Professional and Linguistic Assessments Board (PLAB) General Practice, Public Health and Primary Care Syllabus

Define multimorbidity and explain why it matters for care planning.

Multimorbidity is the co-existence of two or more long-term (chronic) health conditions in one person. It matters because it increases treatment burden, polypharmacy, risk of drug interactions, and reduced quality of life, requiring a patient-centred, goal-oriented approach rather than single-disease guidelines.

Define polypharmacy and distinguish appropriate from problematic polypharmacy.

Polypharmacy is the concurrent use of multiple medicines (commonly defined as $\geq 5$). Appropriate polypharmacy optimises therapy for complex conditions per best evidence; problematic polypharmacy is when medicines are inappropriate, harm outweighs benefit, or interactions/burden are excessive.

Name two validated tools used to review and rationalise medications in older adults.

The STOPP/START criteria (Screening Tool of Older Persons' Prescriptions / Screening Tool to Alert to Right Treatment) and the Beers Criteria for potentially inappropriate medications in the elderly.

Which tool does NICE recommend for primary prevention cardiovascular risk assessment, and what threshold triggers statin offer?

QRISK3, estimating 10-year risk of cardiovascular disease. A 10-year risk $\geq 10\%$ warrants offering atorvastatin $20\,\text{mg}$ for primary prevention (after lifestyle advice).

What is the standard statin regimen for secondary prevention of established cardiovascular disease, and the LDL/non-HDL targets?

Atorvastatin $80\,\text{mg}$ daily. Aim for a reduction in non-HDL cholesterol of $> 40\%$; treatment targets are LDL-C $\leq 2.0\,\text{mmol/L}$ or non-HDL-C $\leq 2.6\,\text{mmol/L}$.

What blood test monitoring is required after starting a statin?

Check lipids (and HbA1c if at diabetes risk) at baseline, liver function (ALT/transaminases) at baseline, 3 months and 12 months. Stop if ALT/AST rises $> 3\times$ upper limit of normal; check creatine kinase if muscle symptoms occur.

In hypertension management, what blood pressure thresholds define stage 1 and stage 2 hypertension (clinic readings)?

Stage 1: clinic BP $\geq 140/90\,\text{mmHg}$ with ABPM/HBPM average $\geq 135/85\,\text{mmHg}$. Stage 2: clinic BP $\geq 160/100\,\text{mmHg}$ with ABPM/HBPM average $\geq 150/95\,\text{mmHg}$.

Outline the NICE step 1 antihypertensive choice based on age and ethnicity.

Age $< 55$ and not Black African/African-Caribbean: ACE inhibitor (or ARB). Age $\geq 55$ OR Black African/African-Caribbean origin of any age: calcium-channel blocker (CCB).

Define frailty and name a simple clinical tool for measuring it.

Frailty is a state of increased vulnerability to poor resolution of homeostasis after a stressor event, increasing the risk of adverse outcomes (falls, disability, death). Tools include the Clinical Frailty Scale (CFS, 1–9), the electronic Frailty Index (eFI), and gait speed/timed up-and-go.

What are the five 'frailty syndromes' that should trigger comprehensive geriatric assessment?

Falls, immobility/reduced mobility, delirium (acute confusion), incontinence, and susceptibility to medication side effects (and 'failure to cope'/functional decline).

What screening tool distinguishes delirium from dementia, and what is the key differentiating feature?

The 4AT or Confusion Assessment Method (CAM). Delirium has acute onset and fluctuating course with inattention and altered consciousness; dementia has gradual onset, chronic progressive course with preserved consciousness until late.

What are the four pillars of the WHO definition of palliative care?

It improves quality of life of patients and families facing life-threatening illness through: prevention/relief of suffering, early identification and treatment of pain and physical problems, and addressing psychosocial and spiritual needs. It affirms life and regards dying as a normal process, neither hastening nor postponing death.

What is the standard approach to converting oral morphine to subcutaneous morphine and to oral oxycodone?

Oral to subcutaneous morphine: divide the oral dose by $2$. Oral morphine to oral oxycodone: divide by $1.5$ to $2$. Example: oral morphine $30\,\text{mg}$/day $\approx$ subcut morphine $15\,\text{mg}$/day $\approx$ oral oxycodone $15$–$20\,\text{mg}$/day.

How do you calculate a breakthrough (rescue) dose of opioid for cancer pain?

The breakthrough dose is one-sixth ($\frac{1}{6}$) of the total 24-hour background opioid dose, given as immediate-release opioid PRN. E.g. for $60\,\text{mg}$ oral morphine/24 h, breakthrough $= 10\,\text{mg}$.

Name the four common symptoms managed with anticipatory ('just in case') medicines in end-of-life care and a drug for each.

Pain/breathlessness: morphine (or diamorphine). Nausea/vomiting: levomepromazine (or haloperidol/cyclizine). Agitation/restlessness: midazolam. Respiratory secretions: hyoscine butylbromide or glycopyrronium.

What are the criteria for a screening programme according to Wilson and Jungner?

The condition should be an important health problem with a recognisable latent/early stage and understood natural history; there should be an acceptable, valid, safe test; an accepted, effective treatment; facilities for diagnosis/treatment; an agreed policy on whom to treat; and the cost should be economically balanced (case-finding continuous, not one-off).

State the current UK NHS cervical screening intervals and primary test.

