PLAB 2 Prescribing Safety & Emergency Management — Questions and Answers
Question 1: A patient in the Emergency Department is found unresponsive. What is the most appropriate immediate action according to the UK Resuscitation Council guidelines?
- Check pupils and blood glucose
- Shout for help, check for danger, check for response, open airway (head tilt-chin lift), check for breathing (look, listen, feel for 10 seconds), call the resuscitation team and start CPR (30:2) if not breathing normally (Correct answer)
- Insert an IV cannula and take blood samples
- Perform a 12-lead ECG
Correct answer: Shout for help, check for danger, check for response, open airway (head tilt-chin lift), check for breathing (look, listen, feel for 10 seconds), call the resuscitation team and start CPR (30:2) if not breathing normally
The UK Resuscitation Council Adult ALS algorithm begins with the basic life support sequence: check safety, check responsiveness, shout for help, open airway, look for normal breathing for no more than 10 seconds, call the resuscitation team (or ask someone to), then start CPR at 30 compressions to 2 breaths at a rate of 100–120/min.
Question 2: During a medical emergency, a patient has anaphylaxis following an antibiotic injection. What is the first-line treatment and route of administration?
- IV hydrocortisone 200mg
- IM adrenaline 0.5mg (1:1000) into the anterolateral thigh (Correct answer)
- IV chlorphenamine 10mg
- Nebulised salbutamol
Correct answer: IM adrenaline 0.5mg (1:1000) into the anterolateral thigh
Adrenaline (epinephrine) 0.5mg IM (1:1000 solution = 0.5ml) into the anterolateral thigh is the life-saving first-line treatment for anaphylaxis. IM injection into the thigh provides faster and more reliable absorption than subcutaneous administration. IV adrenaline is only for use by specialists in specific circumstances. Antihistamines and steroids are adjunctive, not first-line.
Question 3: When prescribing in a hospital setting, which five components are essential for a valid drug prescription?
- Drug name, dose, route, frequency, and prescriber's name only
- Drug name (generic), dose (in approved units), route, frequency/timing, prescriber's signature and date, and the patient's name/date of birth/hospital number on the drug chart (Correct answer)
- Drug name, indication, cost, patient name, and ward
- Drug name, manufacturer, batch number, dose, and prescriber grade
Correct answer: Drug name (generic), dose (in approved units), route, frequency/timing, prescriber's signature and date, and the patient's name/date of birth/hospital number on the drug chart
A valid hospital prescription must include: patient identifiers (name, DOB, hospital number); drug name (generic); dose with units; route of administration; frequency/timing; start date; prescriber signature and name (printed). Incomplete prescriptions are a common source of medication errors and should not be dispensed without clarification.
Question 4: A patient on a surgical ward develops acute confusion, fever (38.8°C), hypotension (BP 90/60), and tachycardia (HR 115 bpm) on post-operative day 2. What is the most important immediate action?
- Prescribe regular paracetamol and reassess in the morning
- Perform a full sepsis assessment (NEWS score), take blood cultures and other sepsis screen, and start the Sepsis Six bundle within one hour (Correct answer)
- Request an urgent CT scan
- Order a 12-lead ECG and cardiac enzymes
Correct answer: Perform a full sepsis assessment (NEWS score), take blood cultures and other sepsis screen, and start the Sepsis Six bundle within one hour
This patient has signs of sepsis (suspected infection + organ dysfunction indicators: confusion, hypotension). The National Early Warning Score (NEWS2) should be calculated. The Sepsis Six bundle must be initiated within one hour: oxygen, blood cultures, IV antibiotics, IV fluids (if hypotensive), measure lactate, catheterise and monitor urine output. Early treatment reduces mortality.
Question 5: A patient's medication chart shows they are prescribed lithium. Which monitoring parameters are essential?
- Full blood count and liver function tests monthly
- Serum lithium level (12 hours post dose), renal function (eGFR, urine output), thyroid function, calcium — all regularly; serum level kept in narrow therapeutic range (0.4–1.0 mmol/L for maintenance) (Correct answer)
- Random serum lithium with no specific timing requirement
- Lithium level and ECG only
Correct answer: Serum lithium level (12 hours post dose), renal function (eGFR, urine output), thyroid function, calcium — all regularly; serum level kept in narrow therapeutic range (0.4–1.0 mmol/L for maintenance)
Lithium has a narrow therapeutic index. Toxicity (>1.5 mmol/L) causes tremor, confusion, nausea, and cardiac arrhythmias. Monitoring: serum lithium level (12 hours post-dose, every 3–6 months when stable); U&E (lithium is renally excreted, renal impairment raises levels); thyroid (lithium causes hypothyroidism); calcium (hypercalcaemia). Dehydration and NSAIDs raise levels.
Question 6: A patient is prescribed oral morphine for cancer pain. Which medication should always be co-prescribed?
- A proton pump inhibitor
- A laxative (e.g., co-danthramer or senna + docusate) — opioid-induced constipation is universal and does not develop tolerance unlike nausea (Correct answer)
- An antiemetic alone is sufficient
- A benzodiazepine for sedation
Correct answer: A laxative (e.g., co-danthramer or senna + docusate) — opioid-induced constipation is universal and does not develop tolerance unlike nausea
Opioid-induced constipation occurs in virtually all patients on regular opioids and, unlike most other opioid side effects (e.g., nausea, sedation), tolerance does not develop. A stimulant laxative (with or without a softener) must always be co-prescribed. Antiemetics are given for the first few weeks (nausea reduces) but not always long-term.
PLAB 2 Prescribing Safety & Emergency Management
A patient in the Emergency Department is found unresponsive.
What is the most appropriate immediate action according to the UK Resuscitation Council guidelines?