Medical Licensing (MD/DO) · Independent exam preparation
PLAB 2: Clinical Decisions and Professional Skills Study Guide
Practise focused assessment, urgent treatment, practical skills and patient-centred decisions through clinical cases and ethical reasoning.
By CertMedbry · Updated 19 October 2026
Learn to recognise urgent presentations, interpret findings, perform selected practical skills and explain defensible decisions in partnership with patients. This selective guide develops 60 teaching concepts. The official GMC MLA content map applicable from September 2026 defines the full scope, including presentations, conditions, capabilities and procedures beyond this selection. These independently authored CertMedbry questions and flashcards support learning without GMC endorsement or use of recalled examination items.
Try 20 free practice questionsWhat is the exam format?
Check the question types, timing and outline before planning your revision.
Which examination and professional level does this guide cover?
It covers the GMC Professional and Linguistic Assessments Board test, PLAB 2, for doctors who qualified abroad. The GMC describes clinical work expected in an F2 role. OSCE describes the examination's assessment format.
Professional and Linguistic Assessments Board · What is the PLAB 2 exam?
How many scenarios are there, and how long do they last?
PLAB 2 has 16 scenarios lasting eight minutes each. Allow additional time for the attendance and administrative arrangements specified in your candidate instructions.
What are the delivery format and item styles?
PLAB 2 is a performance-based clinical and professional skills assessment described as an OSCE. Scenarios assess applied patient care, including clinical assessment, practical skills, management and communication. This guide's four-option questions are revision exercises rather than the examination's delivery format.
Is there a published scored-versus-pretest scenario breakdown?
The candidate guide describes 16 scenarios without a separate scored-versus-pretest breakdown.
Which domains are assessed, and how are they weighted?
Each scenario assesses Data gathering, technical and assessment skills; Clinical management skills; and Interpersonal skills. All three have the same maximum marks. The results guidance does not publish specialty frequencies. This guide assigns concepts according to their principal task: 23 assessment, 21 management and 16 interpersonal concepts. Questions and flashcards each follow a 7/7/6 distribution. These selections are editorial choices, not official topic quotas.
Which content map applies?
The GMC map published in October 2025, updated in September 2026 and applicable from September 2026 is the relevant outline. Its six interconnected content domains are Areas of clinical practice; Areas of professional knowledge; Clinical and professional capabilities; Practical skills and procedures; Patient presentations; and Conditions. These describe underlying scope and are distinct from the three PLAB 2 marking domains.
Has the MLA replaced the PLAB 2 name?
PLAB retains its current name. PLAB stations derive from the MLA content map, and PLAB 2 meets MLA Clinical and Professional Skills Assessment requirements.
How are station standards determined?
The GMC uses borderline regression to determine station pass scores rather than a universal fixed percentage. Prepare to demonstrate clinical and professional performance across all three domains.
Which jurisdiction should guide ethical answers?
Use GMC professional standards alongside the law of the relevant UK nation. The England-and-Wales capacity example in this guide uses the Mental Capacity Act 2005; identify the jurisdiction before applying a statutory test.
Use the cases to connect clinical findings with decisions and explanations. The MCQs support reasoning and the flashcards support recall; examination, procedural and communication skills also require observed practice and feedback.
Outline used: GMC MLA content map, published October 2025, updated September 2026, applicable from September 2026 onward; current PLAB 2 candidate guide consulted on 2026-10-10. The workbook label maps to the GMC's PLAB 2 examination; OSCE describes its assessment format. PLAB 2 remains its current name and meets MLA Clinical and Professional Skills Assessment requirements.
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.
Data gathering, technical and assessment skillsPercentage not stated; same maximum marks as each other assessed domain
1.How should a focused history change the next decision?
A focused history selects information that changes urgency, the working diagnosis or the next investigation. Begin with the presenting problem and its time course, then test important alternatives with relevant positive and negative findings. Medicines, previous illness and the patient's concerns matter when they alter interpretation or management. A useful summary connects the findings to a decision rather than merely repeating everything the patient said during the consultation.
Apply it
A patient presents with back pain and asks for stronger analgesia. Before exploring every mechanical trigger, establish whether new bladder, bowel or perineal symptoms change the encounter from routine pain management to immediate assessment.
Common pitfall: Completing a familiar history sequence can feel thorough while delaying the one warning symptom that changes urgency. Relevance matters more than the number of questions.
How will you be tested? · NG127: Suspected neurological conditions — recommendations for adults
2.Which back-pain symptoms suggest cauda equina syndrome?
Severe low back pain radiating into a leg requires immediate assessment for cauda equina syndrome when accompanied by new bladder, bowel or sexual dysfunction, or new perineal numbness. These findings suggest compromise of the nerve roots responsible for pelvic function and sensation. Ask directly about the change from baseline because patients may not volunteer intimate symptoms. The combination changes urgency even before a definitive diagnosis has been established.
Apply it
A patient with severe radiating back pain mentions that wiping after using the toilet feels different. Ask specifically about perineal sensation and new urinary, bowel and sexual changes, then arrange immediate assessment for the suspected syndrome.
Common pitfall: Treating perineal numbness as an incidental sensory complaint misses its anatomical significance. Do not wait for every pelvic symptom to appear together before escalating.
NG127: Suspected neurological conditions — recommendations for adults
3.What does a normal ECG mean in suspected acute coronary syndrome?
A normal resting twelve-lead ECG does not exclude acute coronary syndrome. Interpret the trace alongside the pain history, timing, associated symptoms and clinical condition rather than using it as a stand-alone clearance test. Obtain an ECG promptly when acute coronary syndrome is suspected, but do not let recording or interpreting it delay necessary transfer. Persistent clinical suspicion remains important even when the first electrical recording is reassuring.
Apply it
A patient has ongoing central pressure with sweating, but the first ECG is normal. Retain acute coronary syndrome in the working differential and organise urgent assessment instead of explaining that the heart has been excluded.
Common pitfall: Equating a normal snapshot of cardiac electrical activity with absence of acute coronary disease creates false reassurance and can prematurely end the assessment.
CG95: Recent-onset chest pain of suspected cardiac origin — recommendations
4.How is a significant postural blood-pressure fall assessed?
When symptoms suggest postural hypotension, measure blood pressure lying down, or seated if necessary, and repeat after standing for at least one minute. A fall of at least 20 mmHg systolic or 10 mmHg diastolic is significant. Relate the measurement to dizziness, falls and medicines because the result informs both interpretation and review. A single normal seated measurement cannot answer a question about a position-dependent blood-pressure change.
Apply it
An older adult reports dizziness on rising. Blood pressure falls from 146/82 lying to 122/70 after standing for one minute. Identify a significant postural fall and review symptoms and possible medication contributions.
Common pitfall: Checking only systolic pressure misses an independently significant diastolic fall. Measuring immediately after standing also fails to follow the stated minimum standing interval.
5.Which early-pregnancy symptoms raise concern for ectopic pregnancy?
Possible pregnancy with lower abdominal pain, especially on one side, and vaginal bleeding requires assessment for ectopic pregnancy. Shoulder-tip pain, marked dizziness or collapse increase concern for serious internal bleeding. Symptoms can occur before a person knows they are pregnant or has obtained a positive test. Ask about pregnancy possibility and the symptom pattern without treating any single reassuring detail as sufficient to exclude a potentially dangerous diagnosis.
Apply it
A patient with a late period reports unilateral lower abdominal pain and unusual bleeding but has not taken a pregnancy test. Explore pregnancy possibility and urgent warning symptoms rather than assuming an ordinary menstrual disturbance.
Common pitfall: Requiring a previously positive home pregnancy test before considering ectopic pregnancy excludes patients whose first clue is pain or bleeding during an unrecognised pregnancy.
