UK Medical Licensing Assessment (UKMLA) General Practice, Primary Care and Population Health Syllabus

What is 'social prescribing' and give two examples of what a link worker might connect a patient to.

Social prescribing connects patients to non-clinical community services to address social, emotional or practical needs. Examples: exercise/walking groups, befriending or peer-support groups, debt or housing advice, arts or volunteering activities.

According to NICE, what blood pressure target is used for treating hypertension in patients under 80 in primary care (clinic reading)?

A clinic target below $140/90\ \text{mmHg}$ (and below $135/85\ \text{mmHg}$ on home/ambulatory monitoring). For patients aged 80 and over, the clinic target is below $150/90\ \text{mmHg}$.

What is the standard HbA1c target for most adults with type 2 diabetes managed on lifestyle or a single non-hypoglycaemic agent?

$48\ \text{mmol/mol}$ ($6.5\%$). For those on a drug with hypoglycaemia risk (e.g. sulfonylurea) the target is $53\ \text{mmol/mol}$ ($7.0\%$).

Which cardiovascular risk tool does NICE recommend for primary prevention, and at what 10-year risk is a statin offered?

QRISK3. Atorvastatin $20\ \text{mg}$ is offered for primary prevention when the 10-year cardiovascular risk is $\geq 10\%$.

How is eGFR conceptually used to stage chronic kidney disease, and what value indicates Stage 3a?

eGFR estimates glomerular filtration rate from creatinine, age and sex. CKD is staged G1-G5; Stage G3a corresponds to an eGFR of $45$-$59\ \text{mL/min/1.73 m}^{2}$, combined with an albuminuria (ACR) category.

What first-line drug class is now recommended in addition to metformin for type 2 diabetics with established CVD, heart failure or high CV risk?

An SGLT2 inhibitor (e.g. empagliflozin, dapagliflozin), which provides cardiovascular and renal protection independent of glucose lowering.

What are the five core domains assessed in a Comprehensive Geriatric Assessment (CGA)?

Medical (diagnoses, medications, nutrition), functional (ADLs/IADLs, mobility, falls), psychological (cognition, mood), social (support, carers, finances), and environmental (home safety, equipment).

What are the classic 'geriatric giants' described by Bernard Isaacs?

The four I's: Immobility, Instability (falls), Incontinence, and Impaired intellect/memory (confusion - delirium and dementia). Iatrogenesis is often added as a fifth.

Differentiate the typical onset and course of delirium versus dementia.

Delirium: acute/fluctuating onset over hours-days, impaired attention/consciousness, often reversible with an underlying cause. Dementia: insidious onset over months-years, progressive, consciousness usually preserved until late, chronic and irreversible.

Define 'frailty' and name a commonly used clinical grading scale.

Frailty is a state of increased vulnerability to poor resolution of homeostasis after a stressor, increasing the risk of adverse outcomes (falls, disability, admission, death). The Clinical Frailty Scale (Rockwood, 1-9) is commonly used; Fried's phenotype is an alternative.

List the five components of the Fried frailty phenotype.

Unintentional weight loss, self-reported exhaustion, weakness (reduced grip strength), slow walking speed, and low physical activity. Three or more = frail; one to two = pre-frail.

What are the four pillars (5 M's) of comprehensive care addressed in frailty/geriatric medicine?

Mind (cognition, mood, delirium), Mobility (falls, gait), Medications (polypharmacy, deprescribing), Multicomplexity (multimorbidity, biopsychosocial), and what Matters Most (patient goals and preferences).

How are pressure ulcers staged (Categories I-IV)?

Category I: non-blanchable erythema of intact skin. II: partial-thickness loss involving epidermis/dermis (shallow ulcer/blister). III: full-thickness skin loss with visible subcutaneous fat. IV: full-thickness loss exposing muscle, tendon or bone.

Name a validated risk-assessment tool for pressure ulcers and four key risk factors it captures.

The Waterlow score (or Braden scale). Risk factors include immobility, reduced sensation, malnutrition, moisture (incontinence), shear/friction, poor perfusion, and older age.

What are the SSKIN bundle elements for pressure ulcer prevention?

Surface (suitable support/mattress), Skin inspection (regular), Keep moving (repositioning), Incontinence/moisture management, and Nutrition/hydration.

What is the WHO analgesic ladder for cancer/palliative pain?

