Medical Licensing (MD/DO) · Independent exam preparation
PLAB Applied Knowledge Guide: Safe Decisions for UK Practice Study Guide
Practise urgent clinical decisions, selected continuing care, prevention, consent, prescribing and procedural safety for PLAB, with 60 focused concepts, explained questions and active-recall cards.
By CertMedbry · Updated 20 October 2026
Recognise time-critical illness, distinguish plausible diagnoses and choose safe next actions while practising consent, confidentiality and procedural safety. This guide follows a PLAB 1-oriented applied-knowledge pathway for doctors who qualified abroad, with communication and practical principles that also support preparation for PLAB 2. Its 60 selected concepts sample all six domains; the official MLA content map defines the full scope.
Try 20 free practice questionsWhat is the exam format?
Check the question types, timing and outline before planning your revision.
Which examination and pathway does this guide cover?
It covers the GMC Professional and Linguistic Assessments Board test for doctors who qualified abroad and are seeking UK practice. The learning pathway emphasises PLAB 1 applied knowledge, including acute illness and continuing care. PLAB 2 assesses clinical and professional performance and requires additional observed practice.
Professional and Linguistic Assessments Board · PLAB and the MLA
Has PLAB been renamed the MLA?
No. GMC confirms that PLAB retains its name. PLAB 1 meets MLA Applied Knowledge Test requirements, and PLAB 2 meets Clinical and Professional Skills Assessment requirements.
Which content-map version applies?
The governing map was published in October 2025, updated in September 2026 and applies to assessments from September 2026 onwards. The September update replaces PCOS with Polyendocrine Metabolic Ovarian Syndrome, abbreviated PMOS. Use the September 2026 update when planning study.
Are official domain percentages available?
The current content map supplies no percentage weights for its six interconnected domains. This guide therefore uses an educational allocation across all six, without claiming an official examination distribution. The conditions list is non-exhaustive, and these 60 concepts do not replace the full map.
MLA content map — September 2026 update · About the MLA content map
How many questions or scenarios are there, and how long do the examinations take?
PLAB 1 has 180 multiple-choice questions, each with five answer options, completed within three hours. PLAB 2 has 16 scenarios lasting eight minutes each; the whole examination takes approximately three hours, including movement and rest stations. The 20 four-option questions here are independent learning drills and differ from the five-option PLAB 1 format. Check current GMC candidate instructions before attending.
Professional and Linguistic Assessments Board · How will you be tested?
How does PLAB 2 assess performance?
GMC describes three marking areas for each scenario: information gathering and technical assessment, clinical management, and interpersonal performance. These marking areas are distinct from the six content-map domains. Preparation should combine clinical reasoning with observed communication, examination and procedural practice.
PLAB retains its name: PLAB 1 meets MLA Applied Knowledge Test requirements and PLAB 2 meets Clinical and Professional Skills Assessment requirements. These independently authored learning materials are not GMC examination items or endorsed resources.
Outline used: Verified on 2026-10-10. The generic workbook label 'General Medical Council (GMC) Registration Exams (UK)' is mapped to the GMC's Professional and Linguistic Assessments Board (PLAB) test, comprising PLAB 1 and PLAB 2. GMC confirms that PLAB retains its name and meets the MLA AKT and CPSA requirements respectively. Governing outline: MLA content map, published October 2025, last updated September 2026, applicable to assessments from September 2026 onwards. Assigned slug 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 should acute-care decisions respond to physiological instability?
Acute care begins by recognising threats to breathing, circulation or consciousness and acting while assessment continues. A plausible diagnosis does not make an unstable patient safe to investigate routinely. Severe breathlessness, collapse or reduced responsiveness changes the urgency of the same symptom. The key decision is whether immediate emergency support is needed before a detailed history, while keeping several possible causes open until discriminating information becomes available.
Apply it
A patient describing pleuritic pain becomes faint and markedly breathless during assessment. Stop the routine history, summon emergency help and reassess immediate physiological threats while arranging urgent evaluation of the suspected cause and competing diagnoses.
Common pitfall: Completing every historical detail first can delay treatment. Diagnostic uncertainty should broaden assessment without lowering the urgency created by physiological deterioration.
Pulmonary embolism · MLA content map — September 2026 update
2.How do cardiovascular assessments distinguish infarction from cardiac arrest?
A heart attack involves interruption of blood supply to heart muscle; cardiac arrest means the heart has stopped pumping blood effectively. A patient with a heart attack may remain conscious and breathing, whereas an unresponsive person who is not breathing normally requires immediate resuscitation action. ECG and blood tests help assess suspected infarction. Recognising the physiological distinction determines whether the immediate task is emergency assessment or resuscitation.
Apply it
Two patients arrive with possible cardiac disease. One is alert with persistent chest pressure; the other has collapsed and is not breathing normally. Recognise that the second presentation demands immediate resuscitation rather than an initial diagnostic ECG.
Common pitfall: Using heart attack and cardiac arrest interchangeably obscures different immediate actions. Consciousness and normal breathing are crucial observations, not merely descriptive details.
3.How do measured bronchiolitis severity findings change referral, admission and oxygen decisions?
Assess respiratory rate and effort, intake as a proportion of usual feeds, hydration, alertness and persistent oxygen saturation in air. NICE advises considering hospital referral for respiratory rate over 60/min, intake around 50–75% of usual, clinical dehydration or persistent saturation below 92%. Apnoea, central cyanosis, serious illness or severe distress, such as grunting, marked recession or respiratory rate over 70/min, requires emergency referral. Oxygen-treatment thresholds differ: persistent saturation below 90% for otherwise healthy children aged at least six weeks, and below 92% for babies under six weeks or children with underlying health conditions.
Apply it
An otherwise healthy four-month-old has respiratory rate 64/min, takes 60% of usual feeds, has fewer wet nappies and persistent saturation 91% in air. Arrange hospital assessment; inadequate intake and dehydration may justify admission. Saturation 91% alone does not meet this child's oxygen-treatment threshold. If it falls persistently to 89%, give oxygen. A four-week-old at 91% meets the higher oxygen threshold.
Common pitfall: Referral, admission and oxygen are separate decisions. A child may need admission for feeding support without needing oxygen. Check probe placement and measurement quality, especially with borderline readings, while assessing the whole child.
Recommendations | Bronchiolitis in children: diagnosis and management | Guidance | NICE
4.How does a diabetes sick-day plan prevent ketoacidosis?
Illness can increase insulin requirements even when food intake falls. Insulin also suppresses fat breakdown and ketone production, so a person using insulin should not simply stop it because they are vomiting or eating less. A usable sick-day plan specifies continued insulin, more frequent glucose and ketone checks, hydration and routes to urgent advice. Dose adjustments should follow the individual plan. Vomiting, abdominal pain, deep breathing or drowsiness require assessment for ketoacidosis, including venous pH and bicarbonate.
Apply it
At diabetes follow-up after a vomiting illness, ask the patient to explain what they would do if unable to eat. Correct any plan to stop insulin, check access to glucose and ketone testing, and agree whom to contact if readings worsen or fluids cannot be retained.
Common pitfall: Treating insulin solely as coverage for meals overlooks its role in preventing ketone production. A written plan is ineffective if the person lacks testing supplies or cannot explain when to seek help.
Diabetic ketoacidosis · JBDS%2002%20DKA%20Guideline%20with%20qr%20code.pdf
5.How does gastrointestinal assessment interpret the appearance of vomited blood?
Haematemesis means vomiting blood and usually indicates bleeding in the upper digestive tract. Blood may appear bright red, dark or like coffee granules after exposure to stomach acid. Appearance helps identify the material but does not reliably establish that bleeding is harmless or has stopped. Assessment must also establish dizziness, faintness, black stools, abdominal symptoms and general condition because physiological impact determines the urgency of the response.
