THE APPLIED KNOWLEDGE TEST

CURRICULUM GUIDE
2021

DR. SHILPA MARY CHERIYAN

DR. MARK SIMS

WALES DEANERY
 INDEX

TOPIC PAGE NO.

CLINICAL TOPIC GUIDES 3
Allergy and Immunology 3
Cardiovascular Health 5
Dermatology 7
Ear, nose and throat 9
Eyes and Vision 11
Gastroenterology 13
Genomic Medicine 16
Gynaecology and Breast 18
Haematology 21
Infectious Disease and Travel Health 23
Kidney and Urology 26
Mental Health 29
Metabolic Problems and Endocrinology 31
Musculoskeletal Health 34
Neurodevelopmental disorders 36
Neurology 38
Population Health 40
Respiratory Health 42
Sexual Health 44
Smoking Alcohol and Substance Misuse 47
PROFESSIONAL TOPIC GUIDES 49
Consulting in GP 49
Equality Diversity and Inclusion 49
Evidence Based Practice 50
Quality Safety and Prescribing 54
Leadership and Management 54
Urgent and Unscheduled Care 56
LIFE STAGES TOPIC GUIDES 58
Children and Young People 58
People with Long Term Conditions and Cancer 61
Maternity and Reproductive Health 62
Older Adults 64
People at End of Life 65
 CLINICAL TOPIC GUIDES

ALLERGY AND IMMUNOLOGY

Emerging Issues-

• Allergy management plans in association with pediatrics

• Role of immunotherapy for chronic allergy disorders
• Immune manipulation

Knowledge and Skills Guide-

Symptoms and signs

• Anaphylaxis
• Angio-oedema
• Atopy – asthma, eczema and hay fever
• Drug reactions
• GI symptoms for example diarrhoea
• Urticaria and rashes

Common and important conditions

• Anaphylaxis, including doses of adrenaline and resuscitation

• Autoimmune conditions in primary care
• Drug allergies and their mechanisms
• Food allergies, including milk allergy (types for example IgE vs. non-IgE mediated, presentation, primary care
management and referral)
• Occupational allergies such as latex allergy and contact allergies such as hair dye, metals, plants
• Pollen Food Syndrome
• Types of allergic reactions: immediate, delayed, possible mechanisms
• Venom allergy: referral and emergency management; the role of immunotherapy
• Immune deficiency states (inherited, primary and acquired such as HIV, chemotherapy) as applicable to primary care
particularly the different requirements for antibiotics
• antibody test results used in guiding management of specific situations such as chickenpox in pregnancy, rubella
immunisation, hepatitis B and C
• routine primary childhood immunisation schedules, contraindications and adverse reactions; and for occupational
medicine such as healthcare workers and Hepatitis B
• Needle stick injuries and risk of Hepatitis B and C, HIV
• Skin manifestations of immune disease such as Kaposi’s sarcoma
• Transplantation medicine as applicable to primary care particularly in management of organ transplants such as
heart, lung, liver, kidney, cornea
• Indications and complications of transplantation for example immunosuppression and immunosuppressant drugs

Examinations and procedures

• Administration of adrenaline
• Risk assessment and prescribing of adrenaline devices
• Effective administration of topical nasal steroids and inhaler devices

Investigations
 • Allergy: skin patch and prick testing, specific IgE testing (blood and skin prick), exclusion and reintroduction in
suspected non-IgE disease
• Immune disorders: immunoglobulin levels including IgG, IgM serology, and complement

Additional important content

• Economic and psychosocial impact of food allergies on the individual and their wider social network.

AKT sample questions-

• Management of chickenpox contact in pregnancy

• Indications and contraindications to routine immunisation in an immunosuppressed child
• Management of urticaria
 CARDIOVASCULAR HEALTH
Emerging issues-

• Assessing lifetime risk for cardiovascular disease

• Assessing depression as risk factor and associated condition of heart disease and stroke
• Examining cognitive impairment due to cardiovascular health
• Improving cardiovascular surveillance system

Knowledge and Skills guide-

Symptoms and signs

• Cardiac murmurs
• Chest pain (including factors suggestive of cardiac origin)
• Circulatory symptoms of ischaemia, thrombosis, chronic arterial and venous insufficiency
• Dyspnoea
• Oedema: peripheral and central
• Palpitations and arrhythmias
• Syncope, dizziness and collapse including non-cardiovascular causes
• Symptoms and signs of stroke/Transient Ischaemic Attack (TIA).

Common and important conditions

• Acute cardiovascular problems including cardiac arrest, acute coronary syndrome, acute myocardial infarct, acute left
ventricular failure, dissecting aneurysms, severe hypertension and life-threatening arrhythmias, cardiogenic shock,
acute ischaemia of limbs and gut, TIA and stroke
• Arrhythmias including conduction defects such as atrial fibrillation and flutter, heart block, supraventricular
tachycardia, ventricular rhythm abnormalities
• Cardiovascular conditions for which anticoagulation may be relevant such as Atrial Fibrillation (AF), myocardial
ischaemia, peripheral vascular disease and TIA/stroke (including heparin, thrombolysis indications, oral
anticoagulation)
• Cardiomyopathies: primary and acquired, including dilated, hypertrophic obstructive
• Cerebral disease for which cardiovascular risk factors are important e.g. stroke, vascular dementia
• Circulation disorders including:
• arterial problems such as peripheral vascular disease, vasculitis, aneurysms (cerebral, aortic and peripheral); and
• venous problems such as venous thromboembolism, pulmonary embolism, Raynaud’s disease, varicose veins, venous
and arterial ulcers
• Congenital heart disease such as coarctation of the aorta, Ventricular Septal Defect (VSD), Atrial Septal Defect (ASD),
Patent Ductus Arteriosus (PDA) and presentation of these both in children and adults
• Coronary heart disease including complications such as mural thrombus, ventricular aneurysm, and rhythm
disturbance
• Drug-induced heart disease (e.g. secondary to cancer treatment with chemotherapy/ radiotherapy, recreational
drugs)
• Heart failure: acute and chronic including left ventricular dysfunction, right heart failure, and cor pulmonale
• Hypertension: essential (and its classification into stages), secondary, and malignant
• Infections such as viral myocarditis, infective endocarditis, pericarditis, rheumatic fever and complications
• Complications and malfunction of pacemakers relevant to primary care
• Pulmonary hypertension: primary and secondary to underlying causes such as fibrotic lung disease and recurrent
pulmonary emboli
 • Risk factors for coronary heart disease and other thromboembolic diseases such as lipid disorders, diabetes,
hypertension
• Valvular problems such as mitral, tricuspid, pulmonary and aortic stenosis and regurgitation.

Examinations and procedures

• Cardiovascular system examination

• Blood pressure monitoring
• Pulse oximetry
• Use of emergency equipment, including defibrillator, and oxygen delivery
• Emergency cardio-pulmonary resuscitation

Investigations

• Knowledge and application of current risk assessment tools such as CHADSVASC and HASBLED for atrial fibrillation,
QRISK/ASSIGN for Coronary Heart Disease
• Relevant blood investigations such as cardiac enzymes, natriuretic peptides, or D-dimer
• Secondary care interventions such as coronary angiography and stents, perfusion scanning, and CT scans
• Specific cardiac investigations including home and ambulatory BP monitoring, electrocardiogram (ECG), exercise ECG,
24 hour and event monitoring ECGs, echocardiography, venous dopplers and Ankle Brachial Pressure Index (ABPI)
measurement

Service issues

• Cardiovascular health screening, including abdominal aortic aneurysm screening, blood pressure, cholesterol and
glucose checks
• Current population trends in the prevalence of risk factors and cardiovascular disease in the community
• Cardiovascular rehabilitation after a stroke or cardiac event
• Appropriate support services nationally and locally (for example, smoking cessation and weight loss)
• Safe prescribing, including indications for and monitoring of commonly used drugs such as antihypertensive drugs,
anticoagulants and statins
• Management of polypharmacy, which is common in patients with cardiovascular problems.

AKT Sample Questions-

• Interpreting ECG tracings

• Adverse drug effects of anti-hypertensives
• Genetics of familial hypercholesterolaemia
 DERMATOLOGY

Emerging issues-

• Increased prevalence of aesthetic surgery

• Biological treatments for chronic skin conditions

Knowledge and Skills Guide-

Symptoms and signs

• Birthmarks
• Blisters
• Dry skin and scaling
• Erythema
• Hair loss and hirsutism
• Hyperhidrosis
• Hyper-, hypo- and depigmentation
• Lichenification
• Nail dystrophies
• Pruritus
• Purpura, petechiae
• Pustules, boils
• Rashes and eruptions
• Scaly and itchy scalp
• Skin lesions, including dermal and subcutaneous lesions
• Ulceration including leg ulcers and pressure sores

Common and important conditions

• Acne rosacea, rhinophyma, perioral dermatitis

• Acne vulgaris including indications and side effects of isotretinoin
• Blistering diseases including pemphigoid, pemphigus, porphyria
• Dermatological emergencies such as Stevens-Johnson syndrome, toxic epidermal necrolysis, erythroderma and
staphylococcal scalded skin syndrome
• Eczema: infantile, childhood, atopic, seborrhoeic, contact allergic, irritant (including occupational), discoid
• Hair disorders including alopecia, hirsutism, fungal infection, infestations including lice
• Hidradenitis suppurativa
• Hypopigmentation (for example, Vitiligo) and hyperpigmentation (for example, acanthosis nigricans)
• Infections: viral (for example, warts, molluscum contagiosum, herpes simplex and zoster), bacterial (for example,
staphylococcal + MRSA, streptococcal), fungal (for example, skin, nails), spirochaetal (for example, Lyme disease,
syphilis), TB, infestations (for examples, scabies, lice), travel-acquired (for example, leishmaniasis)
• Lichen simplex, lichen planus, granuloma annulare, lichen sclerosus, morphoea
• Light sensitive disorders such as polymorphic light eruption, porphyria, drug reactions
• Light treatments such as UVB, PUVA
• Pityriasis rosea and Pityriasis versicolor
 • Pruritus either generalised or localized, including underlying non-dermatological causes (for example, thyroid disease,
iron-deficiency, pregnancy etc.)
• Psoriasis: plaque, guttate, flexural, scalp, nails, pustular and erythrodermic. Associated morbidity; physical such as
cardiovascular disease and psychological such as depression
• Seborrhoeic keratosis
• Skin manifestations of psychiatric conditions such as dermatitis artefacta, trichotillomania
• Skin manifestations of internal disease including pyoderma gangrenosum, systemic lupus erythematosus (SLE), discoid
lupus erythematosus (DLE), necrobiosis lipoidica, erythema nodosum, erythema multiforme, dermatitis herpetiformis,
dermatomyositis, vitamin and mineral deficiencies such as scurvy
• Skin tumours including:
• benign lesions (for example, pigmented naevi, dermatofibroma, cysts)
• malignant lesions (for example, malignant melanoma, squamous cell carcinoma, basal cell carcinoma, mycosis
fungoides, Kaposi’s sarcoma, metastatic tumours); and
• lesions with malignant potential (for example, solar keratoses, Bowen’s disease, cutaneous horns and
keratoacanthomas)
• Ulcers and their causes – for example, arterial, venous, neuropathic, pressure, vasculitic, malignant
• Urticaria, angio-oedema and allergic skin reactions including adverse drug reactions
• Wounds (for example, burns and scalds), scar formation and complications

Examinations and procedures

• Common terminology used to describe skin signs and rashes (for example, macule, papule)
• Examination of the rest of the skin, nails, scalp, hair, and systems such as joints, where appropriate (for example,
psoriasis)
• The need to recognise skin conditions across a range of skin types

Investigations

• Skin and nail sampling, immunological tests including patch and prick testing, biopsy, photography and dermoscopy
• Relevant blood tests for underlying causes of skin conditions (for example, lupus, thyroid disease)

Service issues

• Dermoscopy: indications, availability in practice, when to refer

AKT Sample Questions-

• Recognition of a malignant skin lesion from photographs
• Management of psoriasis
• Differential diagnosis of alopecia
 EAR, NOSE AND THROAT
Emerging Issues-

Latest evidence and guidance on e-cigarettes

Knowledge and Skills Guide-

Symptoms and signs

• Symptoms within the normal range which require no treatment, such as small neck lymph nodes in healthy children
and ‘geographic tongue’
• Cough
• Deafness and the differentiation of types of hearing loss, including sudden hearing loss
• Dental symptoms relevant to general medical practice
• Disturbance of smell and taste
• Earache and discharge
• Epistaxis
• Facial dysfunction: sensory and motor
• Facial pain
• Head and neck lumps
• Hoarseness
• Jaw pain
• Rhinitis and nasal obstruction
• Salivation problems including swelling and obstruction of glands, excessive and reduced salivation
• Sore throat and mouth
• Sore tongue and changes in taste
• Tinnitus
• Vertigo and dizziness
• Snoring and sleep apnoea

Common and important conditions

• Aesthetic and reconstructive surgery and botulinum toxin therapies

• Congenital abnormalities (for example, cleft palate/lip, absent pinna, neck lumps)
• Cranial nerve disorders such as Ramsay-Hunt syndrome, Bell's palsy, trigeminal neuralgia, ototoxicity secondary to
drugs
• Dental problems presenting in general medical practice (such as abscesses); dental disease due to underlying medical
causes (such as anorexia, xerostomia, drug-induced)
• Disorders of the salivary glands such as infection (for example, mumps), salivary duct stones, connective tissue
diseases (for example, Sjögren's syndrome), tumours (for example, adenoma, lymphoma)
• Ear disorders: earache and discharge including otitis externa, otitis media with and without effusion, perforation of
the ear drum, barotrauma, cholesteatoma, mastoiditis, disorders affecting the skin of the pinna such as infection,
eczema, psoriasis, solar damage and malignancy and affecting the cartilage such as injuries and polychondritis
• Emergency treatments such as tracheotomy
• Epidemiology of rarer but potentially serious conditions such as oral, head and neck cancer, taking into account risk
factors, and unhealthy behaviour
• Head and neck malignancies including laryngeal, nasopharyngeal, sinuses, salivary glands, tongue, lips and oral cavity,
tonsillar including lymphomas, unidentified malignancies presenting with lymphadenopathy
 • Hearing aids and cochlear implants, tinnitus maskers
• Hearing problems including deafness such as occupational, presbyacusis, otosclerosis, tinnitus and associated speech
or language disorders
• Increasing incidence of hearing loss in certain groups, such as people with learning disability or dementia
• Nasal problems including perennial and allergic rhinitis, postnasal drip, adverse drug effect, polyps and other causes
of nasal obstruction, epistaxis, trauma, foreign bodies, septal deviation
• Oral problems including pain (for example, ulceration, lichen planus), infections (for example, gingivitis, herpes
simplex, candidiasis), pre-malignant conditions (for example, leukoplakia), malignancies (including tonsils, tongue, lips
and buccal mucosa)
• Sinus problems including acute and chronic infection, polyps, allergic rhinosinusitis, barotrauma
• Throat problems such as infections, globus, pharyngeal pouch or gastrooesophageal reflux causing a cough
• Tracheotomy management in primary care
• Vertigo: central (for example, brainstem stroke) and peripheral (for example, benign paroxysmal positional vertigo,
vestibular neuronitis, Ménière's disease, acoustic neuroma). Factors differentiating vertigo from dizziness and light-
headedness
• Vocal disorders such as hoarseness, dysphonia, aphonia and underlying causes (for example, vocal cord nodules,
laryngeal nerve palsy). Associations with smoking, occupation and environmental factors.