6.What observations help identify dehydration in a young child?
Assess fluid intake and losses together with behaviour and urine output. Fewer wet nappies, reduced tears, dry mouth and sunken eyes can indicate dehydration. Establish whether a sleepy child wakes readily and responds normally. Reduced urine or other dehydration indicators require urgent assessment; difficulty waking or reduced responsiveness requires immediate emergency help. Ask caregivers about changes from normal, ongoing losses and whether fluids are retained.
Apply it
A parent reports repeated diarrhoea and fewer wet nappies despite small drinks. Ask about alertness and responsiveness as well as intake. If the child is difficult to wake, direct the parent to call 999 immediately.
Common pitfall: Counting drinks without considering losses and urine output can underestimate dehydration. Describing a child as sleepy without assessing responsiveness leaves the urgency unclear.
Dehydration · Recommendations | Diarrhoea and vomiting caused by gastroenteritis in under 5s: diagnosis and management | Guidance | NICE
7.Which FAST findings identify a possible stroke?
FAST highlights facial weakness, arm weakness and speech disturbance, with time indicating the need for emergency action. Establish when symptoms began and whether they are present now or have recently resolved. Sudden focal neurological change remains concerning even if the patient appears better during the consultation. Recognition should trigger emergency assessment rather than a prolonged attempt to prove the exact vascular diagnosis before arranging help for the patient.
Apply it
A partner describes sudden facial droop and slurred speech that began twenty minutes ago and have now disappeared. Record the onset and resolution, recognise a possible cerebrovascular event and arrange emergency help despite the improvement.
Common pitfall: A normal-looking face during assessment does not cancel a credible history of sudden focal symptoms. Resolution changes the description, not the need for urgent action.
8.How does the time course distinguish delirium from longstanding impairment?
Delirium involves a recent change in mental function that often fluctuates, so establishing baseline and onset is central to assessment. Ask the patient and someone who knows them about attention, behaviour, alertness and usual abilities. A new change over hours or days should not be explained away by age or a pre-existing cognitive diagnosis. Sudden confusion can reflect serious illness and requires prompt assessment of its underlying cause.
Apply it
A care-home resident with established memory problems becomes disorientated and unusually inattentive overnight. Ask staff about the previous day's function and fluctuations, treating the abrupt change as a new clinical problem requiring urgent assessment.
Common pitfall: Attributing every cognitive change to an existing dementia label overlooks the diagnostic importance of sudden deterioration and can delay recognition of a treatable acute cause.
CG103: Delirium — recommendations · Sudden confusion (delirium)
9.How should suspected delirium, including a quiet presentation, be assessed?
Withdrawal, slow responses, reduced movement, poor concentration or reduced appetite may indicate hypoactive delirium. When delirium indicators are present, a practitioner competent in its use should assess with the 4AT, which examines alertness, orientation, attention and acute change or fluctuation. A suitably experienced healthcare professional makes the final diagnosis. In critical care or postoperative recovery, use CAM-ICU or ICDSC instead. Assess physiological contributors alongside the structured assessment, including hypoxia, dehydration, infection, pain and medicines.
Apply it
A previously conversational inpatient becomes withdrawn and inattentive. Establish baseline and fluctuation, perform a 4AT and arrange diagnostic assessment while checking oxygenation, hydration, infection symptoms, pain and recent medicine changes.
Common pitfall: Absence of agitation does not exclude delirium. A screening result supports assessment but does not replace clinical diagnosis or investigation of causes.
10.What should a psychosocial assessment after self-harm explore?
A psychosocial assessment explores the person's needs, circumstances and reasons for self-harm rather than reducing the encounter to the method used. Relevant areas include current distress, suicidal thoughts or intent, previous episodes, social difficulties, supports and what might help keep the person safe. Physical injury and psychological needs both matter. The purpose is an individual formulation that informs care, with a collaborative account of immediate and longer-term safety needs.
Apply it
After wound treatment, a patient says the injury followed an argument and asks to leave. Explore current thoughts, the meaning of the episode, available support and immediate safety needs rather than assuming the repaired wound completes care.
Common pitfall: Judging seriousness only from the physical injury overlooks psychological distress and future needs. A medically minor injury can still require a substantial psychosocial response.
11.Why should self-harm risk scores not determine discharge?
Risk scales should not be used to predict future suicide or repetition of self-harm, or to decide who receives treatment or is discharged. A numerical category cannot replace assessment of the person's current needs, context and safety. Develop an individual formulation and plan instead. The discriminating issue is the tool's proposed use: collecting information does not justify treating a low score as evidence that discharge is safe.
Apply it
A patient receives a low score on a local self-harm form but describes escalating distress and no safe place to stay. Base further assessment and planning on those needs rather than allowing the score to authorise discharge.
Common pitfall: A completed score can create false objectivity. Neither a low category nor a denial of current intent replaces a broader assessment of needs and safety.
12.Which observed inhaler errors impair medicine delivery?
Ask for a demonstration with the actual device or an appropriate demonstration device. Check dose preparation according to its instructions, exhalation away from the mouthpiece and a good lip seal. A pressurised metered-dose inhaler requires a slow, steady inhalation; without a spacer, actuation must coordinate with inhalation. A dry-powder device requires a quick, deep inhalation. Correct identified errors, demonstrate the device-specific method and ask the patient to demonstrate again. Consider a suitable alternative if effective use remains impossible.
Apply it
A patient inhales sharply through a pressurised metered-dose inhaler and actuates before beginning to breathe in. Demonstrate slow, coordinated inhalation, review spacer use and observe a repeat demonstration. Device-specific steps are illustrated in the NHS leaflet: https://www.geh.nhs.uk/patients-and-visitors/patients/patient-leaflets/seven-steps-good-inhaler-technique.
Common pitfall: The same inhalation instruction does not suit every device. Asking whether the patient knows the technique cannot reveal an observed coordination or inspiratory-flow error.
Recommendations | Asthma: diagnosis, monitoring and chronic asthma management (BTS, NICE, SIGN) | Guidance | NICE · Asthma
13.Which medicine details are needed before prescribing safely?
A prescribing decision requires reliable knowledge of what the patient already takes and the clinical factors that affect suitability. Clarify medicine names, doses, actual use, allergies and relevant previous reactions; include non-prescription products when checking interactions. Distinguish a prescribed list from what the patient is actually taking. Missing information should be resolved before committing to a treatment whose safety depends on it, with appropriate advice when uncertainty remains.
Apply it
A patient requests a new treatment but cannot name several regular tablets and also uses herbal products. Establish an accurate list and check compatibility before prescribing, rather than relying only on the proposed medicine's usual indication.
Common pitfall: Recognising a familiar indication does not establish prescribing safety. An incomplete medicine history can conceal interactions, duplication or a previous clinically important adverse reaction.
14.How is capacity assessed for this decision at this time?
Presume capacity and define the particular decision and time. Provide all practicable support before assessing the ability to understand, retain, use or weigh relevant information and communicate a decision by any means. In England and Wales, the Mental Capacity Act 2005 requires that an inability to decide results from an impairment of, or disturbance in, the functioning of the mind or brain. The disturbance may be temporary or permanent. Establish that causal connection rather than inferring incapacity from diagnosis, age or an unwise choice.
Apply it
In England, a patient with acute delirium cannot use or weigh information about an investigation despite support. Explain how the disturbance causes that inability now, consider whether the decision can wait for recovery and document the specific assessment.
Common pitfall: A diagnosis alone does not establish incapacity, and a functional difficulty alone does not establish the Act's causal requirement. Capacity may change over time and between decisions.
15.How should clinic blood pressure be measured reliably?