Apply it
A patient reports dark granular vomit and feels light-headed when standing. Interpret the material as possible altered blood, assess circulatory compromise and arrange urgent assessment rather than attributing the colour to food without checking.
Common pitfall: Coffee-ground appearance can tempt reassurance because the blood is not bright red. Altered blood still indicates a potentially important gastrointestinal bleed requiring assessment.
6.How should older-adult care use collateral history in sudden confusion?
A patient's usual cognition and function provide the reference point for identifying delirium. Relatives, carers and staff may establish that poor attention or unusual quietness developed over hours rather than months. Delirium may be hypoactive, with withdrawal or drowsiness, and often fluctuates. Assess interacting contributors such as infection, dehydration, pain, constipation and medicines. Listening to collateral observations does not itself require disclosing confidential clinical details.
Apply it
An older patient gives inconsistent answers and appears withdrawn. Their daughter explains that they were independently managing appointments yesterday. Establish the timing and fluctuation, review illness, intake, pain, bowel function and medicines, and respect the patient's disclosure preferences.
Common pitfall: Assuming confusion is normal ageing, or requiring agitation before considering delirium, can conceal acute illness. Finding one contributor does not exclude others.
Delirium (sudden confusion) — Overview · Using and disclosing patient information for direct care
7.How should physical treatment and psychosocial assessment be coordinated after self-harm?
Assess injury or poisoning severity and provide necessary physical treatment while arranging psychosocial assessment at the earliest opportunity. NICE advises concurrent care rather than waiting until all medical treatment is completed. Explore the episode's function, current distress, suicidal thoughts, strengths, vulnerabilities and support needs. Do not use a risk score or a global low, medium or high label to predict suicide or determine discharge. If the person cannot participate, review regularly and complete assessment as soon as possible; an alcohol level alone should not delay it.
Apply it
A patient receiving wound care after self-harm can engage in conversation. Arrange mental-health assessment alongside physical care. If intoxication prevents meaningful participation, provide immediate assistance, review participation regularly and assess as soon as possible.
Common pitfall: A superficial injury or calm appearance does not settle psychological safety. A numerical score cannot replace an individual formulation or determine who receives treatment.
Recommendations | Self-harm: assessment, management and preventing recurrence | Guidance | NICE
8.Why does neurological assessment preserve the time of symptom onset?
Sudden focal neurological symptoms require an accurate chronology because onset and resolution help define the event and guide emergency assessment. Record when symptoms began or when the patient was last known to be well, rather than only the time of arrival. Facial weakness, arm weakness and speech disturbance are key stroke warnings. Resolution does not erase urgency, so a normal examination after a recent episode must not replace the history.
Apply it
A patient's speech is normal when you arrive, but their partner describes abrupt slurring and right-arm weakness earlier that morning. Record the witnessed timing and arrange emergency assessment despite the currently reassuring appearance and examination.
Common pitfall: Documenting only the assessment time loses clinically important information. Recent resolution can falsely reassure clinicians who give the present examination more weight than the episode.
9.How should early-pregnancy assessment handle unilateral pain?
Early pregnancy with lower abdominal pain, particularly on one side, requires consideration of ectopic pregnancy. Vaginal bleeding may occur, but its absence does not exclude the diagnosis. Shoulder-tip pain can accompany internal bleeding; severe pain, dizziness or fainting increases urgency. Establish pregnancy possibility and physiological condition without requiring a prior positive home test or every textbook symptom.
Apply it
A patient with a late period develops one-sided pelvic pain, shoulder-tip discomfort and dizziness but reports no vaginal bleeding. Assess for circulatory compromise and arrange emergency assessment for possible pregnancy-related internal bleeding.
Common pitfall: Visible vaginal blood loss is an unreliable measure of concealed haemorrhage. Menstrual uncertainty or absent recognised risk factors should not prevent assessment of a compatible presentation.
10.Which findings should change an infant's working diagnosis from typical bronchiolitis?
Typical bronchiolitis follows one to three days of coryza with persistent cough, tachypnoea or recession, and wheeze or crackles. NICE advises considering pneumonia when fever exceeds 39°C or crackles are persistently focal. In older infants and young children, recurrent episodic wheeze, persistent wheeze without crackles or an atopic history favours viral-induced wheeze or early asthma; these are unusual under one year. These distinctions guide reassessment rather than justify routine antibiotics or radiography for typical bronchiolitis.
Apply it
A seven-month-old initially thought to have bronchiolitis develops a temperature of 39.5°C and persistently focal crackles. Reassess for pneumonia rather than assuming all new findings belong to the original viral airway diagnosis.
Common pitfall: A bronchiolitis label must remain open to revision. Conversely, routine chest radiographs can show changes that mimic pneumonia and should not determine antibiotic use in otherwise typical bronchiolitis.
Recommendations | Bronchiolitis in children: diagnosis and management | Guidance | NICE
11.How does renal assessment connect fluid loss with medication exposure?
Renal assessment integrates recent fluid loss, blood pressure, urine output, creatinine change and medicines. Vomiting or diarrhoea can reduce kidney perfusion, while some medicines further impair renal function during dehydration. A medication review therefore forms part of identifying contributors, not merely a later administrative task. Reduced urine output is useful, but the absence of a dramatic urinary complaint does not exclude acute kidney injury or remove the need for blood testing.
Apply it
A patient taking several regular medicines develops diarrhoea, poor intake and reduced urine output. Assess hydration, blood pressure and renal function, and review prescribed and non-prescription medicines for contributors to the deterioration and immediate prescribing risk.
Common pitfall: Attributing reduced urine solely to low intake can miss kidney injury. Medication changes should follow clinical assessment rather than blanket advice applied to every illness.
12.How does the two-level Wells pathway select D-dimer or imaging for suspected PE?
For a stable, non-pregnant adult with suspected PE, use the two-level PE Wells score: DVT signs 3; PE more likely than an alternative diagnosis 3; heart rate over 100/min 1.5; immobilisation over three days or surgery in the previous four weeks 1.5; previous DVT/PE 1.5; haemoptysis 1; active, recently treated or palliative malignancy 1. A score above 4 means PE likely: offer immediate CTPA where suitable. A score of 4 or less means PE unlikely: obtain D-dimer, proceeding to imaging if positive. Consider an age-adjusted D-dimer threshold over age 50.
Apply it
A stable adult has DVT signs and heart rate 112/min, with no other scored features: 3 + 1.5 = 4.5, so request immediate CTPA where suitable. If only tachycardia scores, the total is 1.5 and D-dimer comes first. If likely-PE imaging cannot be done immediately, offer interim therapeutic anticoagulation unless contraindicated; in the unlikely group, offer it if the D-dimer result cannot be obtained within four hours.
Common pitfall: A positive D-dimer does not confirm PE. Assess contraindications and obtain baseline blood tests without waiting for results before indicated interim anticoagulation. Contrast allergy, severe renal impairment or radiation concerns may favour V/Q imaging. Shock or rapid deterioration requires emergency resuscitation and specialist high-risk PE management, rather than waiting through a routine D-dimer sequence.
Recommendations | Venous thromboembolic diseases: diagnosis, management and thrombophilia testing | Guidance | NICE · Special circumstances Guidelines | Resuscitation Council UK
Areas of professional knowledgenot stated
13.How does adrenaline reverse anaphylaxis, and how is it administered to adults?
Adrenaline's alpha-receptor activity constricts vessels, reversing vasodilation and reducing oedema. Beta-receptor activity promotes bronchodilation and increases myocardial contraction. These actions address the airway, breathing and circulatory effects of anaphylaxis. For adult healthcare treatment, give 500 micrograms intramuscularly into the anterolateral thigh: 0.5 mL of 1 mg/mL adrenaline. Reassess continuously and repeat after five minutes if there is no improvement. Call for emergency help, stop the trigger if feasible and support breathing and circulation. Skin changes may be absent.
