PLAB Exam overview
I explained the procedure to the patient and had taken the consent. I had some sensation of cystic swelling at the cervical opening. Palpation of the fornices was also difficult. In my opinion, the uterus was retroverted. I completely forgot about the lubricant or the KY jelly. My examiner was pressing me for the differential diagnosis but the finding at the cervix was occupied in my thoughts. So I was repeatedly telling him about the swelling at the cervix. He was not happy with my answer.
She was 4-6 weeks postpartum and visually looking depressed. Anybody could have diagnosed a case of postpartum depression. When I asked further, she was in a mood to commit suicide and harming the baby as well. My recommendation was hospitalization for both of them.
Initially I thought it would be an easy station. Actually during my preparation, I always neglected it and did not practice it so well. Therefore, the net result was always it had to be. My performance was worst there. After the foreword questions, I was having difficulties and was thinking the way out. I maintained silence for about 20 seconds. When I started again, I was trying to exclude malignancies and any emergency condition. I was sure that the effects were due to drugs as the patient was admitted with fracture femur for a long time. He must be prescribed codeine and calcium supplements. But I was having a hard time to ask appropriate questions from a third person to exclude the differential diagnoses. If you can do so, you can expect more marks than merely sticking to a single diagnosis. It is my advice here to practice everything well in advance and not to think to make up in the stage.
The station was a mixed history and counseling type. He gave the history of febrile fit for the first time. As I used up much time to take the history, therefore I had little time to counsel her. I had just the time to explain that it was a simple febrile convulsion and it normally occurs in children. When I said that it was a normal condition and she looked very much surprised. I consumed the stipulated time as I explained her about our next course of action.
Primarily, I explained the procedure to the examiner, taken the consent but not anesthetized the wound. I was provided with prolene suture and was struggling to make a knot. Add to my bad luck were the instruments. They were not of good quality; needle holder was not locking properly and I was provided with tooth forceps. Finally I gave up and made the knot with my hands. I had the time to make only one suture. As I was leaving the room, I did not forget to drop the needle in the bin placed to discard the sharp objects.
I was not sure about the patient. I managed to realize from the primary questionnaire that she was taking medicines irregularly as she was not reviewed her prescription from the GP after 2 weeks. I preferred to start with general advice. Gradually I explained her about each and every medication. She was keen to know about side effect of all the medicines. I informed her about lifestyle modifications and also told her to control her weight and edema of the legs. At the last stage of the station, I thought that I should inform her about frusemide. So, just before the final bell, I told her to take water pills.
I was talking to the father of a child about MMR. He was young and cordial. He had some idea about the vaccine and was speaking continuously. All I had to do was to add some points filling his conversation.
It was one of my toughest jobs. She was continuously pleading to get a discharge and my duty was to convince her to stay. I understood her point as she had a job interview, but she was not a case to be discharge. I told her there might be bleeding per vagina and out of that she may die. Could a job be more important than a life? I gave her telephone number and some letters from the hospital. I also inquired about her other children and her family. She was repeatedly pleading to get a discharge. Later, I thought that I should have revealed some facts about infertility and future ectopic pregnancies.
Next patient was a Painful Arc Syndrome; at least I had this diagnosis. To my contrary, the examiner was not happy with the diagnosis and pressing me for the differentials. I was informed that the patient had injury to supraspinatous. So I thought it could be tendonitis. It never seemed like simple muscular injury as he was having pain and difficulty in abduction after 90 degrees.
I failed here and could not able to complete it. I also forgot about percussion of the back side. I missed face during General Physical Examination. But at the last moment when the 30 seconds bell was there, I managed sometime to take 2 PEFR readings.
I was checking the vibration sense when I heard the 30 sec bell. I thought that I would check the reflexes ideally and asked the patient to stand up and walk. Noting down the gait was so important in this kind of examination. The patient was not having any vibration sense below his ankles. All other sensations and the gait were normal.