Use a validated, maintained device and an appropriate cuff size. Provide a relaxed setting with the patient quiet and seated and the arm outstretched and supported. Palpate the pulse first; an irregular pulse requires manual measurement by direct auscultation over the brachial artery because automated readings may be inaccurate. When considering hypertension, measure both arms. If a difference greater than 15 mmHg persists on repeat measurement, use the arm with the higher reading subsequently.
Apply it
An automated reading appears unexpectedly variable. Palpation reveals an irregular pulse. Repeat manually using brachial auscultation rather than averaging repeated automated values that may be unreliable.
Common pitfall: An unsupported arm, unsuitable cuff or unrecognised pulse irregularity can undermine interpretation before any diagnostic threshold is applied.
Recommendations | Hypertension in adults: diagnosis and management | Guidance | NICE
16.What should respiratory examination establish in suspected asthma?
Explain the examination and obtain consent. Auscultate the chest while the patient breathes, listening for polyphonic wheeze that is predominantly expiratory and for findings suggesting another cause of symptoms. Relate the examination to symptom variability, triggers and the patient's current condition. A normal examination between episodes does not exclude asthma. Diagnosis requires a suggestive history and supporting objective testing; if the patient is acutely unwell, immediate treatment takes priority over completing diagnostic tests.
Apply it
A patient describes recurrent nocturnal wheeze but has a normal chest examination today. Arrange appropriate objective testing instead of rejecting asthma solely because no wheeze is audible during this visit.
Common pitfall: Wheeze is neither required at every examination nor sufficient by itself to confirm asthma. Examination findings must be interpreted with the history and objective evidence.
17.How does dimensional checking prevent calculation errors?
A calculation should make the required output unit explicit and cancel the unwanted units. In a self-contained exercise, volume equals required amount divided by concentration when compatible units are used. Convert units before dividing and check whether the magnitude is plausible. This arithmetic skill is separate from clinical authorisation: a numerically correct volume does not establish that a medicine, dose, route or administration plan is appropriate for a real patient.
Apply it
For an arithmetic exercise only, a supplied amount is 150 mg and a supplied concentration is 50 mg/mL. Dividing 150 mg by 50 mg/mL gives 3 mL, with milligrams cancelling correctly from the calculation.
Common pitfall: Correct calculator entry cannot rescue incompatible units or an inappropriate prescription. Keep the arithmetic check separate from the clinical checks required before actual administration.
How will you be tested? · Keeping up to date and ensuring safe prescribing
18.How should adult bronchodilator reversibility results be interpreted?
In an adult with a suggestive history whose asthma is not confirmed by eosinophils or FeNO, assess bronchodilator reversibility using spirometry. An FEV1 increase of at least 12% and at least 200 mL from baseline supports diagnosis; an increase of at least 10% of predicted normal FEV1 is an alternative criterion. Calculate both the absolute change and the relevant percentage. Inhaled corticosteroids can make test results more likely to be normal.
Apply it
FEV1 rises from 2.00 L to 2.30 L after bronchodilator: the increase is 0.30 L, or 300 mL, and 0.30/2.00 × 100 = 15%. This meets both baseline-based criteria in an adult with a compatible history.
Common pitfall: An increase of 12% alone does not satisfy the combined baseline-based criterion if the absolute increase is below 200 mL. Do not substitute paediatric thresholds for adult criteria.
20.How does a lower-limb neurological examination clarify weakness?
Explain the examination, check pain and compare both sides. Inspect muscle bulk, assess tone with passive movement, and test hip, knee and ankle power against gravity and resistance. MRC grade 3 means movement against gravity but not resistance; grade 4 adds resistance but remains weaker than normal. Compare knee and ankle reflexes, plantar responses, sensation and heel-to-shin coordination. Assess gait only when safe. The [Warwick clinical examination handbook](https://uhmeded.uhcw.nhs.uk/Portals/0/AssetUploads/CHESS%20Book%20Clinical%20Skills%20Workbook%202022-23.pdf?ver=ELcRsPPRSWHk3baBgJ2INQ%3D%3D) illustrates these techniques.
Apply it
An adult develops foot drop after prolonged pressure near the knee. Document dorsiflexion strength and examine other movements, sensation and reflexes before attributing it to compression. Clear common-peroneal compression without root features warrants pressure avoidance, orthotic support and review at six weeks; lack of improvement requires neurological assessment.
Common pitfall: A foot-drop label does not establish the lesion. Sudden weakness may be cerebrovascular, while rapidly progressive symmetrical weakness requires immediate neurological, bulbar and respiratory assessment.
Recommendations for adults aged over 16 | Suspected neurological conditions: recognition and referral | Guidance | NICE · MLA content map — September 2026 update
31.Which hypertension investigations assess renal and metabolic involvement?
Offer urine albumin:creatinine ratio to assess albuminuria and a reagent strip for haematuria. Blood tests include electrolytes, creatinine, estimated glomerular filtration rate, HbA1c, total cholesterol and HDL cholesterol. These answer different questions: urine albumin assesses renal damage, creatinine and eGFR assess filtration, and HbA1c assesses glycaemic status. Examine the fundi and arrange a twelve-lead ECG for other target-organ effects. Interpret results together rather than assuming that one reassuring measure excludes all organ damage.
Apply it
A hypertensive adult has an eGFR within the laboratory reference range. Still obtain urine ACR and the other recommended assessments: a filtration estimate does not answer whether albuminuria or abnormal glycaemia is present.
Common pitfall: A urine dipstick for blood does not replace quantitative urine ACR. Renal assessment and diabetes screening require distinct tests with distinct purposes.
Recommendations | Hypertension in adults: diagnosis and management | Guidance | NICE
52.How should abdominal examination change assessment of a child with diarrhoea and pain?
Explain the examination, obtain appropriate consent and help the child lie comfortably. Inspect for distension and scars. Begin gentle palpation away from the painful area and assess tenderness and guarding while watching the child's response. Examine systematically rather than repeatedly pressing the sore spot. [Hillingdon's abdominal examination guide](https://redevelopment.thh.nhs.uk/documents/_Departments/Undergraduates/year3/ABDO-EXAMINATION.PDF) describes light palpation for tenderness and guarding; [Aberdeen's clinical methods workbook](https://www.abdn.ac.uk/medical/electives/elective_information/download/73/Foundations_of_Clinical_Method_Workbook_Year_2_2013.pdf) explains starting away from pain. Severe localised pain, distension or rebound tenderness raises concern for a diagnosis beyond uncomplicated gastroenteritis.
Apply it
A four-year-old has diarrhoea but also marked right-sided tenderness and guarding. Reassess physiological stability and arrange urgent paediatric or surgical assessment rather than continuing a routine home-rehydration plan. Describe the observed location and guarding without claiming that examination alone proves appendicitis.
Common pitfall: Diarrhoea does not exclude a serious abdominal cause. Painful repeated palpation adds distress and should not delay escalation when concerning findings are already clear.
Recommendations | Diarrhoea and vomiting caused by gastroenteritis in under 5s: diagnosis and management | Guidance | NICE · MLA content map — September 2026 update
54.How should cardiovascular examination characterise a new murmur?
Explain the examination and position the patient comfortably, usually at 45 degrees. Assess pulse rate and rhythm, blood pressure, JVP and peripheral oedema. Inspect and palpate the precordium, including the apex and thrills, then auscultate the valve areas and lung bases. Describe a murmur's timing, maximum intensity and radiation; a carotid pulse can help identify systole, but never compress both carotids together. The [Cardiff and Vale cardiovascular examination guide](https://cavuhb.nhs.wales/files/department-of-medical-and-dental-education/cardiovascular-clinical-examination-pdf/) demonstrates the sequence.