Step 1: non-opioid (paracetamol $\pm$ NSAID) $\pm$ adjuvant. Step 2: weak opioid (e.g. codeine) $\pm$ non-opioid $\pm$ adjuvant. Step 3: strong opioid (e.g. morphine) $\pm$ non-opioid $\pm$ adjuvant. Escalate if pain persists.

When converting oral morphine to subcutaneous morphine, what conversion factor is used?

Divide the oral morphine dose by 2 (oral to subcutaneous morphine ratio is approximately $2:1$). For oral morphine to subcutaneous diamorphine, divide by 3.

How is the breakthrough (rescue) dose of opioid calculated from the total daily dose?

The breakthrough dose is approximately one-sixth ($\frac{1}{6}$) of the total 24-hour opioid dose, given as immediate-release opioid as required.

Name the four common symptoms managed in the last days of life and a typical anticipatory ('just in case') medicine for each.

Pain - morphine/diamorphine; Nausea/vomiting - haloperidol or levomepromazine; Respiratory secretions ('death rattle') - hyoscine butylbromide or glycopyrronium; Agitation/restlessness - midazolam.

List four recognised signs that a patient may be entering the last days of life.

Progressive deterioration/profound weakness, becoming bed-bound, increasing drowsiness/reduced consciousness, reduced oral intake (unable to take food/fluids or oral medication), Cheyne-Stokes breathing, and peripheral cyanosis/mottling.

What is an Advance Decision to Refuse Treatment (ADRT) and when is it legally binding in England/Wales?

An ADRT is a legally binding statement, made while the person has capacity, refusing specified treatments in defined future circumstances. To refuse life-sustaining treatment it must be in writing, signed, witnessed, and explicitly state it applies even if life is at risk.

Distinguish an ADRT from an Advance Statement and from a Lasting Power of Attorney (health and welfare).

ADRT: legally binding refusal of specific treatment. Advance Statement: a non-binding statement of wishes/preferences/values that informs best-interests decisions. LPA (health & welfare): a person legally appointed to make health decisions when the patient lacks capacity.

What does 'Preferred Place of Care/Death' documentation aim to achieve in advance care planning?

To record where a patient would like to receive care and to die (e.g. home, hospice, care home, hospital), so that care can be coordinated to honour those wishes where clinically possible.

What is a ReSPECT form / DNACPR decision, and does CPR status require patient consent?

ReSPECT records personalised recommendations for care in an emergency including CPR. A DNACPR is a clinical decision; CPR cannot be demanded if clinically futile, but the patient (or those close to them if they lack capacity) must be informed/consulted about the decision.

What are the five stages of grief described by Kubler-Ross?

Denial, Anger, Bargaining, Depression, and Acceptance. These are not linear and not everyone experiences all stages.

Distinguish normal grief from prolonged grief disorder (complicated grief).

Normal grief gradually eases over months with intermittent acute pangs. Prolonged grief disorder involves persistent, pervasive grief (typically beyond 6-12 months) with intense yearning, preoccupation, and functional impairment that does not improve, warranting specialist support.

In bereavement support, what practical and emotional support can a GP offer a recently bereaved family?

Acknowledge the loss and offer condolences, provide information on practical matters (death certification, registration), signpost bereavement services (e.g. Cruse), identify those at risk of complicated grief, and arrange follow-up; consider needs of bereaved children.

What red flags in a child with fever should prompt urgent assessment (NICE traffic light 'red' features)?

Non-blanching rash, neck stiffness/bulging fontanelle, status epilepticus or focal seizures, pale/mottled/blue skin, weak/high-pitched/continuous cry, reduced consciousness, grunting, tachypnoea with severe recession, and age under 3 months with temperature $\geq 38^{\circ}\text{C}$.

What is the recommended structured approach to a medication review in polypharmacy (e.g. the 7-Steps / NO TEARS)?

Review aims/goals, identify essential drugs, identify unnecessary drugs, assess effectiveness, evaluate safety (interactions/side effects, ADRs), assess cost-effectiveness, and ensure the regimen is acceptable/agreed with the patient (shared decision-making and deprescribing).

What is the BMI formula and the WHO cut-off defining obesity?

$BMI = \dfrac{\text{weight (kg)}}{[\text{height (m)}]^{2}}$. Obesity is defined as $BMI \geq 30\ \text{kg/m}^{2}$; overweight is $25$-$29.9\ \text{kg/m}^{2}$ (lower thresholds apply for South Asian populations).