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ABG interpretation in Plab
Step by step approach
Normal reference range
Reference range
pH 7.35 - 7.45
PO2 11-14kPa
PCO2 4.7 – 6 kPa
-
HCO3 22-26 mmol/l
BE -2 - +2 meq/l

You all know that:

• CO2 responsible for acidity- when CO2 increases acidity increases- pH decreases
• Bicarbonate (HCO3) responsible for Alkalinity- when HCO3 increases pH increases

Here are the 3 easy steps:

1. First look at pH. If <7.35 -acidosis (low pH)

>7.45 -alkalosis (high pH)

2. Second look at PCO2 -

• Low pH with high PCO2 – Respiratory acidosis
• High pH with low PCO2 – Respiratory alkalosis

3. If you see a pattern which is opposite to step 2, then, use this

• Low pH with low/normal CO2 – Metabolic acidosis
• High pH with high/normal CO2 – Metabolic alkalosis
Answers of most of the ABG questions in Plab can be picked easily only by reading the history
without interpreting the results. Ex: in high altitude sickness- respiratory alkalosis.

What, is it so easy? No I can’t believe.. Must be some more steps...

Yep. You are correct.
With these 3 steps you can pick the correct answers for more than 90% of Plab questions.
Then what about the rest 10%? Hmm.. we will learn that 10% during our mcq practice.

Summary: In this technique, we search for Respiratory acidosis or alkalosis by looking at CO2. When
we see that CO2 is not the cause for acid-base imbalance, we name it as metabolic. That’s it.
Here we go with some real mcqs from previous Plab exams

Plab ABG questions and explanations

1. A 23 year old university student climbed
quickly to a mountain which is 20000 feet height.
His ABG shows
pH – 7.55 (7.35 – 7.45)
O2 – 11kpa (11-14kPa)
PCO2 – 2.1kPa (4.7kPa -7kPa)
HCO3 – 22 mmol/l (22-26 mmol/l)

What is the acid base imbalance

A. Respiratory acidosis
B. Respiratory alkalosis
C. Metabolic acidosis
D. Metabolic alkalosis
2. A 67 year old man with COPD presents with a
COPD exacerbation. His ABG shows
pH – 7.3 (7.35 – 7.45)
O2 – 8kPaO2 (11-14kPa)
PCO2 – 9kpa (4.7kPa -7kPa)
HCO3 – 24mmol/l (22-26 mmol/l)

What is the acid base imbalance

A. Respiratory acidosis
B. Respiratory alkalosis
C. Metabolic acidosis
D. Metabolic alkalosis
3. An arterial blood sample of 63 year old man
with chronic kidney failure taken. His ABG shows
pH – 7.3 (7.35 – 7.45)
O2 – 12kPa (11-14kPa)
PCO2 – 4.9 kPa (4.7kPa -7kPa)
HCO3 – 16 mmol/l (22-26 mmol/l)

What is the acid base imbalance

A. Respiratory acidosis
B. Respiratory alkalosis
C. Metabolic acidosis
D. Metabolic alkalosis
4. An arterial blood sample of 63 year old man
with pottasium loosing villous adenoma. His ABG
shows
pH – 7.5 (7.35 – 7.45)
O2 – 12kPa (11-14kPa)
PCO2 – 6.8kPa (4.7kPa -7kPa)
HCO3 – 32 mmol/l (22-26 mmol/l)

What is the acid base imbalance

A. Respiratory acidosis
B. Respiratory alkalosis
C. Metabolic acidosis
D. Metabolic alkalosis
5.An arterial blood sample of 63 year old man
with severe diarrhoea is taken. His ABG shows
pH – 7.25 (7.35 – 7.45)
O2 – 12kPa (11-14kPa)
PCO2 – 5.2 kPa (4.7kPa -7kPa)
HCO3 – 14 mmol/l (22-26 mmol/l)

What is the acid base imbalance

A. Respiratory acidosis
B. Respiratory alkalosis
C. Metabolic acidosis
D. Metabolic alkalosis
6. An arterial blood sample of 63 year old man
with severe vomiting is taken. His ABG shows
pH – 7.52 (7.35 – 7.45)
O2 – 12kPa (11-14kPa)
PCO2 – 6.5 kPa (4.7kPa -7kPa)
HCO3 – 30mmol/l (22-26 mmol/l)

What is the acid base imbalance

A. Respiratory acidosis
B. Respiratory alkalosis
C. Metabolic acidosis
D. Metabolic alkalosis

Now move to the complicated ABG analysis

7. A 67 year old man with COPD presents with a Note! HCO3 has increased here
COPD exacerbation. His ABG shows
pH – 7.3 (7.35 – 7.45)
O2 – 8kPaO2 (11-14kPa)
PCO2 – 10kpa (4.7kPa -7kPa)
HCO3 – 30mmol/l (22-26 mmol/l)

What is the acid base imbalance

A. Respiratory acidosis
B. Respiratory acidosis with partial metabolic
compensation
C. Respiratory acidosis with complete metabolic
compensation
D. Metabolic acidosis
E. Metabolic alkalosis
8. A 67 year old man with Type2 DM on metformin
has severe diarrhoea. Now become drowzy. GCS
14/15. Creatinine 190micmol/l