My next patient was a young lady lying in right lateral position. She placed her hand over the left lumber region and gave the history of radiating pain from loin to groin. She was also having vague complaints regarding her urinary system and some flu like symptoms. I had to take history and discuss the differentials with the examiner.
To my surprise, I did not forget to check my watch before starting the procedure as I always failed to remember it during practice back home. To me, I did not miss anything. As I finished the station, my examiner told me that the next station is rest time. So I kept sitting till the second bell.
I had to examine the patient and inform him about short and long term management. This time I had an Asian examiner. He was nice. My patient was middle aged and understanding. I asked him whether he had any idea about his present disease and informed about it as he was asking about it. Then I told him about high doses of steroids just to save his vision. I also mentioned about long term steroid for 2 years. The examiner was asking about the long dose schedule but I did not remember it. I informed that I would check the BNF.
All my intention to write this article was to share my experiences in PLAB 2. I know, I am not a writer and this article is not well written. But I think it will benefit the new candidates to have a general idea about how the PLAB 2 is conducted.
My best wishes to all aspirants.
When you have come thus far, I can well guess that you are a doctor from overseas United Kingdom and already cleared the first hurdle of PLAB 1. Now you are entering into the second round of the exam, i.e. PLAB 2, which is also known as OSCE (Objective Structured Clinical Examination). Passing PLAB 2 is not so easy my friend, and yet it is not so difficult either! You must be thinking I am cutting you a joke. No my friend, I am here to help you in passing this test. Being a successful candidate a PLAB 1 and PLAB 2, I felt the urge to help my fellow doctors across the world in clearing the examination with flying colours. There are some secrets which need to be addressed to get a pass mark in PLAB 2. I shall discuss my secrets here.
In PLAB 2, you will have to face the real patients. You will be examined in a way to assess that whether you are capable in eliciting important clinical aspects from the patients. You should be familiar with the common diseases occurring in the UK and have general idea about the epidemiological aspect of the diseases also. It will also be evaluated how you communicate with the patients.
The minimum criterion to pass PLAB 2 is at least 10 ‘C’ with not more than 1 ‘E’ in the entire examination process where C is regarded as marginal pass and E is marked as severe fail.
My first secret will be not to lose your cool in the entire process of the PLAB 2 exam. To pass the exam in a better way, you need to remember the negative aspects of the exam also. This should come in your mind that even if you fail in 4 different stations, there is still a fair chance to pass in the aggregate score. If you consider that your performance was not good in a station, there is another 13 chances to make it brighter. Thinking positive is the only way in passing the PLAB 2. If you continue pondering it over and over again about the dreadful station, there is high chance that you may do more mistakes in the subsequent stations as well. Maintain your focus and you will definitely win.
Let me give you an idea what is considered as ‘Fail’ in PLAB 2.
See, it is very difficult to fail in PLAB 2. I mean, to get 4 Ds and 1 E (i.e. any score less than 4 Ds) and 5 Ds or 4Ds with 1 E or 2 Es (you are marked E in a station if you make any gross mistake) is really hard. If you get this petite score, you were never prepared well to sit for PLAB 2 my dear friend.
Let me share my secrets as to how you should take history in PLAB 2. Just go though the lines and you will find the useful ways to take history nicely in a shortest period of time.
I am sure you all know how to take history. You must have also noticed that there is a specific outline to take history. Let me tell you the essential items that you should not miss during history taking –
Ask about GRIPS
The chief complaints
The duration of the disease
Any other associated complaints
Significant past history (do not bother about single attack of flu 5 years back)
Personal history including history of allergy (never forget to note down this, your examiner will eagerly await whether you miss this)
Any relevant Family history
Any known side effects of medication
Memorise this pattern. This will help you to recap all the points even if you miss any point by any means.
Let me give you a clinical example. This will help you better in memorising the facts.
A 25 years old young lady presented herself to you with headache. Take the history and note down the differential diagnoses.
