A smarter way to study medicine
Medicine is complex. Your learning shouldn't be
Inside SA Note
What you get with SA Note
Notes, questions, flashcards, mock exams and a tutor, all built on the same content. Every card below opens the part of the page that shows it working.
Knowledge bank
A knowledge bank covering the whole curriculum
Every topic follows the same systematic structure, taking you from the underlying mechanism through to how it presents, how it is investigated and how it is managed, so you understand a condition end to end rather than memorising isolated facts.
Mapped to the MLA content map and still expanding. Every topic comes with its own questions, and you can turn any part of it into flashcards.
Question bank
Every option explained, not just the right one
Questions in the format you will sit, each one tied to a topic in the knowledge bank you can open and read. Try one.
- Tutor, timed or full exam conditions
- Build a set from unseen, incorrect or flagged questions
- Highlight any explanation and ask Sal about it
A 19-year-old with type 1 diabetes has been vomiting for two days and has abdominal pain. Capillary glucose 28 mmol/L, capillary ketones 4.2 mmol/L, pH 7.18, bicarbonate 11 mmol/L, potassium 5.4 mmol/L. He is drowsy, with dry mucous membranes and a capillary refill of 4 seconds.
What is the most appropriate immediate management?
Pick an option. All 5 questions are live.
Flashcards
Flip it, grade it, and it comes back on time
Spaced repetition, built in. How well you knew a card decides when you see it again. This is the real thing, with real cards. Run a few.
Free on every planMake cards from wherever you are
- Highlight anything in a topic
- Ask Sal for a deck on a topic
- Turn one of your notes into cards
- Write your own
- Import your Anki decksComing soon
Coming back
Sal
Sal, your personal tutor
Highlight the line you are stuck on and get it explained from the same notes you are reading, with the topic it came from named underneath.
No tab switching, no searching, no answer pulled off the open internet.
Pulmonary embolism › Investigation
A negative D-dimer excludes pulmonary embolism in a low-probability patient, but it cannot exclude it once the Wells score is above 4, which is where most people lose the mark.
Sal
Pick an action. Sal answers live.
Notes
Every note keeps the place it came from
Keep something from a topic, a question or an answer Sal gave you, and it lands in the right specialty with the source attached. Then turn it into flashcards without retyping a word.
AKI: rule out obstruction first
Rule out obstruction before treating it as pre-renal. Bladder scan early, and a renal ultrasound within 24 hours if obstruction is possible, within 6 hours if you suspect infection above it. Then assess fluid status, stop the nephrotoxics, dip the urine and repeat the U&Es daily.
Filed under Renal
Study planner
Open the app. The decision is already made
Give it your exam date and it builds the whole run backwards from there, then hands you three things each morning. Fall behind and it rebuilds itself around you.
16
weeks to go
22
questions a day
97%
covered by exam day
Change the date. Everything below redraws.
Today
About 56 minThree things, already decided. Nothing to plan.
- 22 questionsCardiovascular · Respiratory24m
- Diabetic ketoacidosisOne topic, read end to end25m
- 18 flashcards dueSpaced repetition7m
Endocrine is your weakest system, so I've front-loaded it while there's still time to fix it.
Today to exam day
16 weeks, mapped out
Mini mocks at weeks 8, 11 and 14, then both full papers in the final fortnight.
Progress
It tells you what to fix next
Every answer feeds one list: the topics you get wrong most, worst first, with the way back into each of them already lined up. Pick one and see.
What to fix next
Worst first
The order changes as you answer. Get a topic right often enough and it drops off this list on its own.
Your way back into
Acute kidney injury
You keep picking fluids before checking for obstruction.
- The topic page, in high-yield or in full
- 18 questions you have not seen
- 6 flashcards in your deck
74%
overall accuracy, up 9 points this month
Mock exams
Sit the paper before you sit the paper
Full AKT papers end to end, under the same conditions. Nothing is marked until you submit, and then you get your score against the pass mark and where it sits in the cohort.
- Paper 1 and Paper 2 in full, or a shorter mini
- Timed, flaggable, and no feedback until you submit
- Marked against the pass mark, not a percentage
AKT Paper 1
100 questions, timed, submitted
0
out of 100, against a pass mark of 58Plotted against everyone else who sat the same paper, so you know where you stand rather than only what you scored.
Group study
Practise together in real time wherever you are
One room code, one question, everyone answering at once on their own device. Nobody has to be in the same building, or the same country.
- Up to 100 people in one room
- Join from any device, anywhere
- Free on every plan
Cardiovascular
A 68-year-old woman has had 40 minutes of central chest pain. Her ECG shows 2 mm of ST elevation in leads II, III and aVF. The nearest primary PCI centre is 45 minutes away. What is the most appropriate immediate management?
Pick an option to join the round.
High-yield mode
Two ways to read every topic
Flip the switch and the topic drops to the facts that come up in questions. Flip it back for the full page, which is where the understanding comes from. Same topic, written once. Try it.
1,150words
on the page
6mins
to read it
8of 8
sections kept
Pulmonary embolism
Respiratory
Overview
- Occlusion of the pulmonary arterial tree, almost always by thrombus that has embolised from a deep vein of the leg or pelvis.