Apply it
A stable adult with exertional breathlessness has an ejection systolic murmur loudest in the aortic area and radiating to the carotids. Suspect aortic stenosis and arrange appropriate clinical review and [echocardiography](https://www.nhs.uk/tests-and-treatments/echocardiogram/) to assess valve structure and function; auscultation alone does not establish severity.
Common pitfall: Naming a valve lesion without describing the findings loses the reasoning. Oedema, raised JVP and basal findings also matter when assessing associated cardiac dysfunction.
How will you be tested? · MLA content map — September 2026 update
56.How should venepuncture be performed and a developing haematoma managed?
Confirm identity, explain the test and obtain consent. Check bleeding risks and select the required tubes. Perform hand hygiene, wear gloves, identify a suitable vein, disinfect the skin and let it dry without re-palpating. Anchor the vein and insert the safety needle bevel upwards at a shallow angle. Collect samples in the laboratory's required order, release the tourniquet before needle removal, activate safety protection and discard immediately into a sharps container. Apply pressure until bleeding stops and label samples beside the patient. See the [Leicestershire venepuncture procedure](https://leicspart.nhs.uk/wp-content/uploads/2023/08/Policy-and-Procedure-for-Clinicians-Undertaking-Venepuncture-on-Adults-and-Children-within-LPT-Exp-Nov-26.pdf).
Apply it
An anticoagulated adult develops rapid swelling during sampling. Stop, release the tourniquet, remove the needle and apply direct pressure. Reassess bleeding, pain and swelling before another attempt. Explain and document the haematoma; worsening swelling or new numbness requires review, as described in the [NHS venepuncture policy](https://www.bsmhft.nhs.uk/wp-content/uploads/2023/09/C34-Venepunture-Policy-Final-2.pdf).
Common pitfall: Do not probe blindly through swelling or leave before haemostasis is achieved. Anticoagulation may prolong the pressure needed; it is not an automatic reason to omit an indicated test.
How will you be tested? · MLA content map — September 2026 update
Clinical management skillsPercentage not stated; same maximum marks as each other assessed domain
19.How should a working diagnosis express uncertainty?
A working diagnosis is a reasoned provisional explanation, supported by the findings and open to revision. Distinguish what is likely from what is dangerous and still needs exclusion. Explain which findings support the leading possibility and which unresolved features affect urgency or testing. This allows action without pretending certainty. The strength of an assessment lies in how evidence changes decisions, including when uncertainty itself requires further evaluation or senior input.
Apply it
A patient with possible early pregnancy has unilateral pain but no confirmed location of pregnancy. Describe ectopic pregnancy as an important possibility requiring assessment rather than announcing either a definite diagnosis or an unsupported benign explanation.
Common pitfall: Choosing one label too early can suppress important alternatives. Listing many diagnoses without identifying the dangerous unresolved possibility also fails to guide a useful next step.
21.When should an unresponsive adult be treated as being in cardiac arrest?
An adult who is unresponsive and not breathing normally should be treated as being in cardiac arrest. Abnormal gasping does not establish effective breathing and must not delay the response. Activate emergency help and start CPR, arranging an AED as soon as possible. The decisive distinction is normal breathing rather than the presence of any respiratory movement; waiting for diagnostic certainty can postpone the treatment needed during a time-critical emergency.
Apply it
A person collapses, does not respond and makes occasional irregular gasps. Recognise that the breathing is abnormal, call for emergency help, begin CPR and ask someone to bring an AED while resuscitation continues.
Common pitfall: Mistaking agonal gasps for adequate breathing delays compressions. Do not allow occasional abnormal breaths to overrule unresponsiveness and the absence of normal breathing.
22.What defines effective adult chest compressions?
Adult chest compressions should be delivered at 100–120 per minute to a depth of 5–6 cm, allowing full recoil and minimising interruptions. A trained rescuer providing breaths uses a 30:2 compression-to-ventilation ratio. These features work together: rapid shallow compressions or persistent leaning can undermine otherwise prompt CPR. Effective performance therefore includes rate, depth, recoil and continuity, with attention to fatigue and the practical organisation of help around the patient.
Apply it
During practice, a partner notices that you maintain the correct rate but lean on the chest between compressions. Correct the recoil while preserving depth and rhythm rather than treating rate alone as proof of effective technique.
Common pitfall: Focusing exclusively on speed can produce shallow compressions or incomplete recoil. Avoid unnecessary pauses while trying to make every individual movement appear technically perfect.
23.How should an AED be integrated into CPR?
Use an AED as soon as it is available and follow its spoken or visual instructions. Continue CPR while another rescuer prepares the device when feasible, and ensure nobody touches the patient during rhythm analysis or shock delivery. Resume CPR promptly when instructed, including after a shock. The device guides shock decisions; the rescuer's tasks are timely application, safe clearance and limiting interruptions to compressions throughout the resuscitation attempt.
Apply it
An AED arrives while two rescuers are performing CPR. One prepares and attaches it while the other continues compressions where possible, then both ensure the patient is clear for analysis and any advised shock.
Common pitfall: Stopping compressions as soon as the AED enters the room creates avoidable delay. Touching the patient during analysis or shock delivery compromises safe device use.
24.How should an adult with suspected anaphylaxis be treated and reassessed?
Summon emergency help and give adult adrenaline 500 micrograms IM into the anterolateral thigh: 0.5 mL of 1 mg/mL. Repeat after five minutes if airway, breathing or circulation problems persist. Keep a cardiovascularly unstable patient flat, raising legs where appropriate; prevent standing, walking or sudden postural changes because reduced venous return can precipitate collapse. Predominantly respiratory symptoms without cardiovascular instability may favour supported semi-recumbency. Give oxygen as soon as available, initially at high concentration through a reservoir mask, then titrate to 94–98%, considering 88–92% if hypercapnic respiratory failure is a risk. For hypotension or shock, give a rapid IV crystalloid bolus of 500–1000 mL and reassess.
Apply it
An adult develops throat swelling, wheeze and hypotension. Give IM adrenaline immediately and keep them flat. While help provides oxygen, monitoring and IV access, give the crystalloid bolus and reassess perfusion, blood pressure and breathing. Repeat adrenaline at five minutes if compromise persists; persistent problems after two appropriate doses require expert management.
Common pitfall: Do not sit a shocked patient upright or let them walk. Positioning, oxygen and fluids complement immediate IM adrenaline; they must not delay it.
Special circumstances Guidelines 2025 · Emergency%20Treatment%20of%20Anaphylaxis%20May%202021_0.pdf
25.What immediate care accompanies emergency transfer for suspected acute coronary syndrome?
Arrange emergency hospital transfer for ongoing suspected acute coronary syndrome. Monitor symptoms, pulse, blood pressure, rhythm and oxygen saturation while providing appropriate analgesia, such as glyceryl trinitrate when suitable or an intravenous opioid when indicated. Give a single 300 mg aspirin loading dose unless clearly allergic. Oxygen is not routine: give it when saturation is below 94% in someone without hypercapnic respiratory-failure risk, targeting 94–98%; for someone at risk, target 88–92% pending blood gases. None of these measures should delay transfer.
Apply it
A patient has persistent suspicious chest pain, saturation 97% on air and no aspirin allergy. Arrange emergency transfer, give 300 mg aspirin, monitor and provide suitable pain relief. Do not add oxygen solely because the pain may be coronary.
Common pitfall: A normal ECG does not cancel emergency transfer. Routine oxygen in a normally oxygenated patient and prolonged community investigations do not improve the initial plan.
CG95: Recent-onset chest pain of suspected cardiac origin — recommendations
26.When does childhood gastroenteritis require investigation for infection?