Apply it
After an injection, an adult develops wheeze, throat tightness and hypotension. Give 500 micrograms IM adrenaline promptly and reassess; repeat at five minutes if problems persist. An autoinjector delivers its labelled fixed dose, which may differ from the healthcare dose drawn from an ampoule.
Common pitfall: Antihistamines do not reverse life-threatening airway or circulatory compromise. Do not confuse IM administration with IV adrenaline, which requires specialist expertise and an appropriate monitored setting.
Emergency%20Treatment%20of%20Anaphylaxis%20May%202021_0.pdf · Special circumstances Guidelines | Resuscitation Council UK
14.Why should anaphylaxis patients avoid sudden standing?
Anaphylaxis causes vascular leakage and reduced venous tone, diminishing venous return. Suddenly standing or walking may reduce cardiac filling further and precipitate collapse. Keep a patient with circulatory compromise lying flat, with legs raised where appropriate. Predominantly respiratory difficulty without cardiovascular instability may be eased by a supported semi-recumbent position. Positioning complements adrenaline and emergency support; apparent improvement does not establish circulatory recovery.
Apply it
A patient receiving treatment for anaphylaxis feels slightly better and wants to walk to a nearby chair. Prevent sudden standing, maintain an appropriate supported position and continue emergency monitoring and treatment.
Common pitfall: Sending the patient walking to another room can introduce avoidable danger during an evolving reaction. Adapt positioning to physiology without allowing abrupt unsupported changes.
Emergency%20Treatment%20of%20Anaphylaxis%20May%202021_0.pdf · Resuscitation Council UK — First Aid Guidelines 2025
15.What information makes a medication history clinically usable?
A useful medication history establishes what the person actually takes, relevant doses and schedules, allergies or previous adverse reactions, and other information needed for the prescribing decision. Include non-prescription and complementary products because a prescription list alone may miss important exposure. Compare available records with the patient's account and resolve discrepancies. The safety question is whether the information is sufficiently reliable for the particular medicine and clinical circumstances under consideration.
Apply it
Before prescribing, a patient mentions an online supplement absent from their record and says they stopped a listed medicine weeks ago. Reconcile actual use and the supplement's identity before judging the safety of the proposed treatment.
Common pitfall: Copying a medicine list forward can preserve clinically important errors. A record of previous prescribing is not proof that the patient currently takes each product.
16.When is missing prescribing information important enough to delay a prescription?
Safe prescribing requires enough knowledge of the patient's health and medicines to judge suitability and potential harm. Missing information matters when it could change the treatment decision, such as an uncertain allergy or an unavailable relevant medication history. Obtain clarification, consult an appropriate colleague or use a safer supported plan rather than guessing. Urgency affects how information is obtained and decisions are escalated; it does not make an unsupported prescription inherently safe.
Apply it
A patient requests a medicine previously supplied elsewhere but cannot identify it, and their record is unavailable. Establish the indication and relevant history, seek reliable confirmation and arrange an appropriate interim plan rather than reconstructing treatment from appearance.
Common pitfall: Familiarity with a drug does not compensate for missing patient-specific information. A confident guess can conceal an unresolved contraindication, interaction or mistaken indication.
17.How does dehydration alter the safety of common medicines?
Dehydration reduces kidney perfusion and can make medicines that affect renal blood flow particularly problematic. NSAIDs are a recognised contributor to acute kidney injury, especially when the patient is already unwell or volume depleted. Clinical review should connect current illness with medication exposure and renal assessment. This is a context-dependent safety judgement: a medicine tolerated during stable health may become unsafe when fluid balance, blood pressure or kidney function changes.
Apply it
A patient with several days of vomiting has been taking ibuprofen regularly for aches and is passing little urine. Identify the combination of fluid loss and NSAID exposure as concerning and arrange renal assessment with medication review.
Common pitfall: Over-the-counter status does not imply safety during acute illness. Asking only about prescribed treatment can miss a medicine directly relevant to the patient's kidney injury.
18.How do absolute and relative risk reductions describe different effects?
Absolute risk reduction is the control-group risk minus the treatment-group risk. Relative risk reduction expresses that difference as a proportion of the control risk. If an outcome falls from 20% to 15%, the absolute reduction is five percentage points and the relative reduction is 25%. Both describe the same comparison, but absolute effects reveal how many events change in a defined population over the study's specified follow-up period.
Apply it
A trial reports events in 30 of 300 controls and 15 of 300 treated participants. Calculate risks of 10% and 5%, giving a five-percentage-point absolute reduction and a 50% relative reduction over the trial follow-up.
Common pitfall: Calling a 50% relative reduction a fifty-percentage-point reduction exaggerates benefit. Always retain the underlying event risks and follow-up when interpreting treatment claims for patients.
Cochrane Handbook, Chapter 15 — Interpreting results and drawing conclusions
19.How is number needed to treat calculated and bounded?
Number needed to treat for an additional beneficial outcome is the reciprocal of the absolute risk reduction expressed as a proportion. A reduction from 12% to 8% gives an absolute difference of 0.04 and an NNT of 25. The outcome, comparator and follow-up remain part of its meaning. NNT is not a permanent property of a drug because absolute benefit changes with baseline risk and the clinical setting.
Apply it
Over one year, treatment reduces a specified event from 18% to 12%. Use an absolute reduction of 0.06; its reciprocal is approximately 16.7, conventionally presented as an NNT of 17 for that outcome and period.
Common pitfall: Dividing by the relative risk reduction produces the wrong NNT. Reporting an NNT without its outcome and time horizon strips away information needed to interpret it.
Cochrane Handbook, Chapter 15 — Interpreting results and drawing conclusions
20.Why does baseline risk change absolute treatment benefit?
The same relative effect can produce very different absolute benefits in populations with different baseline risks. If a treatment halves risk, reducing a baseline risk of 20% yields a ten-percentage-point reduction, whereas halving 2% yields one percentage point. This matters when applying evidence to an individual. Compare the patient's circumstances with the study population and communicate plausible absolute effects rather than assuming one headline NNT applies universally.
Apply it
Two populations have untreated event risks of 16% and 4%. Assuming the same relative risk of 0.5 applies, calculate absolute reductions of eight and two percentage points, respectively, before comparing the expected benefits.
Common pitfall: A stable relative effect does not imply equal numbers of prevented events. Transporting absolute results between populations requires attention to baseline risk and applicability.
Cochrane Handbook, Chapter 15 — Interpreting results and drawing conclusions
21.How should confidence intervals change a treatment conclusion?
A confidence interval describes uncertainty around an effect estimate, including the range of effects reasonably compatible with the data under the analysis assumptions. For a risk ratio, one represents no relative difference; for a risk difference, zero represents no difference. An interval crossing the relevant null value does not prove equivalence. Judge whether it also includes clinically important benefit or harm, rather than reducing interpretation to a statistically significant versus non-significant label.
Apply it
A treatment has a risk ratio of 0.90 with a 95% confidence interval from 0.65 to 1.25. Explain that the result remains compatible with meaningful benefit and harm, so it does not establish equal effectiveness.
Common pitfall: A non-significant result can reflect imprecision. Declaring no effect from a wide interval mistakes insufficient information for evidence that clinically relevant differences are absent.
Cochrane Handbook, Chapter 15 — Interpreting results and drawing conclusions
22.Why must treatment information reflect the patient's priorities?
Consent is a decision-making process in which relevant options, potential benefits, harms and uncertainties are discussed in a way the patient can use. What matters is partly individual: an effect that seems minor to a clinician may determine a patient's willingness to proceed. Elicit goals and concerns rather than assuming the medically preferred option is automatically acceptable. Understanding and voluntary choice are more important than obtaining a signature without meaningful discussion.
Apply it
A patient considering treatment prioritises remaining alert enough to care for a relative. Explore how available options affect that goal, explain relevant uncertainty and check understanding before asking whether they wish to proceed with the proposed plan.