Examinations and procedures

• Otoscopic appearances of the normal and abnormal ear

• Tests of hearing such as tympanometry, audiometry, tuning fork tests including Weber's and Rinne's, neonatal and
childhood screening tests
• Detailed tests where indicated (for example, audiological tests and the Dix–Hallpike test to help diagnose benign
paroxysmal positional vertigo (BPPV))
• Skills which can be used in primary care to effect a cure when indicated (for example, nasal cautery, ear wax removal
and the Epley manoeuvre).

Investigations

• Audiology testing
• X ray, USS, CT and MRI scans
• Endoscopy
• Sleep studies

Service issues

• ENT, oral and facial symptoms may be manifestations of psychological distress, for example, globus pharyngeus,
atypical facial pain, burning mouth syndrome
• National paediatric screening programme for hearing loss. Effects of ENT pathology on developmental delay, for
example, 'glue ear' can impair a child's learning
• Pathology in other systems may lead to ENT-related symptoms. Examples include gastro-oesophageal reflux disease
(GORD) and cerebrovascular accident (CVA). Systemic disease such as haematological, dermatological and
gastrointestinal problems may present with oral symptoms, for example, glossitis caused by iron deficiency anaemia
• Community-specific aspects of oromucosal disease related to lifestyle (for example, chewing paan, tobacco, betel nut,
khat/qat, or reverse smoking). Smoking cessation services
• Highly specialised and regionally based services such as the provision of cochlear implants
• Relevant local and national guidelines, including fast track referral guidance for suspected cancer.

AKT Sample Questions-

• Recognition of oral cancer
• Natural history of glue ear in children
• Diagnosis of salivary gland swelling
 Eyes and Vision

Emerging Issues-
• Rehabilitation low vision aid services

Knowledge and Skills Guide-

Symptoms and signs

• Colour blindness, changes in colour vision

• Diplopia, squint and amblyopia
• Discharge from the eye
• Dry eyes
• Entropion/ectropion
• Epiphora
• Eyelid swellings
• Falls
• Orbital swellings
• Red eye: painful and painless
• Visual disturbance: complete/partial loss of vision, distorted vision, floaters, flashes
• Visual field disturbance

Investigations

• Performing and interpreting fundoscopy, visual acuity tests and results, red reflex testing, visual field tests, Amsler
charts
• Interpreting tonometry, optician reports, and tests of colour vision
• Examining eyes for foreign bodies, and corneal staining with fluorescein
• Key blood tests (for example, for giant cell arteritis)

Common / important conditions

• Cataracts – congenital, acquired such as drug induced

• Colour blindness
• Congenital, neonatal and childhood eye problems, such as prematurity, congenital cataract, vitamin A deficiency
• Conjunctivitis including infectious causes (bacterial, viral, parasitic and chlamydial), and allergic causes
• Contact lens use including infections such as acanthamoeba, corneal damage
• Diabetic eye disease
• Disorders of tears and tear ducts such as dacrocystitis, sicca syndrome, epiphora, dry eyes
• Disorders of the pupil such as Horner's syndrome, Holmes-Adie
• Dual sensory impairment and loss (vision and hearing)
• Episcleritis, corneal or dendritic ulcers, pterygium, pinguecula, corneal injury and erosions
• Eye trauma including penetrating trauma, corneal abrasions, chemical burns, contusions, hyphaema
• Eyelid problems such as blepharitis, ectropion, entropion, chalazion, Meibomian cysts, and styes
• Genetic eye problems such as retinoblastoma, retinitis pigmentosa
• Glaucoma – acute, closed angle and chronic open angle
• Intracranial pathology affecting vision
• Keratitis including association with other diseases such as rosacea, thyroid disease
• Keratoconus
• Loss of vision or visual disturbance; differential diagnoses and appropriate management including timescale of
urgency
 • Macular degeneration – age-related (wet and dry), drusen
• Malignancy such as retinoblastoma, lymphoma, melanoma
• Ophthalmic herpes zoster
• Ophthalmic manifestations of infections such as syphilis, TB, toxocariasis, toxoplasmosis
• Optic neuritis and neuropathy
• Orbital infections such as cellulitis, tumours
• Red eye – differential diagnoses and appropriate management including timescale of urgency
• Refractive error including myopia, hypermetropia, astigmatism
• Retinal problems including:
• atrophy
• detachment
• haemorrhage, exudates, blood vessel changes associated with systemic diseases, such as hypertension, diabetes,
haematological diseases thromboses or emboli
• tumours such as melanoma, neuroblastoma; and
• vascular lesions
• Squint – childhood and acquired due to nerve palsy, amblyopia, blepharospasm
• Subconjunctival haemorrhage
• Systemic diseases with associated eye symptoms/signs, such as hypertension, diabetes, raised intracranial pressure,
multiple sclerosis, sleep apnoea, giant cell arteritis
• The effect of stroke and migraine on vision
• Thyroid eye disease
• Uveitis including knowledge of underlying associations for example, inflammatory bowel disease, connective tissue
diseases
• Vitreous detachment

Service issues
• Local NHS guidance on funding for certain treatments (for example, cataract surgery)
• Relevant policies and legislation (including disability)
• Restrictions on driving and employment, including DVLA (Driver and Vehicle Licensing Authority) guidance for visual
acuity
• Services available to those with vision problems; from acute hospital to community optician, support from charities
and the third sector
• Types of low vision aids available (for example, large print, audio, magnifiers, long cane, or braille).

AKT Sample Questions-

• Recognition of serious eye disease in a photograph
• Interpretation of visual field charts
• Management of glaucoma
 Gastroenterology
Emerging Issues-
• Prevention and early treatment of colorectal cancer
• Incidence of liver morbidity and mortality prevention of liver disease
• New treatment approaches for hepatitis and NAFLD

Knowledge and Skills Guide-

Symptoms and signs

Many conditions such as liver disease are often asymptomatic in their early stages. Symptoms and signs include:

• Abdominal masses and swellings including ascites and organ enlargement such as splenomegaly and hepatomegaly
• Abdominal pain including the differential diagnoses from non-gastrointestinal causes (for example, gynaecological or
urological)
• Bloating
• Bowel issues including constipation, diarrhoea, changes in habit, tenesmus and faecal incontinence
• Chest pain
• Cough
• Disturbance of smell and taste
• Dyspepsia, heartburn
• Dysphagia
• Hiccups
• Inflammation (for example, eyes, joint)
• Jaundice
• Mouth ulceration, erythroplakia, leukoplakia, salivary problems
• Nausea and vomiting including non-gastrointestinal causes
• Pruritus
• Rectal bleeding including melaena
• Regurgitation
• Vomiting including haematemesis
• Unexplained weight loss and anorexia
• Weight gain including obesity

Common and important conditions

• Dyspepsia, gastro-oesophageal reflux disease (GORD), and Irritable Bowel disease (IBS) are common conditions,
affecting a significant proportion of the population
• Chronic abdominal conditions: inflammatory bowel disease, diverticular disease, coeliac disease and irritable bowel
syndrome
• Acute abdominal conditions: appendicitis, acute obstruction and perforation, diverticulitis, Meckel's diverticulum,
ischaemia, volvulus, intussusception, gastric and duodenal ulcer, pancreatitis, cholecystitis, biliary colic, empyema and
renal colic
• Medication effects: analgesics (codeine, NSAIDs, paracetamol), antibiotics (nausea, risk of c. difficile), proton pump
inhibitors (potential masking of symptoms)
• Post-operative complications
• Hernias: inguinal, femoral, diaphragmatic, hiatus, incisional
• Functional disorders: non-ulcer dyspepsia, irritable bowel syndrome, abdominal pain in children.

Upper GI conditions

• Gastrointestinal haemorrhage including oesophageal varices, Mallory-Weiss syndrome, telangiectasia, angiodysplasia,

Peutz-Jeghers syndrome
• Gastro-oesophageal reflux disease, non-ulcer dyspepsia, peptic ulcer disease, H. pylori, hiatus hernia
 • Oesophageal conditions including achalasia, malignancy, benign stricture, Barrett's oesophagus, globus

Lower GI conditions

• Constipation: primary and secondary to other systemic diseases such as hypothyroidism, drug-induced,
hypercalcaemia
• Diarrhoea
• Gastrointestinal infection including:
• toxins such as C. difficile and E coli
• bacterial causes such as salmonella, campylobacter, amoebic dysentery
• viral causes such as rotavirus, norovirus; and
• parasitic causes such as Giardia lamblia
• (Note Sexually Transmitted Infections can also cause symptoms)
• Gastrointestinal malignancies including oesophageal, gastric, pancreatic, colorectal, carcinoid, lymphoma
• Inflammatory bowel disease such as Crohn's disease, ulcerative colitis
• Malabsorption including coeliac disease, lactose intolerance, secondary to pancreatic insufficiency such as chronic
pancreatitis, cystic fibrosis, bacterial overgrowth
• Rectal problems including anal fissure, haemorrhoids, perianal haematoma, ischio-rectal abscesses, fistulae, prolapse,
polyps, malignancy
• Liver, gallbladder and pancreatic disease

• Abnormal liver function tests: assessment, investigation and consideration of underlying reasons such as:
• drug-induced: alcohol, medications (paracetamol, antibiotics), chemicals
• infection: viral hepatitis, leptospirosis, hydatid disease
• malignancy: primary and metastatic
• cirrhosis (for example, from alcohol, fatty liver/ non-alcoholic fatty liver disease); and
• autoimmune disease: primary biliary cirrhosis, chronic active hepatitis, α-1 antitrypsin deficiency, Wilson's disease,
haemolysis
• Secondary effects of liver diseases such as ascites, portal hypertension, hepatic failure
• Gallbladder disease: gallstones, cholecystitis, cholangitis, biliary colic, empyema, malignancy
• Pancreatic disease: acute pancreatitis, chronic pancreatitis, malabsorption, malignancy including islet cell tumours
• Nutrition

• Dietary management of disease, inadequate or excessive intake

• Impact of diet on health (for example, risk of cancer from high red meat intake) and dietary approaches to healthy
living and prevention of disease
• Disorders of weight: obesity and weight loss including non-nutritional causes such as cancer, thyroid disease and
other endocrine conditions
• Nutritional problems: vitamin and mineral deficiencies or excess, supplementary nutrition such as dietary, PEG and
parenteral feeding
• Complications and management of stomas

Examinations and procedures

The sensitive nature of GI symptoms and some GI examinations – importance of putting the patient at ease and providing an
environment where abdominal and rectal examinations are performed with dignity and, where appropriate, under chaperoned
conditions.

Investigations

• Stool tests including culture results and faecal calprotectin

• Tests of liver function, including interpretation of immunological results and markers of disease including cirrhosis
and malignancy
 • Endoscopy, ultrasound and other scans (for example, transient elastography), interpretation of relevant tests such as
those for Helicobacter pylori infection, coeliac disease
• Secondary care interventions such as laparoscopic surgery, ERCP, radiological investigations (including contrast and
CT scans)
• Screening programmes for colorectal cancer such as stool tests (for example, occult blood / fecal immunochemical
test), endoscopy and the evidence base

Service issues

Increasing demand for weight loss surgery, and its potential long term effects

Additional important content

• Appropriate tailoring of treatment to cater for the patient's GI function and preferences
• Side effects of common medicines including analgesics, antibiotics and proton pump inhibitors
• Drug and alcohol misuse: range of associated gastrointestinal and liver problems, complex issues, ways these impact
on digestive disorders and the management problems they are associated with (see also RCGP Topic Guide Alcohol
and Substance Misuse)
• Impact of social and cultural diversity, and the important role of health beliefs relating to diet, nutrition and the
presentation of gastrointestinal disorders. Ensure that the practice is not biased against recognising these

AKT Sample Questions-

• Investigation of rectal bleeding in different patient scenarios
• Drug therapies for inflammatory bowel disease
• Interpretation of liver function tests
 Genomic Medicine
Emerging Issues-
Implications of genomic testing

Knowledge and Skills Guide-

Common and important conditions

• Autosomal dominant conditions (for example, familial hypercholesterolaemia, polycystic kidney disease, Huntington's
Disease, thrombophilias)
• Chromosomal disorders (for example, Down syndrome, trisomy 18, Turner syndrome, Klinefelter syndrome)
• Autosomal recessive conditions (for example, cystic fibrosis, hereditary haemochromatosis, haemoglobinopathies)
• X-linked disorders (for example, Fragile X Syndrome (see also RCGP Topic Guide Neurodevelopmental disorders,
intellectual and social disabilities), Duchenne and Becker Muscular Dystrophy, haemophilia).
• Common complex diseases follow a multi-factorial inheritance pattern, for example, ischaemic heart disease,
hypertension, diabetes, cancer, obesity. A proportion of patients with a common complex disease demonstrate
familial clustering of the condition or have an autosomal dominant condition that confers high risk, for example,
BRCA1 pathogenic variant in breast cancer, Lynch syndrome or familial hypercholesterolaemia in Ischaemic Heart
Disease.

Symptoms, signs and modes of presentation

• Clinical suggestion of inherited disease (for example, multiple family members affected at a younger age)
• Genetic 'red flags' (for example, recurrent miscarriage, developmental delay in conjunction with other morbidities)
• Predisposition to common diseases (such as coronary artery disease or cancer)
• Symptoms and signs of specific conditions (see 'Common and important conditions' above)
• Symptom complexes and multisystem involvement
• Variability of symptoms and signs between family members for some genetic conditions, particularly some autosomal
dominant conditions (such as neurofibromatosis type 1) as a result of variation in penetrance and expression.
• Assessing genetic risk

• How to take a family history (relevant questions, interpretation, how to draw a pedigree)
• Basic inheritance patterns (autosomal dominant and recessive, X-linked, mitochondrial, multifactorial)
• Principles of assessing genetic risk, including:
• principles of risk estimates for family members of patients with single gene disorders
• principles of recurrence risks for simple chromosome anomalies (for example, trisomies)
• information from susceptibility variants in common complex conditions (for example, as used in direct-to-consumer
testing)
• conversations around risk in the context of antenatal screening; and
• online risk assessment tools, as they become available
• Other factors contributing to genetic risk (for example, ethnicity, effects of consanguineous marriage)

Investigations

• Genetic and genomic tests (diagnostic, predictive, carrier testing) and their limitations
• Diagnostic tests in primary care (for example, cholesterol, ultrasound for polycystic kidney disease, testing for
hereditary haemochromatosis)
• Carrier testing for families with autosomal recessive conditions such as sickle cell, thalassaemia or cystic fibrosis
• Antenatal and new-born screening programmes (for example, Down syndrome, cystic fibrosis, sickle cell and
thalassaemia)

Service issues

• Services and support available for those with an inherited condition

 • Organisation of genetics and genomics medicine services

Additional important content

• Genomic nomenclature (for example, what is meant by non-coding DNA, susceptibility variant, pathogenic variant
and variant of unknown significance (VUS))
• Difficulties in determining the exact genomic cause of a condition (for example, a learning disability)
• Heterogeneity in genetic diseases
• Skills in communicating genetic and genomic information
• Skills and techniques for non-directive, non-judgemental discussion about genetic conditions, taking into account an
individual's ethnic, cultural and religious context
• Spectrum of risk-reducing measures, from lifestyle modification to targeted treatments for certain conditions (for
example, mastectomy and/or oophorectomy for BRCA1/2 mutation carriers, colectomy for adenomatous polyposis
coli (APC) mutation carriers, statin use for familial hypercholesterolaemia, venesection for haemochromatosis,
losartan for patients with Marfan syndrome)
• Reproductive options available to those with a known genetic condition (including: having no children, adoption,
gamete donation, prenatal diagnosis, neonatal screening or testing)
• Emotional, psychological and social impact of a genetic diagnosis on a patient and his/her family
• Clinical and ethical implications for family members of an affected individual, depending on the mode of inheritance
of a condition (autosomal dominant, recessive and X-linked single-gene inheritance; de novo and inherited
chromosomal anomalies; mitochondrial inheritance and somatic mutation)
• Ethical issues surrounding:
• Confidentiality and non-disclosure of genetic information within families (particularly when information received from
or about one individual can be used in a predictive manner for another family member in the same practice)
• Genetic testing (for example, testing in children, pre-symptomatic testing)
• The 'right not to know'
• The use of information (for example, for insurance or employment issues)
• Pharmacogenomics: the role of genomic information in prescribing.

