Medical Licensing (MD/DO) · Independent exam preparation
MLA Applied Knowledge Test: UK Medical School Preparation Guide Study Guide
Practise urgent clinical decisions, investigation choices, prescribing, prevention, consent and procedural safety for the UK Medical School AKT, using focused cases and explained questions.
By CertMedbry · Updated 27 October 2026
Learn to recognise deterioration, choose useful investigations, interpret results and protect patients through safe treatment and professional judgement. This guide follows the UK medical-school pathway, called the Medical School Applied Knowledge Test (MS AKT). Its 60 selected concepts connect clinical reasoning with professional responsibilities. The GMC MLA content map applicable from September 2026 defines the full assessment scope; this selective guide does not replace it.
Try 20 free practice questionsWhat is the exam format?
Check the question types, timing and outline before planning your revision.
Which assessment pathway does this guide cover?
This guide covers the MS AKT for UK medical students. UK medical schools construct the assessment centrally through Medical Schools Council collaboration and deliver it locally; the GMC regulates and quality assures it. The MLA forms part of the requirements associated with graduation and registration rather than conferring a separate commercial certification.
How many questions are there, and how long are the papers?
The 2026/27 MS AKT handbook specifies two papers of 100 questions each, taken on consecutive days, with two hours per paper. This gives 200 questions overall and an average allowance of 72 seconds per question. Use that average to monitor progress while allowing more time for complex cases and less for straightforward decisions.
UK Medical School Applied Knowledge Test Student Handbook 2026/27
What question style and marking approach are verified?
The MS AKT uses five-option single-best-answer questions and has no negative marking. The 20 questions accompanying this guide are independent four-option learning drills with explanations. They do not reproduce the official paper format or predict a pass.
UK Medical School Applied Knowledge Test Student Handbook 2026/27
How is the assessment delivered, and is it adaptive?
Sections 3.6–3.7 of the 2026/27 handbook specify delivery through Exam-Write, in-person invigilation and mandatory lockdown software. Medical schools determine local venues, device arrangements and approved adjustments, so follow your school's candidate instructions for these details. These delivery arrangements do not establish that the assessment uses an adaptive algorithm.
UK Medical School Applied Knowledge Test Student Handbook 2026/27 · Applied knowledge test (AKT)
Which content map applies?
The GMC map published in October 2025 applies from September 2026 onwards. Its current PDF incorporates the September 2026 update. The map covers both AKT and CPSA through six interconnected domains, and its conditions list is non-exhaustive. It provides the full scope beyond the 60 concepts selected here. Use the [current GMC content map](https://www.gmc-uk.org/cdn/documents/20260820---mla-content-map--english--september-2026-update_pdf-115633825.pdf).
Are official percentages available for the six domains?
The current content map does not state percentage allocations across its six interconnected domains. This guide samples every domain without claiming official proportional weighting. MSC also links an indicative October 2023 clinical-area sampling grid; clinical-area sampling and the six overlapping domain labels should not be treated as equivalent weighting systems.
About the MLA content map · Medical Schools Applied Knowledge Test Sampling Grid, October 2023 · Preparing for the Applied Knowledge Test
Has PLAB 1 been renamed the AKT?
No. PLAB retains its name, and PLAB 1 meets the MLA AKT requirements. That relationship establishes compliance between pathways; it does not make the UK medical-school assessment and PLAB 1 interchangeable delivery arrangements. This guide uses the UK medical-school handbook for examination logistics.
Where should I check passing, fees and resit arrangements?
Use the current MS AKT handbook and your medical school's assessment regulations for the passing, fee and resit arrangements that apply to you. Do not assume a universal fixed pass percentage or infer a pass threshold from performance on this short learning test.
UK Medical School Applied Knowledge Test Student Handbook 2026/27 · Preparing for the Applied Knowledge Test
The AKT assesses applied knowledge at the threshold for safe medical practice. It is one component of the MLA, alongside the clinical and professional skills assessment (CPSA), and is not a separate specialist qualification. These independently authored learning materials are not official examination items.
Outline used: GMC MLA content map, published October 2025 and applicable from September 2026 onwards; the official landing page records a September 2026 terminology revision. Cross-checked against the MSC UK Medical School Applied Knowledge Test Student Handbook 2026/27. Verified on 2026-10-10. The workbook label maps to the AKT component of the MLA; its UK medical-school delivery is called the Medical School AKT (MS AKT). The assigned canonical slug is preserved.
60 key concepts: understand, apply and avoid the traps
Work through the questions by exam domain. Explain the answer in your own words, try the example, then check the common pitfall.
Areas of clinical practicenot stated
1.How does circulatory instability change upper gastrointestinal bleeding care?
Upper gastrointestinal bleeding becomes an immediate resuscitation problem when blood loss compromises circulation. Hypotension, tachycardia, altered consciousness or continuing substantial haematemesis should shift attention from naming the lesion to stabilising the patient. Obtain urgent help, establish intravenous access and assess the need for fluid and blood replacement while arranging definitive care. Endoscopy identifies and may treat the source, but an unstable patient needs resuscitation before the procedure.
Apply it
A patient vomits fresh blood and becomes clammy, with a pulse of 125/min and blood pressure of 84/50 mmHg. Prioritise resuscitation and urgent senior involvement while arranging endoscopic management, rather than sending the patient directly to an unprepared procedure.
Common pitfall: Choosing endoscopy as the immediate isolated action overlooks the physiological threat. A definitive investigation does not replace stabilisation when circulation is already failing.
NHS Ayrshire and Arran Medicines: Management of Upper Gastrointestinal Bleeding
2.How is sustained hypertension confirmed in an adult?
Confirm hypertension when clinic systolic pressure is at least 140 or diastolic pressure at least 90 mmHg and the daytime ABPM or HBPM average is at least 135 systolic or 85 diastolic mmHg. Repeat a raised clinic measurement; take a third if the second differs substantially, and record the lower of the last two. Below the severe threshold, offer ABPM with at least two readings per waking hour and an average of at least 14 readings. If unsuitable or not tolerated, use HBPM: two seated readings at least one minute apart, morning and evening, for at least four days, ideally seven; discard day one and average the remainder. Severe hypertension means clinic systolic pressure at least 180 or diastolic pressure at least 120 mmHg. With retinal haemorrhage, papilloedema, new confusion, chest pain, signs of heart failure or AKI, arrange same-day specialist assessment. Without those features, investigate target-organ damage as soon as possible. If damage is identified, consider immediate antihypertensive treatment without awaiting ABPM or HBPM. If none is identified, repeat clinic measurement within seven days, or arrange ABPM/HBPM with clinical review within seven days.
Apply it
Repeated clinic pressure of 156/96 mmHg and daytime ABPM averaging 138/87 mmHg support hypertension. A clinic pressure of 186/104 mmHg enters the severe pathway through its systolic value alone: assess emergency features and organ damage, then make the appropriate immediate-treatment or seven-day confirmation and review plan.
Common pitfall: Either component can meet the severe threshold. Absence of emergency symptoms does not justify routine follow-up without prompt organ-damage assessment and the specified seven-day pathway.
Recommendations | Hypertension in adults: diagnosis and management | Guidance | NICE
3.How do feeding and oxygen saturation guide bronchiolitis referral and admission?
Assess respiratory rate, work of breathing, alertness, hydration and intake relative to usual feeding, and measure oxygen saturation with pulse oximetry. Consider hospital referral for intake around 50–75% of usual volume, clinical dehydration, respiratory rate over 60/min or persistent room-air saturation below 92%. Apnoea, central cyanosis, severe distress such as grunting or respiratory rate over 70/min, or a seriously unwell appearance require emergency referral. In secondary care, the persistent room-air saturation admission threshold is below 90% from six weeks of age, but below 92% in younger infants or children of any age with underlying conditions. Apnoea, inadequate intake and persistent severe respiratory distress can independently justify admission; saturation alone does not determine disposition.
Apply it
A four-month-old taking 60% of usual feeds with persistent room-air saturation of 91% merits hospital assessment. Although 91% does not alone cross the usual admission saturation threshold at this age, feeding difficulty and the full clinical assessment may still require admission.
Common pitfall: The referral threshold of below 92% is distinct from the usual admission threshold of below 90% in otherwise healthy infants aged six weeks or more.
Recommendations | Bronchiolitis in children: diagnosis and management | Guidance | NICE
4.Why must gluten exposure continue during coeliac investigation?
