Internal Medicine Knowledge Library
Presentation-by-presentation guides written to be said out loud — the investigations, the decisions and the guideline behind each one, mapped to the IMT clinical station.
Acute Medicine
Acute Stroke and Thrombolysis Windows: 4.5 Hours, 6 Hours and 24 Hours
NICE NG128 sets three windows in acute ischaemic stroke: thrombolysis with alteplase or tenecteplase within 4.5 hours of symptom onset, thrombectomy within 6 hours for proximal anterior circulation occlusion, and thrombectomy up to 24 hours where imaging shows salvageable brain.
Alcohol Withdrawal: Who to Admit, Symptom-Triggered Benzodiazepines and Wernicke's
NICE CG100 admits anyone in, or at high risk of, alcohol withdrawal seizures or delirium tremens, treats with a symptom-triggered benzodiazepine regimen scored on a tool such as CIWA-Ar, gives parenteral thiamine for a minimum of 5 days if Wernicke's is suspected, and never uses phenytoin for withdrawal seizures.
Anaphylaxis: Adrenaline 500 Micrograms IM, the Five-Minute Repeat and Refractory Anaphylaxis
Anaphylaxis is a sudden-onset, life-threatening airway, breathing or circulation problem, treated with 500 micrograms of intramuscular adrenaline into the anterolateral thigh, repeated after 5 minutes if there is no improvement, per Resuscitation Council UK 2021.
Bacterial Meningitis: The Red Flag Combination, Antibiotics Within an Hour and When Not to Tap
NICE NG240 asks you to strongly suspect bacterial meningitis in anyone with the red flag combination of fever, headache, neck stiffness and altered consciousness or cognition, and to give intravenous antibiotics within 1 hour of arrival in hospital.
Delirium and the Frail Patient
Delirium is an acute, fluctuating disturbance of attention and cognition with an underlying cause. NICE CG103 asks you to screen anyone aged 65 or over, cognitively impaired, with a hip fracture or severely ill, assess with the 4AT, and treat the cause before the behaviour.
Paracetamol Overdose
Paracetamol overdose is managed by timing the ingestion, taking a level at four hours or later, plotting it against the 100 mg/litre treatment line and starting acetylcysteine without waiting for the level when the timing is staggered or unknown. The BNF summary of TOXBASE guidance carries every threshold.
Seizure and Status Epilepticus: The Five-Minute Rule and the Benzodiazepine Ladder
NICE NG217 defines convulsive status epilepticus as seizures lasting 5 minutes or more, treats it with a benzodiazepine immediately, a second dose if the seizure has not stopped within 5 to 10 minutes, and then intravenous levetiracetam, phenytoin or sodium valproate.
Sepsis and NEWS2: Recognition, the First Hour and Escalation
NEWS2 is a track-and-trigger tool, not a diagnosis; suspect sepsis in any patient with likely infection and a NEWS2 of 5 or more, and deliver the first-hour bundle while escalating.
Cardiology
Acute Coronary Syndrome: The ECG, the Troponin and the Reperfusion Clock
NICE NG185 turns STEMI into a clock: offer primary PCI if the patient presents within 12 hours of symptom onset and PCI can be delivered within 120 minutes of the time when fibrinolysis could have been given, and offer fibrinolysis if it cannot.
Acute Heart Failure: Natriuretic Peptides, Intravenous Diuretics and What NICE Says Not to Give
NICE CG187 rules out new acute heart failure with a BNP below 100 ng/L or NT-proBNP below 300 ng/L, treats with intravenous loop diuretic as a bolus or infusion, does not routinely offer opiates, nitrates or inotropes, and reserves non-invasive ventilation for cardiogenic pulmonary oedema with severe dyspnoea and acidaemia.
Hypertensive Emergency: 180/120, Accelerated Hypertension and Same-Day Referral
NICE NG136 says a clinic blood pressure of 180/120 mmHg or higher with retinal haemorrhage or papilloedema, or with life-threatening symptoms such as new onset confusion, chest pain, signs of heart failure or acute kidney injury, needs specialist assessment carried out the same day.
New-Onset Atrial Fibrillation: The 48-Hour Rule, Rate Versus Rhythm and Stroke Risk
NICE NG196 splits new-onset atrial fibrillation on one number: under 48 hours from onset you may offer either rate or rhythm control, and over 48 hours or uncertain you offer rate control, with cardioversion delayed until three weeks of therapeutic anticoagulation.
Respiratory
Acute Asthma: The Severity Table, Oxygen Targets and Who Goes to Intensive Care
Acute severe asthma in adults is any one of a peak flow of 33 to 50% of best or predicted, a respiratory rate of 25 per minute or more, a heart rate of 110 per minute or more, or inability to complete a sentence in one breath.
COPD Exacerbation: Controlled Oxygen, Prednisolone 30 mg and the Case for NIV
NICE NG115 recommends 30 mg oral prednisolone daily for 5 days in a COPD exacerbation, and non-invasive ventilation as the treatment of choice for persistent hypercapnic ventilatory failure despite optimal medical therapy.
