Pre-clinical and clinical UKMLA questions. A right answer scores 100, plus up to 50 for speed.
Cardiovascular. 58-year-old with central chest pain for 40 minutes. BP 84/50, chest clear, JVP raised. Which drug should you withhold?
12-lead ECG25 mm/s 10 mm/mV
IST ↓
IIST ↑
IIIST ↑
aVR
aVLST ↓
aVFST ↑
V1
V2
V3
V4
V5
V6
ST elevation in II, III and aVF with reciprocal depression in I and aVL is an inferior STEMI. Hypotension with clear lungs and a raised JVP points to right ventricular involvement, which is preload dependent: nitrates can drop the BP profoundly. Give fluid, record V4R and get the patient to the cath lab.
Physiology. Ventricular myocyte action potential. Tap the phase that makes it last around 250 ms, long enough that cardiac muscle cannot be tetanised.
Phase 2, the plateau: L-type calcium channels let Ca²⁺ in while K⁺ leaves, holding the membrane depolarised. Fast sodium channels stay inactivated until repolarisation, so the refractory period outlasts most of the contraction and beats cannot summate.
Cardiovascular. 79-year-old, dizzy and pale, pulse 34. Atropine 500 micrograms has not helped. What is the definitive treatment for this rhythm?
Rhythm strip II25 mm/s 10 mm/mV
P waves 75/min, broad QRS 35/min, no relationship: complete heart block.
P waves march through at their own rate and the broad, slow QRS complexes ignore them: complete heart block. A broad escape rhythm carries a risk of asystole, so this needs pacing (transcutaneous or transvenous now) and a permanent pacemaker. Amiodarone and adenosine slow AV conduction further.
Acute and emergency. Frail 84-year-old with heart failure, 60 kg, nil by mouth. How much water should routine maintenance fluids give in 24 hours?
NICE gives 25 to 30 ml/kg/day for routine maintenance, but advises considering less, 20 to 25 ml/kg/day, for people who are older or frail or have heart or kidney failure. For 60 kg that is 1.2 to 1.5 litres; 1.5 to 1.8 litres is the standard adult rate.
Physiology. Spirometry can measure vital capacity but not functional residual capacity or total lung capacity. Tap the volume that explains why.
Residual volume never leaves the lungs, so a spirometer cannot see it, and both FRC (ERV + RV) and TLC (VC + RV) contain it. Measuring them needs helium dilution or body plethysmography.
Respiratory. Drowsy after opioids on the ward. What does the gas show?
BLOOD GAS, ARTERIAL FiO₂ 0.21 37.0 °C
pH7.27↓7.35–7.45
PaCO₂7.4↑kPa4.7–6.0
PaO₂8.1↓kPa10–13
HCO₃⁻25mmol/L22–26
Base excess+1mmol/L−2 to +2
-- end of report --
Low pH with a high CO₂ is a respiratory acidosis; a normal bicarbonate means the kidneys have not had time to compensate, so it is acute. Opioid hypoventilation: review the drug chart and consider naloxone.
Anatomy. A stab wound hemisects the right side of the cord at T10, and pain and temperature are lost in the left leg. Tap the tract whose damage explains this.
Spinothalamic fibres cross within a segment or two of entering the cord, so a right-sided lesion removes pain and temperature from the left below it. Dorsal column and corticospinal fibres cross in the medulla, so vibration, proprioception and power are lost on the right.
Neurosciences. Head injury in the emergency department. What is the Glasgow Coma Scale?
EyesOpen to painE2
VerbalIncomprehensible soundsV2
MotorWithdraws from painM4
E2 + V2 + M4 = 8
E2 + V2 + M4 = 8. A GCS of 8 or less means the airway is at risk: get anaesthetics.
Acute and emergency. Adult with anaphylaxis: stridor and a falling BP. Which adrenaline do you give first?
Resuscitation Council UK: 500 micrograms IM (0.5 ml of 1 mg/ml) into the anterolateral thigh, repeated after 5 minutes if needed. IV adrenaline is for experienced specialists, and 1 mg IV is the cardiac arrest dose.
Endocrine physiology. 34-year-old woman without diabetes, found confused at work with a low glucose. Tap the result that shows the insulin did not come from her pancreas.
TestResultRange
Proinsulin is cleaved into insulin and C-peptide in equal amounts, so an insulinoma or a sulfonylurea raises both. A high insulin with a suppressed C-peptide means injected insulin, which contains no C-peptide.
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Your answers
1ECGSublingual GTN
ST elevation in II, III and aVF with reciprocal depression in I and aVL is an inferior STEMI. Hypotension with clear lungs and a raised JVP points to right ventricular involvement, which is preload dependent: nitrates can drop the BP profoundly. Give fluid, record V4R and get the patient to the cath lab.
2Action potentialPhase 2
Phase 2, the plateau: L-type calcium channels let Ca²⁺ in while K⁺ leaves, holding the membrane depolarised. Fast sodium channels stay inactivated until repolarisation, so the refractory period outlasts most of the contraction and beats cannot summate.
3Rhythm stripPermanent pacemaker, with temporary pacing until it is in
P waves march through at their own rate and the broad, slow QRS complexes ignore them: complete heart block. A broad escape rhythm carries a risk of asystole, so this needs pacing (transcutaneous or transvenous now) and a permanent pacemaker. Amiodarone and adenosine slow AV conduction further.
4Fluids1.2 to 1.5 litres
NICE gives 25 to 30 ml/kg/day for routine maintenance, but advises considering less, 20 to 25 ml/kg/day, for people who are older or frail or have heart or kidney failure. For 60 kg that is 1.2 to 1.5 litres; 1.5 to 1.8 litres is the standard adult rate.
5Lung volumesResidual volume
Residual volume never leaves the lungs, so a spirometer cannot see it, and both FRC (ERV + RV) and TLC (VC + RV) contain it. Measuring them needs helium dilution or body plethysmography.
6Blood gasAcute respiratory acidosis
Low pH with a high CO₂ is a respiratory acidosis; a normal bicarbonate means the kidneys have not had time to compensate, so it is acute. Opioid hypoventilation: review the drug chart and consider naloxone.
7Spinal cordSpinothalamic tract
Spinothalamic fibres cross within a segment or two of entering the cord, so a right-sided lesion removes pain and temperature from the left below it. Dorsal column and corticospinal fibres cross in the medulla, so vibration, proprioception and power are lost on the right.
8GCS8
E2 + V2 + M4 = 8. A GCS of 8 or less means the airway is at risk: get anaesthetics.
9Emergency drugs500 micrograms IM
Resuscitation Council UK: 500 micrograms IM (0.5 ml of 1 mg/ml) into the anterolateral thigh, repeated after 5 minutes if needed. IV adrenaline is for experienced specialists, and 1 mg IV is the cardiac arrest dose.
10BloodsC-peptide
Proinsulin is cleaved into insulin and C-peptide in equal amounts, so an insulinoma or a sulfonylurea raises both. A high insulin with a suppressed C-peptide means injected insulin, which contains no C-peptide.
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