Coeliac investigations depend on detecting the immune response and intestinal changes associated with gluten exposure. Starting a gluten-free diet before testing can reduce the abnormalities and make confirmation more difficult. For someone eating a normal diet, NICE advises some gluten in more than one meal daily for at least six weeks before testing, with gluten continued during the diagnostic process. Do not start a gluten-free diet until specialist confirmation. If reintroduction is unacceptable or impracticable after restriction, seek specialist assessment because confirmation becomes more difficult.
Apply it
A patient with chronic diarrhoea and fatigue wants to stop gluten before a planned coeliac blood test. Explain how dietary exclusion could undermine testing and agree a diagnostic plan before the patient changes their usual diet.
Common pitfall: Symptom improvement after avoiding bread does not establish coeliac disease. Premature restriction may produce reassuring tests despite an underlying gluten-related immune disorder.
NHS: Coeliac disease diagnosis · Recommendations | Coeliac disease: recognition, assessment and management | Guidance | NICE
5.How does a lifetime mood history improve depression assessment?
A current depressive episode does not describe the whole course of a person's mood disorder. Ask about previous periods of elevated or irritable mood, increased energy, reduced need for sleep and unusually impulsive behaviour. When overactivity or disinhibition lasted four days or more, consider specialist mental health assessment for possible bipolar disorder. Establish changes from usual functioning, their consequences and intervals of stable mood. Suspected current mania requires urgent specialist assessment rather than routine referral.
Apply it
A patient seeking help for low mood recalls an earlier week of very little sleep, unusually high energy and uncontrolled spending noticed by relatives. Explore that episode, including duration and impairment, before assuming a purely unipolar depressive history.
Common pitfall: Ordinary happiness or one late night does not establish mania. Look for a sustained, distinct change in mood, energy, sleep and functioning.
NHS: Bipolar disorder · Recommendations | Bipolar disorder: assessment and management | Guidance | NICE
6.Which joint histories increase concern for septic arthritis?
A suddenly painful, swollen joint warrants particular concern when infection risk is increased. Relevant contexts include a prosthetic joint, recent joint surgery, immunosuppression or infection elsewhere. These factors change the probability of septic arthritis but are not prerequisites for it. Combine the history with onset, pain, swelling, movement restriction and systemic illness. The clinical task is to identify a potentially destructive infection promptly, rather than waiting for every recognised risk factor to be present.
Apply it
An adult with a knee replacement develops abrupt pain, swelling and difficulty bearing weight. Treat the prosthetic-joint history as an additional reason for urgent assessment, rather than attributing the symptoms to ordinary wear of the implant.
Common pitfall: Absence of a prosthesis or immunosuppression does not exclude joint infection. Risk factors modify suspicion; they do not replace assessment of the acute presentation.
7.Why is early brain imaging essential in suspected stroke?
Sudden focal neurological deficits can result from an ischaemic stroke or bleeding into the brain. Clinical findings establish urgency but cannot reliably determine which mechanism is present. Brain imaging helps distinguish these categories and informs treatment decisions whose benefits and hazards differ between them. Record symptom onset or last known well while arranging emergency assessment. Avoid selecting a treatment directed at arterial blockage before the possibility of intracranial haemorrhage has been appropriately evaluated.
Apply it
A person develops sudden facial weakness and arm weakness while eating breakfast. Establish the onset time and activate emergency stroke assessment with brain imaging; do not assume that the pattern alone identifies an arterial clot.
Common pitfall: The presence of typical stroke signs establishes urgency, not the stroke subtype. Similar deficits can accompany bleeding, making mechanism-specific treatment unsafe without appropriate assessment.
8.When does early pregnancy pain require emergency escalation?
Ectopic pregnancy can rupture and cause internal bleeding, so early pregnancy pain must be interpreted with circulatory symptoms and referred pain. Severe abdominal pain, shoulder-tip pain, dizziness or collapse are important warning signs. Vaginal bleeding may be absent or limited and does not measure the amount of internal blood loss. The emergency decision is driven by possible rupture and physiological compromise, rather than waiting for a routine pregnancy appointment or a complete symptom pattern.
Apply it
A patient with a positive pregnancy test develops one-sided abdominal pain, shoulder-tip discomfort and faintness. Arrange emergency assessment for possible ruptured ectopic pregnancy even though the reported vaginal bleeding has been only light.
Common pitfall: Small-volume vaginal bleeding can falsely reassure. A ruptured ectopic pregnancy may bleed internally, so external blood loss does not reliably indicate severity.
9.How can glaucoma progress without a painful red eye?
Open-angle glaucoma usually develops gradually and may initially cause no obvious symptoms. Progressive optic nerve damage can affect peripheral vision before the person recognises a major visual problem. This differs from acute angle closure, which can cause a suddenly painful red eye, blurred vision and systemic symptoms. Distinguishing these patterns supports appropriate urgency, but absence of pain does not establish healthy eyes. Gradual, painless disease still requires detection and continuing specialist management.
Apply it
An older adult reports slowly noticing objects less well at the edges of vision but has no eye pain. Consider chronic glaucoma and arrange eye assessment rather than dismissing glaucoma because the dramatic acute symptoms are absent.
Common pitfall: Using pain as a prerequisite for glaucoma misses its common insidious form. Conversely, sudden painful visual loss should not enter a routine chronic-disease pathway.
10.When does possible urinary obstruction change AKI investigation?
Acute kidney injury can arise from reduced blood supply, intrinsic kidney injury or obstruction to urine drainage. Ask about difficulty passing urine and relevant urinary history instead of interpreting oliguria as proof of dehydration. NICE recommends urinary tract ultrasound within 24 hours when the cause is unidentified or obstruction is possible, and within six hours when an infected obstructed kidney is suspected. Pyonephrosis, bilateral upper-tract obstruction or obstruction of a solitary kidney requires immediate urological referral.
Apply it
An older adult develops AKI with increasing difficulty passing urine. Assess obstruction and arrange appropriate imaging. Fever and suspected infected obstruction make the investigation and referral more urgent.
Common pitfall: Repeated fluid administration cannot relieve blocked drainage. An infected obstructed urinary system requires urgent source relief as well as assessment of circulation.
NHS: Acute kidney injury · Recommendations | Acute kidney injury: prevention, detection and management | Guidance | NICE
11.How can a leg clot produce a respiratory emergency?
Pulmonary embolism commonly results when part of a deep venous clot travels to the pulmonary circulation. Obstruction there can cause sudden breathlessness, pleuritic chest pain or coughing up blood, while associated leg symptoms may include unilateral pain and swelling. The respiratory presentation and venous history belong to one mechanism. Their combination should increase suspicion, although absence of noticeable leg symptoms does not exclude embolism because the original thrombosis may not have been recognised.
Apply it
A patient develops sudden breathlessness and pain on inspiration after several days of unilateral calf swelling. Connect the leg and chest symptoms through possible venous thromboembolism and arrange urgent assessment rather than treating them as unrelated complaints.
Common pitfall: Requiring visible leg swelling before considering pulmonary embolism misses patients whose deep venous thrombosis was silent or whose embolic symptoms dominate the presentation.
34.How should breathlessness be managed in an adult in the last days of life?
Assess potentially reversible contributors, including pulmonary oedema or pleural effusion, and agree management consistent with the person's wishes and care plan. Use non-drug measures such as positioning and a fan. Oxygen should be offered for known or clinically suspected symptomatic hypoxaemia, rather than routinely for breathlessness alone. Consider an opioid, a benzodiazepine or their combination for symptom relief, with individual prescribing and reassessment of benefit and unwanted sedation. These recommendations concern adults in the last days of life. [NICE NG31](https://www.nice.org.uk/guidance/ng31/chapter/Recommendations).
Apply it
A dying adult is distressed by breathlessness but has no clinical evidence of hypoxaemia. Assess reversible causes, improve positioning and airflow, and consider appropriate symptom medication rather than automatically starting oxygen.
Common pitfall: Breathlessness and hypoxaemia are different findings. Recognising that someone is dying does not remove the need to assess treatable contributors or review whether symptom treatment is helping.
MLA content map · Recommendations | Care of dying adults in the last days of life | Guidance | NICE
Areas of professional knowledgenot stated
12.How do overt and subclinical primary hypothyroidism differ?
In primary hypothyroidism, insufficient thyroid hormone reduces negative feedback on an intact pituitary, causing TSH to rise. Raised TSH with low free T4 supports overt primary hypothyroidism. Raised TSH with free T4 still within the reference interval describes subclinical hypothyroidism: increased pituitary stimulation is maintaining circulating hormone. Subclinical is a biochemical classification, not proof that symptoms are absent or an automatic indication for treatment. Interpret the paired measurements and clinical context.
Apply it
Two patients have raised TSH. The patient with low free T4 has an overt primary pattern; the patient with normal free T4 has a subclinical pattern, even if both report tiredness.