His ABG shows:

pH – 7.25 (7.35 – 7.45)
O2 – 12kPaO2 (11-14kPa)
PCO2 – 3kpa (4.7kPa -7kPa)
HCO3 – 12 mmol/l (22-26 mmol/l)

What is the acid base imbalance

A. Metabolic acidosis
B. Metabolic acidosis with partial respiratory
compensation
C. Metabolic acidosis with complete respiratory
compensation
D. Diabetic ketoacidosis
E. Respiratory Alkalosis
9. 58 year old man with alcoholic cirrhosis with
hypokalemia (K 2.6mmol/l).
His ABG shows
pH – 7.54 (7.35 – 7.45)
O2 – 14kpa (11-14kPa)
PCO2 – 8.5kPa (4.7kPa -7kPa)
HCO3 – 30mmol/l (22-26 mmol/l)

What is the acid base imbalance

A. Respiratory acidosis
B. Respiratory alkalosis
C. Metabolic acidosis
D. Metabolic alkalosis with partial respiratory
compensation
E. Metabolic alkalosis with total respiratory
compensation
10. A 17 year boy with Type 1 DM on insulin
complains of abdominal pain. He becomes drowzy
and hyperventilating. GCS 14/15.
His ABG shows:
pH – 7.2 (7.35 – 7.45)
O2 – 14kPaO2 (11-14kPa)
PCO2 – 2kpa (4.7kPa -7kPa)
HCO3 – 10 mmol/l (22-26 mmol/l)

What is the acid base imbalance

A. Metabolic acidosis
 B. Metabolic acidosis with partial respiratory
compensation
C. Metabolic acidosis with complete respiratory
compensation
D. Lactic acidosis
E. Respiratory Alkalosis
11. A 23 year old university student climbed
quickly to a mountain which is 20000 feet height.
His ABG shows
pH – 7.55 (7.35 – 7.45)
O2 – 11kpa (11-14kPa)
PCO2 – 2.1kPa (4.7kPa -7kPa)
HCO3 – 16mmol/l (22-26 mmol/l)

What is the acid base imbalance

A. Respiratory acidosis
B. Respiratory alkalosis
C. Metabolic acidosis
D. Respiratory alkalosis with partial metabolic
compensation
E. Respiratory alkalosis with total metabolic
compensation
12. Which of the following is a known side effect of
metformin
A. Hypoglycemia
B. Neural tube defect in fetus
C. Lactic acidosis
D. Bladder carcinoma
E. Water retension

Few more mcq for candidte who need always more (above plab level)
13. 69 patient with lobar pneumonia becomes
increasingly confusing. Become more breathless.
Tachypnic and becomes hypotensive. He was
admitted to ICU for the treatment of septicemia.
His ABG shows
pH – 7.27 (7.35 – 7.45)
O2 – 9kPa (11-14kPa)
PCO2 – 9kPa (4.7kPa -7kPa)
HCO3 – 16mmol/l (22-26 mmol/l)
What is the acid base imbalance
A. Respiratory acidosis
B. Metabolic acidosis
C. Respiratory acidosis with partial metabolic
compensation
D. Metabolic acidosis with partial respiratory
compensation
E. Mixed acidosis
14. A 23 year old university student climbed
quickly to a mountain which is 20000 feet height.
His ABG shows
pH – 7.45 (7.35 – 7.45)
O2 – 11kpa (11-14kPa)
PCO2 – 2.1kPa (4.7kPa -7kPa)
HCO3 – 8mmol/l (22-26 mmol/l)

What is the acid base imbalance

A. Respiratory acidosis
B. Respiratory alkalosis
C. Metabolic acidosis
D. Respiratory alkalosis with partial metabolic
compensation
E. Respiratory alkalosis with total metabolic
compensation
15. A 17 year boy with Type 1 DM on insulin
complains of abdominal pain. He becomes drowzy
and hyperventilating. GCS 14/15.
His ABG shows:
pH – 7.35 (7.35 – 7.45)
O2 – 14kPaO2 (11-14kPa)
PCO2 – 2kpa (4.7kPa -7kPa)
HCO3 – 14 mmol/l (22-26 mmol/l)

What is the acid base imbalance

A. Metabolic acidosis
B. Metabolic acidosis with partial respiratory
compensation
C. Metabolic acidosis with complete respiratory
compensation
D. Lactic acidosis
E. Respiratory Alkalosis