Common pitfall: A standard information sheet cannot identify every personally important concern. Listing risks without exploring values can leave the patient informed superficially but unsupported in deciding.
Clinical and professional capabilitiesnot stated
23.Why should capacity be presumed before it is assessed?
Start by presuming that an adult can make their own decision. A diagnosis, communication difficulty or choice that seems unwise does not by itself establish incapacity. If there is reason for concern, assess the person's ability to make the particular decision after offering appropriate support. This protects autonomy while allowing genuine impairment to be recognised. The relevant question concerns functional decision-making ability, rather than whether the clinician agrees with the patient's conclusion.
Apply it
A patient with a psychiatric diagnosis refuses a proposed investigation and explains coherent reasons. Explore understanding and the decision itself; do not treat the diagnosis or disagreement as proof that someone else should decide for them.
Common pitfall: Using diagnostic labels as shortcuts can remove autonomy without assessing ability. An unexpected decision should prompt exploration of reasons, not an automatic finding of incapacity.
Decision making and consent — Circumstances that affect the decision-making process, part 3
24.How is a functional capacity assessment structured?
Assess whether the person can understand relevant information, retain it sufficiently for the decision, use or weigh it, and communicate a choice. Explain the actual options and consequences in accessible terms before testing these abilities. A repeated phrase or simple agreement is not enough if the person cannot engage with its significance. Capacity assessment should address the decision's demands and applicable legal framework, rather than substitute a general cognitive score for functional evaluation.
Apply it
A patient repeats that surgery is recommended but cannot explain any consequence of accepting or declining it. Re-explain using simpler language, then assess understanding and weighing of the actual options before concluding whether capacity is impaired.
Common pitfall: Orientation questions alone do not test capacity for a treatment decision. Conversely, a memory difficulty does not automatically prevent a person retaining information long enough to decide.
Decision making and consent — Circumstances that affect the decision-making process, part 3
25.Why can capacity differ between decisions and times?
Capacity relates to a particular decision at a particular time. A person may manage a straightforward choice while being unable to weigh a more complex one, and acute illness may cause ability to fluctuate. Where clinically safe, timing discussion when the person is better able to participate can support autonomy. Reassess relevant changes instead of treating one finding as a permanent global label that automatically governs every later decision.
Apply it
A delirious patient cannot weigh a non-urgent treatment choice overnight but is more attentive the next morning. If delay is clinically safe, support and reassess the specific decision then rather than relying indefinitely on the overnight assessment.
Common pitfall: A previous incapacity finding does not settle future decisions. Equally, managing a simple daily preference does not prove capacity for every complex treatment choice.
Decision making and consent — Circumstances that affect the decision-making process, part 3
26.How should a clinician respond to an informed refusal?
Explore the patient's reasons, clarify misunderstandings and explain relevant consequences without coercion. If the adult has capacity for the decision and chooses voluntarily, disagreement does not itself justify overriding refusal. Consider acceptable alternatives and document the discussion and agreed safety advice. The clinician's responsibility is to support an informed decision, including a decision to decline, rather than secure acceptance by repeatedly reframing an unwanted recommendation as the only permissible choice.
Apply it
A patient understands the purpose and significant consequences of declining an investigation but still refuses because of a strongly held priority. Check voluntariness, discuss alternatives and document the decision with appropriate follow-up and warning advice.
Common pitfall: Repeating information until the patient agrees can become pressure. Respecting refusal does not mean abandoning explanation, alternatives, follow-up or attention to misunderstandings and support needs.
27.What conditions permit implied consent for direct-care information sharing?
GMC paragraph 28 requires all four conditions: access or disclosure serves the individual patient's direct care; patients can readily obtain information explaining how their information is used and their right to object; there is no reason to believe the patient objects; and the recipient understands that the information is confidential and must respect that confidentiality. Share relevant information for the care purpose. Under paragraph 29, if the patient would probably be surprised by the access or disclosure, seek explicit consent unless doing so is impracticable, when another valid justification must be considered.
Apply it
Before sending a referral, confirm the recipient's direct-care purpose, the availability of accessible information about sharing and objections, the absence of a patient objection, and the recipient's understanding of confidentiality. If access to another agency's shared record would surprise the patient, explain it and seek explicit consent.
Common pitfall: A care role and absence of a recorded objection alone do not satisfy every condition. Healthcare employment does not confer unrestricted access to records.
28.How can relatives contribute when a patient restricts disclosure?
A patient's restriction on disclosure does not prevent a clinician from listening to concerns raised by relatives. Receiving information and giving confidential information are separate actions. Explain that you can hear their observations without promising an update that the patient has declined to authorise. Their account may still inform assessment and care. Avoid inadvertently confirming sensitive facts through responses, and consider the patient's preferences when deciding what can appropriately be said.
Apply it
A patient asks you not to discuss their treatment with a sibling. The sibling calls to describe recent confusion. Listen to the observations, explain the confidentiality boundary and use relevant information without disclosing the restricted treatment details.
Common pitfall: Refusing to listen can discard valuable safety information. Conversely, gratitude for a relative's help does not create permission to reveal information the patient has restricted.
29.When should candour begin after a harmful error?
When something has gone wrong that causes or may cause harm or distress, communicate openly and promptly with the patient or an appropriate person. Explain what is known, apologise, describe immediate care and clarify what remains uncertain. A complete investigation is not a prerequisite for an honest initial discussion. Avoid speculation, document the conversation and arrange updates as reliable information emerges so that uncertainty is managed transparently rather than used to justify silence.
Apply it
A medication error has reached a patient, and its consequences are still being assessed. Arrange appropriate clinical review, explain the known error promptly, apologise and state what is being checked and when further information will be provided.
Common pitfall: Waiting for a final report can unnecessarily delay disclosure. An apology does not require pretending that the cause or eventual consequences are already fully established.
30.How should clinicians explain uncertainty after an error?
Separate established facts, possible consequences and unanswered questions. Patients need a clear account of what happened and the current plan, without unsupported reassurance or speculation about blame. Explain how further information will be obtained and who will provide updates. Documentation should capture the discussion and follow-up arrangements. This approach makes uncertainty explicit while preserving the obligation to apologise and respond to the patient's immediate clinical needs and concerns.
Apply it
After a procedure-related problem, the patient asks whether it will cause permanent harm. Explain the findings currently known, acknowledge that the long-term effect is uncertain and describe the planned assessment and next discussion without guessing the outcome.
Common pitfall: Saying everything will be fine may feel comforting but can mislead. Listing alarming possibilities without context is also unhelpful; connect uncertainty to concrete assessment and follow-up.
31.When should a clinician seek help with an unfamiliar task?
Recognise the limits of current competence before undertaking a task whose safe performance requires skills you do not have. Seeking appropriate supervision or another qualified clinician is an active safety decision, not a failure to contribute. Continue actions within competence and communicate urgency so that help arrives appropriately. The content map explicitly includes seeking help for tasks beyond competence; confidence, seniority or pressure alone cannot establish that a procedure can be performed safely.
Apply it
You are asked to perform an urgent procedure that you have only observed. Explain the competence limit, summon an appropriately skilled clinician and assist with preparation and monitoring that you can safely undertake while the patient receives necessary support.
Common pitfall: Attempting a procedure solely to appear capable exposes the patient to avoidable risk. Seeking help should be timely and specific, rather than a passive withdrawal from care.
32.What makes a self-harm safety plan usable, and when is early aftercare indicated?
Write a safety plan collaboratively, identifying personal warning signs, coping actions, people and places that provide support, professional and emergency contacts, and agreed steps to make the environment safer. Confirm that contacts and practical actions are accessible. NICE recommends initial aftercare within 48 hours of the psychosocial assessment when ongoing safety concerns remain. This is conditional on those concerns; it is not a universal deadline for every presentation, and immediate danger requires immediate intervention.