Common pitfall: TSH alone cannot distinguish overt from subclinical primary hypothyroidism. Symptoms alone cannot establish either biochemical classification.
13.How is initial antihypertensive treatment selected?
For adults starting treatment under NICE's uncomplicated hypertension pathway, offer an ACE inhibitor or ARB when type 2 diabetes is present at any age, or when the person is under 55 and not of Black African or African–Caribbean family origin. Without type 2 diabetes, offer a calcium-channel blocker from age 55, or at any age for adults of Black African or African–Caribbean family origin. Consider an ARB in preference to an ACE inhibitor for adults of that family origin. ACE-inhibitor cough supports switching to an ARB; do not combine the two classes. Pregnancy and disease-specific indications require their respective pathways.
Apply it
A 62-year-old without diabetes or another disease-specific indication is starting hypertension treatment: a calcium-channel blocker is appropriate. A 42-year-old with type 2 diabetes instead generally starts an ACE inhibitor or ARB.
Common pitfall: Age alone does not determine treatment when diabetes or a disease-specific indication changes the pathway. ACE inhibitors and ARBs should not be prescribed together for hypertension.
Recommendations | Hypertension in adults: diagnosis and management | Guidance | NICE
14.Why can a normal TSH fail to exclude central hypothyroidism?
TSH is most straightforward to interpret when pituitary function is intact. In central hypothyroidism, hypothalamic or pituitary dysfunction may prevent an appropriate TSH rise despite low free T4. A TSH within its reference interval can therefore be physiologically inappropriate rather than reassuring. Consider the paired hormone results and the clinical context, particularly evidence of pituitary disease. Screening logic developed for primary thyroid failure should not be applied unquestioningly to suspected central disease.
Apply it
A patient with known pituitary disease has persistent fatigue, low free T4 and TSH within the reference interval. Recognise that the TSH response is inappropriate for the low hormone concentration and investigate a central thyroid disorder.
Common pitfall: A reference interval describes a population range, not whether the response fits the paired result. Low free T4 should normally stimulate increased TSH.
15.How is absolute risk reduction calculated?
Absolute risk reduction is the control-group event risk minus the treatment-group event risk when treatment prevents an undesirable outcome. Use comparable populations, the same outcome and the same follow-up period. If risks are 12% and 8%, the reduction is four percentage points, or 0.04 as a proportion. This describes the actual difference in event frequency. It is distinct from the relative reduction, which expresses that difference as a fraction of the control risk.
Apply it
Over one year, 30 of 300 untreated participants and 18 of 300 treated participants experience an event. Calculate risks of 10% and 6%, giving an absolute risk reduction of four percentage points over that year.
Common pitfall: Subtracting percentages gives percentage points, not a relative percentage reduction. Keep the outcome and follow-up attached to the number so its meaning remains clear.
Cochrane Handbook: Chapter 15, Interpreting results and drawing conclusions
16.How does absolute benefit become a number needed to treat?
The number needed to treat for an additional beneficial outcome is the reciprocal of the absolute risk reduction expressed as a proportion. An absolute reduction of 0.04 gives an NNT of 25. When the result is not a whole number, round upward for this conventional calculation. Always state the outcome and follow-up interval because NNT depends on both. It is a group-level summary of benefit, not a promise that a particular numbered patient will benefit.
Apply it
A treatment lowers two-year event risk from 15% to 9%. The absolute reduction is 0.06, so the reciprocal is 16.67. Report an NNT of 17 over two years for the specified outcome.
Common pitfall: Using six instead of 0.06 produces a meaningless reciprocal. An NNT without its outcome and time horizon also loses essential information for interpretation.
Cochrane Handbook: Chapter 15, Interpreting results and drawing conclusions
17.Why does baseline risk change absolute treatment benefit?
The same relative treatment effect can produce different absolute benefits when baseline risks differ. A relative risk of 0.5 reduces a 20% event risk to 10%, but a 2% risk to 1%. The respective absolute reductions are ten and one percentage points. This makes baseline risk central to communicating expected benefit. Applying a study's absolute benefit to another population requires considering whether the new population has a comparable underlying risk and follow-up period.
Apply it
Compare two groups with untreated event risks of 20% and 2%. If treatment halves each risk, calculate NNTs of 10 and 100 respectively over the same follow-up, despite the identical relative risk reduction.
Common pitfall: A large relative reduction can coexist with a small absolute benefit. Reporting only the relative figure can distort decisions for people at low baseline risk.
Cochrane Handbook: Chapter 15, Interpreting results and drawing conclusions
18.Which prescribing decisions matter during dehydration-associated AKI?
During vomiting, diarrhoea or sepsis, review medicines that can worsen kidney injury or require dose adjustment. NSAIDs can impair renal perfusion and should be reviewed urgently in a dehydrated patient. NICE advises considering temporary interruption of ACE inhibitors and ARBs until the acute condition has improved and stabilised. Seek pharmacist advice on drug dosing and establish a review plan rather than allowing an acute interruption to become unexplained permanent withdrawal. Loop diuretics do not routinely treat AKI itself, although they may be appropriate for fluid overload.
Apply it
A patient taking ramipril develops vomiting, hypotension and AKI while also using ibuprofen. Review the NSAID, consider temporarily withholding ramipril, assess fluid status and arrange reassessment of renal function and ongoing treatment.
Common pitfall: Neither continuing every medicine unchanged nor stopping all long-term treatment indefinitely is a safe substitute for an individual prescribing decision.
Recommendations | Acute kidney injury: prevention, detection and management | Guidance | NICE · NHS: Acute kidney injury
19.How can prevention advice account for practical barriers?
Hypertension prevention and management include diet, physical activity, reduced excessive alcohol intake, lower sodium intake and smoking cessation support. Ask about the person's routines and access to food, activity and support before agreeing achievable changes. NICE recommends linking people to local initiatives and patient organisations that can help sustain change. Advice should also account for clinical risk: potassium-containing salt substitutes are unsuitable for groups including people with kidney disease or those taking ACE inhibitors or ARBs.
Apply it
A patient with hypertension and kidney disease wants to replace table salt with a potassium-based product. Explain the potassium risk and discuss other ways to reduce sodium, while identifying affordable dietary changes and available local support.
Common pitfall: A generic instruction to eat better may leave practical obstacles unresolved. A product promoted as a healthy substitute may also be inappropriate for the person's medicines or kidney function.
Recommendations | Hypertension in adults: diagnosis and management | Guidance | NICE
20.When must an informed refusal of treatment be respected?
An adult who has capacity for the particular decision may refuse treatment, including treatment clinicians believe is necessary to preserve life. Explore understanding, provide relevant information and clarify the person's wishes without coercion. Religious or personal beliefs do not themselves establish incapacity. The professional obligation is to support an informed decision and respect it, while considering acceptable alternatives. Distinguish disagreement with the person's values from evidence that they cannot make the decision.
Apply it
An adult who understands the consequences refuses a blood transfusion for religious reasons. Discuss risks and acceptable alternatives, assess any genuine capacity concerns and respect an informed refusal rather than treating the belief as proof of incapacity.
Common pitfall: A decision can be medically hazardous yet capacitous. The seriousness of the consequences justifies careful discussion, not automatic authority to override the person's refusal.
21.How do cardiovascular risk and organ damage influence hypertension treatment?
Hypertension treatment aims to prevent future vascular and organ damage even when the person feels well. NICE recommends drug treatment alongside lifestyle advice for persistent stage 2 hypertension. In adults under 80 with persistent stage 1 hypertension, discuss treatment when target-organ damage, established cardiovascular disease, renal disease, diabetes or estimated ten-year cardiovascular risk of at least 10% is present. Stage 1 means clinic pressure 140/90–159/99 mmHg with an out-of-office average 135/85–149/94 mmHg. Stage 2 starts at clinic 160/100 mmHg and out-of-office average 150/95 mmHg, below the severe clinic threshold. Assess frailty, multimorbidity and preferences.
Apply it
A 58-year-old with confirmed stage 1 hypertension and diabetes should have a discussion about antihypertensive treatment as well as lifestyle support, despite reporting no symptoms.
Common pitfall: Absence of symptoms does not imply low cardiovascular risk. Conversely, a stage label should not replace discussion of benefits, adverse effects, frailty and the person's preferences.
Recommendations | Hypertension in adults: diagnosis and management | Guidance | NICE · NHS: High blood pressure
Clinical and professional capabilitiesnot stated
22.What abilities should a capacity assessment examine?