AKT Sample Questions-

• Interpretation of a genogram
• Recognising the presentation of common genetic conditions in primary care
• Consent, capacity and confidentiality of genetic testing
 Gynaecology and Breast Health
Emerging Issues-
• FGM
• PCOS and Endometriosis
• Breast Cancer Screening Programme

Knowledge and Skills Guide-

Symptoms and signs

Breast

• Breast development and abnormalities of development

• Breast lumps (men and women)
• Breast skin changes
• Gynaecomastia
• Mastalgia
• Nipple discharge

Pelvic

Bleeding symptoms:
• Menstrual bleeding problems such as amenorrhoea, oligomenorrhoea, polymenorrhoea, heavy menstrual bleeding
• Non-menstrual vaginal bleeding including intermenstrual and post-coital bleeding
• Postmenopausal bleeding

Other pelvic symptoms and signs:

• Continence problems (urinary and faecal)
• Pelvic and abdominal masses
• Pelvic and abdominal pain
• Vaginal discharge and vaginal dryness
• Vaginal swellings and prolapse symptoms
• Vulval pain, lump, irritation, ulceration, pigmentation, leucoplakia and other vulval skin lesions.

Other

• Menopause and peri-menopause physical and psychological symptoms including bleeding disturbances, hot flushes,
night sweats, urogenital symptoms
• Non-specific symptoms that could be consistent with ovarian cancer such as abdominal distension, ascites, bloating,
early satiety, new onset IBS symptoms in women over 50, urinary symptoms, weight loss
• Pre-menstrual syndrome
• [Urinary symptoms such as dysuria and haematuria are covered in RCGP Topic Guide Kidney and Urology. Sexual
health symptoms are covered in the Sexual Health Topic Guide. Symptoms relating to pregnancy and reproductive
health are covered in the Maternity and Reproductive Health Topic Guide.]

Common and important conditions

Breast

• Benign breast conditions including eczema, infection (mastitis, breast abscess), lumps (for example, cysts,
fibroadenoma) and mastalgia
• Breastfeeding, including common problems
• Malignant breast conditions including DCIS, invasive ductal and lobular carcinomas, Paget's disease of the nipple and
secondary malignancy such as lymphoma, including awareness of treatment (surgery, radiotherapy, hormonal) and its
complications
 • Surgery for breast reconstruction, breast enlargement and breast reduction

Pelvic

Bleeding problems (which may have pelvic or extra-pelvic cause):

• Amenorrhoea (primary and secondary), oligomenorrhoea, polymenorrhoea, irregular menstrual cycles and
anovulatory cycles
• Intermenstrual bleeding
• Medication induced bleeding problems (including secondary to hormonal contraceptives)
• Menstrual problems including heavy menstrual bleeding, dysmenorrhoea (primary and secondary), dysfunctional
uterine bleeding
• Post-coital bleeding
• Post-menopausal bleeding
• Pelvic pain

Ovarian:
• Benign ovarian swellings including ovarian cysts, dermoid
• Ovarian cancer including adenocarcinoma and teratoma
• Polycystic ovary syndrome: gynaecological aspects and associated metabolic disorders such as insulin resistance and
obesity, and symptoms such as acne and hirsutism

Uterine:
• Endometrial polyps, hyperplasia and cancer
• Endometriosis and adenomyosis
• Fibroids
• Prolapse including cystocele and rectocele

Cervical:
• Cancer, cervical intraepithelial neoplasia (CIN), dysplasia, ectropion and polyps

Vulvo-vaginal:
• Female genital mutilation (FGM) (including legal aspects) and cosmetic genital surgery
• Malignancy including vulval intraepithelial neoplasia (VIN), melanoma
• Skin disorders such as lichen sclerosus, psoriasis, intertrigo, pigmented lesions, genital warts
• Vaginal discharge including infectious causes such as candida, bacterial vaginosis and sexually transmitted infections
(please refer also to Topic Guide Sexual Health)
• Vulval pain with causes such as atrophic changes, Bartholin's problems, dysesthesia, vulvodynia.
• (Urinary conditions including incontinence are covered in the Kidney and Urology topic guide)

Fertility

• Infertility and subfertility – causes and investigations:

• Male factors including impaired sperm production and delivery (for example, drug induced, cystic fibrosis)
• Female factors including ovulatory disorders, tubal disorders, uterine disorders and genetic causes
• Principles of assisted conception with knowledge of associated investigations
• Recurrent miscarriage

Other

• Premenstrual disorders including premenstrual syndrome and premenstrual dysphoric disorder

• Menopause:
• Normal and abnormal menopause and peri-menopause including premature ovarian insufficiency
• Post-menopausal bleeding
• Systemic symptoms such as skin changes, hot flushes, psychological symptoms
 • Treatment options including hormone replacement therapy (HRT) – systemic and local methods
• Urogenital aspects including atrophic vaginitis
• Wider health issues associated with menopause including increased cardiovascular risk and osteoporosis
• (Sexually transmitted infection, Pelvic Inflammatory Disease, dyspareunia, pregnancy (including miscarriage and
ectopic pregnancy) are covered in the RCGP Topic Guides on Sexual Health and Maternity and Reproductive Health.
Urinary problems are covered in the Topic Guide Kidney and Urology).

Examinations and procedures

• Abdominal assessment for ascites, distension and masses

• Bimanual pelvic examination
• Breast examination
• Cervical cytology sampling
• Obtaining informed consent for breast examination, vaginal examination and speculum examination, including use of
chaperones where appropriate
• Speculum examination including appropriate choice of size
• Vaginal and endocervical swabs
• Vulval examination

Investigations

• Breast imaging (including mammography, MRI and ultrasound)

• Common secondary care gynaecological investigations including colposcopy, hysteroscopy and laparoscopy
• Investigations within primary care such as blood tests (CA125, full blood count, hormone profile) cervical smears,
clinician taken vaginal and cervical swabs, patient taken swabs, vaginal pH testing
• Primary care investigation of female subfertility including blood tests and ultrasound
• Semen analysis
• Ultrasound – abdominal and pelvic ultrasound including trans-vaginal scans

Service issues

• HPV vaccination programme

• Practical and legal aspects around FGM including reporting mechanisms, safeguarding concerns and protecting girls at
risk of FGM

Other important content

• After-care of women who have had gynaecological or breast surgery and radiotherapy including 'late effects' of
treatment and risk of cancer recurrence
• Gynaecological issues in transgender patients.Transgender issues are covered more fully in Sexual health and
Equality Diversity and Inclusion Topic Guides
• The physiological and hormonal changes of the menstrual cycle
• Genetic mutations related to breast and gynaecological malignancy including BRCA and indications for referral for
genetic counselling
• Screening programmes for cervical and breast cancer – including practicalities, benefits, risks, interpretation of
results, non-participation. Awareness of controversies around possible screening for ovarian cancer
AKT Sample Questions-
• Use and interpretation of CA125 ,Diagnosis of the menopause ,Diagnosis of endometriosis
 Haematology
Emerging Issues-
• Chronic haematological disorders
• Evolving new agents for anticoagulation treatment and prophylaxis in primary care.

Knowledge and Skills Guide-

Symptoms and signs

• 'B' symptoms of lymphoma

• Bleeding, bruising, petechiae and purpura
• Bone pain or pathological fractures
• DVT or PE
• Fatigue
• Hyperviscosity symptoms (headache, visual loss, acute thrombosis)
• Jaundice secondary to haemolysis
• Lymphadenopathy, splenomegaly and hepatomegaly
• Pallor and anaemia
• Recurrent infection
• Recurrent miscarriage
• Skin manifestations of haematological disease (for example, mycosis fungoides)
• Systemic manifestations of haematological disease (for example, sickling crisis)
• Weight loss

Common and important conditions

• Anaemia and its causes including iron, folate and vitamin B12 deficiency, sideroblastic, haemolytic, chronic disease
• Anticoagulants: indications, initiation, management and reversal/withdrawal including heparin, warfarin, Direct Oral
Anticoagulants such as dabigatran, drug interactions and contra-indications
• Clotting disorders including genetic causes such as haemophilia and von Willebrand's disease, infective causes such as
meningococcal septicaemia and disseminated intravascular coagulation
• Common abnormalities of blood films and their management (for example, macrocytosis, microcytosis, spherocytosis,
neutrophilia)
• Enlarged lymph nodes of any cause +/- splenomegaly, including infection and malignancy (both primary and
secondary); management of a single enlarged lymph node
• Enzyme diseases such as G6PD deficiency
• Gout associated with haematological malignancies and myelodysplasias
• Haematological malignancies such as acute and chronic leukaemias, lymphomas (including Hodgkin's, non-Hodgkin's
lymphomas, gut and skin lymphomas), multiple myeloma
• Haemochromatosis
• Haemoglobinopathies such as thalassaemia, sickle cell disease
• Haemolytic diseases including management of rhesus negative women in pregnancy, autoimmune and transfusion
haemolysis
• Lymphatic disorders such as primary lymphoedema
• Myelodysplasia and aplastic anaemia
• Myeloproliferative disorders such as polycythaemia rubra vera, thrombocytosis
• Neutropenia: primary and secondary including chemotherapy and drug-induced
• Pancytopenia and its causes
• Polycythaemia: primary and secondary such as to hypoxia, malignancy
• Purpura: recognition and causes such as drug-induced, Henoch-Schönlein
• Splenectomy including functional asplenia
• Thrombocytosis and thrombocytopaenia, including causes and associations, indications for referral

Examinations and procedures

 • Appropriately obtaining blood samples and requesting clearly selected and targeted tests with informed consent
• Use of near patient testing for anticoagulation

Investigations

• Blood grouping such as ABO and rhesus status including antenatal blood disorders; safe transfusion practice
• Normal haematological parameters and interpretation of laboratory investigations such as full blood count,
haematinics, monitoring of anticoagulants and investigation of coagulation disorders including thrombophilia and
excessive bleeding, protein electrophoreses, immunoglobulins
• Other relevant primary care investigations (for example, x-rays, paraprotein urine testing in myeloma)
• Relevant secondary care investigations such as bone marrow, bone scans
• Antenatal screening for inherited haematological disorders (for example, thalassaemia, sickle cell)

Service issues

• Cancer care reviews and follow-up, including safe prescribing, management of multi-morbidity, and recognising signs
of disease progression
• Indications for urgent (or semi-urgent) referral to secondary care

Additional important content

• Conditions with higher prevalence in certain ethnic groups (for example, benign ethnic neutropenia, sickle cell
anaemia)
• Ethical issues related to blood transfusion
• Psychosocial impact of living with a haematological condition
• Major side effects of chemotherapy

AKT Sample Questions-

• Appropriate use of different anticoagulant therapies
• Interpretation of haematinic results
• Differential diagnosis of lymphadenopathy
 Infectious Disease and Travel Health
Emerging Issues-
Local and global epidemiology of major infectious diseases
Antimicrobial resistance
GMC guidance and law for trafficking, forced marriage, FGM

Knowledge and Skills Guide-

Common and important conditions include:

• Bone, joint and soft tissue infections (for example, septic arthritis, osteomyelitis, necrotising fasciitis)
• Cardiovascular infections (for example, endocarditis, rheumatic fever)
• Common and serious childhood infections (including viral, bacterial, fungal) (see RCGP Topic Guides on Children and
young people and Dermatology)
• Common ENT infections (see RCGP Topic Guide Ear, Nose, Throat and Mouth Problems)
• Fever in the returning traveller and its potential causes (for example, malaria, dengue, typhoid/paratyphoid,
chikungunya, viral haemorrhagic fevers)
• Gastrointestinal infections (for example, amoebiasis, amoebic dysentery, food poisoning (including causative
organisms), giardiasis, hydatid disease, Travellers’ diarrhoea, typhoid)
• Genitourinary infections including sexually transmitted and urinary tract infections
• Healthcare-associated infections (HCAI) (for example, MRSA, Clostridium difficile)
• Helminth infections (for example, schistosomiasis, hookworm, strongyloides)
• Hepatitis of infectious origin
• Human Immunodeficiency Virus (HIV)/AIDS including prevention, testing, transmission (including mother-to-child
transmission), therapies, prophylaxis, and associated diseases (such as pneumocystis jirovecii (formerly carinii),
cryptococcus spp., cytomegalovirus, candida)
• Immune deficiency; infectious disease in the immune-compromised patient
• Malaria (including malarial prophylaxis)
• Multi-systemic infections for example, bacterial (for example, staphylococcal, streptococcal), viral (for example,
Epstein Barr Virus), fungal, parasitic (for example,
• toxoplasma, Chagas disease)
• Neurological infections (for example, meningitis, encephalitis)
• Occupational infections and their management (for example, needle stick infections)
• Ocular infections (for example, conjunctivitis, ophthalmia neonatorum)
• Pandemics (for example, pandemic influenza)
• Post-operative infections
• Respiratory disease (for example, pneumonia, Legionnaires' disease, influenza)
• Sepsis and the deteriorating patient
• Skin infections (for example, bed bugs, cutaneous larva migrans, exanthemata, flea, louse, ringworm, scabies,
threadworm, orf, leishmaniasis)
• Tick borne diseases including Lyme disease
• Trauma including injuries, animal bites and wounds
• Tuberculosis and its different manifestations
• Travel related conditions (for example, altitude related sickness, DVT, PE, motion sickness, sun/cold exposure, water
activities)
• Vaccine preventable communicable diseases including cholera, diphtheria, Haemophilus influenzae B, hepatitis A,
hepatitis B, Human Papilloma Virus, influenza, Japanese encephalitis, measles, meningitis ACWY, meningitis B,
meningitis C, mumps, pertussis, pneumococcus, poliomyelitis, rabies, rotavirus, rubella, shingles, tetanus, tick-borne
encephalitis, tuberculosis, typhoid, yellow fever
• Zoonotic diseases (for example, leptospirosis, brucellosis)

Examinations and procedures

• Features of common and important infectious diseases through relevant, focused systems examination
 • Rashes related to, or pathognomonic of, specific infectious diseases (for example, meningococcal meningitis,
erythema chronicum migrans, erythema multiforme, erythema nodosum, viral exanthemata)
• Assessment of an acutely unwell patient with possible infection (including signs of sepsis)
Investigations

• Use, limitations and interpretation of investigations such as serological testing, swabs, blood films, urine and stool
microscopy and culture, near patient testing (for example, CRP)
• Colonisation versus infection
• Common laboratory tests for example, haematology (including significance of eosinophilia in travellers or those born
outside the UK) and biochemistry (including normal parameters)
• Imaging such as chest X-ray
• Screening in asymptomatic patients (for example, chlamydia, HIV, TB)

Service issues

Immunisation including:
• childhood immunisation schedules
• immunisation in pregnancy, travellers, and other important situations for example, contact tracing
• vaccinations available on the NHS; and
• mandatory vaccinations for travel to certain areas
• Translation services
• Safe working practice in personal, clinical and organisational settings (including principles and practice of infection
control)
• Statutory notification of diseases
• Fitness to travel documentation
• Contact tracing and treatment of contacts
• NHS travel health service provision and the role of the independent sector
• Local emergency response plans and emergency preparedness
• UK's health protection agencies and other major local, national and international organisations involved in emergency
planning for and control of outbreaks of infection
• UK screening and reporting programmes that relate to infection

