Respiratory Medicine for PLAB 1: Breathless Patients and Pleural Disease

Scope and time budget

Eleven questions is about eleven minutes. Respiratory stems tend to be short and structured: a breathless patient, a set of observations including oxygen saturation, sometimes a chest X-ray description or a blood gas. Because the block is small, it is a good place to be efficient. Learn the standard severity grading and the first-line treatment, and the domain becomes some of the most reliable marks in the paper.

What is tested

• Airways disease. Asthma, including acute severity grading and long-term stepwise management, and COPD, including diagnosis, exacerbation and long-term oxygen.
• Infection. Community-acquired pneumonia and CURB-65, hospital-acquired and aspiration pneumonia, tuberculosis diagnosis, treatment and contact tracing, bronchiectasis and cystic fibrosis in adults.
• Pleural and vascular disease. Pulmonary embolism with Wells score, D-dimer and CTPA, pneumothorax (primary versus secondary), and pleural effusion with Light's criteria and drainage.
• Respiratory failure. Type 1 and type 2 failure, oxygen targets and non-invasive ventilation.
• Chronic and occupational disease. Interstitial lung disease and sarcoidosis, occupational lung disease (asbestos, pneumoconiosis), obstructive sleep apnoea.
• Symptoms and cancer. Chronic cough, haemoptysis and breathlessness work-up, lung cancer presentations and urgent referral, and smoking cessation with drug treatment.

UK points to anchor your answers

• Lung cancer screening: the NHS offers it at ages 55 to 74 to people who have ever smoked, in some parts of England. It is not a nationwide programme, so read the stem for the setting.
• Notifiable disease: tuberculosis and other respiratory infections raise public-health duties. Learn the doctor's notification duty from the GOV.UK source, and the principle that you do not wait for laboratory confirmation in urgent cases.
• Guidelines: the usual UK authorities are NICE, the British Thoracic Society and the BNF. We could not verify numeric thresholds on those sites for this page, so confirm severity criteria, oxygen targets and drug steps on the current source.
• Units: arterial blood gases use kPa, and drugs are written with UK names such as salbutamol and in micrograms.

How the questions are framed

Respiratory stems tend to give you three things: the clinical picture, a severity marker and a test result. The task is usually to grade the severity, choose the first treatment or decide the setting of care. For asthma and COPD, the exam favours the stepwise approach and the safe immediate response. For pneumonia, it favours severity assessment and antibiotic stewardship. For thromboembolism, it favours risk stratification and the correct test sequence. For pleural disease, it favours the choice between observation, aspiration and drainage.

Look for the detail that moves the patient into a different category: a patient who is exhausted, silent or confused, a rising carbon dioxide level, a patient on home oxygen, or a pregnant woman with breathlessness.

What examiners ask about each group

• Asthma. Grade the attack from observations and speech, give the first-line acute treatment, decide on admission, and recognise the signs of a life-threatening attack. For long-term care, follow the stepwise ladder and check inhaler technique.
• COPD. Confirm diagnosis with spirometry, manage an exacerbation, and decide on antibiotics, steroids and controlled oxygen. Know when long-term oxygen is considered and the role of smoking cessation.
• Pneumonia. Use the severity tool to choose the setting of care, select an antibiotic according to local and national guidance, and consider aspiration and hospital-acquired causes.
• Pulmonary embolism and pneumothorax. Choose the probability tool, the test and the first treatment, and decide between observation, aspiration and a chest drain.
• Pleural effusion. Interpret the fluid result, using Light's criteria, to separate transudate from exudate, and decide on drainage.
• Tuberculosis, cancer and interstitial disease. Recognise the presentation, choose the investigation, start the right referral and apply public-health duties such as contact tracing.

Many questions in this domain depend on one number: a saturation, a respiratory rate, a peak flow or a carbon dioxide level. Practise reading it first.

Three typical traps

1. Giving oxygen without thinking of carbon dioxide retention. In patients at risk of type 2 respiratory failure, the exam expects a controlled target, not a high flow. Learn the target ranges from the source.
2. Ordering the wrong test for suspected pulmonary embolism. The correct step depends on the pre-test probability and the patient's other conditions. Know the sequence your guideline uses, and notice contraindications to contrast.
3. Treating primary and secondary pneumothorax the same. The management differs by underlying lung disease, size and symptoms. Read the history for COPD or another lung condition.

How to revise it

1. Write a severity ladder for acute asthma, COPD exacerbation and pneumonia. Add the first action at each level.
2. Make a pleural table with pneumothorax, effusion and empyema: the typical history, the test, the first treatment and when to refer.
3. Do chest X-ray and blood gas drills. Ten minutes daily until the patterns are automatic.
4. Revise inhalers and oxygen as prescribing topics. Know device, drug and the common error in use.
5. Finish with 20-question timed blocks mixed with acute care, since the two overlap.

Pair this domain with acute and emergency care, infection and cancer and child health, where bronchiolitis, croup and asthma appear.