Presume adult capacity and assess a specific decision at the relevant time only when there is reason for doubt. GMC guidance examines whether the person can understand relevant information, retain it, use it in deciding and communicate a decision. Provide accessible information and communication support first. In England and Wales, the Mental Capacity Act 2005 requires an impairment or disturbance of mind or brain that causes inability to understand, retain, use or weigh relevant information, or communicate the decision. Brief retention can be sufficient if it permits the decision. This statutory formulation must not be presented as one UK-wide legal test.
Apply it
In England, a patient with acute delirium can repeat the treatment explanation but cannot use or weigh the consequences of accepting or refusing it because of the delirium. Assess and document that causal link for this decision rather than relying on the diagnosis alone.
Common pitfall: Disagreement, disability or an unwise choice does not establish incapacity. Repeating information accurately also does not by itself demonstrate the ability to use or weigh it.
GMC: Circumstances that affect the decision-making process, part 3 · ukpga_20050009_en.pdf
23.How can communication support improve a consent decision?
Difficulty communicating is not equivalent to inability to decide. Adapt the discussion through clear language, suitable information formats, interpretation or communication aids. Allow enough time and check whether the person can understand, retain and use relevant information and communicate their choice with that support. Where a reversible difficulty can improve and the decision can safely wait, consider a better time. Assess actual decision-making ability after addressing the barrier, under the relevant jurisdiction's law.
Apply it
A patient with hearing impairment appears unable to follow a proposed treatment discussion. Arrange effective communication support and repeat the explanation before drawing conclusions about decision-making ability from the unsuccessful conversation or from the patient's initially brief responses.
Common pitfall: Repeating the same explanation more loudly may not resolve the barrier. Assess the person's decision after providing usable information, rather than assessing the barrier itself.
GMC: Circumstances that affect the decision-making process, part 3
24.What should an early candour conversation contain?
When care has gone wrong and caused or could cause harm or distress, professional candour requires openness with the patient. Explain what is known, acknowledge what remains uncertain, apologise and describe the immediate response and further enquiries. Do not substitute speculation for an honest account. An incomplete investigation does not justify withholding all information. The conversation can begin with established facts and be updated as the explanation becomes clearer, with attention to the patient's questions and support needs.
Apply it
A patient receives a medicine intended for someone else. You know the administration occurred but do not yet know its consequences. Explain the error promptly, apologise, outline assessment and monitoring, and distinguish established facts from issues still being investigated.
Common pitfall: Waiting for a final investigation can leave the patient uninformed about an event affecting their care. Early honesty does not require inventing a complete causal explanation.
25.Why are apology and incident reporting separate responsibilities?
An apology addresses the patient's experience and acknowledges that something has gone wrong. Incident reporting supports organisational learning and investigation. Completing one does not automatically accomplish the other: a report may never explain the event to the patient, while a conversation may not alert the organisation to a recurring hazard. Follow professional candour duties and appropriate local reporting processes. Avoid treating an apology as a substitute for clinical action, explanation or prevention of further harm.
Apply it
After a medication error, a colleague says that submitting an incident form completes the response. Explain that the patient also needs an appropriate account and apology, while clinical monitoring and organisational learning proceed through their respective processes.
Common pitfall: An administrative report is not communication with the patient. Professional candour also should not be confused with one universal statutory reporting threshold across all UK jurisdictions.
26.How should adrenaline be administered in adult anaphylaxis?
Rapidly developing airway, breathing or circulation compromise after a likely trigger warrants immediate treatment for suspected anaphylaxis, even without a rash. Call for emergency help and give an adult 500 micrograms of adrenaline intramuscularly into the anterolateral thigh, using 1 mg/mL solution: the injection volume is 0.5 mL. Repeat after five minutes if there is no improvement. Continue airway, breathing and circulation support and resuscitation. Antihistamines cannot treat shock or airway obstruction. Intravenous adrenaline requires specialist expertise and monitoring. This adult dose must not be applied automatically to children, whose doses differ.
Apply it
After an antibiotic, an adult develops throat tightness, wheeze and hypotension. Give 500 micrograms intramuscular adrenaline promptly, summon emergency help, support resuscitation and reassess for a repeat dose after five minutes.
Common pitfall: Confusing micrograms, milligrams and injection volume can produce a dangerous error. Confirm the 1 mg/mL concentration and intramuscular route; do not delay because skin changes are absent.
Resuscitation Council UK: Special circumstances Guidelines 2025
27.How should fluid decisions respond to the cause of acute kidney injury?
Treat acute kidney injury by identifying the underlying cause and assessing the patient's circulation and fluid state. Dehydration or low blood pressure may require fluid replacement, but AKI can also accompany obstruction or other disease, and excess fluid can create harm. Review medicines and monitor the response rather than prescribing fluid solely because creatinine has risen. The decision should connect the proposed treatment to a demonstrated problem and be reassessed as clinical findings change.
Apply it
Two patients have rising creatinine: one has vomiting and clinical dehydration; the other is breathless with signs of fluid overload. Assess and treat their different physiological problems rather than giving identical fluid prescriptions for the shared laboratory abnormality.
Common pitfall: A rising creatinine does not prove fluid depletion. Repeated fluid administration without reassessment may worsen overload while leaving the actual cause of kidney injury untreated.
28.When should suspected pulmonary embolism proceed to pulmonary arterial imaging?
For a stable, non-pregnant adult with suspected PE, use the two-level PE Wells score. A score above 4 means PE likely: offer immediate CTPA if possible. A score of 4 or less generally leads to D-dimer testing; a positive result leads to imaging, while a negative result supports exclusion within this pathway. Consider an age-adjusted D-dimer threshold above age 50. For contrast allergy, creatinine clearance below 30 mL/min or high irradiation risk, assess V/Q SPECT, or planar V/Q if SPECT is unavailable. Offer interim therapeutic anticoagulation when indicated imaging cannot be performed immediately, or when an indicated D-dimer result cannot be obtained within four hours, considering contraindications.
Apply it
A stable, non-pregnant adult has clinical DVT signs worth 3 points and a heart rate above 100/min worth 1.5 points. A Wells score of 4.5 supports immediate CTPA rather than waiting for D-dimer.
Common pitfall: A positive D-dimer does not confirm PE. This pathway does not replace emergency stabilisation in shock or the separate assessment required during pregnancy.
29.How should recurrent bleeding after endoscopic treatment be handled?
Recurrent haematemesis or circulatory deterioration after treatment suggests that bleeding may have resumed. Reassess airway, breathing and circulation, restart appropriate resuscitation and involve the relevant senior team urgently. Repeat endoscopic treatment or escalation beyond endoscopy may be needed according to the clinical course. Previous successful haemostasis is historical information, not proof of present stability. A change in physiology should trigger a new decision rather than passive continuation of the original post-procedure plan.
Apply it
Several hours after endoscopic haemostasis, a patient vomits fresh blood and becomes hypotensive again. Reassess and resuscitate immediately, then escalate for renewed bleeding control rather than waiting for the next scheduled review because treatment was initially successful.
Common pitfall: An earlier reassuring procedure does not override new bleeding or shock. Continuing the old plan without reassessment mistakes a past result for current clinical status.
NHS Ayrshire and Arran Medicines: Management of Upper Gastrointestinal Bleeding
30.How should you communicate with someone who is suddenly confused?
Sudden confusion needs urgent assessment for an underlying cause, while communication should reduce distress and help orientation. Introduce yourself, use simple sentences, explain where the person is and provide calm reassurance. Avoid overwhelming them with repeated questions or arguments about mistaken beliefs. Seek a familiar person's account when possible because baseline function and timing are diagnostically useful. Supportive communication complements investigation; it does not make acute cognitive change safe to manage as reassurance alone.
Apply it
An older patient becomes frightened and disorientated in hospital. Speak calmly, explain your role and the setting, and ask a relative about the person's usual cognition and onset of change while arranging assessment for an acute medical cause.
Common pitfall: Arguing over every incorrect statement may increase distress without correcting the cause. Calm reassurance is helpful, but it must accompany rather than replace urgent clinical assessment.
Practical skills and proceduresnot stated
31.Which checks authorise initial use of a nasogastric tube?
Do not introduce water, feed or medicine through a newly placed nasogastric tube until accepted confirmation is complete. Gastric aspirate pH within 1 to 5.5, measured with appropriate indicator strips and documented, supports the initial pH pathway. An unavailable, unsuitable or uncertain result requires further confirmation, commonly radiography. Do not substitute air-insufflation auscultation, aspirate appearance, insertion length or absence of coughing. A trial flush is still administration through an unconfirmed tube and may harm a patient if the tube lies in the respiratory tract.
Apply it
Aspirate pH is 6.0 after insertion. Withhold all administration and follow the radiographic confirmation pathway; do not round down, flush with water or accept a reassuring whoosh test.