In an under-five with suspected gastroenteritis, perform stool microbiological investigations when septicaemia is suspected, blood or mucus is present in the stool, or the child is immunocompromised. Consider testing after recent travel, diarrhoea not improving by day seven or diagnostic uncertainty. Do not routinely prescribe antibiotics; specific infections and serious systemic illness change that decision. Bilious vomiting, altered consciousness or severe localised abdominal pain should prompt consideration of another serious diagnosis.
Apply it
A child has watery diarrhoea for two days and remains well hydrated: routine antibiotics and stool testing are usually unnecessary. Blood in the stool or immunocompromise changes the investigation plan.
Common pitfall: Treating all diarrhoea as uncomplicated viral gastroenteritis misses specific investigation indications. Conversely, routine antibiotics are not appropriate for every child with gastroenteritis.
27.Which suspected ectopic-pregnancy symptoms demand emergency action?
Possible ectopic pregnancy accompanied by severe sudden abdominal pain, marked dizziness, fainting or collapse raises concern for rupture and internal bleeding. This requires emergency help rather than waiting for a routine pregnancy appointment. Explain that the immediate concern is a potentially serious complication, while acknowledging that assessment is needed to establish the diagnosis. The urgency comes from the clinical deterioration, not from whether a home pregnancy test has already been positive.
Apply it
A patient with a missed period and one-sided pain becomes faint and develops severe abdominal pain. Arrange emergency assistance immediately rather than sending them home to repeat a pregnancy test before deciding whether further assessment is needed.
Common pitfall: Requiring diagnostic confirmation before responding to collapse reverses the safe sequence. Emergency action addresses the suspected complication while definitive assessment establishes its cause.
28.How do prevention, active rehydration and recovery differ in childhood gastroenteritis?
Without clinical dehydration, continue usual feeds and fluids and offer supplemental ORS to children at increased risk. For an under-five with clinical dehydration suitable for oral treatment, give low-osmolarity ORS 50 mL/kg for deficit replacement over four hours plus maintenance, in small frequent amounts, with regular reassessment. During rehydration, continue breastfeeding but withhold solid foods. After rehydration, reintroduce usual solids and full-strength milk. Suspected shock or deterioration requires escalation; difficulty waking or reduced responsiveness requires immediate emergency help.
Apply it
For a 10 kg child suitable for oral rehydration, deficit replacement is 500 mL ORS over four hours, with maintenance added separately. Continue breastfeeding, withhold solids during treatment and reassess regularly. Persistent vomiting, worsening signs or inability to take ORS changes the route and setting of care.
Common pitfall: Usual-diet advice depends on the stage of illness. Do not apply recovery feeding instructions during active rehydration or continue home treatment when responsiveness deteriorates.
Recommendations | Diarrhoea and vomiting caused by gastroenteritis in under 5s: diagnosis and management | Guidance | NICE · Dehydration
29.What action is needed when stroke symptoms have resolved?
Recent sudden facial weakness, arm weakness or speech disturbance requires emergency action even if symptoms have stopped. Improvement does not make the event safe to ignore, and the patient should not drive themselves for assessment. Establishing onset remains useful, but it should not delay calling for help. The transferable decision is to respond to the credible recent focal neurological event rather than base urgency only on the examination at this moment.
Apply it
A patient calls after ten minutes of slurred speech and one-sided arm weakness earlier that morning. Advise emergency help despite complete recovery, and explain that waiting for another episode would risk delaying important assessment.
Common pitfall: Offering a routine appointment because the patient now speaks normally mistakes recovery for reassurance. Recent resolved stroke-like symptoms still require an emergency response.
30.What concrete sequence helps identify contributors to delirium?
After recognising the acute change and arranging structured assessment, assess physiological stability and oxygen saturation, then review hydration, fluid intake, constipation, infection symptoms, pain and medicines. Use examination and targeted investigations to test these possibilities; more than one contributor may coexist. Correct hypoxia, address dehydration with attention to comorbidities, investigate and treat infection, provide appropriate pain relief and review medication burden. Continue reorientation and reassurance while treating causes.
Apply it
A newly confused inpatient has low oxygen saturation, poor intake and a recent medicine change. Address oxygenation promptly, assess hydration and infection, and review the medicine rather than assuming that one abnormality explains everything.
Common pitfall: Sedating behaviour alone leaves the cause unresolved. Becoming quieter does not establish that delirium or its precipitating illness has improved.
CG103: Delirium — recommendations · Sudden confusion (delirium)
32.How should physical and psychosocial care proceed after self-harm?
Physical treatment and psychosocial assessment address different needs and should be coordinated rather than treated as mutually exclusive stages. Provide necessary medical care while arranging timely psychosocial assessment; do not use physical recovery alone as evidence that discharge is appropriate. The eventual plan should reflect the person's needs and safety, including the context of the episode. A completed procedure or resolved physical symptom does not complete the broader clinical task.
Apply it
A patient's self-inflicted wound has been repaired and observations are stable. Continue arrangements for psychosocial assessment and an individual care plan rather than assuming that successful wound closure establishes readiness to leave the department.
Common pitfall: Sequential thinking can create unnecessary delay or omit psychological care altogether. Physical stability answers one question, while psychosocial assessment addresses different decisions about support and safety.
33.What makes a self-harm safety plan collaborative and usable?
A safety plan should be developed with the person and identify their warning signs, coping strategies, supportive contacts and sources of urgent help. Discuss reducing access to means of self-harm in a collaborative way. The plan should be accessible and practical during distress, with the person's agreement guiding appropriate sharing. Its value lies in specific actions linked to their circumstances, rather than a generic instruction to seek help if things worsen.
Apply it
A patient identifies isolation after arguments as an early warning sign. Build a plan naming a coping activity, a trusted contact, urgent support routes and agreed steps to reduce access to the means used previously.
Common pitfall: A generic leaflet or promise not to self-harm does not provide the personalised actions of a safety plan. Check that contacts and strategies are actually usable.
34.Which decisions should a personalised asthma action plan enable?
Separate usual treatment, deterioration and emergency actions. Increasing symptoms, nocturnal waking, activity limitation or greater reliever use require review. Example: a 10-year-old prescribed twice-daily low-dose inhaled corticosteroid and a separate salbutamol pMDI continues the preventer as prescribed. During an attack, sit upright and give one salbutamol puff every 30–60 seconds through a spacer, shaking between puffs, up to ten unless the personal plan specifies otherwise. Call 999 if worsening at any point or not improving after the permitted doses. Recovery still requires urgent review within two days.
Apply it
Contrast that child's plan with an adult using AIR or MART. AIR supplies ICS/formoterol as needed; MART adds scheduled maintenance doses of the same inhaler. NHS attack advice is one inhalation every 1–3 minutes up to six, unless the personal plan specifies another maximum. Do not apply the blue-inhaler ten-puff instruction to AIR/MART. Ask the patient to explain their own regimen, limit and emergency action.
Common pitfall: Attack-dose limits and total daily limits depend on the prescribed product and plan. Never wait to exhaust a dose allowance when breathing is worsening.
Asthma · Recommendations | Asthma: diagnosis, monitoring and chronic asthma management (BTS, NICE, SIGN) | Guidance | NICE
35.How should proposed ACE-inhibitor plus ARB treatment change a hypertension plan?
Do not combine an ACE inhibitor with an angiotensin-receptor blocker to treat hypertension. Both inhibit the renin–angiotensin system, so combining them increases the risks of hyperkalaemia, hypotension and impaired renal function compared with either class alone. Reconcile the actual medication list, assess blood pressure and review creatinine, eGFR and potassium. Reduced renal function and diabetic nephropathy heighten concern. For uncontrolled hypertension on an ACE inhibitor or ARB, assess adherence and consider a calcium-channel blocker or thiazide-like diuretic instead, according to suitability.