Apply it
A patient identifies evening isolation and repeated messages from an abusive former partner as warning signs. Their plan is to silence those messages, use an agreed grounding exercise, move to a shared room, call their named friend Maya, and contact their crisis team if distress persists. Record the actual contact details, agree that Maya will hold surplus medicines with consent, and specify 999 or emergency attendance if they cannot remain safe. Because safety concerns remain, arrange initial aftercare within 48 hours.
Common pitfall: A generic leaflet or promise not to self-harm does not demonstrate a workable plan. Check what happens if the first contact is unavailable, and do not substitute a future appointment for managing immediate risk.
Recommendations | Self-harm: assessment, management and preventing recurrence | Guidance | NICE
Practical skills and proceduresnot stated
33.How should physiological observations be recorded for clinical interpretation?
Physiological observations become useful when measured correctly, attributed to the right patient and recorded with timing and relevant context. A value is part of an assessment rather than a standalone assurance of safety. Repeat or clarify an unexpected result when appropriate, while responding immediately to obvious deterioration. Trends can reveal change that a single measurement obscures, so documentation and communication are integral parts of the practical skill rather than optional administrative additions.
Apply it
A patient's observations differ substantially from those documented earlier and they now look unwell. Check measurement quality without delaying help, record the current findings and timing, and communicate the deterioration clearly to the responsible clinical team.
Common pitfall: Repeating a concerning measurement should not become a reason to ignore the patient. Equally, copying previous values forward creates a false picture of current physiology.
34.Which bedside and acid-base tests are needed in suspected ketoacidosis?
Capillary glucose measures glucose, and a blood ketone meter measures ketonaemia; neither establishes acidosis. Obtain a venous blood gas for pH and bicarbonate, alongside electrolytes including potassium. The JBDS adult framework requires diabetes or glucose above 11 mmol/L, blood ketones above 3 mmol/L or significant ketonuria of at least 2+, and venous pH below 7.3 and/or bicarbonate below 15 mmol/L. Record and communicate results together. Known diabetes permits diagnosis even without marked hyperglycaemia.
Apply it
A patient with diabetes, vomiting and deep breathing has glucose 9 mmol/L and ketones 4.5 mmol/L. A venous pH of 7.24 with bicarbonate 12 mmol/L establishes the acid-base component: the modest glucose does not exclude DKA.
Common pitfall: Ketosis and ketoacidosis are different findings. A glucose result alone cannot exclude DKA, particularly with SGLT2 inhibitor exposure or partial treatment before presentation.
Outcomes for graduates — Practical skills and procedures · JBDS%2002%20DKA%20Guideline%20with%20qr%20code.pdf
35.How is a dependable resting 12-lead ECG acquired?
Confirm identity and consent, preserve privacy, position comfortably and prepare clean, dry skin; clip obstructing hair if needed. Place limb electrodes symmetrically on the appropriate arms and legs. Chest placement: V1 fourth intercostal space at right sternal border; V2 fourth at left sternal border; V4 fifth at left midclavicular line; V3 midway between V2 and V4; V5 left anterior axillary and V6 left midaxillary, both horizontally level with V4. Check connections, patient details, 25 mm/s speed, 10 mm/mV gain and trace completeness. Ask the patient to relax and remain still.
Apply it
V2 found in the second intercostal space must be moved to the fourth. By contrast, irregular baseline noise appearing during shivering suggests movement artefact: improve comfort and repeat after movement settles.
Common pitfall: A quiet baseline does not prove correct electrode placement. Check anatomical landmarks separately from artefact, and do not delay emergency care while troubleshooting.
Outcomes for graduates — Practical skills and procedures · ECG-policy.pdf
36.What makes venepuncture a complete clinical procedure?
Venepuncture includes preparation, correct patient identification, explanation and consent, safe sampling, labelling, sharps disposal, documentation and aftercare. Obtaining blood is only one part of successful performance. The sample must answer the intended clinical question and remain attributable to the correct patient, while the patient and staff are protected from avoidable harm. A competent procedure therefore combines technical handling with communication and a deliberate completion process before the clinician leaves.
Apply it
After obtaining blood from a nervous patient, you are called elsewhere. First complete essential patient care, safe needle disposal and correct sample identification, then document and hand over any outstanding task rather than leaving an unfinished procedure.
Common pitfall: Technical success does not excuse missing aftercare or unsafe waste handling. A sample drawn efficiently can still be clinically unusable or dangerous if completion steps are omitted.
37.Why is sample labelling a patient-safety decision?
Laboratory results are useful only when the sample is reliably linked to the intended patient and request. Appropriate labelling is therefore part of the clinical procedure, not merely transport preparation. If identity is uncertain, do not repair the uncertainty by guessing which tube belongs to whom. Follow the applicable laboratory process and obtain a correctly identified sample when required. Documentation should preserve traceability rather than create confidence unsupported by the sampling process.
Apply it
Two unlabelled blood tubes are found beside requests for different patients. You remember drawing both but cannot reliably distinguish them. Treat the identity as unresolved and follow the laboratory rejection and resampling process rather than guessing.
Common pitfall: Matching a tube to the nearest request creates an appearance of certainty without evidence. A plausible label can turn an obvious identification problem into a hidden clinical error.
38.How should a concrete blood-culture contamination risk be corrected?
Touching the disinfected puncture site with a non-sterile gloved finger can reintroduce organisms, producing growth from collection contamination rather than bloodstream infection. Before puncture, stop, repeat skin antisepsis and allow drying; then maintain non-touch technique. Prepare bottle ports with antisepsis, collect aseptically, dispose of sharps, label bottles and document indication, time and site. The GMC supplement specifies direct supervision for peripheral blood-culture collection by newly qualified doctors. Experienced clinicians' supervision needs depend on individually established competence.
Apply it
After cleaning the site, you re-palpate through a non-sterile glove. Do not puncture immediately. Re-clean with the specified skin antiseptic, allow it to dry and avoid touching the site again before insertion. Complete bottle identification and collection documentation.
Common pitfall: Gloves do not make re-palpation aseptic. If contamination is suspected after collection, document and discuss the event; do not silently present a compromised sample as dependable or automatically dismiss subsequent growth. Bottle colours and access-specific collection procedures must follow the relevant local system.
Outcomes for graduates — Practical skills and procedures · 1636
39.When should a used needle enter the sharps container?
Dispose of a used sharp safely at the point of use into the appropriate sharps container. Plan the workspace so disposal is immediately accessible and avoid unnecessary handling, recapping or carrying an exposed needle elsewhere. Point-of-use disposal reduces the time during which staff or others can be injured. The relevant decision occurs before starting the procedure: equipment layout should make the safe finishing action straightforward rather than dependent on improvisation afterward.
Apply it
Before venepuncture, you notice the sharps container is across the room. Arrange suitable disposal access before beginning so that the used needle can be discarded immediately without carrying it past the patient or other staff.
Common pitfall: Recapping or placing a used needle on a tray for later disposal adds exposure opportunities. A successful procedure does not justify an unsafe final handling step.
40.How should a needlestick injury be managed immediately?
After a sharps injury, encourage gentle bleeding, wash with running water and soap, and cover the wound. Do not scrub or suck it. Obtain urgent medical advice because exposure assessment and any preventive treatment may be time-sensitive, and report the incident through the workplace process. Immediate wound care, clinical risk assessment and reporting serve different purposes; completing one does not remove the need for the others after a potentially significant exposure.
Apply it
You sustain a puncture while handling a used needle. Perform appropriate wound care, seek urgent occupational or emergency advice and report the incident rather than finishing the shift before asking whether preventive treatment might be needed.
Common pitfall: Waiting to see whether symptoms develop misses the purpose of exposure assessment. Aggressive scrubbing or sucking the wound is not an appropriate substitute for recommended immediate care.
