MRCGP AKT practice questions

The ECG demonstrates atrioventricular dissociation: regular P waves occur at a faster rate than the regular QRS complexes, with no consistent relationship between them. This indicates complete atrioventricular block, with an escape rhythm maintaining the ventricular rate.

Atrial fibrillation would produce absent organised P waves and an irregular ventricular rhythm. First-degree block has a prolonged but constant PR interval, while Mobitz type I block shows progressive PR prolongation before a dropped QRS complex. Sinus bradycardia retains a P wave before every QRS complex.

His near-syncope and marked bradycardia require immediate hospital assessment by emergency ambulance because urgent pacing may be needed.

Correct answer: E — Fluoxetine taken continuously or during the luteal phase.

Selective serotonin reuptake inhibitors are first-line pharmacological treatments for severe premenstrual syndrome and can be taken continuously or during the luteal phase. A gonadotrophin-releasing hormone agonist is generally reserved for severe symptoms unresponsive to simpler treatments and requires specialist supervision. Progesterone, spironolactone and a levonorgestrel intrauterine system are not appropriate first-line treatments for prominent cyclical mood symptoms.

Reference: Royal College of Obstetricians and Gynaecologists, Management of Premenstrual Syndrome, Green-top Guideline No. 48, published December 2016. https://www.rcog.org.uk/guidance/browse-all-guidance/green-top-guidelines/management-of-premenstrual-syndrome-pms-green-top-guideline-no-48/

Correct answer: D — Start oral iron, address dietary causes and arrange response monitoring. The microcytic anaemia with low ferritin is diagnostic of iron deficiency in this clinical context. Oral iron and dietary intervention are appropriate initially, with repeat blood testing to confirm a haematological response and adherence. Failure to respond should prompt reassessment for continued blood loss, malabsorption, inflammation or an alternative haemoglobin disorder. Reference: NICE CKS, Anaemia – iron deficiency, https://cks.nice.org.uk/topics/anaemia-iron-deficiency/

Correct answer: E — Agree a gradual, individualised reduction with support for pain and mental health. Physical dependence can develop during prescribed opioid use and does not by itself imply illicit misuse. Abrupt cessation may cause significant withdrawal and psychological distress, so dose reduction should be collaborative, flexible and regularly reviewed. Pain management, function, anxiety and depression should be addressed alongside the taper.

References: NICE, Medicines associated with dependence or withdrawal symptoms: safe prescribing and withdrawal management for adults, NG215, 2022. https://www.nice.org.uk/guidance/ng215

NICE, Chronic pain in over 16s: assessment and management of chronic primary pain, NG193, updated 2021. https://www.nice.org.uk/guidance/ng193

People discharged with lower-limb immobilisation should have individual venous thromboembolism and bleeding risks assessed. NICE advises considering low-molecular-weight heparin or fondaparinux when thrombotic risk outweighs bleeding risk. Previous venous thromboembolism and obesity increase this patient's risk, while aspirin and D-dimer testing are not recommended substitutes for risk-based prophylaxis.