Apply it
An adult taking ramipril for hypertension is offered losartan as an addition. Identify dual RAS blockade before prescribing and choose an appropriate different-class option after assessment. If cough makes ramipril intolerable, an ARB may replace it rather than be added. Existing dual therapy requires review of its indication and monitoring.
Common pitfall: The hypertension instruction is specific and firm. Do not turn it into a claim that no specialist indication ever exists; exceptional dual blockade requires specialist supervision and close blood-pressure, renal and potassium monitoring.
Recommendations | Hypertension in adults: diagnosis and management | Guidance | NICE · Combination use of medicines from different classes of renin-angiotensin system blocking agents: risk of hyperkalaemia, hypotension, and impaired renal function—new warnings - GOV.UK
36.How does type 2 diabetes change initial hypertension treatment decisions?
For an adult under 80 with persistent stage 1 hypertension, diabetes is a reason to discuss antihypertensive treatment alongside lifestyle measures, even without a high calculated cardiovascular risk. For step 1 treatment in type 2 diabetes, offer an ACE inhibitor or ARB regardless of age; for Black African or African–Caribbean family origin, consider an ARB in preference to an ACE inhibitor. Check pregnancy considerations, renal function, electrolytes and other disease-specific indications. Do not combine an ACE inhibitor with an ARB.
Apply it
A 60-year-old with type 2 diabetes and confirmed persistent stage 1 hypertension asks whether age alone means starting a calcium-channel blocker. Explain the diabetes-specific recommendation and discuss an ACE inhibitor or ARB after suitability checks.
Common pitfall: Applying the age-based pathway without checking diabetes can select the wrong initial branch. ACE inhibitor plus ARB is not the recommended way to intensify hypertension treatment.
Recommendations | Hypertension in adults: diagnosis and management | Guidance | NICE
37.How do positional vertigo and acute vestibular syndrome lead to different decisions?
Transient rotational vertigo triggered by head movement suggests BPPV and warrants a Hallpike manoeuvre by a trained practitioner. If BPPV is diagnosed, offer a canalith-repositioning manoeuvre such as Epley when appropriately trained and there is no unstable cervical spine disease. Sudden persistent vertigo with nausea or vomiting and gait unsteadiness is an acute vestibular syndrome. HINTS is appropriate only when performed by someone trained and experienced; a normal head impulse, direction-changing nystagmus or skew deviation requires immediate neuroimaging referral.
Apply it
An adult has brief spinning when rolling in bed without persistent imbalance: assess for BPPV. Another has continuous new vertigo, vomiting and inability to walk steadily. If BPPV or postural hypotension does not explain that presentation and no HINTS expert is available, refer immediately through the stroke pathway.
Common pitfall: Do not use an untrained HINTS examination to reassure or perform Epley automatically for every dizzy patient. Check cervical-spine suitability before repositioning.
38.How should follow-up be made actionable?
A follow-up plan should identify what happens next, why it is needed and how the patient will know the outcome. When investigations are pending, explain how results connect to the next decision and clarify the arrangements for review. Check practical understanding rather than assuming that a referral or test request completes management. An actionable plan allows the patient to participate in carrying it out.
Apply it
A patient agrees to further investigation but thinks no contact means the result is normal. Clarify the agreed route for receiving results and arranging review, then ask them to explain what they will do if communication fails.
Common pitfall: Ordering a test without explaining the review arrangements leaves a gap between investigation and care. Vague instructions can be interpreted differently by clinician and patient.
39.What makes safety-netting specific enough to use?
Safety-netting links an unresolved possibility to recognisable changes and a clear action. Explain the current assessment, what remains uncertain, which symptoms should prompt help and how urgently to obtain it. The advice should fit the presentation and the patient's ability to act. For possible early-pregnancy complications, for example, severe pain, fainting or collapse require emergency action. Specific instructions make uncertainty manageable without falsely presenting the initial assessment as definitive.
Apply it
A patient undergoing assessment for early-pregnancy pain asks what to do while awaiting the next step. Explain that severe worsening pain, marked dizziness or collapse requires emergency help, and ask them to repeat the agreed action.
Common pitfall: “Come back if worse” leaves the patient to define both deterioration and urgency. Safety-netting should name meaningful changes and the response they require.
40.How should raised clinic blood pressure be confirmed before routine long-term treatment?
For clinic blood pressure from 140/90 mmHg up to but below 180/120 mmHg, offer ambulatory monitoring to confirm hypertension; use home monitoring if ambulatory monitoring is unsuitable. Confirm hypertension when clinic pressure is at least 140/90 and daytime ambulatory or home average is at least 135/85. For home monitoring, take two seated readings at least one minute apart, morning and evening, for at least four days, ideally seven; discard day one and average the rest. Severe hypertension requires its separate assessment pathway.
Apply it
A stable patient has clinic pressure 152/94 and daytime ambulatory average 132/82. The out-of-office diagnostic threshold is not met. Explain the difference and review cardiovascular risk and target-organ assessment rather than diagnosing sustained hypertension from the clinic value alone.
Common pitfall: Using clinic thresholds for home averages overlooks the lower out-of-office threshold. One high clinic reading does not establish the usual blood pressure.
Recommendations | Hypertension in adults: diagnosis and management | Guidance | NICE
58.How should peripheral IV access be established and checked before use?
Confirm indication, identity and consent, select a suitable vein and device, and use aseptic technique. Disinfect the skin, allow it to dry and avoid touching the prepared site. Insert bevel upwards; blood flashback indicates needle entry into the vein. Advance the catheter using the device-specific technique, release the tourniquet, remove and safely discard the introducer, attach the primed connector and secure with a sterile transparent dressing. Check patency with an appropriate saline flush while observing for pain, swelling or leakage. Document insertion and review continuing need. See the [NHS peripheral vascular-device procedure](https://apps.worcsacute.nhs.uk/KeyDocumentPortal/Home/DownloadFile/1913).
Apply it
A newly inserted adult cannula causes pain and local swelling during its first saline flush, before any medicine is given. Stop flushing and do not administer treatment through it. Assess for infiltration or displacement, remove the failed cannula and obtain new access if needed. [NHS cannula guidance](https://www.gloshospitals.nhs.uk/your-visit/patient-information-leaflets/peripheral-intravenous-iv-cannula/) identifies these warning signs.
Common pitfall: Initial flashback does not guarantee a usable catheter. Pain, leakage or swelling during a flush must change the plan; do not overcome the problem by injecting more forcefully.
How will you be tested? · MLA content map — September 2026 update
Interpersonal skillsPercentage not stated; same maximum marks as each other assessed domain
41.How does an opening question reveal the patient's agenda?
An open invitation lets the patient describe the problem and reveal concerns that may not match the referral label. Listen initially, then clarify the main issues and agree priorities while remaining alert to urgent symptoms. Rapport develops through attention to the person's account rather than a memorised introduction alone. Establishing the agenda also helps direct later explanations: advice is more useful when it addresses the question or fear that brought the patient to care.
Apply it
A patient booked for an asthma review begins by describing fear of using inhalers in public. Acknowledge that concern and include it in the consultation agenda while still assessing control, technique and any immediate clinical problems.
Common pitfall: Following the appointment label without hearing the patient's concern can produce a technically organised consultation that fails to address the reason they sought help.
42.How should distress be acknowledged without making assumptions?
Acknowledge an observed emotion tentatively and invite the patient to explain what matters to them. A statement such as noticing that news seems upsetting creates space without claiming to know exactly how they feel. Allow a response before moving into more information. Understanding the source of distress can reveal a misconception, priority or barrier that changes the discussion and the agreed plan.
