PLAB 2 Acute Management

Question 1

A patient in A&E presents with an acute asthma attack.
Their peak flow is 40% of predicted, they cannot complete sentences, and their respiratory rate is 28/min.
According to BTS/SIGN guidelines, how should this be classified and what is the immediate management?

Accepted Answer

Acute severe asthma — give high-flow oxygen, nebulised salbutamol 5 mg, nebulised ipratropium bromide 500 mcg, and oral prednisolone 40-50 mg (or IV hydrocortisone 100 mg)

Answer

Mild asthma — prescribe a salbutamol inhaler and discharge

Answer

Moderate asthma — advise the patient to use their inhaler more frequently

Answer

Life-threatening asthma — proceed directly to intubation

Question 2

A 65-year-old man presents to A&E with central crushing chest pain for 30 minutes, diaphoresis, and nausea. ECG shows 3 mm ST elevation in leads II, III, and aVF. What is the immediate management?

Accepted Answer

Give MONA (Morphine, Oxygen if SpO2 <94%, Nitrate, Aspirin 300 mg) and arrange emergency primary percutaneous coronary intervention (PCI) or thrombolysis if PCI not available within 120 minutes

Answer

Observe and repeat ECG in 6 hours

Answer

Prescribe GTN spray and discharge with GP follow-up

Answer

Start oral beta-blocker and admit to a general ward

Question 3

A patient with type 1 diabetes presents with vomiting, abdominal pain, Kussmaul breathing, and a blood glucose of 28 mmol/L. Blood gases show pH 7.1, bicarbonate 10 mmol/L, and ketones 5.5 mmol/L. What is the diagnosis and first priority of management?

Accepted Answer

Diabetic ketoacidosis — IV 0.9% sodium chloride fluid resuscitation is the first priority, followed by fixed-rate IV insulin infusion (0.1 units/kg/hour)

Answer

Hyperglycaemic hyperosmolar state — give oral fluids

Answer

Hypoglycaemia — give IV dextrose

Answer

Lactic acidosis — give IV sodium bicarbonate

Question 4

A 75-year-old woman is found on the floor at home. She is confused with a GCS of 12. Her blood glucose is 1.8 mmol/L. What is the immediate management?

Accepted Answer

Administer IV glucose (10% or 20% dextrose) as the patient has reduced consciousness and cannot safely swallow, followed by longer-acting carbohydrate once conscious

Answer

Give oral glucose gel

Answer

Wait and recheck glucose in 30 minutes

Answer

Administer insulin to stimulate glucose release

Question 5

A patient presents to A&E with sudden onset weakness of the right arm and leg and slurred speech. Symptoms started 90 minutes ago. CT head excludes haemorrhage. According to NICE stroke guidelines, what is the most appropriate acute management?

Accepted Answer

Administer IV alteplase (thrombolysis) within the 4.5-hour window, as the patient has an acute ischaemic stroke with no contraindications

Answer

Admit to a general medical ward and start aspirin

Answer

Prescribe warfarin and discharge

Answer

Arrange an MRI brain as an outpatient

Question 6

A patient in A&E develops anaphylaxis after a penicillin injection. They have widespread urticaria, wheeze, stridor, and a blood pressure of 70/40 mmHg. What is the first-line treatment?

Accepted Answer

IM adrenaline 500 micrograms (0.5 mL of 1:1000) into the anterolateral thigh, repeated every 5 minutes if needed

Answer

IV chlorphenamine and hydrocortisone

Answer

Nebulised salbutamol only

Answer

Oral antihistamine and observation