Community-Acquired Pneumonia and CURB-65: The Score, the Four-Hour Targets and the New Steroid
NICE NG250, which replaced NG138 in September 2025, keeps CURB65 in hospital and adds two four-hour targets: chest X-ray within 4 hours of presentation, and antibiotics within 4 hours of presentation.
Pulmonary Embolism and Wells Scoring: More Than 4 Points, and What Follows
NICE NG158 splits suspected pulmonary embolism on the two-level Wells score: more than 4 points is PE likely and goes to immediate CTPA, and 4 points or less is PE unlikely and goes to a D-dimer with the result available within 4 hours.
Gastroenterology
Acute Liver Failure and Decompensated Cirrhosis: The BSG/BASL Six-Hour Bundle and When to Call the Transplant Unit
Decompensated cirrhosis is jaundice, ascites, encephalopathy or suspected variceal bleeding in a known cirrhotic, managed with the BSG/BASL first-six-hours bundle; acute liver failure is coagulopathy with an INR above 1.5 and encephalopathy in a previously normal liver, discussed with a transplant unit early.
Acute Pancreatitis: Diagnosis, Fluids, No Prophylactic Antibiotics and Feeding Within 72 Hours
Acute pancreatitis is confirmed by a raised lipase or amylase, or CT if they are not raised; NICE NG104 says do not give prophylactic antimicrobials, do not keep patients nil by mouth without a clear reason, and start enteral nutrition within 72 hours in moderately severe or severe disease.
Acute Upper GI Bleeding: Risk Scores, Resuscitation and Endoscopy Timing
Score every upper GI bleed with the Glasgow-Blatchford score at first assessment; a score of 0 can be considered for early discharge without inpatient endoscopy, and unstable patients go to endoscopy immediately after resuscitation.
Endocrine
Diabetic Ketoacidosis: Diagnosis, Fixed-Rate Insulin and the Traps
DKA needs all three of ketonaemia, acidosis and hyperglycaemia (or known diabetes); treat with fluid first, then fixed-rate insulin at 0.1 units/kg/hr, and continue long-acting insulin throughout.
Hypercalcaemia: Severity Bands, Saline First and When Bisphosphonates Work
Adjusted calcium above 3.5 mmol/L needs urgent correction: intravenous 0.9% saline 4 to 6 litres in 24 hours first, then zoledronic acid 4 mg over 15 minutes, with the calcium nadir arriving 2 to 4 days later.
Hyponatraemia: Symptoms, Hypertonic Saline and the Correction Limits
Society for Endocrinology 2022 guidance says hyponatraemia is treated on the patient's symptoms rather than the sodium number: 150 mL of 3% hypertonic saline over 20 minutes, repeated until serum sodium rises by 5 mmol/L, then a limit of 10 mmol/L in the first 24 hours.
Renal
Acute Kidney Injury: Staging, the Reversible Causes and When to Call Renal
Stage AKI on creatinine rise or urine output, work through pre-renal, renal and post-renal causes, and know the four indications for urgent dialysis by heart.
Hyperkalaemia: Severity, Protecting the Heart and the Five Steps
The UK Kidney Association's October 2023 guideline defines hyperkalaemia as a serum potassium of 5.5 mmol/L or above, severe at 6.5 mmol/L or above, and sets out a five-step approach: assess arrhythmia risk, protect the heart, shift potassium into cells, remove it from the body, then prevent recurrence.
Ethics and Professionalism
Capacity and the Mental Capacity Act
A capacity answer at the IMT interview has two parts: the Mental Capacity Act 2005's two-stage test (an impairment of the mind or brain, and an inability to understand, retain, use or weigh, or communicate) and its five principles, starting with the presumption of capacity. GMC Decision making and consent 2020 turns that law into what you say.
Confidentiality
GMC Confidentiality 2017 says the duty is important but not absolute: you may disclose with consent, for a patient who lacks capacity when it is of overall benefit, when the law requires it, or in the public interest to prevent death or serious harm. The interview answer is that framework, applied to one request.
DNACPR and ReSPECT Conversations
GMC end-of-life guidance says a recorded DNACPR decision is not in itself legally binding, and is a clinical assessment made in advance by the person with lead responsibility for the patient's care. ReSPECT places that CPR recommendation inside a wider, also non-legally binding, plan for emergency treatment.
Duty of Candour
There are two duties of candour: a professional one on you, set out in the GMC and NMC joint guidance, and a statutory one on the organisation, set out in Regulation 20 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The interview answer names both and applies the professional one.
The SBAR Handover
NHS England describes SBAR as situation, background, assessment and recommendation, a structured way of communicating information that requires a response from the receiver. At the IMT interview it is the shape of the one-minute handover that closes station 2, scored as its own domain at a weighting of 0.8.
The Struggling Colleague
GMC Good medical practice 2024 paragraph 51 gives the whole answer in two sentences: you must be compassionate towards colleagues who have problems with their performance or health, but you must put patient safety first at all times.
FAQ
What is the Internal Medicine Knowledge Library?
Free guides to the acute presentations the IMT interview's clinical station draws on, written to be said out loud: the investigations, the decisions and the guideline behind each one. No account is needed.
How does it help with the IMT interview?
The guides cover the clinical reasoning behind the station's scenarios. The question bank turns the same presentations into full practice stations with model answers.