Apply it
After hearing about a proposed investigation, a patient becomes silent and tearful. Pause, acknowledge that the discussion appears upsetting and ask what is worrying them before continuing through the remaining information at the same pace.
Common pitfall: Automatic reassurance may close down an important concern before it is understood. Naming an emotion confidently can also impose an interpretation the patient does not share.
43.How can explanations remain understandable without losing precision?
Use familiar language, explain necessary technical terms and present information in manageable sections. Connect each explanation to the decision the patient faces, then pause to check understanding and invite questions. Precision comes from stating the relevant benefit, risk or uncertainty clearly, not from using specialised vocabulary. Adapt the amount and format of information to the person rather than assuming that a longer explanation necessarily produces a better informed decision.
Apply it
Instead of only naming a suspected diagnosis, explain what problem is being considered, why further assessment is needed and what will happen next. Pause after each section so the patient can raise questions or correct a misunderstanding.
Common pitfall: Replacing every technical term with a vague reassurance loses meaning. Equally, delivering a dense uninterrupted explanation can leave the patient unable to identify the actual choice.
The dialogue leading to a decision — part 1 · The dialogue leading to a decision — part 2
44.When should professional interpreting support be arranged?
Arrange appropriate interpreting support when a language barrier prevents an effective discussion or informed decision. Address the patient directly and allow time for questions and clarification. A relative's willingness to translate does not automatically ensure accurate communication, privacy or freedom from influence, especially for sensitive choices. The aim is to enable the patient to understand and express their own decision, not merely to obtain a translated agreement with the clinician's recommendation.
Apply it
A patient's partner answers all questions and offers to translate consent for an intimate examination. Arrange appropriate interpreting support so the patient can discuss the examination, ask questions and express a voluntary choice directly.
Common pitfall: Fluent social conversation does not establish understanding of a complex medical decision. Relying automatically on relatives can conceal inaccuracies, sensitive concerns or unwanted influence.
45.How can teach-back support rather than test a patient?
Frame teach-back as a check on the clarity of your explanation: ask the patient to describe the plan in their own words so that you can identify anything that needs explaining differently. Focus on the practical decision and next steps, not verbatim recall. If understanding is incomplete, change the explanation and check again. This preserves partnership and avoids treating communication difficulty as a personal failure or as automatic evidence of incapacity.
Apply it
After discussing a safety plan, say that you want to check you explained it clearly and ask what the patient would do if distress rises tonight. Use their response to clarify an uncertain contact route.
Common pitfall: Asking for exact repetition can feel like an examination and may reward memorisation. The goal is usable understanding, not recall of the clinician's wording.
46.How should patient preferences influence shared decisions?
Shared decision-making requires finding out what outcomes and burdens matter to the patient, then discussing reasonable options in that light. A preference becomes clinically useful when its reasons are understood: concern about pain, independence, work or caregiving may change which trade-off is acceptable. The clinician contributes evidence and professional advice while the patient contributes values and circumstances. Agreement should emerge from this exchange rather than from persuasion towards a predetermined choice.
Apply it
A patient initially declines a procedure because they believe recovery will prevent caring for a child. Explore that concern, explain the realistic options and burdens, and revisit the choice after correcting any relevant misunderstanding.
Common pitfall: Recording “patient preference” without exploring its basis may preserve a remediable misconception. Shared decisions require both accurate information and genuine attention to personal priorities.
47.Which risks are important enough to discuss?
Risk discussion should be individualised rather than limited to the most common complications. Explain risks that a reasonable person in the patient's position would consider significant and those you know, or should recognise, matter particularly to this patient. Seriousness, likelihood and personal consequences all influence significance. Ask about priorities so that unusual individual concerns are not missed. A standard form can support the discussion but cannot identify every personally important consequence.
Apply it
A patient whose work depends on fine hand movements asks about a possible functional complication. Discuss that consequence explicitly even if uncommon, because its effect on this person's livelihood makes it important to the decision.
Common pitfall: A rare risk is not automatically an irrelevant risk. Conversely, listing complications without explaining their consequences may fail to communicate why they matter personally.
48.Why must reasonable alternatives be explained?
An informed choice requires understanding reasonable alternatives to the proposed intervention, including taking no action when relevant. Explain the likely benefits, harms and uncertainties of each option in a balanced way. This makes the recommendation assessable rather than presenting acceptance as the only possible decision. The range of reasonable options depends on the clinical circumstances; discussing alternatives does not require presenting unsuitable treatments as equivalent or promising outcomes that cannot be supported.
Apply it
A patient asks whether a proposed intervention is unavoidable. Explain the reasonable alternatives and the likely consequences of waiting or declining where relevant, then discuss why you recommend a particular option in their circumstances.
Common pitfall: Mentioning that alternatives exist without explaining them provides little basis for choice. Balance does not mean describing clinically unsuitable options as equally appropriate treatments.
49.How does consent remain valid during an examination?
Consent is an ongoing process with an agreed scope, not a single permission that covers every later action. Explain proposed changes and remain attentive to verbal and non-verbal signs that the patient wants to pause or stop. During an intimate examination, stop if the patient asks you to stop. A chaperone supports appropriate practice but does not provide consent on the patient's behalf or override a withdrawal of permission.
Apply it
A patient initially agrees to an intimate examination but then says it is too distressing and asks you to stop. Stop, preserve dignity and discuss whether they want a pause, an alternative approach or no further examination.
Common pitfall: Initial agreement does not authorise completion despite withdrawal. Clinical usefulness and the presence of a chaperone do not remove the patient's ability to stop.
50.What is the purpose of a trained chaperone?
A trained chaperone provides an impartial presence during an intimate examination and should understand their role in observing appropriate conduct and supporting the patient. Explain the offer and respect the patient's preferences within safe professional arrangements. A friend or relative may provide comfort, but that role is different from acting as a trained chaperone. The examination still requires explanation, consent, attention to dignity and a response to any request to stop.
Apply it
A patient wants a partner present during an intimate examination. Discuss that support person's role and separately explain the offer of a trained chaperone, ensuring that the patient understands the examination and continues to consent.
Common pitfall: Treating any accompanying person as a chaperone overlooks the distinct responsibilities of a trained observer. A chaperone also cannot substitute for consent or explanation.
51.When may information be shared with relatives?
Explore what the patient wants shared, with whom and for what purpose. A relative's involvement or relationship does not automatically entitle them to confidential clinical details. Sharing for direct care must follow the relevant confidentiality principles and circumstances, with appropriate respect for the patient's wishes. If disclosure without consent is being considered, it requires a separate lawful and professional justification. Receiving a relative's concerns does not itself create permission to disclose information back.
Apply it
A patient agrees that their sister may hear the discharge arrangements but does not want diagnostic details discussed. Share within the agreed scope and clarify any uncertainty rather than treating permission as access to the entire medical history.
Common pitfall: Permission to share one aspect of care is not blanket permission. Family involvement can be valuable while confidentiality boundaries still remain specific and meaningful.
53.Why should capacity be presumed before disagreement is interpreted?
Presuming capacity protects the patient's role as the decision-maker unless there is a reason to assess their ability for the particular choice. A diagnosis, disability or communication difficulty must not become a shortcut to excluding them from the discussion. Provide support and accessible information before drawing conclusions. The relevant question is whether the person can make this decision under the applicable legal framework, not whether they communicate or choose as the clinician expects.
Apply it
A patient with a learning disability attends with a carer who answers immediately. Address the patient, adapt the explanation and explore their own decision before considering whether a specific capacity assessment is needed for the proposed treatment.
Common pitfall: Directing every question to a carer can manufacture apparent inability by denying the patient an opportunity to understand, respond and participate with suitable support.