- Sits on a spectrum with deep vein thrombosis, and the two are managed as one disease process under the heading of venous thromboembolism.
- Untreated, mortality approaches 30%. Treated promptly, it falls to around 8%, which is why empirical anticoagulation while you wait for imaging is standard practice.
- Diagnosis rests on pretest probability rather than on any single test, which is why the Wells score comes before imaging in every UK pathway.
- Around a third of cases are found incidentally on imaging requested for something else, most often staging CT in a patient with cancer.
- Guidelines prefer the term venous thromboembolism because prophylaxis, investigation and treatment are largely shared across both presentations.
Epidemiology
- Roughly 60 to 70 cases per 100,000 people per year in the UK, rising steeply with age and roughly doubling every decade after 40.
- Slightly more common in women of reproductive age, largely accounted for by pregnancy and combined hormonal contraception.
- Around one in ten hospital deaths has pulmonary embolism as a contributing factor, and most of those are not diagnosed before death.
- Provoked cases outnumber unprovoked ones, with surgery, immobility, long-haul travel and malignancy accounting for most of the provoked group.
- Incidence has risen over the last two decades, largely because CT pulmonary angiography detects small subsegmental clots that older imaging missed.
- Mortality is concentrated in the first week, and most of those deaths happen before any treatment has been started.
Pathophysiology
- Virchow's triad, stasis and endothelial injury and hypercoagulability, underpins every risk factor you will be asked about.
- Obstruction raises pulmonary vascular resistance, which dilates the right ventricle and, in a large embolus, drops cardiac output.
- Released mediators including serotonin and thromboxane cause reflex bronchoconstriction and worsen ventilation-perfusion mismatch beyond the vessel that is physically blocked.
- Infarction of lung tissue is uncommon because of the dual blood supply from the bronchial arteries, which is why a normal chest radiograph does not exclude the diagnosis.
- Right ventricular strain is the mechanism behind almost every abnormal sign you will be asked to interpret, from the raised JVP to the ECG changes.
- A saddle embolus straddling the bifurcation of the main pulmonary artery is the classic finding in a massive embolus, though most fatal emboli are smaller and multiple.
- Hypoxaemia comes from mismatch and from shunting through collapsed lung, not from the obstruction alone, which is why oxygen by itself rarely corrects it.
- Small peripheral emboli can produce a wedge-shaped area of infarction, described as Hampton's hump when it is visible on the plain film.
Presentation
- Sudden pleuritic chest pain, dyspnoea and tachycardia. Haemoptysis in a minority, and often a silent deep vein thrombosis sitting behind it.
- Massive pulmonary embolism presents as syncope or shock with hypotension, and is the presentation that changes your management.
- Low-grade pyrexia is common and regularly leads to an initial working diagnosis of chest infection.
- Tachycardia with a normal chest radiograph in a breathless patient should move pulmonary embolism to the top of your list rather than off it.
- Signs are unreliable. A normal respiratory rate, a normal oxygen saturation and a clear chest are all compatible with a significant embolus.
- In older patients the presentation is frequently a fall, confusion or a decompensation of existing heart failure rather than chest pain.
- A pleural rub and a pleural effusion both occur, and an effusion is present in roughly a third of cases.
Investigation
- Wells score first. Above 4, go straight to CTPA. Four or below, send a D-dimer and only image if it is raised.
- A negative D-dimer in a low-probability patient rules the diagnosis out. It cannot rule it out in a high-probability patient, which is the trap in most exam questions.
- V/Q scanning replaces CTPA in renal impairment, contrast allergy and pregnancy.
- ECG most often shows sinus tachycardia. The S1Q3T3 pattern is classic, examined constantly and genuinely uncommon.
- Arterial blood gas typically shows type 1 respiratory failure with a low carbon dioxide from hyperventilation.
- CTPA is first-line in the UK. It confirms the diagnosis directly, shows the clot burden, and offers an alternative diagnosis when it is negative.
- A raised D-dimer is not a diagnosis. It rises in infection, malignancy, pregnancy and after surgery, so it is only ever useful as a rule-out test.
- Troponin and brain natriuretic peptide are prognostic rather than diagnostic, and a rise in either marks out the patient who needs closer monitoring.
- Bedside echocardiography has a role in the shocked patient who is too unstable for the scanner, where right ventricular dilatation supports thrombolysis.
- The PERC rule can exclude the diagnosis without any test at all in a genuinely low-risk patient, though it is applied less often in UK practice.
Management
- Anticoagulate with a DOAC, apixaban or rivaroxaban, started immediately and before imaging if suspicion is high.
- Thrombolyse only if the patient is haemodynamically unstable. Alteplase, and accept the bleeding risk.
- Three months of anticoagulation if there was a reversible provoking factor. Longer, often indefinitely, if it was unprovoked.
- Low molecular weight heparin rather than a DOAC in pregnancy and in active cancer with a gastrointestinal primary.
- Anticoagulation should not wait for the scan when clinical suspicion is high, because the delay costs more than the treatment risks.
