and detail

Peripheral vision is usually preserved.

NICE CKS – Macular degeneration

Clinical takeaway: Bilateral central vision loss in elderly = ARMD.

Question 5 – Ophthalmology

A 64-year-old man presents with sudden onset of a curtain-like loss of vision in his right eye. He
also noticed floaters and flashes of light prior to this. There is no pain or redness.

What is the most likely diagnosis?

A. Retinal detachment
B. Glaucoma
C. Vitreous haemorrhage
D. Optic neuritis
E. Temporal arteritis

Correct Answer: A. Retinal detachment

Explanation:
Classic red flags for retinal detachment:
 • Flashes, floaters, then sudden visual field defect ("curtain over vision")
• No pain, no redness

Immediate urgent ophthalmology referral is essential.

NICE CKS – Visual loss

Clinical takeaway: Curtain-like vision loss + flashes/floaters = retinal detachment.