Common pitfall: Combining several unreliable observations does not create a valid placement check. A small trial administration cannot establish safety retrospectively.
NHS Improvement: Initial placement checks for nasogastric and orogastric tubes
32.What anatomical criteria confirm nasogastric placement on a radiograph?
First confirm the correct patient and that the image is current and relates to the present tube placement. Trace the tube along an oesophageal course, avoiding the bronchial contours; it should pass centrally at the carina, cross the diaphragm in the midline and have a clearly visible tip below the left hemidiaphragm. The image must show enough of the course and tip to judge every criterion. A trained, competent interpreter must document the assessment and explicitly authorise use before anything is administered. A tip apparently below the diaphragm alone is insufficient.
Apply it
A placement image shows the tip below the left hemidiaphragm, but the tube's course through the chest is obscured. Do not authorise feeding from the tip position alone; resolve the inadequate anatomical assessment.
Common pitfall: Requesting an X-ray is not confirmation. Wrong-patient images, an old image, an unseen tip or uncertain interpretation leave placement unresolved.
NHS Improvement: Initial placement checks for nasogastric and orogastric tubes
33.How should technique change when measuring blood pressure?
Use a validated, maintained device, an appropriate cuff and a quiet seated patient with the arm supported. Palpate the pulse first: an irregular pulse can make automated readings unreliable, so measure manually by direct auscultation over the brachial artery. Initially measure both arms. If the difference exceeds 15 mmHg, repeat; if it persists, use the higher-reading arm subsequently. These steps reduce technical misclassification before diagnostic thresholds are applied.
Apply it
A patient's automated readings vary widely and the pulse is irregular. Obtain a careful manual auscultatory measurement instead of averaging unreliable automated values.
Common pitfall: A precise-looking digital number can still be inaccurate. Cuff size, positioning, pulse rhythm and arm selection are part of interpretation.
Recommendations | Hypertension in adults: diagnosis and management | Guidance | NICE
35.How should a device-specific safety alert change practice?
Safe procedural practice includes checking whether the particular device remains authorised for use, rather than relying only on a familiar clinical principle. The MHRA's 2026 NGPod alert instructs immediate cessation of use, quarantine and disposal of all NGPod devices. That device-specific instruction must inform local practice even though gastric aspirate pH remains part of established nasogastric placement pathways. Identify the device precisely and follow the alert; do not generalise the instruction to unrelated equipment.
Apply it
A ward still has NGPod devices available for nasogastric checks after the relevant MHRA alert. Remove them from use through the required quarantine and disposal process, and use an accepted alternative placement-confirmation method rather than assuming all pH devices are interchangeable.
Common pitfall: A valid physiological measurement principle does not guarantee that every product implementing it is safe. Conversely, one device alert does not invalidate all accepted pH testing.
MHRA: NGPod pH testing device, DSI/2026/009 · NHS Improvement: Initial placement checks for nasogastric and orogastric tubes
36.How should a young child's temperature be measured?
Use a suitable digital thermometer in the armpit when checking a young child's temperature, following the device instructions and holding the arm against the body for the measurement. Recent bathing or heavy wrapping can temporarily affect the result, so interpret the reading with those circumstances in mind. An objective temperature helps apply age-specific urgency thresholds. It remains one part of assessment: breathing, responsiveness, hydration and other concerning symptoms can require action regardless of the measured number.
Apply it
A parent reports that a two-month-old feels hot after being heavily wrapped. Obtain a careful digital axillary temperature and assess the infant's condition; do not rely on touch or dismiss a confirmed fever because wrapping might have contributed.
Common pitfall: Touch alone is too imprecise for an age-specific fever threshold. A modest temperature also cannot overrule concerning changes in breathing, responsiveness or hydration.
37.Why check blood glucose in sudden confusion?
Low blood glucose is a potentially reversible cause of acute confusion, particularly in a person with diabetes receiving glucose-lowering treatment. A prompt bedside glucose measurement can identify this cause while wider assessment continues. Do not assume that abnormal behaviour is psychiatric or simply part of dementia before considering acute physiological disturbance. Interpret and act on the result in clinical context, and continue searching when it does not explain the presentation. One normal measurement does not exclude other urgent causes.
Apply it
A person treated for diabetes becomes abruptly confused and sweaty. Include an immediate bedside glucose check in the urgent assessment rather than waiting for a detailed cognitive interview or assuming that the behaviour reflects a primary mental health problem.
Common pitfall: Treating confusion as a purely behavioural symptom can delay recognition of a reversible metabolic problem. A normal glucose result narrows the differential without completing the assessment.
Patient presentationsnot stated
38.How does suspected DVT probability guide testing and action after a negative scan?
For a non-pregnant adult with suspected DVT, use the two-level DVT Wells score after assessing other causes. A score of at least 2 means DVT likely: obtain proximal leg-vein ultrasound within four hours if possible. If delayed, obtain D-dimer, offer interim therapeutic anticoagulation when appropriate and obtain ultrasound within 24 hours. In this initially likely pathway, a negative proximal scan with positive D-dimer means stop interim therapeutic anticoagulation and repeat proximal ultrasound six to eight days later. Preserve anticoagulation independently required for another indication, including long-term secondary prevention or indicated COVID-19 VTE prophylaxis. If the repeat scan is positive, treat confirmed DVT; if negative, consider alternatives and provide safety advice. An initial score of 1 or less means DVT unlikely: obtain D-dimer first, giving interim therapeutic anticoagulation if the result cannot be obtained within four hours. A positive result leads to ultrasound within four hours if possible, or interim anticoagulation and ultrasound within 24 hours. If that scan is negative, stop the interim treatment, preserve independently indicated anticoagulation, assess alternative diagnoses and explain when and where to seek help. Do not automatically apply the repeat-scan branch to this initially unlikely pathway.
Apply it
A patient initially scoring 3 has a negative proximal scan and positive D-dimer: stop anticoagulation given only as interim DVT treatment and arrange repeat scanning in six to eight days. With an initial score of 1 and the same subsequent test results, follow the alternative-diagnosis and safety-netting branch instead.
Common pitfall: The initial probability remains relevant after testing. Neither a positive D-dimer nor a negative scan alone specifies the whole pathway, and stopping interim treatment must not accidentally stop anticoagulation required for a separate indication.
39.What does coffee-ground vomiting tell you about severity?
Coffee-ground material can represent blood altered within the upper gastrointestinal tract. Its appearance supports a bleeding presentation but does not establish haemodynamic safety or identify the lesion. Assess circulation, ongoing bleeding, comorbidity and the wider clinical picture rather than equating darker material with a minor event. Fresh haematemesis and coffee-ground vomiting can both require urgent assessment. The immediate decision should follow the patient's physiological condition, while investigation addresses the source and appropriate haemostatic treatment.
Apply it
A patient reports coffee-ground vomiting and feels faint on standing. Measure vital signs and assess for significant bleeding rather than reassuring them because the material is dark instead of bright red; its appearance cannot establish circulatory stability.
Common pitfall: Colour describes the vomit, not the patient's circulating volume. A visually less dramatic presentation can coexist with clinically important blood loss or continuing deterioration.
NHS Ayrshire and Arran Medicines: Management of Upper Gastrointestinal Bleeding
40.When is fever in an infant an urgent age-specific concern?
A temperature of 38°C or above in an infant younger than three months requires urgent medical advice and assessment. The age threshold matters because serious illness can be harder to recognise in very young infants, who may not show the same localising features as older children. Do not apply the usual reassurance given to an otherwise well older child. Feeding, responsiveness, breathing and hydration remain important, but an apparently comfortable infant still needs the age-specific fever response.
Apply it
A seven-week-old has a carefully measured temperature of 38.1°C and is still taking some milk. Arrange urgent medical assessment based on age and fever rather than waiting for a rash, persistent crying or complete feeding refusal.
Common pitfall: Continued feeding does not cancel the significance of fever in a very young infant. Older-child advice should not be transferred without considering the age threshold.
41.Why should childhood fever treatment focus on distress?
In children, antipyretic medicines are used to relieve distress or discomfort rather than simply to normalise a temperature reading. Assess the child as a whole, including responsiveness, breathing, fluid intake and urine output. A fall in temperature after medicine does not prove that the underlying illness is harmless. Provide fluids and appropriate safety advice, and respond to warning signs or age-specific thresholds. The thermometer contributes information but should not become the sole target of care.
Apply it
A febrile child is drinking, interacting and comfortable, while another is drowsy and breathing abnormally despite a lower temperature. Prioritise the second child's clinical deterioration rather than ranking urgency solely by the higher number on the thermometer.