Additional important content

• Modes of transmission, incubation periods, and periods of communicability of common and important infectious
agents
• Diseases likely to affect prospective or returning travellers and those who were born or have lived outside the UK
• Diagnostic overshadowing (i.e. assuming that illness in returning travellers or those born outside the UK are solely
related to travel)
• Health advice for travellers (including vaccination and other precautions, use of electronic resources, and signposting
to appropriate services)
• Pre- and post-exposure prophylaxis
• Infectious diseases during pregnancy, birth, and breastfeeding, in elderly people, the immunosuppressed, and
drug/alcohol users
• Travel health during pregnancy (including specific risks, fitness to fly certification)
• Risk-benefit conversations (for example, around screening and testing for infectious diseases, immunisation and
specific vaccines, travel, and therapies) based on patient’s current and past health and individual circumstances
• Use of appropriate language in communicating the status of a deteriorating patient to other services (for example,
ambulance)
• Health of refugees, asylum seekers, people born or lived outside the UK, victims of human trafficking
• Loss of innate immunity in immigrants and its impact on travel prophylaxis
• Psychosocial impact of infectious diseases on individuals and their wider social networks
 • Relevant guidelines and legislation ( Civil Aviation Authority, NICE, SIGN, national patient safety initiatives, local
antimicrobial guidelines)
• Ethical and legal considerations (for example, around confidentiality/disclosure, data protection, consent,
immunisation, rights of migrants to healthcare, capacity and competence)

AKT Sample Questions-

• Appropriate antibiotic therapy for specific infections

• Recognition and management of skin infections from photographs
• Interpretation of abnormal blood results
 Kidney and Urological Health
Emerging Issues-
• Cystatin C based eGFR

Knowledge and Skills Guide-

Symptoms and signs

Urinary

• Dysuria
• Haematuria

Lower Urinary Tract Symptoms (LUTS):

• storage symptoms: frequency, nocturia, urgency
• voiding symptoms: hesitancy, poor stream, terminal dribble
• post micturition symptoms: post micturition dribble, sensation of incomplete emptying
• Oliguria, anuria, polyuria
• Proteinuria
• Strangury
• Urinary incontinence – stress, urgency and mixed
• Urinary retention – acute and chronic

Genital

• Abnormal digital rectal examination

• Erectile dysfunction
• Haematospermia
• Penile problems including deformity, skin lesions
• Perineal pain
• Scrotal pain, swelling and lumps
• Testicular pain, swelling and lumps

Abdominal

• Abdominal and loin masses including palpable kidneys and bladder

• Abdominal and loin pain

Systemic

• Anaemia
• Fever and rigors
• Hypertension
• Oedema
• Pruritus
• Thirst
• Systemic symptoms of vasculitis for example, rash, arthralgia

Common and important conditions

• Acute Kidney Injury (AKI)

• Cancer: bladder, kidney, penile, prostate, testicular, ureteric
• Chronic Kidney Disease (CKD) including causes, classification, management, monitoring and indications for referral
• Congenital abnormalities of the urinary tract
 • Haematuria (visible or non-visible)
• Inherited kidney diseases such as polycystic kidney disease, Alport syndrome
• Intrinsic renal disease (for example, glomerulonephritis)
• Overactive bladder syndrome
• Penile problems such as malignancy, paraphimosis, Peyronie's disease, phimosis, priapism, balanitis, skin disorders
• Prostatic problems such as acute and chronic prostatitis, benign prostatic hyperplasia, prostatic carcinoma
• Proteinuria (including microalbuminuria)
• Renovascular disease (renal artery stenosis)
• Systemic conditions causing kidney disease for example, connective tissue diseases, diabetes mellitus,
glomerulonephritis, hypertension, malignancy such as multiple myeloma, nephrotic syndrome
• Testicular problems including epididymitis, hydrocele, orchitis, sperm granuloma, torsion, tumours (such as
seminoma and teratoma), undescended and maldescended testes, varicocele
• Urinary incontinence in men
• Urinary incontinence in women: stress and/or urge incontinence. (Prolapse is covered in Topic Guide Gynaecology
and Breast)
• Urinary tract infections in children and in adults including lower urinary tract infection, pyelonephritis and
persistent/recurrent infection
• Urinary tract obstruction including acute and chronic retention; causes including prostatic and other structural
abnormalities (strictures, congenital renal tract abnormality such as posterior urethral valves, duplex systems)
• Urolithiasis (stone disease): renal colic, management of stones including lithotripsy and ureteric stents
• Erectile dysfunction and sexually transmitted infection are covered in Topic Guide Sexual Health).

Examinations and procedures

• Abdominal examination to include bladder and kidney palpation

• Assessment of fluid balance status
• Digital Rectal Examination including prostate size, tenderness, nodules
• Genital examination
• Urine dipstick testing

Investigations

• Blood tests: including creatinine, eGFR, electrolytes, full blood count, prostate specific antigen (PSA), calcium,
phosphate, parathyroid home (PTH) and Vitamin D
• International Prostate Symptom Score (IPSS) to assess LUTS
• Renal tract imaging including ultrasound and CTKUB
• Secondary care investigations (such as cystoscopy, ureteroscopy, urodynamic studies and flow rate studies)
• Urine tests: including biochemistry, microscopy, culture and sensitivities, quantification of urinary albumin and
protein

Service issues

• Circumcision for religious or cultural beliefs – including ethical issues

Additional important content

• Being aware that the patient's physiology and anatomy may be different from the patient's gender
• Catheters: types, indications, management, problems such as bypassing, infection, self-catheterisation, use of
catheters in paraplegic patients
• Conservative management of end stage renal failure including management of anaemia
• Dialysis: peritoneal and haemodialysis, including complications that may be encountered in primary care (such as
infection of catheter sites, fluid balance disturbance)
 • Methods to estimate and measure glomerular filtration rate (GFR), including their limitations and necessary
adjustments
• Nephrostomy and cystostomy care
• Prescribing in kidney disease (for example dose adjustment in renal impairment) and an awareness of nephrotoxic
medications
• Renal transplantation and post-transplant care that is relevant to primary care

AKT Sample Questions-

• Monitoring of chronic kidney disease
• Drug therapy for prostatic cancer
• Investigations for haematuria
 Mental Health
Knowledge and Skills Guide-
Symptoms and signs

• Abdominal symptoms such as bloating, discomfort and altered bowel habit

• Appetite changes including secondary amenorrhea
• Awareness of heart beat and chest tightness including palpitations and bradycardia
• Biological features of depression.
• Fatigue and feeling tired all the time
• Hallucinations
• Medically unexplained physical symptoms, including somatoform disorders
• Mood and behaviour changes, such as anger, anhedonia, hypervigilance and self- harming behaviours
• Poor concentration
• Psychomotor agitation or retardation
• Sleep disturbance including insomnia, night terrors and early morning awakening
• Tearfulness
• Thought disorders.

Common and important conditions

• Abuse including child, sexual, elder, domestic violence, emotional including non-accidental injury
• Acute mental health problems including acute psychoses, acute organic reactions, the suicidal patient, psychological
crises and the application of the Mental Health Act as applicable to all the UK Home countries
• Addictive and dependent behaviour such as alcohol and substance misuse. This is common in those experiencing
mental health problems (termed ‘dual diagnosis’) and is often unrecognised
• Affective disorders, including depression and mania
• Anxiety including generalised anxiety and panic disorders, phobias, obsessive compulsive disorder, situational anxiety
and adjustment reactions
• Behaviour problems such as attention deficit /hyperactivity disorder, enuresis, encopresis, school refusal
• Bereavement reactions
• Cultural and societal aspects of mental health including work, spiritual and religious beliefs and practices
• Self-harm including putting themselves in dangerous situations as well as self-poisoning, cutting and skin picking.
Suicidal thought disorders. Men who self-harm have a higher risk of suicide
• Eating disorders including morbid obesity, anorexia and bulimia nervosa, body dysmorphia and Other Specified
Feeding and Eating Disorders (OSFED)
• Emotions and their relevance in well-being and mental illness
• Learning difficulties - the range of mental health problems that people with learning difficulties may experience
• Mental health disorders associated with physical health disorders e.g. psychosis associated with steroid therapy,
depression associated with Parkinson’s disease, diabetes and other chronic diseases
• Mental health disorders due to substance misuse
• Mood (affective) problems such as depression including features of a major depression such as psychotic and
biological symptoms; bipolar disorder, assessment of suicidal risk; detection of masked depression
• Obsessive compulsive behaviours
• Organic reactions– acute and chronic such as delirium with underlying causes such as infection, adverse reactions to
drugs
• Personality disorders including borderline, antisocial, narcissistic
• Pregnancy associated disorders such as antenatal, perinatal and postnatal depression, puerperal psychosis
• Psychological problems including psycho-social problems and those associated with particular life stages such as
childhood, adolescence and older people
• Relationship with substance misuse and dependence including alcohol and drugs of misuse and other habit disorders
such as gambling
• Severe behavioural disturbance including psychotic disorders such as schizophrenia, acute paranoia and acute mania
• Sleep disorders including insomnia, sleep walking
• Trauma including rape trauma syndrome, post-traumatic stress disorder, dissociative identity disorder
Examinations and procedures
• Relevant physical examinations including cardiovascular and abdominal examinations
• Exploring both physical and psychological symptoms, family, social and cultural factors, in an integrated manner
• Assessing and managing suicidal ideation and risk - Co-creating and implementing an immediate safety plan with a
suicidal patient.
• The role of the GP in detaining patients under the Mental Health Act; awareness of the Mental Health Act and the
Mental Capacity Act (or equivalent legislation)
• Electroconvulsive therapy indications and side effects
• Self-help and psychological therapies such as cognitive behavioural therapy, eye movement desensitisation and
reprogramming, counselling, psychotherapy, psychoanalysis, aversion, flooding and desensitisation therapies.

Investigations
• Screening for metabolic and cardiovascular risk factors, in people with severe mental illness, and that such risks are
minimised through appropriate lifestyle advice and management, including facilitating behaviour change
• Assessment tools for mental health conditions such as depression, anxiety, postnatal depression screening scales,
dementia screening, suicide risk assessment and risk of self-harm
• Monitoring of treatments such as anxiolytics and antipsychotic medication
• Relevant physical investigations such as blood tests, ECG and relevant neurological investigations.
Service issues
• Voluntary and community services and charities that promote mental health and wellbeing
• The range of psychological therapies available including cognitive behavioural therapies, mindfulness, counselling,
psychodynamic, psychosexual and family therapy

Additional important content

• Balancing confidentiality with safeguarding including liaising with family and carers
• The usefulness of models of mental illness that create an artificial separation between mind and body – particularly in
understanding psychosomatic complaints, psychological consequences of physical illness and medically unexplained
symptoms
• Impact of social circumstances such as poverty, debt, inequalities and upbringing on mental illness; effective
management of these social circumstances to aid recovery
• The evidence base for the positive relationship between work and mental health, and the association between
unemployment and declining mental health
• Contribution of mental health problems to disability and social exclusion
• Depression and anxiety in people with long-term physical conditions, and their role in increased morbidity and
mortality in these conditions
• Stigma that can be associated with the label of a mental health condition and the potential associated discrimination
and isolation
• Cultural sensitivity and awareness; cultural dimensions of mental illness, including assumptions that may not be
universal, e.g. that a psychological intervention may not be acceptable to some people who have alternative
explanations for, and understanding of, their symptoms
• The well-being agenda, mental health promotion and psychosocial interventions in preventing mental ill-health.

AKT Sample Questions-

• Symptoms of schizophrenia
• Increased health risks of a typical antipsychotic drugs
• Cognitive behavioural therapy in anxiety management
 Metabolic problems and Endocrinology
Emerging Issues-
Pre-diabetes- diagnosis and management
Role of surgery in obesity and diabetes

Knowledge and Skills Guide-

Symptoms and signs

• Changes in reproductive and sexual function for example, menstrual irregularities, loss of libido, body hair changes
and erectile dysfunction
• Collapse and coma
• Falls
• Fractures
• Gastrointestinal symptoms for example, nausea, vomiting, diarrhoea, constipation
• Headache and visual problems
• High blood pressure
• Joint pains and muscle problems
• Mood changes
• Polydipsia and polyuria
• Pruritus
• Skin changes
• Symptom complexes and their characteristics
• Thirst
• Tiredness and lethargy
• Weight gain/weight loss

Common and important conditions

• Adrenal diseases including Addison's disease, Cushing's syndrome and disease, phaeochromocytoma,
hyperaldosteronism, primary and secondary malignancy, ACTH secreting tumours, congenital adrenal hyperplasia
• Adverse metabolic effects of prescribed drugs (for example, hypokalaemia with diuretics)
• Carcinoid syndrome, multiple endocrine neoplasia
• Diabetes mellitus — type 1, type 2, and rarer types such as MODY (maturity onset diabetes of the young) and LADA
(latent autoimmune diabetes in adults), pre-diabetes, impaired fasting glucose, impaired glucose tolerance, insulin
resistance, gestational diabetes. In the context of these conditions, you should be aware of:
• diagnostic thresholds
• self-monitoring of glucose levels
• skin and eye manifestations, renal and neurological complications
• macrovascular complications and cardiovascular risk
• acute complications such as hypoglycaemia, diabetic ketoacidosis, non-ketotic hyperglycaemia
• lifestyle factor modification (for example, diet, physical activity, smoking)
• medication in diabetes management, including glucose and lipid lowering therapies, anti-platelets, ACE inhibitors and
antihypertensives; recommended treatment targets; and
• insulin regimes, administration and dosages
• Disorders of calcium metabolism, including hypoparathyroidism, hyperparathyroidism and osteomalacia; association
with chronic kidney disease and malignancy (for example, bony metastases and myeloma)
• Disorders of sex hormones (for example, hirsutism, virilism, gynaecomastia, impotence, androgen deficiency,
androgen insensitivity syndrome)
• Endocrine manifestations of non-endocrine diseases (for example, bronchogenic carcinoma with inappropriate ADH
secretion)
• Haemochromatosis: primary and secondary, and other disorders of iron metabolism
• Hyperlipidaemias: familial and acquired
 • Hyperprolactinaemia and its causes (for example, drug-induced, chronic renal failure, bronchogenic carcinoma,
hypothyroidism, pituitary)
• Hyperuricaemia: primary and secondary (including haematological and drug-induced causes) and its associations with
obesity, diabetes, hypertension and dyslipidaemia
• Hypothalamic causes of hormonal disturbances (for example, hyperprolactinaemia, drug-induced)
• Inherited metabolic diseases (for example, phenylketonuria, glycogen storage diseases, porphyrias)
• Metabolic causes of unconsciousness (for example, hypoglycaemia, diabetic ketoacidosis, hyponatraemia,
hypothyroidism, adrenal insufficiency)
• Non-alcoholic fatty liver disease (NAFLD), including its associations with diabetes, obesity and metabolic syndrome,
and its consequences
• Osteoporosis
• Overweight and obesity
• Assessment and classification using Body Mass Index (BMI), and limitations of this method
• Health consequences of obesity (including malnutrition, increased morbidity and reduced life expectancy)
• Health promotion advice (including nutrition, smoking cessation, physical activity)
• Pharmacological therapies for weight reduction
• Risks and benefits of bariatric surgery
• Direct and indirect impact of obesity on a wide range of disease areas
• Pituitary diseases including acromegaly, primary and secondary hypopituitarism, diabetes insipidus
• Poisoning (deliberate or unintentional) including by food, drugs (prescribed, over the counter or non-medicinal) or
other chemicals
• Polycystic ovary syndrome (see RCGP Topic Guide Gynaecology and Breast Health)
• Psychogenic polydipsia
• Replacement and therapeutic steroid therapy
• Thyroid diseases including goitre, hypothyroidism, hyperthyroidism, benign and malignant tumours, thyroid eye
disease, thyroiditis, neonatal hyper- and hypo-thyroidism:
• Antibody testing, thyroxine replacement therapy and monitoring
• Associations with other conditions, including cardiovascular disease
• Potential for thyroxine abuse and strategies to reduce dosage
• Vitamin D deficiency, including its causes, health consequences/complications, testing, and replacement therapy