Primary high-risk HPV testing on cervical samples. Ages $25$–$49$: every 3 years; ages $50$–$64$: every 5 years. If hrHPV positive, reflex cytology is performed.

What are the UK breast and bowel cancer screening programmes (ages and method)?

Breast: mammography every 3 years for women aged $50$–$71$ (being extended $47$–$73$ in trials). Bowel: faecal immunochemical test (FIT) every 2 years, age $50$–$74$ (rolling out from 50).

Define sensitivity and specificity and give their formulas.

Sensitivity = ability of a test to correctly identify those WITH disease: $\text{Sens} = \frac{TP}{TP + FN}$. Specificity = ability to correctly identify those WITHOUT disease: $\text{Spec} = \frac{TN}{TN + FP}$.

Define positive and negative predictive value and explain their dependence on prevalence.

$PPV = \frac{TP}{TP + FP}$ (probability disease is present given a positive test); $NPV = \frac{TN}{TN + FN}$. Both depend on prevalence: as prevalence falls, PPV falls and NPV rises, whereas sensitivity and specificity are intrinsic to the test.

What does 'number needed to treat' (NNT) mean and how is it calculated?

NNT is the number of patients who must be treated to prevent one additional adverse outcome. $\text{NNT} = \frac{1}{ARR}$, where ARR (absolute risk reduction) $= \text{CER} - \text{EER}$ (control event rate minus experimental event rate). Lower NNT means greater effect.

Distinguish relative risk, odds ratio and absolute risk reduction.

Relative risk $= \frac{EER}{CER}$ (ratio of risks, used in cohort/RCTs). Odds ratio $= \frac{\text{odds in exposed}}{\text{odds in unexposed}}$ (used in case-control studies). Absolute risk reduction $= CER - EER$ (actual difference in risk, used to compute NNT).

Define incidence and prevalence and state how disease duration links them.

Incidence = number of NEW cases in a population over a time period. Prevalence = number of EXISTING (new + old) cases at a point/period. For stable chronic disease: $\text{Prevalence} \approx \text{Incidence} \times \text{Duration}$.

What is the basic reproduction number ($R_{0}$) and what does the herd immunity threshold formula give?

$R_{0}$ is the average number of secondary cases produced by one infected individual in a fully susceptible population. The herd immunity threshold is $1 - \frac{1}{R_{0}}$; e.g. measles with $R_{0} \approx 15$ needs roughly $93$–$95\%$ immunity.

List the stages of the transtheoretical (Stages of Change) model used in health promotion.

Precontemplation, Contemplation, Preparation, Action, Maintenance (and relapse). It guides tailoring of behaviour-change interventions such as smoking cessation to the patient's readiness.

Which infectious diseases are notifiable to UK Health Protection authorities? Give five examples.

Examples include measles, mumps, rubella, tuberculosis, meningococcal disease/meningitis, food poisoning, cholera, diphtheria, whooping cough (pertussis), and viral haemorrhagic fever. The registered medical practitioner has a statutory duty to notify the local health protection team.

State the antibiotic prophylaxis given to close contacts of meningococcal meningitis.

Single-dose ciprofloxacin (preferred, all ages including pregnancy) or rifampicin for close household/kissing contacts within the preceding 7 days, given as soon as possible (ideally within 24 hours).

What are the core principles of antimicrobial stewardship?

Start smart then focus: prescribe only when there is clear evidence of bacterial infection; use the narrowest effective spectrum; document indication, dose and review/stop date; obtain cultures before starting where possible; review at 48–72 h to de-escalate, switch IV-to-oral, or stop; and use the shortest effective course.

Why are broad-spectrum antibiotics (e.g. co-amoxiclav, quinolones, cephalosporins) restricted in stewardship?

They drive antimicrobial resistance and increase risk of Clostridioides difficile infection. Stewardship favours narrow-spectrum agents to preserve efficacy and minimise collateral damage to the microbiome.

Classify adverse drug reactions into the traditional Type A and Type B, with examples.

Type A (Augmented): dose-dependent, predictable from the drug's pharmacology, common, low mortality — e.g. bleeding on warfarin, hypoglycaemia on insulin. Type B (Bizarre): idiosyncratic, not dose-related, unpredictable, rarer but higher mortality — e.g. anaphylaxis to penicillin, malignant hyperthermia.

What is the UK Yellow Card Scheme and what should be reported?

The MHRA's national pharmacovigilance system for reporting suspected adverse drug reactions. Report ALL suspected reactions to black-triangle (newly licensed) medicines and vaccines, and all serious reactions to established drugs, even if causation is uncertain.

Outline the principles of safe prescribing in renal impairment and the elderly ('start low, go slow').

Reduce doses of renally-cleared drugs according to eGFR/creatinine clearance, avoid nephrotoxins (NSAIDs, aminoglycosides), start at lower doses and titrate slowly in older/frail patients due to altered pharmacokinetics, review regularly, and check for interactions and cumulative anticholinergic burden.

What key prescribing considerations apply to medication use in pregnancy?

Avoid teratogens (e.g. ACE inhibitors/ARBs, warfarin, sodium valproate, retinoids, methotrexate, tetracyclines); use the lowest effective dose of essential drugs; prefer agents with established safety data; consult resources such as the BNF/UKTIS; and balance maternal disease control against fetal risk.