Common pitfall: Response to an antipyretic does not reliably distinguish serious from minor illness. Treating the number can distract from altered responsiveness, dehydration or respiratory compromise.
42.How does onset distinguish acute confusion from chronic cognitive decline?
A sudden change in attention, orientation or behaviour suggests an acute process and requires urgent assessment. Gradual cognitive decline over months or years has a different time course, although a person with dementia can also develop delirium. Establish the baseline and when the change occurred using relatives, carers and records. The key discrimination is new change from usual function, not simply whether memory difficulty is present. Do not let an existing dementia diagnosis obscure a superimposed illness.
Apply it
A resident with stable dementia becomes markedly disorientated over several hours. Ask carers what is new and investigate an acute cause rather than attributing the change to inevitable progression of the longstanding cognitive disorder without further assessment.
Common pitfall: Dementia and delirium can coexist. A previous cognitive diagnosis is not an explanation for abrupt deterioration and should not remove the need for urgent assessment.
43.When does a swollen joint need urgent infection assessment?
Severe pain and swelling developing quickly in a joint should prompt concern for septic arthritis, especially with fever or systemic illness. Rapid onset and restricted use are important discriminating cues because joint infection can progress quickly. Other causes of acute monoarthritis exist, but they should not be assumed without considering infection. Urgency follows the possibility of a damaging, treatable infection rather than certainty of the final diagnosis. Arrange prompt assessment instead of a routine musculoskeletal review.
Apply it
A patient develops a hot, very painful knee overnight and feels generally unwell. Arrange urgent assessment for possible septic arthritis rather than advising several days of rest to see whether the presumed inflammatory flare settles on its own.
Common pitfall: A familiar history of joint pain can encourage premature closure. A new acute, swollen joint still needs assessment for infection rather than automatic attribution to the old diagnosis.
44.Which back-pain symptoms suggest cauda equina compression?
Back pain accompanied by altered sensation around the genitals or anus, new bladder or bowel dysfunction, or significant symptoms affecting both legs raises concern for cauda equina compression. These features indicate possible dysfunction of the lower spinal nerve roots and require emergency assessment. The decision is driven by neurological and sphincter change, not simply pain intensity. A person with tolerable pain may still have a serious compressive process, while severe uncomplicated pain has a different risk profile.
Apply it
A patient with back pain reports new difficulty passing urine and numbness when wiping after using the toilet. Arrange emergency assessment for possible cauda equina syndrome rather than managing the encounter as a routine recurrence of mechanical back pain.
Common pitfall: Do not wait for complete incontinence or paralysis. Early bladder change and saddle sensory symptoms are sufficient warning features to change the urgency of assessment.
45.When is a painful red eye a sight-threatening presentation?
A suddenly painful red eye with reduced or blurred vision, halos, headache or nausea should raise concern for acute angle-closure glaucoma. The combination of pain and visual change differentiates this emergency pattern from many minor surface complaints. Prompt eye assessment is required because pressure-related optic nerve damage can threaten sight. Do not allow vomiting or headache to redirect attention away from the eye when ocular symptoms are prominent; the symptoms may arise from one acute process.
Apply it
A patient presents with vomiting, headache and a red eye that has become painful and blurred over several hours. Recognise the ocular emergency pattern and arrange immediate eye assessment instead of treating the vomiting as an isolated gastrointestinal illness.
Common pitfall: Calling every red eye conjunctivitis overlooks visual loss and severe pain. These accompanying symptoms should change the differential and urgency rather than merely the symptomatic treatment.
46.Why can early ectopic pregnancy resemble a gastrointestinal complaint?
Ectopic pregnancy can cause lower abdominal pain and symptoms that overlap with gastrointestinal or urinary problems. A possible pregnancy therefore changes the interpretation of one-sided pain, unusual bleeding or discomfort associated with passing urine or opening the bowels. Ask about pregnancy possibility even when the presenting complaint is not explicitly obstetric. Symptoms alone do not determine pregnancy location, but they can identify the need for assessment before rupture. Atypical features should not create false reassurance.
Apply it
A patient of reproductive age reports lower abdominal pain and discomfort opening the bowels after a missed period. Ask about pregnancy possibility and assess for ectopic pregnancy rather than assuming that the bowel-associated symptom establishes a gastrointestinal cause.
Common pitfall: A symptom triggered by toileting does not locate the pathology to bowel or bladder. Pregnancy-related disease can overlap with these complaints and needs deliberate consideration.
47.What distinguishes pelvic inflammatory disease from an isolated vaginal complaint?
PID affects the upper reproductive tract and may produce pelvic pain, deep pain during sex, abnormal discharge and bleeding between periods or after sex. Chlamydia and gonorrhoea are common causes, but other vaginal bacteria can also be responsible. Assess pregnancy possibility, examine with consent and obtain appropriate samples; a pregnancy test helps address competing pregnancy-related causes. Arrange prompt antibiotic treatment and sexual-health assessment, including partner testing when an STI is suspected. Severe or worsening pain, faintness, heavy bleeding or marked systemic illness requires emergency assessment. Lack of improvement after three days of antibiotics requires urgent review. [NHS PID guidance](https://www.nhs.uk/conditions/pelvic-inflammatory-disease-pid/).
Apply it
A patient has lower abdominal pain, deep dyspareunia and postcoital bleeding. Assess for PID and pregnancy-related alternatives rather than treating discharge alone. Include partner management and explain the need for review if improvement has not occurred within three days.
Common pitfall: Treating only the presenting discharge can miss upper-tract infection. PID may have few symptoms, and delayed treatment can lead to infertility, chronic pelvic pain or increased ectopic pregnancy risk.
48.Which hearing-loss histories need immediate ENT assessment?
For an adult whose hearing loss developed over three days or less within the preceding 30 days, and is not explained by external or middle-ear disease, refer immediately to ENT or an emergency department for assessment within 24 hours. Sudden loss beginning more than 30 days ago, or rapid worsening over four to 90 days, requires urgent assessment within two weeks. Examine for an external or middle-ear explanation without allowing routine audiology arrangements to delay the appropriate referral. Acquired unilateral hearing loss with ipsilateral altered sensation or facial weakness also needs immediate assessment; use the stroke pathway when stroke is suspected. [NICE NG98](https://www.nice.org.uk/guidance/ng98/chapter/recommendations).
Apply it
An adult reports hearing in one ear falling abruptly yesterday, with no wax obstruction or middle-ear explanation on examination. Arrange assessment within 24 hours rather than a routine hearing-aid appointment.
Common pitfall: Painless hearing loss can still be urgent. Referral depends on onset, elapsed time and examination findings, rather than simply on how much hearing remains.
MLA content map · Recommendations | Hearing loss in adults: assessment and management | Guidance | NICE
49.When should a pigmented skin lesion enter a suspected melanoma pathway?
Use the weighted seven-point checklist for a suspicious pigmented lesion. Give two points each for changing size, irregular shape and irregular colour; give one each for diameter at least 7 mm, inflammation, oozing and altered sensation. A score of at least 3 warrants a suspected cancer pathway referral. Dermoscopy suggesting melanoma independently warrants referral. Also consider this pathway for a lesion suggesting nodular melanoma, which may be pigmented or non-pigmented. The checklist supports referral decisions; it does not establish histological diagnosis. [NICE NG12](https://www.nice.org.uk/guidance/ng12/chapter/recommendations-organised-by-site-of-cancer).
Apply it
A 5 mm pigmented lesion has enlarged and developed irregular colour. Those two major features score 4, supporting referral despite its diameter remaining below 7 mm.
Common pitfall: Small diameter or absent itching does not exclude melanoma. A non-pigmented suspicious nodule also needs consideration outside a checklist focused on pigmented lesions.
MLA content map · Recommendations organised by site of cancer | Suspected cancer: recognition and referral | Guidance | NICE
Conditionsnot stated
50.Why can anaphylaxis impair both breathing and circulation?
Anaphylaxis involves rapid mediator-driven effects that can narrow airways, cause tissue swelling and reduce effective circulation through vasodilation and fluid movement out of vessels. This explains why wheeze, upper-airway symptoms and shock may occur together after a trigger. Adrenaline counters these effects through vasoconstriction, support of cardiac function and bronchodilation. In an adult, give 500 micrograms intramuscularly using 1 mg/mL solution and repeat after five minutes if there is no improvement, alongside emergency help and resuscitation. Paediatric doses differ. Treating itching alone cannot reverse shock or airway compromise.
Apply it
A patient becomes wheezy and hypotensive soon after an injection. Interpret the respiratory and circulatory findings as linked manifestations of possible anaphylaxis and give first-line treatment promptly rather than treating them as unrelated events.