Again I would like you to refer the pattern I have just furnished. According to the list, the first thing is to be done is to rule out the diseases that may be life threatening. You can well guess the probable differential diagnoses – SOL (Space Occupying Lesion) or SAH (Sub Arachnoid Haemorrhage). Then you should think about the common diseases like diminished vision, migraine, Glaucoma, tension headache and depression. You must take proper history and can ask leading question to elicit the diagnosis.
By asking questions about the life threatening diseases, you can prove yourself to be a safe doctor before the examiner and that will help you in building your impression.
I am giving you what I faced in my exam. One of my patients was an elderly lady having painful menstruation. She was in early menopause and my provisional diagnosis was Menorrhagia. I made my diagnosis with few questions and oh boy, I was relieved. But I had to think about other differential diagnoses also. You know, there is a long list for the causes of menorrhagia. I gave her an open question, whether she wants to tell any other information. She told me – “Doctor, one of my relative has cancer Uterus. Is there any chance I may suffer from this?” Bells was ringing in my head and I asked a few questions related to CA Uterus and CA Cervix (CA Cervix is very common in the UK). I gladly noticed that my examiner was nodding in affirmation and putting a tick mark as I was clarifying the patients to rule out CA.
2. I was supposed to clear out the common d/ds next. By taking epidemiological history you can catch the disease better. I asked about family history of migraine as it is common in the UK than sinusitis. You have only 5 minutes out there for history taking. So better to prioritising the questions and asking only the relevant ones is the better idea. Noting down the duration and severity of complaints will also help you a lot. It will give you an insight to important d/ds. If any patient says the headache he is suffering is the worst in his lifetime, you can easily think of SAH.
3. Next you should ask about any associated symptoms as well. Vomiting is associated with migraine and history of hypertension or injury to the skull is the clue for SAH. Patient suffering from glaucoma will have visual disturbances.
4. The important of past history should not be emphasised much. It gives you vital information to reach a diagnosis. A case of Herpes Zoster will definitely have an episode of Chicken Pox in his childhood. If any patient gives you similar history of headaches in the past, the probability of migraine is high as it is episodic in nature.
5. Personal history like smoking, drinking and drug abuse has to be taken according to the relevance of the disease. The current status of hypertension and Diabetes may be asked. If any person is suffering from long standing unstable hypertension, he be a case of SAH is there is severe headache.
Always ask about any allergy including drug allergy. Allergy is quite common in the UK. You will make an impression before your examiner that not only you practice safe medicine, but you know the subject also.
6. Most of the people are on a medication. Therefore, it is imperative to take history of medication. Please do not ask “Do you take drugs?” as this means whether he is a narcotic abuser. Ask him/ her “Do you take any regular medicines?” If the patient is taking Contraceptive pills for a long time, there is chance of headache. If you miss it, you are missing an important triggering agent of headache.
7. Keep all the psychiatric aspects of the diseases in mind. Let me give you examples – depression can precipitate insomnia, stress can precipitate headache and anorexia may precipitate weight loss.
As you can see from the example mentioned here that following a specific pattern will help you to keep in mind all the important aspects of history taking. It also carries good impression to the examiner and help you in scoring higher grade in exam.
Let us recapitulate the important points of history taking once more. Do not forget three vital points as per given order while calculating the important differential diagnosis as you are offered a station –
Lastly, complete your history taking by asking “Is there any other thing you wish to tell me?”
Remember my fellow aspirants, passing history stations with flying colors is not a game of a child. You may get 2-3 such stations in PLAB 2. It may become a nightmare if you don’t know exactly how to proceed methodically. Also remember that history taking is such a station you cannot concoct anything if you have no idea about proper clinical methods. I have seen a few well prepared candidates are getting mental blocks and roam about the relevant questions to be asked.
At the end of this discussion, let me wish you all the best in your PLAB 2. There is nothing better than a hard work and success is not achieved if you don’t have the guts for hard work.