Examinations and procedures

• Relevant focused examinations in order to identify: features of common and important metabolic/endocrine
conditions, underlying causes, manifestations of disease progression, and associated conditions
• Specific examinations (for example, assessment of neuropathy in diabetes, examination of a neck lump, visual field
testing)

Investigations

• Common primary care tests to investigate and monitor metabolic/endocrine disease (for example, fasting blood
glucose, HbA1c, urinalysis, urine albumin:creatinine ratio, 'near patient testing' (point of care testing), lipid profile,
thyroid function tests, and uric acid)
• Other laboratory investigations such as renal, liver, pancreatic, adrenal, pituitary, hypothalamic, ovarian and testicular
function, antibody tests (for example, GAD, thyroid antibodies)
• Normal biochemical parameters for common laboratory tests of metabolic/endocrine disease
• Imaging (for example, DEXA scan and interpretation) and tests of endocrine and metabolic dynamic function
• Screening of asymptomatic individuals to diagnose metabolic conditions (for example, diabetes and pre-diabetes)

Service issues

• Screening tools and prevention programmes for conditions such as diabetes and osteoporosis
 • Prescription charge exemptions for patients with certain conditions

Additional important content

• Key guidance (for example, NICE, SIGN) and research findings (for example, UKPDS) influencing the management of
metabolic/endocrine conditions
• Associations between autoimmune diseases (for example, diabetes, Coeliac and thyroid disease)
• Rare secondary causes of diabetes and thyroid disease (for example, pancreatic disease, amyloid)
• ‘Sick day rules’ (for example, in diabetes, adrenal insufficiency)
• Genetic and environmental factors (for example, ethnicity, lifestyle, social inequalities) affecting prevalence and
outcomes in conditions such as diabetes
• Lifestyle interventions (including social prescribing) for conditions such as obesity, diabetes mellitus, hyperlipidaemia
and hyperuricaemia
• Behaviour change consultation tools, such as motivational interviewing, Very Brief Advice (VBA) for smoking cessation
• Risk-benefit conversations with patients (including risks of complications)
• Risk calculation tools (for example, QRISK, QDiabetes)
• Psychosocial impact of long-term metabolic conditions on individuals and their wider social networks (for example,
the risk of depression and other mental health problems, sexual dysfunction, impact on employment and driving
(including DVLA guidance))
• Indications for referral to an endocrinologist, metabolic medicine or other specialist.

AKT Sample Questions-

• DVLA regulations for diabetes
• Symptoms of acute Addisonian crisis
• Pituitary hormone test interpretation
 Musculoskeletal Health
Emerging Issues-
• Inflammatory arthritis

Knowledge and Skills Guide-

Symptoms and signs

• Extra-articular symptoms associated with musculoskeletal disease (for example, skin, eye, gastrointestinal
manifestations)
• Falls
• Joint pain, stiffness, swelling, deformity, redness (including individual joints such as back and neck, jaw, hip, knee,
ankle, foot, shoulder, elbow, wrist, hand or generalised)
• Lumps and deformities of bone, joint or soft tissue
• Muscle pain and weakness

Common and important conditions

• Avascular necrosis
• Bone cancers including metastatic disease, Ewing's and soft-tissue sarcoma
• Cervical spinal disorders including cervical spondylosis, torticollis and 'whiplash' injuries, vertebral fracture and long-
term consequences
• Congenital/inherited diseases such as osteogenesis imperfecta, Marfan's syndrome, Ehlers-Danlos syndrome,
Gaucher's disease, hypermobility syndromes
• Crystal arthropathies such as gout, pyrophosphate arthropathy
• Fractures, dislocations, haematoma, sprains, strains and other significant soft-tissue trauma: recognition and
principles of management
• Hand disorders such as trigger finger, Dupuytren's contracture, carpal tunnel syndrome, ulnar nerve compression.
Foot disorders such as plantar fasciitis, digital neuroma
• Infection such as septic arthritis and osteomyelitis
• Inflammatory arthritis and connective tissue diseases such as: rheumatoid arthritis, sero-negative arthritis such as
psoriatic arthropathy and axial spondyloarthritis
• Lymphoedema
• Muscle disorders such as polymyalgia rheumatica and giant cell arteritis, polymyositis and dermatomyositis,
fibromyalgia, muscular dystrophies and myasthenia gravis
• Osteoarthritis including joint replacement surgery risks and complications
• Osteoporosis: primary and secondary
• Reactive arthritis, viral arthropathy; connective tissue disorders such as systemic lupus erythematosus, scleroderma,
systemic sclerosis
• Skeletal problems including disorders of calcium homeostasis such as osteomalacia, rickets, Paget's disease (see also
RCGP Topic Guide Endocrinology and Metabolic Problems)
• Soft tissue disorders such as bursitis, epicondylitis, Achilles tendon problems
• Spinal disorders including mechanical back pain, disc lesions, malignancy (primary or metastatic), infection (including
osteomyelitis, osteoarthritis, spinal stenosis, osteochondritis), developmental disorders (such as scoliosis and
kyphosis), trauma including vertebral fracture and long-term consequences, acute neurological emergencies (such as
cauda equina)
• Chronic pain (such as complex regional pain syndrome)
• Trauma including fractures and primary care management of injuries/ first-aid
• Wounds (including surgical) and lacerations: management and principles of care

Examinations and procedures

• Examinations: functional assessment, examination of back and spine, joint examinations, systemic manifestation of
musculoskeletal problems, exclusion of red flags, screening examinations (for example, GALS)
 • Procedures: knowledge of the appropriate use of steroid injections (although the ability to administer them is not
essential)

Investigations

• Investigations: blood tests, X-rays, CT and MRI scans, DEXA scans, bone scans, ultrasound, biochemical and
immunological indicators of musculoskeletal problems, nerve conduction studies, tissue biopsy
• Local service provision for musculoskeletal problems
• Service provision for veterans
• Practice policies for supporting staff and patients with musculoskeletal problems, including creating a healthy
workplace

AKT Sample Questions-

• Risk factors for osteoporosis
• Differential diagnosis of muscle pain
• Recognition of acute, inflammatory arthritis
 Neurodevelopmental disorders intellectual and social disability

Knowledge and Skills Guide-

Common and important conditions

• Autism and autism spectrum disorder

• Dyspraxia
• Genetic causes of intellectual disability (for example, Fragile X, Williams, Prader-Willi, Rett’s, Down and Sturge-Weber
syndromes, phenylketonuria, neurofibromatosis, tuberous sclerosis)
• Non-genetic causes of intellectual disability (for example, fetal alcohol syndrome, brain injury, neglect)
• Common associated physical health disorders include (but are not limited to):
• cardiovascular disease
• type 2 diabetes
• epilepsy
• musculoskeletal problems
• obesity
• oropharyngeal and gastrointestinal disorders
• respiratory disorders
• sleep disorders; and
• visual, speech, hearing and mobility problems
• Common associated mental health problems (which may present differently from the general population) include:
• Alzheimer's disease
• anxiety and depression
• bereavement reactions
• bipolar affective disorder
• schizophrenia; and
• specific associations (for example, autism spectrum disorder and ADHD are linked)

Examinations and procedures

• Tailored physical and mental state assessments in patients with intellectual disability and in those unable to describe
or verbalise symptoms
• Screening tools for autism
• Screening tests to detect neurological and psychiatric problems such as dementia and depression
• Investigations

• Prenatal screening for genetically-linked conditions (for example, Down syndrome)

• Appropriate referral for specialist assessment and diagnosis
• Appropriate investigation and follow-up of associated conditions

Service issues

• Annual health checks:

• Identification or management of common associated physical conditions (for example, epilepsy, obesity, diabetes),
mental health conditions and specific associations (for example, Down syndrome and hypothyroidism); appropriate
referral and follow-up of these conditions, tailored to individual needs

Additional important content

• Impact of intellectual disability on outcomes and management of associated conditions such as diabetes, asthma,
schizophrenia, bipolar disorder and epilepsy
 • Effects of intellectual disability on the ageing process, particularly in relation to the development and recognition of
dementia
• Emotional and sexual needs of adults with intellectual and social disabilities, and how they may be expressed
• Impact on family dynamics, including parenting experiences, bereavement reactions (see also RCGP Topic Guide on
People at the End-of-Life); physical, psychological and social morbidity in carers
• Risk-benefit conversations about childhood vaccinations (including controversies such as MMR and autism)
• Risk of physical, sexual, financial, institutional, discriminatory and emotional abuse, including negative responses of
the community in the area around communal homes (hate crimes)
• Safeguarding of vulnerable adults and children and the ethics of caring for people with intellectual disability (including
risks to carers)
• Key recommendations from policy reports on quality of care for people with intellectual disability (for example,
reports referring to Winterbourne View hospital)
• Key guidance (for example, NICE, SIGN, GMC guidance on consent, capacity, and confidentiality)
• Mental capacity assessment and associated legislation (Mental Capacity Act 2005 in England and Wales, common law
in Northern Ireland, and the Adults with Incapacity (Scotland) Act 2000). Implications for treatment consent and
screening programmes
• Legislation around Power of Attorney, advanced directives and DNAR notices; its relevance to the needs of people
with intellectual disability
• Other relevant legislation (for example, Equality Act 2010, Autism Act 2009)
• Equal rights of all citizens to health care, health information and health promotion

AKT Sample Questions-

• Increased risks of physical disease in Down syndrome
• Genetic causes such as Fragile X
• Statutory legislation for vulnerable adults
 NEUROLOGY
Knowledge and Life Skills-
Symptoms and signs

• Cognitive impairment such as memory loss, delirium and dementia

• Collapse
• Disturbance of smell and taste
• Dizziness
• Features differentiating between upper and lower motor neurone function
• Movement disturbances such as athetosis, chorea, tremor
• Neuralgic and neuropathic pain
• Nystagmus and symptoms/signs of cerebellar and vestibular dysfunction
• Seizures and convulsions
• Sensory and motor symptoms: weakness (for example, foot drop), spasticity, paraesthesia
• Signs of raised intracranial pressure
• Speech and language deficits
• Visual problems such as diplopia, ptosis, pupillary abnormalities and visual field defects

Examinations and procedures

• Assessment of capacity
• Counselling and investigating people with a family history of genetic neurological disease
• Fundoscopy
• Targeted central and peripheral nervous system examination including testing of peripheral nerve and root symptoms
and signs (for example, dermatomes, reflexes, sensory and motor testing) and tests of cranial nerve function
• Tests of cognition and interpretation in relation to memory loss, dementia, delirium and associated diseases
• Visual assessment (for example, visual fields)

Common and important conditions

• Acute confusional states or coma with underlying causes such as metabolic, infective, or drug-induced
• Autonomic neuropathies such as diabetic, drug induced, metabolic, multi-system atrophy
• Causes and risk factors for recurrent falls
• Cerebellar disorders including tumours, demyelination such as multiple sclerosis and inherited such as Friedrich's
ataxia
• Chronic fatigue syndrome
• Complex regional pain syndrome
• Cranial nerve disease for example, Bell's palsy, trigeminal neuralgia, bulbar palsy
• Dementia for example Alzheimer's, vascular, Lewy body, Pick's disease, normal pressure hydrocephalus, other causes
of memory loss and confusion
• Epilepsy including generalised and focal seizures, febrile convulsions and other causes of seizures (such as
hypoglycaemia, alcohol and drugs)
• Falls, their causes and risk factors
• Head injuries with or without loss of consciousness, concussion and more serious cranial or intracranial injuries, and
relevant long-term care with brain injuries including secondary epilepsy and behavioural problems
• Headaches including tension, migraine, cluster, raised intracranial pressure including idiopathic intracranial
hypertension
• Infections such as meningitis, encephalitis, arachnoiditis
• Inherited neurological diseases for example, Huntington's disease, Charcot-Marie-Tooth, myotonic dystrophy,
neurofibromatosis
• Intracranial haemorrhage including subarachnoid, subdural and extradural and thrombosis such as sinus thromboses,
congenital aneurysms
• Motor neurone disease including progressive bulbar palsy and muscular atrophy
 • Movement disorders including tremor and gait problems including athetosis, chorea, tardive dyskinesia, dystonia, tics.
Underlying causes such as Sydenham's chorea, Huntington's disease, drug-induced, parkinsonism
• Multiple sclerosis and other demyelinating disorders such as transverse myelitis
• Muscle disorders such as muscular dystrophy, myasthenia gravis and associated syndromes
• Parkinson's disease and other progressive degenerative disorders such as Progressive Supranuclear Palsy; and Multi-
System Atrophy
• Sensory and/or motor disturbances (peripheral nerve problems) including mono- and poly-neuropathies such as
nerve compression and palsies, Guillain-Barré syndrome
• Speech disorders including stroke, cerebellar disease, cerebral palsy, motor neurone disease
• Spinal cord disorders such as root and cord compression, cauda equina syndrome, spinal stenosis, syringomyelia.
Metastatic cord compression in at-risk patients
• Spinal injuries causing paralysis and relevant care of tetra- and paraplegic patients including bowel and bladder care,
potential complications such as pressure sores, autonomic dysfunction, aids to daily living and mobility
• Stroke including transient ischaemic attacks, with underlying causes such as cardiac arrhythmias, arterial disease,
thrombophilia
• Tumours of the brain and peripheral nervous system such as meningiomas, glioblastomas, astrocytomas,
neurofibromatosis, secondary metastases

Additional important content

• Appropriate advice regarding epilepsy medication including drug interactions, side effects, and contraceptive and
pregnancy advice
• Appropriate further investigations such as CT, MRI scans, nerve conduction studies, lumbar puncture
• Indications for referral to a neurologist for chronic conditions that require ongoing specialist management and
conditions that require early treatment to avoid permanent deficit
• Indications for referral of people with other neurological emergencies (for example, spinal cord compression, cauda
equina)
• Management of the acute presentation of meningitis and meningococcal septicaemia and people presenting with
collapse, loss of consciousness or coma
• The effect of neurological conditions on patients' working lives and the potential impact on the family’s social and
economic well-being
• Understanding of Standards on Fitness to Drive

AKT Sample Questions-

• Investigation of possible multiple sclerosis
• Use of appropriate medication for Parkinson's disease
• Differential diagnosis of paraesthesia
 Population Health

Knowledge and Skills Guide-

Health improvement

• The concepts of 'health' and 'wellbeing'

• The multiple determinants of health
• The relationship between social determinants of health and health inequalities
• Socio-economic, political and cultural factors affecting people's lifestyle choices
• The impact on health of factors such as alcohol and substance misuse, poor diet, smoking, inadequate exercise and
risky sexual behaviour, including in specific populations such as pregnant women, people with mental ill health, and
other vulnerable groups
• Approaches to behaviour change and their relevance to health promotion and self-care
• Actions to address lifestyle factors that affect health (for example, nutrition, sleep, physical activity) and implement
behaviour change
• Pharmacological approaches to addressing lifestyle risk factors (for example, weight management medications,
treatments for alcoholism etc.)
• Clinical, social, and environmental risk factors in healthy individuals for a range of common/important conditions (for
example, cancer, heart disease, diabetes, falls)
• Doctor-patient partnership in conversations relating to self-care
• Effects of an individual's health behaviours on their wider social network
• Ethical issues around prevention, pre-symptomatic testing, therapy in asymptomatic individuals, lifestyle choices, and
tensions between individual and community needs
• Risk factors and safeguarding for different patient groups (for example, the frail elderly, children at risk of accidents,
and people at risk of abuse including at home, in institutions etc.)