Answers with explanation

1 step 1 PH high – alkalosis 1. First look at pH. If <7.35 -acidosis (low
step 2 PCO2 low pH)
>7.45 -alkalosis (high
Answer: Respiratory Alkalosis pH)
2. Second look at PCO2 -
• High PCO2 with low pH –
Respiratory acidosis
• Low PCO2 with high pH–
Respiratory alkalosis
3. If you see a pattern which is opposite to
step 2, then, use this
 • Low-normal CO2 with low pH –
Metabolic acidosis
• High-normal CO2 with low pH –
Metabolic alkalosis
2 step 1: PH low – acidosis
step 2: PCO2 – High
Answer: Respiratory Acidosis
3 step 1 - PH low – acidosis The renal production of HCO3 reduced in
step 2 – Not applicable renal diseases. This can cause metabolic
step 3 – CO2 -Normal acidosis.
That’s why we give Bicarbonate tablets to
Answer: Metabolic acidosis patients with chronic renal failure.
4 step 1 - PH High – alkalosis Patients with hypokalemia often develop
step 2 – Not applicable Metabolic alkalosis. Why? Try to find out
step 3 – CO2 -Normal the interesting mechanism. Not necessary to
pass plab
Answer: Metabolic alkalosis
5 step 1 - PH low – acidosis Reduced perfusion secondary to dehydration.
step 2 – Not applicable Dehydration has Increased lactate which
step 3 – CO2 -Normal produces lactic acidosis, is a kind of
metabolic acidosis
Answer: Metabolic acidosis
6 step 1 - PH High – alkalosis When someone vomit he looses Hydrogen
step 2 – Not applicable here ions from gastric juice.
step 3 – CO2 -Normal So the body looses some acids and become
alkaline.
Answer: Metabolic alkalosis
7 step 1: PH low – acidosis
step 2 : PCO2 – High
Respiratory Acidosis
How to find out whether there is a
compensation?
If HCO3 is normal- No metabolic compensation
But HCO3 is elevated here.
However the pH remains acidic. It means, the
compensatory increase in HCO3 is not adequate
enough to normalize the pH.
So this is partial compensation
Answer B

8 step 1: PH low – acidosis

step 2: Not applicable here.
Step 3: PCO2 – low
So, Metabolic Acidosis
How to find out whether there is a
 compensation?
If CO2 is normal-No respiratory compensation.
But, CO2 is reduced here. However the pH
remains acidic.
It means the compensatory decrease in CO2 by
hyperventilation not adequate enough to
normalize the pH.
So this is a partial compensation.
Answer B
9 step 1: PH high – Alkalosis
step 2 : Not applicable here.
Step 3: PCO2 –High
So, Metabolic Alkalosis
How to find out whether there is a
compensation?
If CO2 is normal-No respiratory compensation.
But CO2 is elevated here. However the pH
remains alkaline.
It means the compensation by increase in CO2
not adequate enough to normalize the pH.
So this is a partial compensation.
Answer D
10 step 1: PH low – acidosis Diabetes keto-acidosis (DKA) is a metabolic
step 2 : Not applicable here. acidosis.
Step 3: PCO2 – low DKA patients often presents with
So, Metabolic Acidosis vomiting. Why?
How to find out whether there is a Because by vomiting body can eliminate
compensation? some acids from the body. This is a
If CO2 is normal-No respiratory compensation. reaction body shows to a severe acidic
But CO2 is reduced here. However the pH condition
remain acidosis.
It means, the respiratory compensation (decrease
in CO2 by hyperventilation) not adequate
enough to normalize the pH.
So this is a partial compensation.
Answer B
11 step 1: PH High – alkalosis
step 2: PCO2 – Low
Respiratory Acidosis
How to find out whether there is a
compensation?
If HCO3 is normal- No metabolic compensation
But HCO3 which is low here. However the pH
remains alkaline. It means, the compensation
(decrease in HCO3) not adequate enough to
normalize the pH.
So this is partial compensation
 Answer D
12 Metformin can produces lactic acidosis in patient Diabetic ketoacidosis and lactic acidosis are
with reduced renal function. important types of metabolic acidosis
Answer C
13 step 1: PH low – acidosis
step 2 : PCO2 high
Preliminary thinking is Respiratory acidosis

Now we check for compensation?

If HCO3 is normal-No metabolic compensation.
If HCO3 is high- there is a metabolic
compensation
But watch here, the HCO3 is also reduced here.
This will further aggravate the acidosis.

So this is a mixed acidosis. (Respiratory &

metabolic acidosis)
14 To interpret this results you must know that in
high altitude sickness –Patient develops
respiratory alkalosis
step 1: PH – Normal. However there is an
Hidden alkalosis. How do we know? Because
PCO2 is Low
How to find out whether there is a
compensation?
If HCO3 is normal- No metabolic compensation
But HCO3 which is low here which normalizes
the pH. It means, the compensation (decrease in
HCO3) is adequate enough to normalize the pH.
So this is partial compensation
15 To interpret this results you must know that in In this place you must look at the HCO3 for
DKA –Patient develops metabolic acidosis. the initial judgement
step 1: PH – Normal. However there is an
Hidden acidosis. How do we know?
Look at PCO2- low – Not the cause for acidosis
here.
Now look at HCO3 is low.-.This is the cause for
acidosis.
How to find out whether there is a
compensation?
If PCO2 is normal- No respiratory compensation
But PCO2 which is low here which normalizes
the pH. It means, the compensation (decrease in
PCO2) is adequate enough to normalize the pH.
So this is partial compensation
You will NEVER be given an ABG results with total compensation in plab level

Base excess= How much excess of HCO3. Values can be either positive or negative