- Catheter-directed thrombolysis and surgical embolectomy are reserved for patients in whom systemic thrombolysis has failed or is contraindicated.
- An inferior vena cava filter is considered only when anticoagulation is genuinely contraindicated, and it should be retrieved once it is not.
- Outpatient management is appropriate for low-risk patients selected with a validated score such as the simplified PESI.
- Warfarin remains the drug of choice in antiphospholipid syndrome and in severe renal impairment, where the DOAC evidence is thin.
Complications
- Chronic thromboembolic pulmonary hypertension in around 3% of survivors, and worth suspecting in anyone still breathless months later.
- Recurrence, right heart failure, and bleeding as a consequence of the treatment rather than the disease.
- Anyone still breathless three months after treatment needs an echocardiogram, because chronic thromboembolic pulmonary hypertension is treatable and easily missed.
- Post-thrombotic syndrome affects the leg rather than the lung, but it arises from the same episode and is a common source of ongoing morbidity.
- Recurrence after stopping treatment runs at around 10% in the first year for unprovoked disease, which is what drives the indefinite-treatment decision.
History and eponyms
- Described by Rudolf Virchow in 1856 following his work on venous thrombosis in Berlin, which is where the triad takes its name from.
- The Wells score was published by Philip Wells in 1998 and has been revised several times since, including a simplified two-level version.
- The D-dimer assay entered routine practice in the 1990s, and its low specificity has been a source of unnecessary imaging ever since.
- Virchow's own account described the mechanism decades before any imaging existed to demonstrate it in a living patient.
The full topic: 55 lines across 8 sections.
How it works
The same four steps for every topic
Read the topic, answer questions on it, turn what caught you out into flashcards, then sit a mock exam. Anything you get wrong comes back around.
Presentation
- Sudden pleuritic chest pain, dyspnoea and tachycardia.
- Haemoptysis in a minority. Often a silent DVT behind it.
Investigation
- Wells score first. Above 4 go straight to CTPA.
- Four or below: D-dimer, and only image if raised.
32-year-old, pleuritic chest pain after a long-haul flight. Wells score 6.
Most appropriate next investigation?
Why not. Wells above 4 already makes PE likely, so a negative D-dimer cannot rule it out.
Correct. Above a Wells of 4, CTPA is first-line and confirms the diagnosis directly.
Answer
Triad of nephrotic syndrome
- Proteinuria over 3.5 g in 24 hours
- Hypoalbuminaemia
- Oedema
Again
1d
Hard
3d
Good
8d
Easy
21d
Rate it and the next sighting schedules itself.
A 48-year-old has a thunderclap headache. Non-contrast CT at 8 hours is normal.
- AImmediate CT head
- BLumbar puncture at 12 hours
- CCT angiogram
Answers lock when you submit. Feedback is held until you finish the paper.
The difference
How SA Note compares
Most people end up paying for a question bank, a flashcard app and a set of notes separately.
| Feature | Typical question bank | Flashcard apps | SA Note |
|---|---|---|---|
| Structured knowledge bank | No | No | Yes |
| Reasoning on every option | Yes | No | Yes |
| Spaced repetition flashcards | No | Yes | Yes |
| Mapped to the MLA content map | Yes | No | Yes |
| High-yield mode | No | No | Yes |
| Mock exams marked against the pass mark | No | No | Yes |
| Live multiplayer questions | No | No | Yes |
| A study plan built from your exam date | No | No | Yes |
| An AI tutor that works from the notes | No | No | Yes |
| Notes you can capture into from anywhere | No | No | Yes |
| Import your Anki decks | No | Yes | Coming soon |
| Shared decks from other students | No | Yes | No |
| Offline mode | No | Yes | Coming soon |
| Native mobile apps | Yes | Yes | Coming soon |
| A year of it | £££ | ££ | Free, or £39.99 |
Pricing
Free to start. The price of a coffee per month for the rest
One subscription, no add-ons, cancel whenever you like.
Free
£0
No card. It never expires.
- Knowledge bank10 topics a week
- Question bank20 questions a week
- Mock examsThe free sample paper
- High-yield modeNot on Free
- Study planNot on Free
- Sal, the AI tutorNot on Free
- ProgressNot on Free
- FlashcardsIn full
- Group studyIn full
Premium
£3.33a month
£39.99 billed once a yearSave £19.89, 33%
- Knowledge bankEvery topic
- Question bankThe whole bank
- Mock examsPaper 1, Paper 2 and every mini
- High-yield modeOn every topic
- Study planIncluded
- Sal, the AI tutorOn every page
- ProgressIncluded
- FlashcardsIn full
- Group studyIn full
Cancel whenever you like. Weekly counts reset every Monday.
UKMLA & AKT revision questions
Common questions about the UKMLA Applied Knowledge Test and about SA Note.
Everything, for a year
£3.33a month
Billed £39.99 once a year. About what one coffee costs, once a month.
Or start free, and see if it suits you
The free plan does not expire and does not ask for a card.
Cancel whenever. No card needed to start.
Coming soon to the App Store and Google Play
SA Note works in any browser today, on a phone as well as a laptop.