Health protection

• Disease prevention programmes for common and important communicable and non-communicable diseases
• NHS screening and immunisation programmes
• Health surveillance systems that that involve GPs (for example, RCGP Weekly Returns Service)
• Notifiable diseases and the role of the Health Protection Agency
• Risk-benefit conversations in relation to health protection, (for example, child immunisation)
• Health benefits of being in work
• Occupational hazards and risk factors (for example, occupational cancers, respiratory diseases, musculoskeletal
disorders)
• Return to work and rehabilitation after illness or accident
• Fitness for work certification and guidance on its use
• Support and encouragement of disabled patients in the workplace
• Roles of other health professionals (for example, occupational health staff, physiotherapists and counsellors) in
managing work and health issues.

Service issues

• Audit and clinical governance

• Role of the GP in service redesign and commissioning
• Structure of health services in the UK
• Role of public health organisations in the UK
• Role of third sector, voluntary, and non-governmental organisations in population health
• Effect on health of government policies (for example, housing, environment, infrastructure, taxation, tobacco control)
• Evidence and epidemiology (see also Topic Guide Evidence based practice, research and sharing knowledge)
• Concept of the hierarchy of evidence in relation to patients requesting Interventions Not Normally Funded (INNF)
 • Sources of routinely available data about the health of local populations

Additional important content

• The influence of ageing, dependency, multiple co-morbidities, and frailty on individual and population-level
healthcare needs
• The health of minorities and marginalised populations (including but not limited to refugees, asylum seekers,
institutionalised groups, sex workers, the homeless, travellers, undocumented migrants, and victims of trafficking and
torture)
• Global factors affecting the health and wellbeing of individuals and populations (for example, climate change, air
quality and pollution, health systems, pandemics, conflict and migration (including migration of health workers))
• Global institutions with a health remit (for example, World Health Organisation)
• The WHO global burden of disease
• Models of healthcare delivery and financing

AKT Sample Questions-

• Natural history of minor illnesses for example, URTI
• Screening programmes
• Appropriate advice for self-care
 Respiratory Health

Knowledge and Skills Guide-

Symptoms and signs

• Chest pain
• Clubbing
• Collapse
• Cough, acute and chronic
• Cyanosis
• Dyspnoea: acute and chronic
• Fever
• General malaise including weight loss and fatigue
• Haemoptysis
• Lymphadenopathy
• Pleural effusion
• Signs of respiratory distress in children (for example, recession, nasal flaring)
• Stridor and hoarseness
• Tachypnoea
• Wheeze

Common and important conditions

• Asthma: acute and chronic in children and adults

• Asthma-COPD overlap
• Bronchiectasis
• Chronic obstructive pulmonary disease
• Connective tissue diseases affecting the lung, such as rheumatoid arthritis, SLE and sarcoidosis
• Cough including haemoptysis, and non-respiratory causes such as GORD
• Cystic fibrosis
• Emphysema including α1-antitrypsin deficiency
• Immunosuppression affecting the respiratory system including opportunistic infections such as TB, fungal and
parasitic Lower respiratory tract infections (for example, bronchiolitis, bronchitis, pertussis and pneumonia (of any
cause), atypical pneumonias including Legionnaire's disease and tuberculosis), sepsis
• Lower respiratory tract infections
• Lung fibrosis and associated causes including adverse drug reactions
• Occupational respiratory diseases such as the pneumoconioses, asthma, extrinsic allergic alveolitis and asbestos
related diseas
• Pleural effusion causes including infection, connective tissue diseases and malignancies
• Pneumothorax including simple and tension
• Pulmonary embolism
• Respiratory failure and methods of ventilation such as CPAP for sleep apnoea
• Respiratory malignancies, including laryngeal, bronchial and pleural such as mesothelioma. Primary and secondary
lung malignancies, and related para-neoplastic syndromes
• Stridor and hoarseness: differential diagnosis including assessment of urgency for investigation and management
• Upper respiratory tract infections including tonsillitis, peri-tonsillar abscess, epiglottitis, laryngitis, pharyngitis and
tracheitis

Examinations and procedures

 • Appropriate focused clinical examination to identify respiratory disease (for example, clubbing, lymphadenopathy,
significance of measuring respiratory rate, chest exam, signs of sepsis)
• Specific procedures, such as peak expiratory flow rate measurement
• Demonstrate the correct use of a dry powdered and metered dose inhaler and check that a patient can use their
device properly
• Administration of inhaled bronchodilators with spacer or nebuliser, including correct techniques

Investigations

• Primary care investigations such as peak expiratory flow rates, spirometry, exhaled nitric oxide testing (FeNO), pulse
oximetry, blood tests and sputum culture (including indications for, correct technique, interpretation of results, and
factors affecting results)
• Disease scoring tools (for example, CURB for community acquired pneumonia)
• Indications for chest-x-rays, CT and MRI scans, and bronchoscopy

Service issues

• Local and national guidelines to manage common respiratory diseases (asthma, COPD, lung cancer) in primary care
• Indications for the use of oxygen in emergency, acute and chronic management including domiciliary oxygen and use
in palliative care
• Patients’ understanding of prescribed inhaled medication, both routinely and in an emergency, including its
appropriate use and technique
• Inhaler devices, including types of devices and their ease of use, prescribing, cost-effectiveness and patient's
preference
• Support available to patients and their carers from health, social services and charities/voluntary sector organisations

Additional important content

• History-taking key points with respect to specific respiratory diseases (for example, in relation to occupation,
smoking, 'red flag' symptoms, family history)
• The importance of lifestyle changes, particularly smoking cessation and pulmonary rehabilitation
• The impact of co-morbidity such as muscle wasting, osteoporosis, cardiovascular disease or mental health problems
in people with long-term respiratory conditions such as asthma and COPD, and the effect of these on morbidity and
mortality
• The potential for financial compensation for those diagnosed with mesothelioma and other occupational lung
diseases. Appropriate signposting to specialist services, and appropriate death certification for these conditions.

AKT Sample Questions-

• Interpretation of spirometry results
• Symptoms of lung cancer
• Aetiology of community-acquired pneumonia
 Sexual Health

Emerging Issues-
• Gender dysphoria
• The incidence of STIs is changing (for example, reduced incidence of genital warts, increased rates of syphilis and
antibiotic resistant gonorrhoea)

Knowledge and Skills Guide-

Symptoms and signs

• Abnormal vaginal bleeding suggestive of infection including post-coital and intermenstrual bleeding
• Dyspareunia
• Dysuria
• Erectile dysfunction and premature ejaculation
• Feelings and behaviours related to Gender dysphoria
• Genital ulcers and warts
• Pelvic and abdominal pain
• Penile discharge
• Psychosexual dysfunction including anorgasmia, loss of arousal, loss of libido and vaginismus
• Systemic manifestations of STIs (for example, reactive arthritis, rash)
• Vaginal discharge
• Vulval pain or irritation

Common and important conditions

Infections

• Bacterial vaginosis
• Candida
• Infestations (including pubic lice and scabies)
• Pelvic Inflammatory Disease (PID)
• Sexually Transmitted Infections including chlamydia, genital herpes simplex, genital warts, gonorrhoea, human
papilloma virus (HPV), sexually transmitted blood borne viruses (HIV, Hepatitis B and (rarely) Hepatitis C), syphilis and
trichomonas
• Sexual dysfunction

• Female sexual dysfunction, including anorgasmia, dyspareunia, hypo-oestrogenism, loss of libido and vaginismus
• Male sexual dysfunction, including erectile dysfunction due to organic causes (such as diabetes, drug induced
(including smoking), neurological disease and vascular disease) and psychological causes. Premature ejaculation.
Other

• Female genital mutilation (FGM) including practical and legal aspects, reporting mechanisms and protecting girls at
risk of FGM
• Gender identity, dysphoria and reassignment including children and young people
• Genito-urinary skin disorders including lichen sclerosus, balanitis
• Provision of, and access to, pregnancy termination services (including variation in this between the four nations of the
United Kingdom)
• Sexual abuse and assault (both adult and child) including care of patients who have been abused and indicators of
assault (including STI in children). Child sexual exploitation
• Unwanted pregnancy and termination of pregnancy (including legal and ethical aspects)
Examinations and procedures

• Male and female genital examination (including bimanual pelvic examination and speculum examination)
• pH testing for bacterial vaginosis
• Vaginal swabs: use of 'self-taken' samples (vulvo-vaginal and urine) for chlamydia and gonorrhoea; indications for
clinician-taken swabs
• Investigations

• Investigation of STI: swabs, urine and blood tests (including timing of testing, practicalities and interpretations of
results)
Other important content

• Empirical management of vaginal discharge

• Female contraception including:
• hormonal contraception: combined oral/patch/ring contraception, progesterone only methods including oral, depot
injection, sub-dermal implant, intrauterine systems (IUS)
• non-hormonal contraception: cap, diaphragm, female condom, intrauterine device (IUD)
• long acting reversible contraception (LARC)
• sterilisation
• emergency contraception
• Male contraception including condoms, spermicides, vasectomy
• Methods of natural family planning
• Prescribing for patients taking HIV medications from specialist clinics, including drug interactions
• Safe sex advice, sexual health promotion and risk reduction (adults and young people)
• Screening for sexually transmitted infection including chlamydia and HIV

Service issues

• Access to Gender Identity Clinics and care of patients with gender dysphoria in primary care, including sensitive
record keeping and appropriate use of titles and personal pronouns
• Access to sexual health services for individuals with learning or physical disability or with different communication
needs
• Awareness of local prevalence of HIV and blood borne viruses (BBV), including some awareness of overseas
prevalence as relevant to international patients
• Consent and confidentiality in respect of under 16s accessing sexual health services (Fraser Guidelines)
• HPV vaccination programme
• Local and national strategies to reduce teenage and unplanned pregnancies
• Local service arrangements for:
• Provision of LARC services and sterilization procedures
• Access to emergency contraception
• STI testing and access to GUM clinics
• Patients presenting following sexual assault
• Provision of sexual health promotion services, including
• health promotion and 'safe sex' advice particularly in higher risk groups (such as young people, men who have sex
with men (MSM) and sex workers); and
• Hepatitis A and B vaccinations for MSM and the use of Pre-Exposure Prophylaxis (PrEP)
• Screening for domestic and intimate partner violence in the context of sexual health consultations

AKT Sample Questions-

• Appropriate use of LARC for different scenarios
• Investigation of vaginal discharge
• HIV exposure prophylaxis
 Smoking alcohol and substance misuse
Emerging Issues-
• E cigarettes
• Illegal street drugs

Knowledge and Skills Guide-

Smoking
• Types of tobacco (for example, cigarettes, chewing tobacco, hookah, etc.)
• Health effects of tobacco, including:
• its effects on the body
• as a risk or causative factor for a range of diseases (for example, cardiovascular, respiratory, metabolic)
• morbidity in people with established diseases
• its impact on the mental health of individuals and their wider social network
• in specific groups (for example, pregnant women, adolescents)
• risks of passive smoking
• Tobacco dependence and why people struggle to stop smoking
• Nicotine addiction (including risk factors) and withdrawal (including physical and psychological symptoms)
• Relationship between tobacco use and socio-economic status
• The concept of compensatory smoking, especially related to cutting down as a harm reduction technique
• Assessment of the individual, including relevant focused physical and mental health examinations and investigations
(for example, carbon monoxide testing, spirometry, chest X-ray) where appropriate

Benefits of cessation, including:

• in the prevention of conditions such as COPD, CVD, cancer etc.
• as a frontline treatment for long term conditions such as COPD
• in improving morbidity in conditions such as lung cancer

Treatment of tobacco dependence, including:

• Pathways to successful quitting and their effectiveness
• Theory and practice of evidence-based primary care strategies for smoking cessation (for example, brief
interventions, Very Brief Advice)
• Pharmacotherapy for smoking cessation (including nicotine replacement therapy, varenicline, buproprion)
• The role of e-cigarettes in smoking cessation
• The role of behavioural support in smoking cessation
• Conversations with smokers in the GP consultation

Alcohol and substance misuse

Symptoms and signs

• Accidents and injuries occurring whilst under the influence of drugs or alcohol
• Behavioural changes such as neglecting other activities, poor hygiene, secrecy, self-neglect and social withdrawal
• Drug seeking behaviour (including criminal activity, diversion of prescribed medication, neglecting children, risk taking
behaviour, sex work)
• Intoxication
• Loss of control of use
• Malnourishment
• Mental health problems related to substance misuse including mood disorders, post-traumatic stress disorder (PTSD)
and psychosis
• Overdose
• Poor oral hygiene
 • Social consequences of substance misuse for example, contact with the criminal justice system (including
incarceration), domestic violence, homelessness, poor attendance or functioning at school or work, relationship
issues, safeguarding concerns, unemployment
• Signs and symptoms of medical conditions occurring in relation to alcohol misuse ascites, confusion, hematemesis,
jaundice, melena, other upper gastrointestinal tract symptoms, features of Wernicke-Korsakoff syndrome
• Signs and symptoms of medical conditions related to substance use including cachexia and weight loss, chest pain,
cough, fever, injection site problems, jaundice, limb erythema, pain or swelling, respiratory depression, shortness of
breath
• Symptoms of withdrawal

Common and important conditions

• Common effects of the main problem drugs including anabolic steroids, antidepressants, benzodiazepines, cannabis,
cocaine, gabapentinoids, new psychoactive substances (NPS), opiates, solvents, stimulants and Z-drugs
• Complications of alcohol and substance misuse in pregnancy including foetal alcohol spectrum disorder, growth
retardation, neonatal withdrawal and pre-term delivery. Antenatal care for women misusing substances and alcohol
including involvement of social services and safeguarding of unborn children
• Crises occurring in relation to substance and alcohol misuse including intoxication, mental health emergencies,
overdose, safeguarding emergencies, trauma, Wernicke’s encephalopathy and withdrawal
• Medical complications of substance misuse including:
• infections
• local infection in injecting drug misuse: cellulitis and abscess
• systemic infection directly related to injecting drug misuse, including blood borne viruses (BBV) (hepatitis B and C, and
HIV), endocarditis
• opportunistic infection including tuberculosis
• malnutrition
• nasal and respiratory symptoms secondary to nasal substance (for example, cocaine) use
• non-infective cardiac complications for example, acute coronary syndrome, arrhythmia, ischaemic heart disease
• venous thromboembolic disease.