Patient presentationsnot stated
41.Which chest-pain clues warrant emergency assessment?
Chest discomfort suggesting a heart attack may feel like pressure, tightness or squeezing and can spread to other areas. Associated breathlessness, sweating, nausea or light-headedness increases concern. Not every patient describes dramatic central pain, so the overall pattern matters more than one phrase. Emergency assessment is appropriate for a concerning ongoing presentation; symptom improvement or an alternative explanation suggested by the patient should not replace evaluation of potentially dangerous cardiac disease.
Apply it
A patient describes new chest pressure with sweating and nausea but calls it indigestion. Recognise the potentially cardiac pattern and arrange emergency assessment rather than accepting the patient's label as sufficient evidence of a benign gastrointestinal cause.
Common pitfall: A familiar word such as indigestion can anchor reasoning prematurely. The patient's interpretation is useful history, but associated symptoms and onset still require independent assessment.
42.When should unexplained AKI raise concern for an underlying malignancy requiring specialist treatment?
AKI without a clear cause requires investigation rather than automatic attribution to dehydration or chronic kidney disease. NICE identifies myeloma among possible causes that may need specialist treatment and recommends discussing such AKI with nephrology as soon as possible and within 24 hours of detection. Review the clinical history, previous renal function, medicines, urine findings and evidence of obstruction. Suspecting a malignant cause changes the assessment pathway; the creatinine rise alone does not diagnose cancer.
Apply it
A patient has persistent unexplained AKI despite correction of an initial fluid deficit, and the wider assessment raises concern for myeloma. Discuss nephrology assessment within 24 hours and coordinate investigation of the suspected underlying disease rather than continuing fluids without revisiting the cause.
Common pitfall: An apparent contributor can coexist with a malignancy requiring specific treatment. Conversely, unexplained AKI is not itself proof of myeloma; investigation must establish the cause.
Recommendations | Acute kidney injury: prevention, detection and management | Guidance | NICE
43.How should palliative goals influence a decision about dialysis for AKI?
For a person with significant comorbidity or possible end-of-life deterioration, consider whether renal replacement therapy would offer benefit in the context of their overall condition, prognosis and priorities. NICE recommends discussion with the person and the multidisciplinary team, involving family or carers appropriately. Assess reversible contributors and complications while clarifying goals; neither an isolated creatinine value nor a palliative-care label settles the decision. When benefit is uncertain in severe illness near the end of life, discuss management with nephrology.
Apply it
A patient with advanced life-limiting illness develops AKI and asks whether dialysis would help them return home. Explain the expected benefits, burdens and uncertainty in their circumstances, assess reversible causes, and agree a plan with the patient, nephrology and the wider team that addresses symptoms and their preferred goals.
Common pitfall: Offering dialysis solely because creatinine is high ignores the whole patient. Equally, assuming that palliative involvement excludes treatment of reversible illness prevents an individual decision.
Recommendations | Acute kidney injury: prevention, detection and management | Guidance | NICE · Decision making and consent
44.Which back-pain symptoms suggest cauda equina compression?
Back pain accompanied by new saddle sensory change, bladder or bowel dysfunction, or relevant leg neurological symptoms raises concern for cauda equina syndrome. Ask specifically about altered urinary sensation or control rather than only incontinence, because patients may describe changes in several ways. The emergency concern is compression affecting nerve roots that serve pelvic organs and lower limbs. Do not wait for every possible deficit before arranging urgent assessment of a compatible presentation.
Apply it
A patient with worsening back pain reports numbness when wiping and a new change in the sensation of passing urine. Recognise these as neurological warning symptoms and arrange emergency assessment instead of routine management for uncomplicated mechanical pain.
Common pitfall: Asking only whether the patient is incontinent can miss earlier urinary changes. A normal-sounding description of back pain does not neutralise new saddle or sphincter symptoms.
45.How does a painful red eye differ from simple irritation?
A red eye with severe pain and visual disturbance requires a different level of concern from mild irritation without visual change. Sudden blurred vision, coloured haloes, headache, nausea or vomiting can accompany acute glaucoma. These associated features should prompt immediate assessment rather than an assumption of conjunctivitis. Ask about onset, vision and systemic symptoms explicitly and assess visual function, because redness alone does not establish the underlying cause.
Apply it
A patient requests drops for a red eye. Examination confirms redness and substantially reduced vision in the painful eye; they also report sudden haloes and vomiting. Arrange immediate ophthalmic assessment for suspected acute glaucoma.
Common pitfall: Severe pain and visual loss can occur in several ocular emergencies. The symptom combination raises suspicion for acute glaucoma but does not remove the need for urgent diagnostic examination.
46.How should haematemesis severity be judged beyond blood colour?
Blood in vomit needs assessment of both the bleeding history and its physiological consequences. Faintness, confusion, rapid breathing, pale clammy skin or other signs of significant illness increase urgency. Neither a small reported volume nor dark colour reliably establishes low risk, because estimates are imprecise and altered blood still indicates bleeding. Ask about black stools and associated symptoms while deciding whether emergency assessment is required for the patient's current condition.
Apply it
A patient says they vomited only a little dark blood but now feels faint and appears pale and clammy. Prioritise emergency assessment based on the overall condition rather than allowing the estimated amount to lower concern.
Common pitfall: Patient-estimated volume can be misleading. Apparent small quantities should not overrule symptoms of circulatory compromise or other evidence that the person is acutely unwell.
47.How do urinary findings distinguish possible nephritis from uncomplicated volume depletion?
When AKI is suspected, test urine for blood, protein, leucocytes, nitrites and glucose, and document the findings. Haematuria with proteinuria, without urinary infection or catheter trauma and without an obvious cause of AKI, should raise concern for acute nephritis and nephrology referral. Reduced urine output alone does not distinguish volume depletion, intrinsic renal disease and obstruction. If obstruction is possible or the cause remains unidentified, offer urgent urinary tract ultrasound within 24 hours; suspected pyonephrosis requires ultrasound within six hours.
Apply it
A patient has rising creatinine, blood and protein on dipstick, no catheter and no evidence of urinary infection or obvious fluid loss. Consider an intrinsic inflammatory renal process rather than automatically diagnosing dehydration, and discuss nephrology assessment.
Common pitfall: An abnormal dipstick is a clue requiring interpretation, not a standalone diagnosis. Conversely, treating every AKI episode with fluids without assessing cause can miss nephritis or obstruction.
Recommendations | Acute kidney injury: prevention, detection and management | Guidance | NICE
48.How should safeguarding concerns be explored when distress may involve abuse or exploitation?
Ask about domestic abuse, violence or exploitation at the earliest appropriate opportunity, including speaking with the person alone when appropriate. Establish immediate safety, explore whether their needs require assessment under local safeguarding procedures, document concerns and seek advice from the named safeguarding lead when needed. For a young person, include home, peers, education, online experiences and caring responsibilities. Coordinate with relevant agencies when a safeguarding referral is made.
Apply it
A patient presenting after self-harm becomes silent whenever their partner enters. Arrange an appropriate private conversation, ask about safety and coercion, assess immediate danger and document what they disclose. Use the safeguarding pathway and seek specialist advice according to the findings.
Common pitfall: A companion's reassuring account does not replace the person's opportunity to speak privately. Safeguarding assessment should address the actual concern rather than assume that distress has only an individual psychiatric cause.
Recommendations | Self-harm: assessment, management and preventing recurrence | Guidance | NICE
49.Which features support stable angina, and what investigation follows?
NICE describes three anginal features: constricting discomfort in the chest, neck, shoulders, jaw or arms; precipitation by exertion; and relief by rest or GTN within about five minutes. All three indicate typical angina, two atypical angina, and one or none non-anginal pain. Typical or atypical symptoms generally warrant CT coronary angiography when CAD is not already established. A normal resting ECG does not exclude stable angina. New rest pain, prolonged episodes or abrupt deterioration requires reassessment for ACS.
