PLAB 1 UK Clinical Guidelines & Prescribing Safety 2 — Questions and Answers
Question 1: According to NICE guidance (NG12), which patients should be referred on a 2-week wait (suspected cancer) pathway for colorectal cancer?
- Any patient with rectal bleeding, regardless of age
- Patients aged 40 or over with unexplained rectal bleeding; OR aged 60 or over with change in bowel habit; OR aged 40 or over with iron deficiency anaemia without an obvious cause (Correct answer)
- Patients with abdominal pain and bloating only
- Patients with haemorrhoids and rectal bleeding
Correct answer: Patients aged 40 or over with unexplained rectal bleeding; OR aged 60 or over with change in bowel habit; OR aged 40 or over with iron deficiency anaemia without an obvious cause
NICE NG12 criteria for 2WW colorectal referral include: ≥40 with unexplained rectal bleeding; ≥50 with unexplained abdominal pain or weight loss; ≥60 with change in bowel habit; ≥60 with iron deficiency anaemia; any age with rectal mass/unexplained iron deficiency anaemia. Haemorrhoids are not an automatic exclusion for referral if other criteria are met.
Question 2: A 30-year-old woman with newly diagnosed mild-to-moderate ulcerative colitis (proctosigmoiditis) should be offered which first-line treatment according to NICE guidelines?
- Oral prednisolone
- Topical aminosalicylate (mesalazine suppository or enema) ± oral aminosalicylate (Correct answer)
- Azathioprine
- Infliximab
Correct answer: Topical aminosalicylate (mesalazine suppository or enema) ± oral aminosalicylate
NICE (NG130) recommends first-line treatment for mild-to-moderate UC as topical mesalazine (suppository for proctitis, enema for proctosigmoiditis) with or without oral mesalazine. Oral steroids are used for moderate-to-severe disease or insufficient response. Immunosuppressants are for maintenance of remission or steroid-dependent disease.
Question 3: According to NICE guidance on sepsis (NG51), what is the 'Sepsis Six' hour-1 bundle for a patient with suspected sepsis?
- Blood cultures, IV antibiotics, IV fluids, urine output monitoring, blood glucose, and reassessment
- High-flow oxygen, blood cultures, IV broad-spectrum antibiotics, IV fluid bolus, lactate measurement, and urine output monitoring (Correct answer)
- IV antibiotics, chest X-ray, ECG, full blood count, CRP, and ITU referral
- Oral antibiotics, blood cultures, catheter, and urine dipstick
Correct answer: High-flow oxygen, blood cultures, IV broad-spectrum antibiotics, IV fluid bolus, lactate measurement, and urine output monitoring
The Sepsis Six (to be completed within 1 hour): (1) High-flow O2; (2) Blood cultures; (3) IV broad-spectrum antibiotics; (4) IV fluid bolus (500ml crystalloid if hypotensive); (5) Serum lactate; (6) Urine output monitoring (catheterise if needed). Early completion reduces sepsis mortality significantly.
Question 4: A patient presents with an acute severe asthma attack (SpO2 91%, PEFR 35% predicted, RR 30, pulse 125). According to BTS guidelines, what is the most appropriate immediate management?
- Nebulised salbutamol only and discharge with oral prednisolone
- High-flow oxygen, back-to-back nebulised salbutamol + ipratropium, oral/IV prednisolone, and hospital admission (Correct answer)
- Intubation and ventilation immediately
- IV magnesium sulphate alone
Correct answer: High-flow oxygen, back-to-back nebulised salbutamol + ipratropium, oral/IV prednisolone, and hospital admission
BTS/SIGN asthma guidelines for acute severe attack: high-flow O2 (target SpO2 94–98%), back-to-back (or continuous) nebulised salbutamol + ipratropium bromide every 20–30 minutes, systemic steroids (prednisolone 40–50mg oral or IV hydrocortisone 100mg), and admission. IV magnesium sulphate is added for life-threatening features.
Question 5: According to NICE guidance, which patients with community-acquired pneumonia should be considered for hospital admission using the CRB-65 score?
- All patients with pneumonia, regardless of severity
- Patients with CRB-65 score ≥2 should be considered for hospital admission; score of 1 requires clinical judgement (Correct answer)
- Only patients with SpO2 below 90%
- Only elderly patients over 65
Correct answer: Patients with CRB-65 score ≥2 should be considered for hospital admission; score of 1 requires clinical judgement
CRB-65 (Confusion, Respiratory rate ≥30, BP systolic <90 or diastolic ≤60, age 65+): 0 = low risk, consider home treatment; 1–2 = moderate risk, hospital assessment considered; 3–4 = high severity, urgent hospital admission. CURB-65 adds urea >7 mmol/L and is used in hospital settings.
Question 6: A 70-year-old woman with osteoporosis has a T-score of -2.8 on DXA scan and has had one vertebral fracture. According to NICE guidelines, what is the most appropriate treatment?
- Calcium and vitamin D supplementation alone
- Bisphosphonate (e.g., alendronate) plus calcium and vitamin D (Correct answer)
- HRT
- Denosumab as first-line therapy
Correct answer: Bisphosphonate (e.g., alendronate) plus calcium and vitamin D
NICE (TA160/TA161) recommends bisphosphonates (alendronate is first-line) for women with osteoporosis (T-score ≤-2.5) confirmed on DXA scan, particularly those with a prior fragility fracture. Calcium and vitamin D should be co-prescribed. Denosumab or other agents are second-line if bisphosphonates are not tolerated or contraindicated.
PLAB 1 UK Clinical Guidelines & Prescribing Safety 2
According to NICE guidance (NG12), which patients should be referred on a 2-week wait (suspected cancer) pathway for colorectal cancer?