• Medical complications of long term alcohol misuse, including:

• alcoholic liver and abdominal disease including ascites, cirrhosis, pancreatitis, portal hypertension and varices
• common health conditions where alcohol use may be a contributing factor, including cancer and hypertension
• neurological complications including encephalopathy, peripheral neuropathy and Wernicke-Korsakoff syndrome
• vitamin deficiencies.
• Misuse of prescribed and over-the-counter medications
• Polyabuse of drugs and combined misuse of drugs and alcohol
• Mental health problems in the context of alcohol and substance misuse, including dual diagnosis, and 'self-medicatio'
of mental health problems with drugs or alcohol
• Tolerance, dependence and withdrawal

Examinations and procedures

• Assessment of alcohol problem drinking to assess the nature and severity of misuse
• Assessment of social circumstances and functioning of alcohol and substance misusers
• Substance misuse assessment including identifying substances used, quantity, frequency and pattern of use, routes of
administration, sources of drugs and evidence of dependence
• Injection site assessment
• Mental health assessment
• Relevant physical examinations (including cardiovascular and abdominal examination and examination for stigmata of
chronic liver disease)

Investigations
 • Assessment of liver damage due to alcohol misuse including blood tests and imaging
• Blood tests including blood borne viruses (Hepatitis B and C and HIV), full blood count, haematinics, liver function,
renal function, thyroid function
• ECG monitoring of QT interval in methadone prescribing
• Evidence based screening tools to identify alcohol misuse for example, AUDIT-C
• Near patient testing for drug misuse

Additional important content

• Behaviour change including psychosocial interventions

• Driving regulations (DVLA) in relation to drug and alcohol use (including prescribed and over the counter drugs) and
the responsibility of the GP in relation to this
• Harm reduction in alcohol and substance misuse including needle exchanges, patient education, safer injecting
education, sharps bins
• Impact of parental alcohol and drug misuse, including ability to function as a parent, domestic violence, safeguarding
concerns, funding of drug habit, storage of drugs and paraphernalia
• Impact of parental smoking on children (for example, SIDS, asthma)
• Particular considerations regarding children and young people who smoke, misuse alcohol or drugs, including risk of
grooming or abuse
• Preventing drug related deaths, including identifying patients at high risk, local knowledge relating to drug supplies,
identifying and treating overdose and withdrawal (role of naloxone), patient education, safe substitute prescribing
• Prevention or treatment of medical complications related to alcohol or substance misuse (for example, treatment of
BBVs, thiamine supplementation, vaccination against hepatitis A and B)
• Relapse prevention strategies, including psychosocial and pharmacological methods, and management of continued
smoking or alcohol and drug misuse amongst patients
• Risk minimisation strategies and safe prescribing (for example, benzodiazepines, analgesics, NRT)
• Risks to general health whilst misusing drugs and alcohol (for example, smoking, risky sexual activity, non-
participation in screening programmes, neglect of chronic disease care, poor nutrition)
• 'Street slang' terms for drugs and how they are used
• Substitute prescribing of methadone and buprenorphine – medical, legal, practical and safety aspects including
shared care with addictions services

AKT Sample Questions-

• Natural history of viral hepatitis B and C infections
• Drug substitutes for drug and alcohol misuse
• Cardiac risks of cocaine use
 Professional Topic Guides

Consulting in General Practice

AKT Sample Questions-
• Understanding and use of decision aids
• Confidentiality and disclosure of medical records
• Advance care and decision-to-treat plans.

Equality Diversity and Inclusion

AKT Sample Questions-
• Disease patterns in different populations
• Awareness of protected characteristics of Equality legislation
• Genetic variation affecting response to drugs
 Evidence Based Practice

As a GP, you are expected to understand the principles, strengths and limitations of evidence-based practice. The
process of evidence-based practice was defined in the Sicily statement, 20031. It involves five steps:

• Translation of uncertainty into answerable questions

• Systematic retrieval of the best evidence available
• Critical appraisal for validity, clinical relevance and applicability
• Application of results in practice
• Evaluation of performance (at an individual or organisational level)

Transferrable research and academic skills

• the clinical management of patients, including treatment, referral, and acute care;
• dealing with uncertainty (through the use of best available evidence);
• challenging established practice and abandoning ineffective practices;
• prescribing;
• enabling safer working systems;
• improving the quality of health promotion and preventive medicine in your practice;
• audit and quality improvement within your practice or organisation;
• lifelong learning;
• improving population health, through engagement in activities ranging from local healthcare commissioning and
public health policy to global climate change and sustainability; and
• primary care research, management, medical education or specialist roles.

Qualitative and quantitative research:

• differences in forms of research and when each is appropriate;
• patient factors requiring both quantitative and qualitative analysis (for example, concordance with treatment); and
• techniques such as pilot studies, questionnaire design, field observations, interviews, focus groups and analysis of
transcripts of narrative material; ethnography and observation, action research, case study; consensus methods such
as Delphi or nominal groups

Study designs and their advantages and disadvantages including:

• systematic reviews and meta-analysis;
• experimental: randomised controlled double blind;
• quasi-experimental: non-randomised control group; and
• observational: cohort (prospective, retrospective), case-control, cross-sectional.

The most appropriate research design to examine a hypothesis:

• knowledge of the 'hierarchy of evidence' ranging from case reports, through case-control and cohort studies, to
randomised controlled trials, systematic reviews and meta-analyses;
• strengths and limitations of research methodologies; and
• multi-morbidity research and its limitations
• Differences between research, clinical audit and quality improvement

Epidemiology concepts (see also Topic Guides on Population Health and Infectious Disease and Travel Health)

• Population statistics including incidence, prevalence, mortality ratios, death rates

• Differences between population and individual risk
• Risk of disease in population groups, including your own practice population
• Qualitative measurements of health and approaches to qualitative research such as focus groups, Delphi analysis,
ethnography
 • Decisions or interventions made in the interests of a community or population of patients (for example,
immunisation)
• Psychosocial, cultural, political, economic and other social determinants affecting evidence-based practice
• Inequalities in healthcare access and delivery.

Statistical Concepts and Terminology

• Absolute risk (AR)
• Meta-analysis
• Absolute risk increase (ARI) or reduction (ARR)
• Mode
• Association
• Negative predictive value (NPV)
• Bayesian probability
• Null hypothesis
• Bias
• Number needed to harm (NNH)
• Blinding
• Number needed to treat (NNT)
• Case control
• Odds & Odds Ratio
• Case fatality
• Positive predictive value (PPV)
• Cohort
• Prevalence
• Confidence intervals
• Probability
• Confounding
• p-values
• Correlation
• QALY (quality adjusted life year)
• Crossover
• Randomised controlled trial (RCT)
• Cross-sectional
• Range
• DALY (disability adjusted life year)
• Regression to the mean
• Data types (categorical, ordinal, continuous)
• Relative risk (RR)
• Discrimination
• Relative risk reduction (RRR)
• Distributions (normal and non-parametric)
• Reliability
• Event rate
• Risk ratio
• Generalisability
• Sampling
• Hazard Ratio
• Sensitivity
• Incidence
• Specificity
• Inclusion/exclusion criteria
• Standard deviation (SD)
 • Likelihood ratios
• Standardised mortality rates and ratios
• Mean
• Systematic review
• Median
• Trends
• Triangulation
• Type 1 and 2 errors
• Validity (internal and external)

Critical Appraisal
• Clinical interpretation of results from common statistical tests, for example:
• analysis of variance, multiple regression, t-tests and non-parametric data (for example, chi squared, Mann-Whitney
U); and
• simple (symmetrical, skewed) distributions, scatter diagrams, box plots, forest plots, funnel plots, statistical process
control charts, Cates diagrams, decision aids
• Difference between causation and correlation
• Types of bias, reliability, validity, and generalisability
• Influence of individual bias and social factors on interpretation of research results
• Evaluation of guidelines to determine how suitable they are for clinical practice (including methodology, evidence-
base, validity, applicability, authorship and sponsorship)
• Strengths and limitations of surveys and local healthcare reviews.

Evidence in Practice
• Applicability of population-level studies to individuals and certain groups (for example, groups commonly excluded
from clinical trials, disadvantaged groups)
• Applicability of research results/conclusions to clinical practice
• Effective communication about evidence-based interventions to help patients make decisions about their health,
including methods of calculating, demonstrating and explaining risk to patients
• How to search for and retrieve valid information (including using online and other resources to help your own
learning)
• Influence of health economics studies on healthcare resource allocation and guidelines
• Pharmaceutical marketing
• Potential tensions between evidence-based practice and patient values/choices
• Predictive personalised care (for example, drug treatment)
• Reasons for lack of evidence about certain interventions (for example, rare conditions, conditions that have low
morbidity or low pharmacological input)
• Recognising that poverty is a common cause of ill health and consider this when interpreting research. For example, a
health outcome attributed to a certain characteristic (for example, ethnicity) may be due to an underlying
environment of disadvantage
• Role of large GP records databases (for example, QResearch, the Clinical Practice Research Datalink etc.) and how to
contribute patient data to these
• Use of decision aids and information technology in clinical and professional practice.

Screening

• Information available to patients to aid decision making with regard to screening

• Population-based prevention strategies including immunisation, health screening and population screening
• Principles of screening (for example, Wilson’s criteria) and the concepts of primary, secondary and tertiary
prevention; their application to screening programmes and recall systems
• Risks and benefits of screening programmes.
Ethics and governance-

• Autonomy and patient choice

• Confidentiality and information governance (including relevant legislation)
• Conflicts of interest (for example, incentives for certain interventions)
• Consent
• Ethical approval and role of ethics committees
• Impact on patients and staff of GP research
• Patient safety
• Research fraud

AKT Sample Questions-

• Interpretation of prescribing data audit and prioritising changes
• Calculating and explaining common terms used in risk communication such as ARR, RRR, NNT and NNH
• Interpretation of graphical and tabular data
 Improving Quality Safety and Prescribing
AKT Sample Questions-
• Drug monitoring requirements
• Safe prescribing in multi-morbidty
• Controlled Drug regulations

Leadership and Management

Knowledge and Skills Guide-

Ethical Principles of leadership and management

This includes the knowledge and application of principles such as beneficence, non-maleficence, justice, autonomy to everyday
leadership decisions.

Common leadership and management issues arising in general practice

• Equality and diversity including disability registration, rights and access, discrimination law including race, gender,
disability, age, sexual orientation
• Probity for example, gifts, conflicts of interest, financial probity, effect of payment by results such as referral
management and other targets
• NHS Complaints procedure and principles, litigation and medical negligence and raising and acting on concerns about
patient safety, whistleblowing.
• Poor performance (NCAS, LMC, Deanery, GMC, primary care organisation, Occupational Health)
• Welfare of practitioners such as health, conduct issues.

National regulations, contractual and legal frameworks

• Medical indemnity applied to primary and secondary care including medical negligence
• Other Acts and regulations relevant to medical practice including (but not limited to):
• Access to Medical Records – children, deceased, compensation, research, what to withhold
• Children's Act
• Controlled drug regulations including register, prescribing, storing, destruction
• Data protection – Caldicott principles, GDPR, record-keeping, legal basis and consent models for information sharing,
lost records, privacy and fair processing notices, sharing electronic records, storing and destroying medical records
• Driving regulations – duties in relation to advising patients on fitness to drive and DVLA regulations
• Health and Safety at work regulations relevant to general practice including infection control, vaccine storage,
decontamination/spillage (COSSH regulations), safe practice and methods in the working environment relating to
biological, chemical, physical or psychological hazards, which conform to health and safety legislation
• Mental Health Act
• Misuse of Drugs
• NHS Prescription regulations
• Performers List/Health Care Board regulations
• Removing patients from a List.

Administration

• Death and cremation certificates including regulations on completing certificates, when to refer to the
Coroner/Procurator Fiscal
• Insurance certificates including for life insurance, critical illness insurance (Personal Medical Attendant's reports),
travel insurance
• Notification of infectious diseases (see RCGP Topic Guide Infectious Disease and Travel Health)
 • Private certificates/medicals – principles such as disclosure of information for example, firearms, insurance
cancellation, probation, adoption, critical Illness cover, fitness to fly/travel
• Registration including visual impairment, disability
• Relevant benefits and allowances (for example, DS1500, maternity benefits /MAT B1 forms)
• Relevant regulations for Mental Capacity and Mental Health Acts
• Statements of Fitness to Work certificates and related sickness regulations such as Statutory Sick Pay, Employment
Support Allowance, principles of returning to work.
• Practice management and business matters

You should have a working knowledge of:

• Contract requirements such as clinical outcome frameworks and enhanced services.

• External assessment and inspections (for example, CQC, training inspections, Care Inspectorate)
• Federations and GP networks
• Financial aspects of a medical practice (for example, interpreting simple profit and loss accounts, a balance sheet,
sources of income and expenditure)
• Freedom of Information and information governance including Caldicott guardians, management of data,
confidentiality
• Information technology to facilitate clinical and business practice (for example, chronic disease surveillance, audit,
financial management)
• Key issues of being self-employed, including partnerships and locum work
• Key issues of employing or being employed (fo example, as salaried doctor, or doctor in training)
• Legal and contractual frameworks for provision of primary care services in all four nations
• Patient Participation Groups
• Patient registration and eligibility for NHS care
• Pensions
• Practice development plans and strategy
• Premises management (for example, leases, insurance, fire regulation)
• Principles of commissioning, including roles of GPs as commissioner and provider
• Principles of employment regulation including appointment, discrimination, redundancy, dismissal. Occupational
health for staff including immunisation, ill health, infectious disease
• Principles of partnership agreements
• Provision of additional services (for example, dispensing medication, travel clinics)
• Record keeping - clear, accurate, legible and contemporaneous record keeping, amending records
• Staff development, training and appraisal
• UK health priorities and regional and local variations
• Workload issues and Major incident planning and the role of the GP

AKT Sample Questions-

• Ethical principles working within the NHS with scarce resources
• Statutory legislation such as information governance and confidentiality
• Completing insurance claim forms from medical records
 Urgent and Unscheduled Care

Common and important conditions

• 'Dangerous diagnoses' – these are conditions that always require urgent action if they are suspected. Some important
examples include:
• Acute psychosis/mania
• Aneurysms
• Appendicitis
• Cancer (for example, hypercalcaemia, neutropenic sepsis, spinal cord compression, superior vena cava obstruction)
• Intestinal obstruction or perforation
• Limb ischaemia
• Meningitis
• Mental health including crisis
• Myocardial infarction
• Pregnancy related issues including ectopic
• Pulmonary embolus
• Sepsis
• Stroke / CVA
• Subarachnoid haemorrhage
• Emergency conditions where the underlying diagnosis may not be known (for example, anaphylaxis, choking, loss of
consciousness, cardio-respiratory arrest)
• Emergencies that may occur in relation to certain healthcare activities (for example, anaphylaxis or allergic reaction
after immunisation, local anaesthetic toxicity, vasovagal episodes)
• Emergencies arising in patients receiving palliative or end-of-life care (see RCGP Topic Guide on People at the End-of-
Life)
• Multi-factorial problems associated with patients who live alone and / or with multiple co-morbidities, particularly
older adults, with an acute presentation may be frail and have both social and medical care needs
• Conditions associated with social, cultural and lifestyle factors that influence the incidence, severity and presentation
of acute illnesses (for example, delayed presentation and increased mental distress in cultures in relation to certain
illnesses that may be considered stigmatising; or acute illness relating to omitting medication during periods of
religious fasting)
• Death (both expected and unexpected) including the assessment, confirmation and the legal requirements.