55.How should suspected coercion affect consent and safeguarding?
Explore the patient's wishes privately, using independent communication support when needed. Assess immediate danger and whether they can choose freely. Suspected abuse or denial of rights requires following local safeguarding procedures and considering raising a concern. Offer specialist support, allow a safe space and time, and document concerns, the patient's wishes and agreed actions. Coercion concerns voluntariness; it does not itself establish incapacity.
Apply it
A partner threatens consequences if treatment is accepted. Speak privately through an independent interpreter, ask about threats and immediate safety, and offer specialist domestic-abuse support. Follow safeguarding procedures and consider raising a concern; do not rely solely on the refusal expressed before the partner.
Common pitfall: Privacy begins the response; it does not replace safeguarding action. Avoid confronting the partner in a way that could increase danger.
Circumstances that affect the decision-making process — part 2
57.When should a patient be told that something has gone wrong?
When care has gone wrong and caused harm or distress, explain the problem openly and honestly as soon as appropriate. Give the facts known at that time, acknowledge uncertainty and explain the immediate response and further review. Do not wait for every investigation to finish before beginning the conversation. The patient needs a truthful account of what is understood now, with a commitment to update them as the situation becomes clearer.
Apply it
A treatment error has caused harm, but its full explanation is still being investigated. Tell the patient what is known, apologise, describe the immediate care and explain how further findings will be communicated as they become available.
Common pitfall: Waiting for a final report can prolong avoidable uncertainty and undermine trust. Early honesty does not require speculation about facts that have not been established.
59.How is dignity protected during an intimate examination?
Explain why the examination is needed and what it involves, obtain consent and offer an appropriate chaperone. Provide privacy for undressing and dressing, keep the patient covered as much as possible and avoid unnecessary exposure. Check comfort and respond to distress throughout. Dignity is maintained through the practical conduct of the examination as well as respectful language; an efficient technique does not excuse exposure or a failure to notice the patient's discomfort.
Apply it
Before an intimate examination, explain the steps and arrange privacy for changing. During the examination, keep areas not being examined covered and pause if distress appears, checking whether the patient wants to continue with the assessment.
Common pitfall: Treating draping and privacy as optional courtesies overlooks their role in appropriate examination practice. Consent does not make unnecessary exposure acceptable or remove ongoing responsibilities.
60.What should a record of a consent discussion capture?
A useful record reflects the decision-making conversation: relevant information provided, important risks and alternatives, the patient's priorities and the decision reached. Include meaningful communication support and any limits to the agreed intervention. Documentation supports continuity and understanding, but a form cannot replace the dialogue or make an inadequately informed decision valid. The record should show how the choice was reached rather than merely state that consent was obtained before treatment began.
Apply it
A patient agrees to a procedure after discussing a personally important risk and declines one optional component. Record that discussion and the agreed scope so the next clinician does not mistake general agreement for permission to perform everything.
Common pitfall: A signed form may conceal an unclear discussion. Recording only “risks explained” loses the individual concerns and boundaries that shaped this patient's actual decision.
The dialogue leading to a decision — part 1 · The dialogue leading to a decision — part 2
What to focus on during revision
The following are CertMedbry study suggestions. Use the official outline to check the full scope of your examination.
- Link each focused history and examination to a diagnosis, urgency decision or next investigation.
- Practise abdominal, cardiovascular and neurological examination, describing findings and their implications.
- Rehearse venepuncture and peripheral cannulation, including asepsis, complications and decisions to stop or obtain new access.
- Practise emergency responses, including adult adrenaline preparation, positioning, oxygen, fluid resuscitation and reassessment.
- Interpret numerical results through worked blood-pressure, fluid and spirometry calculations.
- Distinguish dehydration prevention, active rehydration and recovery, with explicit emergency warning signs.
- Connect renal, metabolic, infectious and respiratory findings to specific investigations and management choices.
- Demonstrate supported capacity assessment, voluntary consent, safeguarding, confidentiality and candour through specific words and actions.
- Use the full official MLA content map to identify clinical and procedural learning needs beyond this selection.
A practical preparation plan
1. Map the full scope
Use the September 2026 MLA content map to organise presentations, conditions, capabilities and practical skills. Mark the areas covered here and identify additional learning needs across clinical practice.
2. Build decision-linked assessments
For each presentation, state the dangerous possibility, the discriminating questions or findings and the action they would trigger. Practise short summaries that explain why the next step follows from the findings.
3. Rehearse observable performance
Use supervised practice for abdominal, cardiovascular and neurological examination, venepuncture and cannulation. Include blood-pressure measurement, device-specific inhaler assessment, CPR and adult anaphylaxis treatment. Seek feedback on technique, interpretation, complications and subsequent decisions.
4. Work through results
Calculate positional blood-pressure changes, bronchodilator responses and rehydration volumes. Explain the threshold, the clinical context and the next decision, including what a reassuring result cannot exclude.
5. Use the questions diagnostically
Answer the MCQs before reading their explanations. For each error, identify the decisive cue and explain why each competing plan fails in that particular case. Rehearse the decision aloud as part of a clinical conversation.
6. Make recall practical
Use the flashcards to recall thresholds, warning patterns and ethical distinctions. Convert each answer into a patient explanation or immediate action, and revisit weak areas against current UK guidance and the full official outline.
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
- What is the PLAB 2 exam?
- How will you be tested?
- Understanding your results
- What resources should you use to prepare for PLAB 2?
- PLAB and the MLA
- MLA content map
- MLA content map — September 2026 update
- NG127: Suspected neurological conditions — recommendations for adults
- CG95: Recent-onset chest pain of suspected cardiac origin — recommendations
- NG136: Hypertension in adults — recommendations
- NG225: Self-harm — recommendations
- NG225: Self-harm — guideline PDF
- CG103: Delirium — recommendations
- Ectopic pregnancy — symptoms
- Dehydration
- Symptoms of a stroke
- Sudden confusion (delirium)
- Asthma
- Adult basic life support Guidelines 2025
- Special circumstances Guidelines 2025
- Mental capacity
- Personal beliefs and medical practice
- The dialogue leading to a decision — part 1
- The dialogue leading to a decision — part 2
- Circumstances that affect the decision-making process — part 2
- Using and disclosing patient information for direct care
- Being open and honest with patients when things go wrong
- Intimate examinations and chaperones
- Keeping up to date and ensuring safe prescribing
- suspected-neurological-conditions-recognition-and-referral-pdf-66141663923653
- Recommendations | Hypertension in adults: diagnosis and management | Guidance | NICE
- Recommendations | Self-harm: assessment, management and preventing recurrence | Guidance | NICE
- Recommendations | Diarrhoea and vomiting caused by gastroenteritis in under 5s: diagnosis and management | Guidance | NICE
- Recommendations | Asthma: diagnosis, monitoring and chronic asthma management (BTS, NICE, SIGN) | Guidance | NICE
- ukpga_20050009_en.pdf
- Recommendations for adults aged over 16 | Suspected neurological conditions: recognition and referral | Guidance | NICE
- algorithm-a-objective-tests-for-diagnosing-asthma-in-adults-and-young-people-aged-over-16-years-with-a-history-suggesting-asthma-bts-nice-sign-pdf-13556516365
- Seven Steps to Good Inhaler Technique :: George Eliot Hospital
- Emergency%20Treatment%20of%20Anaphylaxis%20May%202021_0.pdf
- Combination use of medicines from different classes of renin-angiotensin system blocking agents: risk of hyperkalaemia, hypotension, and impaired renal function—new warnings - GOV.UK
Confirm current eligibility, fees, scheduling and policies directly with the examination provider. CertMedbry is independent and is not endorsed by these organisations. How we handle content and corrections.