Apply it
A patient has reproducible chest tightness when walking uphill, resolving within three minutes of rest, and a normal ECG. The three features support typical angina, so arrange diagnostic assessment rather than excluding coronary disease because the ECG is normal.
Common pitfall: Relief with GTN alone does not diagnose ACS or establish a coronary cause. The pattern of symptoms and whether it is stable determine the assessment pathway.
50.How should acute chest pain be managed while emergency transfer is arranged?
For suspected ACS, begin management while arranging emergency transfer and obtain an ECG without delaying transfer. NICE recommends a single 300 mg aspirin loading dose unless there is clear evidence of allergy, with a record if given before hospital arrival. Monitor symptoms, pulse, blood pressure, rhythm and oxygen saturation. Oxygen is not routine: give it for saturation below 94% in people without hypercapnic respiratory-failure risk, targeting 94–98%; for those at risk, target 88–92% pending blood gases. Provide appropriate pain relief.
Apply it
An adult has ongoing ischaemic-sounding chest pain, no aspirin allergy and oxygen saturation 97% on air. Arrange emergency transfer, give aspirin, monitor and obtain an ECG without delay. Normal saturation does not justify routine supplemental oxygen.
Common pitfall: Completing tests before arranging transfer can delay care. Oxygen and symptom improvement should not be used as substitutes for treating and investigating suspected ACS.
Conditionsnot stated
51.How do anticoagulants help in pulmonary embolism?
Pulmonary embolism occurs when a clot blocks a blood vessel in the lungs, commonly after travelling from a leg vein. Anticoagulants reduce further clot formation and help prevent existing clot from enlarging while the body deals with it. They should not be described as instantly dissolving the obstruction. Understanding this distinction supports accurate explanation of treatment, the need for continued prescribed therapy and the importance of reassessing new or worsening symptoms during recovery.
Apply it
A patient starting anticoagulation asks why breathlessness has not disappeared immediately. Explain that treatment limits further clotting rather than instantly removing the obstruction, and assess any worsening symptoms instead of assuming all persistent symptoms are expected.
Common pitfall: Calling anticoagulation an immediate clot-dissolving treatment creates unrealistic expectations. Improvement may not be instantaneous, but deterioration still requires assessment rather than reassurance based solely on treatment having started.
52.Which adult criteria establish acute kidney injury?
NICE adult AKI detection criteria include any of the following: serum creatinine rises by at least 26 micromol/L within 48 hours; creatinine rises by at least 50% within seven days; or urine output falls below 0.5 mL/kg/hour for more than six hours. Dehydration is a possible cause, not a diagnostic synonym. Compare current creatinine with a relevant baseline and assess urine output, medicines and underlying causes. Meeting a detection criterion establishes AKI; severity staging is a separate assessment using the full staging framework.
Apply it
Creatinine rises from 80 to 110 micromol/L in 36 hours: the 30 micromol/L increase meets the 48-hour criterion despite being only a 37.5% rise. Alternatively, 80 to 120 within seven 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: Waiting for creatinine to double misses AKI. A value within the laboratory reference range can still meet criteria when compared with that patient's baseline.
Recommendations | Acute kidney injury: prevention, detection and management | Guidance | NICE · Acute kidney injury
53.How do chronic kidney impairment and previous AKI change prevention and follow-up?
Chronic kidney disease requires persistent kidney abnormality: eGFR below 60 mL/min/1.73 m² for at least three months, or persistent evidence of kidney damage even at higher eGFR. CKD increases AKI risk, and an acute creatinine rise must not automatically be attributed to chronic progression. Prevention includes discussing dehydration and NSAID risks, reviewing medicines during acute illness and planning renal monitoring. NICE advises considering temporary ACE inhibitor or ARB interruption during vomiting, diarrhoea or sepsis until the clinical condition improves and stabilises.
Apply it
A patient with eGFR around 45 for six months develops gastroenteritis. Explain their increased AKI risk, assess hydration and creatinine against baseline, review medicines and give an individual plan for reassessment and resumption of any temporarily withheld treatment. After AKI, set creatinine monitoring according to renal stability at discharge.
Common pitfall: One low eGFR does not establish chronicity. Equally, known CKD does not exclude superimposed AKI, and temporary medicine interruption should not become unintended permanent discontinuation.
Recommendations | Acute kidney injury: prevention, detection and management | Guidance | NICE
54.How do sensory aids support recovery from delirium?
Glasses and hearing aids help a person interpret their surroundings and communicate, reducing avoidable sensory barriers during delirium. Familiar reassurance, orientation, appropriate hydration and a supportive routine can complement treatment of underlying contributors. These measures do not replace investigation of acute illness, but they make assessment and recovery more person-centred. Remove correctable obstacles to understanding instead of assuming every confused response reflects irreversible cognitive impairment.
Apply it
A delirious inpatient repeatedly mishears staff and becomes frightened. Ensure their hearing aids work, offer glasses and calmly reorient them while continuing assessment and treatment of the underlying illness rather than treating communication failure as deliberate resistance.
Common pitfall: Supportive measures are useful but not a substitute for finding causes. Conversely, medical treatment alone may leave avoidable sensory and environmental barriers that worsen distress.
55.How is suspected cauda equina compression investigated, and what follows confirmation?
Suspected cauda equina syndrome requires emergency assessment with lumbosacral MRI to identify or exclude a compressive lesion and urgent spinal or neurosurgical review. Bladder scanning can contribute information about retention but does not visualise the spinal canal or replace MRI. If imaging confirms compressive disease, the specialist team considers urgent surgical decompression according to the lesion, neurological findings and clinical circumstances. There is no single universal surgical deadline that can replace individual emergency assessment.
Apply it
A patient has new saddle numbness and altered urinary sensation. A bladder scan does not show substantial retention. Continue the emergency spinal assessment and MRI pathway: this scan has not excluded nerve-root compression. If MRI shows a compressive lesion, obtain urgent specialist review for definitive treatment.
Common pitfall: Waiting for complete retention or using a reassuring bladder scan to cancel spinal imaging can miss compressive disease. Recognition and referral are only the beginning; imaging determines whether a surgically treatable cause is present.
56.How do insulin deficiency, ketones and acid-base results establish DKA?
Insufficient insulin promotes fat breakdown and hepatic ketone production; accumulating ketoacids cause metabolic acidosis. The JBDS adult framework requires diabetes or glucose above 11 mmol/L, blood ketones above 3 mmol/L or urine ketones at least 2+, and venous pH below 7.3 and/or bicarbonate below 15 mmol/L. DKA can occur without marked hyperglycaemia. Initial hospital treatment addresses circulating volume with IV fluids, suppresses ketogenesis with IV insulin and monitors and replaces potassium according to results; treating glucose alone does not establish resolution.
Apply it
An adult with type 1 diabetes has glucose 10 mmol/L, ketones 5 mmol/L, venous pH 7.20 and bicarbonate 11 mmol/L after missed insulin. Known diabetes, substantial ketonaemia and acidosis establish DKA despite modest glucose. Start urgent monitored treatment and identify the precipitant.
Common pitfall: A falling glucose is not proof that ketoacidosis has resolved. Insulin treatment also changes potassium balance, so glucose, ketones, venous pH, bicarbonate and potassium require coordinated monitoring.
JBDS%2002%20DKA%20Guideline%20with%20qr%20code.pdf · Diabetic ketoacidosis
57.How do investigations and haemodynamic status guide ectopic-pregnancy assessment?
Ectopic pregnancy implants outside the womb, usually in a fallopian tube. In a stable patient, pregnancy testing, transvaginal ultrasound and, when needed, serial serum hCG help establish the pregnancy's location and course. hCG may be measured 48 hours apart; a trend supports assessment but does not itself locate the pregnancy. Severe pain with fainting or shock suggests rupture and requires emergency management rather than waiting for serial results. Treatment options include monitored expectant care, methotrexate or surgery, selected according to clinical findings and investigations.