Examinations and procedures

• Basic Life Support skills including performing cardio-pulmonary resuscitation (CPR), using Automated External
Defibrillators and giving emergency drugs
• Examination of the relevant system or body part as appropriate
• Mental state examinations and risk assessments to ensure the safety of others
• Giving emergency or urgent medications in primary care, including oxygen, adrenaline, GTN, intramuscular or
subcutaneous injections, inhalers and nebulisers

Investigations

• ECG interpretation
• Recognise and differentiate between patients who require urgent investigation, patients who can wait longer for a
routine investigation and those where time should be used as a diagnostic tool
• Near patient blood testing (for example, glucose, haemoglobin, CRP, d-dimer)
• Peak flow measurement and interpretation
• Urinalysis tests including pregnancy test
• Vital signs measurement including respiratory rate, blood pressure and oxygen saturation
AKT Sample Questions-
• Recognition of less common presentations of CVA
• Symptoms and signs of sepsis
• Management of an epileptic seizure
 Life Stages Topic Guides
Children and Young People
Knowledge and Life Skills-

• Normal developmental milestones and assessment of development delay, including language, gross and fine motor
and social development
• Normal growth including interpretation of growth charts
• Normal maturation including puberty
• Normality in the neonatal period including screening (for example, phenylketonuria, hypothyroidism, cystic fibrosis)
• Normality of physical development with normal variations (for example, orthopaedic variations such as genu
valgus/varus and plagiocephaly)
• Normal development of emotional and psychological maturity and normal variation in childhood behaviour
• Awareness of norms and referral standards when undertaking Newborn and Infant Physical Examination Programme
(NIPE) examinations

Symptoms and signs

• Behavioural problems
• Developmental problems
• Faltering growth
• Features of the acutely unwell child including fever, rashes, irritability, breathing and circulatory signs
• Mental health problems including bullying, stress and suicide
• Adolescents and Young people aged 10-25yr as a distinct group with respect to brain development, physiology and
pharmacokinetics
• Adolescence as a developmental stage and its particular issues, in particular the importance of being opportunistic in
assessing mental well-being
• Gender identity issues. Lesbian, gay, bisexual and transgender (LGBT+) patients face inequalities in their experience of
NHS healthcare
Common and important conditions

• Early and undifferentiated presentations, and recognition of a seriously ill child (and urgent intervention when
appropriate)
• Acute paediatric emergencies (for example, febrile convulsions, anaphylaxis, asthma, septicaemia, meningitis, surgical
conditions)
• Urgent resuscitation in line with Resuscitation Council (UK) guidelines
• Appropriate acute and repeat prescribing and reviews
• Behavioural problems (for example, enuresis, encopresis, eating disorders, tantrums)
• Childhood infections including exanthemata (for example, mumps, measles, rubella, chickenpox, herpes simplex,
parvovirus, Coxsackie, Kawasaki, and other infections listed under dermatological disorders below)
• Childhood malignancies (for example, leukaemias, lymphoma, brain tumours, retinoblastoma, neuroblastoma,
nephroblastoma, sarcoma)
• Chromosomal disorders (for example, Down syndrome, Fragile X, Klinefelter's syndrome, trisomy 18, Turner's
syndrome)
• Congenital abnormalities (for example, congenital heart disease, hypothyroidism, musculoskeletal, neurological
abnormalities and sensory impairment)
• Dermatological disorders in childhood (for example, seborrheic dermatitis, atopic eczema, infections such as impetigo
and fungal infections especially tinea capitis and kerions, alopecia areata, vitiligo and infantile haemangiomas)
• Diagnosis and management of diseases relating to children (for example, asthma, diabetes, epilepsy, respiratory
infections such as pneumonia, bronchiolitis, croup)
• Disease prevention, well-being and safety including in the following areas:
• prenatal diagnosis;
• health benefits of breastfeeding;
• infant feeding, effective milk transfer, and breastfeeding substitute guidelines
 • healthy diet;
• social and emotional well-being;
• immunization;
• smoking;
• avoiding the use of volatile substances and other drugs; and
• minimising alcohol intake
• Faltering growth and underlying causes, including ineffective intake (for example, due to lack of breast milk), chronic
diseases (for example, cystic fibrosis, coeliac disease), chronic infection, non-medical causes such as abuse or neglect
• GI conditions that present in childhood (for example, appendicitis, Meckel's diverticulum, intussusception,
malabsorption such as coeliac disease, cows' milk protein allergy, cystic fibrosis and the risks/treatment of iron
deficiency. Inflammatory bowel disease and other chronic malabsorption conditions which might be confused with
other conditions such as eating disorders)
• Immunisation in children (routine primary schedule and other immunisations, contraindications to immunisation)
• Learning disabilities in children (for example, cerebral palsy, disorders with developmental delay, autism, dyslexia,
dyspraxia, autistic spectrum disorders including Asperger's syndrome)
• Behavioural and mental health problems (for example, attention deficit hyperactivity disorder (ADHD), depression,
eating disorders, substance misuse and self-harm, autistic spectrum disorder and related conditions (see also RCGP
Topic Guides on Mental Health and Alcohol and Substance Misuse). Risks and consequences of bullying including
cyberbullying.
• Musculoskeletal problems relevant to children (for example, inflammatory arthritides (infective, autoimmune),
osteochondritis, Osgood-Schlatter's, Perthes' disease, slipped epiphysis, injuries such as greenstick fractures, pulled
elbow)

Neonatal issues:
Congenital abnormalities as above
• Feeding problems (breast and bottle feeding), gastro-oesophageal reflux, hypoglycaemia
• Jaundice (for example, breastfeeding, haemolytic and haemorrhagic disease of the newborn, biliary atresia)
• Respiratory problems (for example, respiratory distress syndrome, sleep apnoea)
• Skin disorders for example, birthmarks, erythema neonatorum, miliaria and neonatal acne)
• Complications of prematurity such as chronic lung disease, cerebral palsy
• Neurological problems relevant to children including seizures (for example, febrile convulsions, epilepsy and their
overlap in presentation with cardiogenic causes), awareness of rare degenerative neurological diseases (for example,
Rett's syndrome, Battens)
• Sleep physiology and pathology of sleep disorders in infants and adolescents
• Obesity in childhood: long term health effects and interventional strategies for weight reduction
• Poisoning: accidental ingestion, iatrogenic, overdose and deliberate self-harm, and deliberate harm by carers
• Renal diseases relevant to children (including recurrent urinary tract infections, structural anomalies posterior
urethral valves, renal pelvic dilatation, haemolytic uraemic syndrome; nephrotic syndrome and glomerulonephritis)

Safeguarding children:
• Recognition of non-accidental injury including physical, emotional and sexual abuse, and appropriate actions
• Maltreatment and neglect, parental problems including domestic violence and abuse, substance and alcohol misuse
and mental health problems
• Recognising the significance if a child is not brought to an appointment and taking appropriate action
• Balancing children's rights and wishes with professional responsibility to keep children safe from harm
• Sex identity and intersex, appearance of genitals including fused labia, hypospadias, clitoral hypertrophy. Risk of
Female Genital Mutilation
• Teenage pregnancy, risks of sexually transmitted infections, and Child Sexual Exploitation
• Transitional issues from child to adolescent and from adolescent to adult. This applies to all children but especially
those who are vulnerable such as those with gender identity issues

Examinations and procedures

Appropriate use of and techniques for venesection in children and young people
Indication and administration of injections and immunization
Additional important content

• Childhood immunisation schedules. These should be kept under review as they can frequently change
• Communication skills specific to child and adolescent health and 'three-way consulting' (consulting with both parent
and child); recognition and assessment of behaviour as a form of communication; recognition of the importance of
seeing adolescents alone; use of tools for structured psychological assessment in adolescents such as HEADSS
• Prescribing and advising appropriately about the use of medicines in newborn, children and young people, being
competent at calculating drug doses, understanding the risks and benefits of medicines in relation to children, and
cultural differences in beliefs about illness and the use of medicines. Best evidence in clinical management and
prescribing of medicines for children and licensing implications
• Pain management in children
• Co-morbidities in the child, young person and family with additional vulnerability or special circumstances
• Access for young people to confidential contraceptive and sexual health advice services that are tailored to meet their
needs

AKT Sample Questions-

• Recognition of normal stages of child development
• Current immunisation schedules
• Shared protocols for treating ADHD with methylphenidate
 People with Long-term Conditions including Cancer

Common and important conditions

• Non-communicable diseases (for example, cancer and cardiovascular disease);

• Communicable diseases (for example, Human Immunodeficiency Virus (HIV) / Acquired Immunodeficiency Syndrome
(AIDS));
• Certain mental health disorders (for example, schizophrenia, depression) and
• Ongoing defined impairments (for example, blindness, musculoskeletal disorders)

Examples of common long-term physical health conditions include:

• Diabetes
• Cardiovascular (for example, hypertension, angina)
• Chronic respiratory (for example, asthma, Chronic Obstructive Pulmonary Disease (COPD))
• Chronic neurological (for example, Multiple Sclerosis)
• Chronic pain (for example, from arthritis)
• Other long-term conditions (for example, Chronic Fatigue Syndrome, Irritable Bowel Syndrome (IBS), cancer) etc.
• Benefits of Collaborative Care and Support Planning process

AKT Sample Questions-

• Risk of second malignancies after treatment for cancer

• Prescribing in patients with multi-morbidity
• Entitlement to statutory benefits
 Maternity and Reproductive Health
Emerging Issues-
• Developments in antenatal testing including pre-implantation genetic screening and Non-Invasive Prenatal Diagnosis
(NIPD)

Knowledge and Life Skills-

Symptoms and signs

• Normal pregnancy symptoms and signs

• Abnormal pregnancy symptoms and signs, including abnormal abdominal palpation (fetal size and lie), bleeding,
hyperemesis, pain (abdominal or pelvic), pre-eclampsia symptoms and signs, pre-term labour, reduced fetal
movements, symptoms of venous thromboembolic disease, symptoms suggestive of exacerbation of co-existent
medical conditions
• Perinatal mental health symptoms
• Postnatal symptoms including abnormal bleeding and symptoms of breastfeeding problems

Common and important conditions

• Perinatal mental illness (PMI) including adjustment disorders, antenatal depression, baby blues, chronic mental illness
in the perinatal period, OCD, paternal PMI, postnatal depression, post-partum psychosis, post-traumatic stress
disorder and tokophobia
• Pre-conception care and advice including health promotion advice (for example, smoking cessation and weight loss),
medication adjustments, optimisation of pre-existing medical conditions, rubella immunisation, supplementation
• Pregnancy with social complications – such as domestic violence, drug and alcohol misuse, homelessness,
safeguarding concerns, teenage pregnancy
• Prescribing pre- and perinatally, including teratogenesis

Antenatal care

• Principles and guidelines for routine antenatal care including recommended supplements, dietary and lifestyle advice,
immunisation in pregnancy
• Antenatal screening for fetal and maternal conditions
• Pregnancies complicated by pre-existing medical conditions including asthma, cancer, cardiac disease, diabetes
mellitus, epilepsy, hypertension, HIV infection, mental health conditions, obesity, thyroid disease and venous
thromboembolism
• Indications for aspirin prophylaxis
• Antenatal complications, such as:
• Bleeding and pelvic/abdominal pain in pregnancy
• Congenital abnormalities
• Early pregnancy loss: miscarriage, ectopic and molar pregnancy
• Growth problems: abnormal symphysial fundal height
• Haematological problems for example, haemoglobinopathies (including sickle cell disease and thalassaemia),
haemolytic disease (including rhesus incompatibility and prophylaxis) and thromboembolism
• Infections for example, urinary tract infection, asymptomatic bacteriuria, group B streptococcus, chicken pox,
chorioamnionitis cytomegalovirus, hepatitis, herpes simplex, HIV, listeria, parvovirus and rubella
• Intrauterine death and stillbirth
• Mal-presentation including breech and transverse lie
• Metabolic problems arising in pregnancy for example hyperemesis, gestational diabetes, jaundice, obstetric
cholestasis
• Multiple pregnancy
• Pregnancy induced hypertension, pre-eclampsia and eclampsia
• Reduced fetal movements
Delivery

• Normal labour and common problems of labour including premature labour, prolonged pregnancy, induction of
pregnancy
• Caesarean sections: indications and associated complications, options for subsequent deliveries including vaginal
birth
• Postnatal care

• Normal postnatal care including routine 'neonatal examination' and 'maternal six-week check'
• Infant feeding including breastfeeding. (Please also see Topic Guide on Children and Young People)
• Postnatal problems including breastfeeding problems, bladder and bowel problems, mental health problems,
retained products, uterine infection, wound problems.
• Providing contraception advice postnatally and after pregnancy loss.
• Unwanted pregnancy and termination of pregnancy are covered in the RCGP Topic Guide Sexual health.

Examinations and procedures

• Antenatal examination including abdominal palpation, assessment of symphysial fundal height and fetal heart rate,
blood pressure and urinalysis

Investigations

Pregnancy investigations, including:

• laboratory tests to evaluate gestational diabetes, obstetric cholestasis and pre-eclampsia
• screening and prenatal diagnosis for congenital abnormalities including:
• amniocentesis and chorionic villus sampling
• antenatal screening including triple test, quad test, nuchal test, haemoglobinopathy screening and anomaly
ultrasound scan
• tests for infection including asymptomatic bacteriuria, HIV, syphilis
• ultrasound for dating, growth and fetal well-being; and
• urinary and serum β-HCG
• Primary care investigation of female subfertility including blood tests and ultrasound
• Semen analysis

Service issues

• Local arrangements for fertility treatments, antenatal care and delivery including shared care with midwifery services
and with secondary care
• Local services to support women who are breastfeeding
• Local support and services for women with perinatal mental health problems, including strategies to identify these
women
• Maternity rights, benefits, schemes and associated administration for example, Healthy Start, MatB1, maternity
exemption from prescription charges
• Safeguarding of unborn children and neonates
• Screening for domestic and intimate partner violence in the context of antenatal care
• Strategies to reduce teenage and unplanned pregnancies

AKT Sample Questions-

• Primary care investigations for failure to conceive
• Prescribing in pregnancy and breastfeeding
• Routine antenatal screening tests
 Older People
Knowledge and Life Skills Guide-
Common and important conditions

• Cancer: recognise the common, early, 'red flag' symptoms and signs of malignancy (for example weight loss,
dysphagia, melaena, diaphoresis etc.), many of which may be non-specific if taken in isolation. Many cancers are
more prevalent in the elderly population and may be insidious
• Cardiovascular: atrial fibrillation, heart failure, hypertension, ischaemic heart disease, risks for stroke and dementia
• Co-morbidity, difficulties in communicating, polypharmacy, malnutrition, social isolation and the need for additional
support for the increasingly dependent patients in general practice are important issues and can delay the early
recognition of adverse clinical patterns in older people
• End-of-life care: moral, ethical and emotional issues relating to the end of life as well as after death (for example
living wills, palliative care) (see also RCGP Topic Guide on People at the End-of-Life)
• Musculoskeletal: falls, fractures, gait disorders, osteoporosis, osteoarthritis
• Neglect and abuse (emotional, mental and physical) in the elderly
• Neurological: Parkinson's disease, stroke and confusion
• Psychiatric: anxiety and depression, delirium (hyperactive, hypoactive or mixed) and dementia (including vascular,
Alzheimer's and Lewy Body and the importance of avoiding antipsychotics with the latter). Early use of
anticholinergics where appropriate. The effects of these conditions on the person, the family and community, and the
effects of physical function on the patient's mental state (See RCGP Topic Guide on Mental Health)
• Renal: chronic kidney disease (CKD), hydration
• Respiratory: COPD
• Skin: pruritus, ulcers, skin malignancies, lichen sclerosus, benign lesions associated with ageing
• Urogenital: infections, incontinence, LUTS, benign prostatic hypertrophy

Examinations and procedures

• Consider any adjustments that may be needed to examine appropriately and the normal variation in biometrics
• Informed consent and assessment of capacity
• Accurate measurements including dementia screening and assessing for arrhythmias
• Appropriate monitoring and use of investigations
• Indication and administration of vaccinations (seasonal flu, pneumococcal, shingles)

Investigations

• Changes in the normal range of laboratory values that are found in older people
• Interpretation of ECG (for example diagnosing AF)
• Blood pressure (for example risk of hypertension and also postural hypotension)

AKT Sample Questions-

• Diagnosis of frequent falls

• Tools for assessing cognitive impairment
• Use of advance directives
 End of Life Care

Common and important conditions

Pain is a common symptom in palliative care. Recognition of the type, expression and possible causes of pain and its
management are important (physical, psychosocial, cultural and spiritual)

Emergencies in palliative care include:

• haemorrhage
• hypercalcaemia
• superior vena cava obstruction
• spinal cord compression
• raised intracranial pressure
• sepsis
• pancytopenia and
• venous thromboembolic events (for example pulmonary embolus or deep vein thrombosis).

Service issues

• Financial implications for patients and their carers including access to benefits (for example DS1500).

Additional important content

• Ethical considerations in palliative care and the use of GMC guidance (for example autonomy, beneficence, non-
maleficence).