Common pitfall: Improvement in skin symptoms after an antihistamine does not establish resolution of airway or circulatory danger.
Resuscitation Council UK: Special circumstances Guidelines 2025
51.Which numerical changes identify AKI in an adult?
Identify adult AKI through any of the following: serum creatinine rising by at least 26 micromol/L within 48 hours; a rise of at least 50% known or presumed to have occurred within seven days; or urine output below 0.5 mL/kg/hour for more than six hours. Compare with baseline and interpret the time interval explicitly. These are alternative criteria, so oliguria can establish concern before a qualifying creatinine rise is documented. Recognition should lead to assessment of circulation, medicines, intrinsic disease and obstruction.
Apply it
Creatinine rising from 80 to 110 micromol/L in 36 hours meets the 26 micromol/L criterion. A rise from 100 to 150 micromol/L over six days meets the 50% criterion. In a 70 kg adult, output below 35 mL/hour for more than six hours meets the urine-output criterion.
Common pitfall: A value within a laboratory reference interval can still represent AKI when it has risen sufficiently from baseline. Do not require all three criteria to be present.
Recommendations | Acute kidney injury: prevention, detection and management | Guidance | NICE
52.When should illness during anticancer treatment trigger treatment for neutropenic sepsis?
Suspect neutropenic sepsis when a person receiving anticancer treatment becomes unwell, and arrange immediate hospital assessment. Treat the suspected syndrome as a medical emergency with immediate empirical antibiotics. Initial investigations include full blood count, renal and liver function, CRP, lactate and blood cultures. Confirm neutropenic sepsis with neutrophils at or below 0.5 × 10^9/L plus temperature above 38°C or other features of clinically significant sepsis. For patients needing intravenous treatment, NICE recommends piperacillin–tazobactam monotherapy unless patient-specific or local microbiological contraindications apply. [NICE CG151](https://www.nice.org.uk/guidance/cg151/chapter/recommendations).
Apply it
A patient receiving chemotherapy is confused and hypotensive with a temperature of 37.4°C. Begin emergency assessment and empirical treatment for suspected neutropenic sepsis; absence of fever does not justify waiting for the neutrophil result.
Common pitfall: The confirmation criteria must not delay treatment of a suspected emergency. Clinically significant sepsis can occur without a temperature above 38°C.
MLA content map · Recommendations | Neutropenic sepsis: prevention and management in people with cancer | Guidance | NICE
53.How do duration and severity distinguish mania from hypomania?
Both syndromes involve a distinct period of elevated or irritable mood with increased activity or energy, reduced need for sleep and associated changes such as rapid speech or disinhibition. NICE describes mania as lasting seven days or more with severe functional impairment or psychotic symptoms. Hypomania lasts four days or more and does not have the severe impairment or psychotic features of mania. Establish departure from baseline, duration, consequences and possible substance or physical causes. Suspected mania requires urgent specialist assessment; do not wait for a duration threshold when current risk demands action.
Apply it
For eight days, a previously cautious person has slept two hours without tiredness, spent savings and been unable to work because of grandiose behaviour. The duration and severe impairment support mania rather than hypomania and require urgent specialist assessment.
Common pitfall: Ordinary sleep loss causes tiredness and a wish to sleep. Reduced need for sleep belongs to a broader episodic syndrome; duration alone does not distinguish severity.
Recommendations | Bipolar disorder: assessment and management | Guidance | NICE · NHS: Bipolar disorder
54.Which serological tests should begin coeliac investigation?
First-line testing is total IgA together with IgA tissue transglutaminase antibodies (tTG). Total IgA identifies deficiency that can make an IgA-based antibody result falsely reassuring. If IgA is deficient, consider IgG endomysial antibodies, IgG deamidated gliadin peptide or IgG tTG. For young people and adults with weakly positive IgA tTG, use IgA endomysial antibodies to clarify serological positivity. Persistent clinical suspicion despite negative serology warrants gastrointestinal specialist assessment, particularly when gluten restriction or IgA deficiency may reduce test reliability. Initial HLA testing is not recommended in non-specialist settings.
Apply it
A patient with unexplained iron deficiency has negative IgA tTG but very low total IgA. Do not treat the antibody result as exclusion: use an appropriate IgG-based test and assess the need for specialist investigation.
Common pitfall: Ordering IgA tTG alone can miss the significance of IgA deficiency. Negative serology also cannot overrule persistent clinical suspicion without further assessment.
Recommendations | Coeliac disease: recognition, assessment and management | Guidance | NICE
55.Why does an ectopic pregnancy threaten maternal circulation?
An ectopic pregnancy develops outside the normal uterine cavity, most commonly in a fallopian tube. As it grows, the affected structure can rupture and bleed internally. This explains why local abdominal pain may progress to dizziness, collapse or shoulder-tip pain associated with internal bleeding. The amount of vaginal bleeding may not reflect this danger. Recognise the transition from a possible early pregnancy complication to a potential haemorrhagic emergency and act on the warning signs.
Apply it
A patient with a possible early pregnancy develops worsening unilateral pain followed by faintness. Consider internal bleeding from ectopic rupture and arrange emergency assessment, even if there has been no heavy vaginal bleeding to suggest major blood loss.
Common pitfall: The pregnancy's small size does not make rupture harmless. Internal bleeding can become life-threatening before external bleeding or a complete classic symptom pattern appears.
56.Which prescribing and reproductive safeguards apply to bipolar treatment?
Suspected mania requires urgent specialist assessment. Do not start lithium for a new patient in primary care except under shared-care arrangements, or start valproate for bipolar disorder in primary care. Below age 55, first initiation of valproate requires two specialists independently to agree and document that no other effective, tolerated treatment exists or compelling reasons mean reproductive risks do not apply. Women and girls able to have children require the specified safeguards, including a Pregnancy Prevention Programme where appropriate. Separately counsel men of any age who could father children, including those over 55, about the possible paternal association with neurodevelopmental disorders; causation is unconfirmed. Recommend effective contraception during treatment and for at least three months after stopping: generally condoms plus effective contraception used by the female partner, accounting for MHRA qualifications where pregnancy is impossible or highly effective contraception is already used. Advise against sperm donation during the same interval. Ask about plans for a family in the next year and arrange specialist discussion of alternatives. Patients should not stop valproate without clinical advice. Lamotrigine should not treat mania; long-term lithium monitoring includes renal and thyroid function and calcium.
Apply it
A 60-year-old man taking valproate plans to father a child. His age does not remove the counselling responsibility: explain the possible risk, contraception and sperm-donation precautions, and arrange specialist discussion before a treatment change or attempts at conception.
Common pitfall: The under-55 initiation restriction and counselling for men who could father children are separate duties. The precautionary paternal advice applies beyond age 55 and does not establish a proven causal mechanism.
Recommendations | Bipolar disorder: assessment and management | Guidance | NICE · Valproate use in men: as a precaution, men and their partners should use effective contraception - GOV.UK
57.What makes acute angle closure an emergency?
Acute angle closure obstructs drainage of fluid from the eye and can rapidly raise intraocular pressure. The resulting painful red eye, blurred vision, halos and sometimes nausea or vomiting require immediate assessment because continuing pressure can damage the optic nerve. This mechanism differs from the slower course of open-angle glaucoma. Recognise the symptom cluster and urgency rather than waiting for gradual peripheral visual loss, which belongs to a different common presentation of glaucomatous disease.
Apply it
A person suddenly develops a very painful red eye, blurred vision and coloured halos around lights. Arrange emergency ophthalmic assessment because a rapid pressure rise can threaten sight, rather than scheduling a routine review for chronic visual deterioration.
Common pitfall: A previous understanding that glaucoma is painless applies poorly to acute angle closure. The abrupt painful presentation changes urgency even before the pressure is measured.
58.How is anticoagulation selected after confirmed PE?
For a stable, non-pregnant adult with confirmed PE and no feature requiring a different regimen, NICE offers apixaban or rivaroxaban. Treat for at least three months, then review recurrence risk, bleeding risk and preferences before deciding about continuation. If neither is suitable, one alternative is LMWH for at least five days followed by dabigatran or edoxaban. Another is LMWH given concurrently with a vitamin K antagonist (VKA). Maintain the overlap for at least five days and until the INR is at least 2.0 on two consecutive readings, then stop LMWH and continue the VKA alone. Five elapsed days with an inadequate INR, or one therapeutic INR reading alone, does not establish readiness for that transition. Renal impairment, extremes of weight, active cancer, triple-positive antiphospholipid syndrome and haemodynamic instability can change treatment selection. Assess contraindications and baseline blood tests.