Apply it
A stable patient with pain and a positive pregnancy test has an inconclusive initial scan. Arrange specialist follow-up with repeat assessment and hCG testing as indicated. If severe pain, pallor or collapse develops, change immediately to the emergency pathway rather than waiting for the planned test.
Common pitfall: A pregnancy test confirms pregnancy possibility, not implantation site. Neither a single hCG value nor absent vaginal bleeding safely excludes ectopic pregnancy.
58.What different information do ECG and cardiac troponin provide in suspected ACS?
The ECG records electrical activity and may show ischaemic ST-segment or T-wave changes; a normal resting ECG does not exclude ACS. High-sensitivity cardiac troponin I or T provides biochemical evidence of myocardial injury. Interpret it with symptoms, timing, ECG findings and pre-test probability. A rise or fall with at least one value above the 99th-percentile reference limit supports acute injury; diagnosing infarction also requires evidence of ischaemia. Elevated troponin can have other causes, including myocarditis or pulmonary embolism.
Apply it
A patient presents soon after prolonged pressure-like pain with sweating. The first ECG is normal and the initial troponin is not raised. Continue assessment: recent symptom onset and clinical risk may require serial ECGs and repeat troponin within a validated pathway. These initial results alone do not justify automatic discharge.
Common pitfall: A detectable troponin does not automatically diagnose infarction, and an initially reassuring result does not automatically exclude it. Apply the assay-specific pathway with clinical assessment.
Recommendations | Recent-onset chest pain of suspected cardiac origin: assessment and diagnosis | Guidance | NICE · Heart attack
59.How is feeding support selected for an admitted child with bronchiolitis?
Assess hydration and whether oral intake can meet requirements safely. NICE recommends nasogastric or orogastric fluids when the child cannot take enough by mouth. Use intravenous isotonic fluids if enteral fluids are not tolerated or impending respiratory failure is present. Exhaustion, recurrent apnoea or failure to maintain adequate saturation despite oxygen suggests impending failure and may require intensive care and CPAP. Routine antibiotics, salbutamol, corticosteroids, chest radiographs and blood tests are not indicated for typical uncomplicated bronchiolitis.
Apply it
An admitted infant remains alert but cannot sustain sufficient oral feeds because of respiratory effort. Provide nasogastric or orogastric hydration and monitor response. If recurrent apnoea and exhaustion develop, escalate respiratory support and use IV isotonic fluids rather than persisting with enteral feeding.
Common pitfall: Supplemental oxygen does not correct inadequate hydration. Conversely, routine IV fluids are unnecessary when enteral support is tolerated and respiratory failure is not impending.
Recommendations | Bronchiolitis in children: diagnosis and management | Guidance | NICE
60.How does long-term glaucoma treatment prevent further visual loss?
Glaucoma damages the optic nerve and often progresses without noticeable early symptoms. Treatment aims to slow further damage, rather than restore lost vision. Eye drops can reduce fluid production or improve drainage; laser treatment and surgery are other options selected according to glaucoma type and clinical findings. Regular follow-up checks whether treatment is working. Feeling well is not a reason to stop prescribed drops or monitoring because symptom awareness is an unreliable measure of disease control.
Apply it
A patient with chronic glaucoma has stopped daily drops because vision seems unchanged. Explain the preventive purpose, identify difficulties using or obtaining treatment, and arrange review of the prescribed regimen and monitoring rather than waiting for symptomatic deterioration.
Common pitfall: Absence of pain or perceived visual change does not establish stability. Sudden painful visual deterioration requires immediate assessment even in someone already receiving chronic glaucoma care.
What to focus on during revision
The following are CertMedbry study suggestions. Use the official outline to check the full scope of your examination.
- Use the September 2026 MLA content map as the full scope; track these selected concepts against its six interconnected domains.
- Distinguish physiological instability from diagnostic uncertainty in chest pain, breathlessness, neurological symptoms and early-pregnancy pain.
- Apply measured thresholds and pathways: bronchiolitis referral versus oxygen treatment, Wells-directed PE testing, AKI detection and adult DKA criteria.
- Extend recognition into decisions about investigation and treatment, including emergency spinal MRI and definitive review for confirmed compression.
- Include infection reassessment, possible malignant causes of AKI, safeguarding and individual decisions about dialysis near the end of life.
- Separate capacity, consent and confidentiality questions; practise supported reassessment and usable self-harm safety planning.
- Calculate absolute effects and NNT with the outcome, comparator and follow-up stated.
- Pair knowledge practice with observed procedural and communication practice across the three PLAB 2 marking areas.
A practical preparation plan
1. Map the complete scope
Read the current official map and identify unfamiliar clinical areas, presentations, conditions and capabilities. Use this guide as a starting sample, then extend study to topics absent from its 60 concepts.
2. Explain each decision
For every concept, state the mechanism, decisive cue and action aloud. Compare plausible alternatives, identifying which finding changes urgency, investigation or management.
3. Use the question set diagnostically
Complete the 20 questions without notes, then review every alternative. Classify errors as missed cues, mechanism gaps, threshold errors, calculation errors or professional-reasoning errors; do not interpret the score as a pass prediction.
4. Recall and vary
Use the flashcards repeatedly, explaining the reasoning before checking the answer. Change one feature, such as infant age, Wells score, symptom resolution or capacity fluctuation, and reconsider the decision.
5. Rehearse observed performance
Practise consent discussions, focused histories and procedures with feedback. For each scenario, review information gathering and technical assessment, clinical management, and interpersonal performance separately.
6. Close gaps with the official map
Revisit weak topics and unrepresented areas of the full outline. Continue broad clinical study beyond this selective guide and check current GMC candidate instructions for operational details.
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
- Professional and Linguistic Assessments Board
- PLAB and the MLA
- MLA content map
- MLA content map — September 2026 update
- About the MLA content map
- MLA content map — earlier October 2025 publication
- How will you be tested?
- Outcomes for graduates — Practical skills and procedures
- Heart attack
- Pulmonary embolism
- Symptoms of a stroke
- Acute kidney injury
- Ectopic pregnancy
- Bronchiolitis
- Delirium (sudden confusion) — Overview
- How to prevent delirium and help your recovery
- Same Day Emergency Clinic — Cauda Equina Syndrome
- Glaucoma
- Diabetic ketoacidosis
- Vomiting blood
- Resuscitation Council UK — First Aid Guidelines 2025
- Decision making and consent
- Decision making and consent — Circumstances that affect the decision-making process, part 3
- Using and disclosing patient information for direct care
- Being open and honest with patients when things go wrong
- Deciding if it is safe to prescribe
- Managing the risk of needlestick or sharps injuries
- Needlestick or sharps injuries — Overview
- Cochrane Handbook, Chapter 15 — Interpreting results and drawing conclusions
- Self-harm — Assessment and treatments
- Special circumstances Guidelines | Resuscitation Council UK
- Emergency%20Treatment%20of%20Anaphylaxis%20May%202021_0.pdf
- JBDS%2002%20DKA%20Guideline%20with%20qr%20code.pdf
- Recommendations | Acute kidney injury: prevention, detection and management | Guidance | NICE
- Recommendations | Recent-onset chest pain of suspected cardiac origin: assessment and diagnosis | Guidance | NICE
- Ectopic pregnancy - Diagnosis - NHS
- Recommendations | Venous thromboembolic diseases: diagnosis, management and thrombophilia testing | Guidance | NICE
- Recommendations | Bronchiolitis in children: diagnosis and management | Guidance | NICE
- Recommendations | Self-harm: assessment, management and preventing recurrence | Guidance | NICE
- ECG-policy.pdf
- 1636
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