Apply it
A stable adult may start suitable apixaban without a preceding LMWH course. With a chosen LMWH/VKA regimen, an INR of 1.7 after five days means continuing overlap; after the minimum overlap and two consecutive INR readings of at least 2.0, transition to VKA alone.
Common pitfall: The oral agents have different initiation regimens. Starting a VKA does not immediately replace parenteral anticoagulation, and one satisfactory INR is insufficient for the stated transition.
59.How should suspected native-joint septic arthritis be investigated and treated?
Arrange urgent aspiration of a suspected infected native joint. Send synovial fluid for bacterial identification, including Gram stain and culture, white-cell count with differential and crystal analysis; if sample volume is limited, prioritise bacterial identification. Obtain blood cultures when fever, bacteraemia or sepsis is suspected. In a clinically stable patient, obtain diagnostic samples promptly before starting empirical antibiotics because prior antibiotics can reduce culture yield; do not wait for culture results before treating a continuing suspicion of infection. In sepsis or septic shock, start antibiotics and resuscitation promptly without delaying them for aspiration. Crystals can coexist with bacterial infection, so their presence does not exclude septic arthritis. Arrange urgent orthopaedic assessment for joint drainage or lavage and tailor antibiotics to microbiology. This native-joint sequence follows the [SANJO guideline](https://jbji.copernicus.org/articles/8/29/2023/); prosthetic-joint infection requires a separate specialist pathway.
Apply it
A febrile adult with a hot native knee is alert, well perfused and haemodynamically stable, with aspiration immediately available. Obtain blood cultures and aspirate urgently, then begin empirical antibiotics and arrange drainage assessment. If hypotension or other sepsis features develop, do not postpone antibiotics while awaiting joint sampling.
Common pitfall: Neither crystals nor an inflammatory synovial cell count alone rules bacterial infection in or out. Sampling before antibiotics preserves diagnostic yield in a stable patient; it must never become a reason to delay sepsis treatment.
60.Which causes should be sought in sudden delirium?
Delirium is an acute disturbance of cognition and attention that often reflects an underlying illness or physiological problem. Potential causes include infection, low blood glucose, medicines, stroke and alcohol-related problems, among others. Establish the onset and baseline, examine for acute illness and investigate likely causes rather than assigning a purely behavioural label. More than one contributor may be present. Identifying one plausible cause should therefore lead to treatment and reassessment, not automatic closure of the diagnostic process.
Apply it
An older adult becomes acutely confused during an illness and has recently started a medicine. Assess infection, medication effects and other relevant physiological causes, using the timeline and examination rather than assuming that age alone explains the change.
Common pitfall: Delirium names a syndrome rather than its cause. Sedating or reassuring the patient without investigating the trigger can leave a serious, potentially reversible problem untreated.
What to focus on during revision
The following are CertMedbry study suggestions. Use the official outline to check the full scope of your examination.
- Connect presentations to physiology: identify airway, breathing, circulatory and neurological threats before selecting definitive investigations.
- Apply numerical diagnostic criteria and time intervals for hypertension, acute kidney injury and severity assessment in bronchiolitis.
- Interpret paired and serial information: TSH with free T4, creatinine with baseline values, and symptoms with their time course.
- Practise substantive prescribing decisions, including adult adrenaline administration, antihypertensive selection, anticoagulation and medicine review during acute illness.
- Recognise age-specific and context-specific urgency in infant fever, early pregnancy pain, acute monoarthritis and back pain with sphincter symptoms.
- Assess decision-making abilities, support communication and distinguish GMC professional duties from jurisdiction-specific capacity law.
- Integrate prevention, practical barriers, carer support and access to urgent care into management decisions.
- Use accepted procedural confirmation criteria and current device safety alerts before authorising treatment.
- Calculate absolute benefit and NNT with the correct denominator, outcome and follow-up period.
- Connect mapped cancer care with neutropenic sepsis, dermatology with suspicious skin lesions, ENT with sudden hearing loss, sexual health with PID, and palliative care with breathlessness in the last days of life.
- Use the complete September 2026-onwards GMC map to extend revision beyond this selection across all six interconnected domains. These selected decisions do not establish proportional coverage or the full clinical scope.
A practical preparation plan
1. Map the full scope
Read the current GMC content map and build a revision tracker across its six interconnected domains. Link the selected cancer, dermatology, ENT, sexual-health and palliative decisions to their clinical areas and relevant presentations or conditions. Add the remaining mapped content; this guide does not represent official domain proportions.
2. Study decisions in contrasting pairs
Compare primary with central hypothyroidism, delirium with gradual cognitive decline, mania with hypomania, and referral with admission criteria in bronchiolitis. State the cue, threshold or consequence that changes the decision.
3. Rehearse safety-critical sequences
Explain aloud what happens before endoscopy in shock, before using a nasogastric tube, during suspected anaphylaxis and after a harmful error. Include the relevant dose or anatomical criteria, reassessment and escalation.
4. Use the learning questions diagnostically
Complete the drills, justify your chosen option and explain why each alternative fails. Classify errors as missed urgency, wrong mechanism, misread data or professional judgement, then revise the relevant concept.
5. Practise timed clinical decisions
Use timed cases to identify the decisive findings, choose the next appropriate action and maintain progress. Review whether delays arose from missing knowledge, overlooking a discriminating cue or repeatedly reconsidering a well-supported decision.
6. Review with active recall
Use the flashcards to recall mechanisms and discriminating cues, then vary the case details. Revisit weak areas in the full map and check current clinical guidance when studying management beyond the situations covered here.
Use your sample score as a starting point
The free set contains 20 original practice questions. It is a small learning sample, not an official examination or a validated pass prediction. Review each explanation and its source before moving to another topic.
Start the free sampleOfficial sources and updates
- Medical Licensing Assessment
- Applied knowledge test (AKT)
- MLA content map
- About the MLA content map
- MLA content map: applicable from September 2026 onwards
- PLAB and the MLA
- Preparing for the Applied Knowledge Test
- UK Medical School Applied Knowledge Test Student Handbook 2026/27
- Medical Schools Applied Knowledge Test Sampling Grid, October 2023
- Resuscitation Council UK: Special circumstances Guidelines 2025
- NHS: High blood pressure
- NHS: Pulmonary embolism
- NHS: Diagnosing a stroke
- NHS: Acute kidney injury
- NHS Ayrshire and Arran Medicines: Management of Upper Gastrointestinal Bleeding
- NHS: Ectopic pregnancy symptoms
- NHS: Bronchiolitis
- NHS: High temperature in children
- NHS: Sudden confusion (delirium)
- NHS: Bipolar disorder
- NHS: Septic arthritis
- Newcastle Hospitals Laboratories: TSH, serum
- NHS: Coeliac disease diagnosis
- East Lancashire Hospitals NHS Trust: Understanding Glaucoma
- NHS: Back pain
- NHS Improvement: Initial placement checks for nasogastric and orogastric tubes
- MHRA: NGPod pH testing device, DSI/2026/009
- GMC: Circumstances that affect the decision-making process, part 3
- GMC: Personal beliefs and medical practice
- GMC: Being open and honest when things go wrong
- Cochrane Handbook: Chapter 15, Interpreting results and drawing conclusions
- Recommendations | Hypertension in adults: diagnosis and management | Guidance | NICE
- Recommendations | Acute kidney injury: prevention, detection and management | Guidance | NICE
- Recommendations | Venous thromboembolic diseases: diagnosis, management and thrombophilia testing | Guidance | NICE
- Recommendations | Bronchiolitis in children: diagnosis and management | Guidance | NICE
- Recommendations | Coeliac disease: recognition, assessment and management | Guidance | NICE
- Recommendations | Bipolar disorder: assessment and management | Guidance | NICE
- bronchiolitis-in-children-diagnosis-and-management-pdf-51048523717
- Recommendations | Stroke and transient ischaemic attack in over 16s: diagnosis and initial management | Guidance | NICE
- Valproate use in men: as a precaution, men and their partners should use effective contraception - GOV.UK
- ukpga_20050009_en.pdf
- Recommendations | Venous thromboembolic diseases: diagnosis, management and thrombophilia testing | Guidance | NICE
- Recommendations | Stroke and transient ischaemic attack in over 16s: diagnosis and initial management | Guidance | NICE
- Recommendations | Care of dying adults in the last days of life | Guidance | NICE
- Recommendations | Hearing loss in adults: assessment and management | Guidance | NICE
- Recommendations organised by site of cancer | Suspected cancer: recognition and referral | Guidance | NICE
- Recommendations | Neutropenic sepsis: prevention and management in people with cancer | Guidance | NICE
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