Yeah! PLAB 2 is not a difficult exam if you know where exactly they are testing you; and take it from me that this exam tests only how professional you are.
At this stage of our profession, I think all of us have enough knowledge to elicit a relevant history and reach a probable diagnosis. All of us have acquired all relevant skills to perform basic examination of any system. We had been doing all these things all these years, and PLAB 2 is just a chance to show off how good you are at it.
Introduction: The test starts as soon as you enter the cubicle. The way you have dressed up for the exam, the confidence with which you walk in, your genuine smile, they way you introduce yourself to the examiner and shake hands. You get your first grade here.
The coaching centres usually have their own way of teaching you this but when it comes to introducing urself, I think all of us have our own way to do that and I sticked to my own style. Of course, try an avoid using 'Sir' when u greet them. A casual 'Good Morning Doctor' is a good way to start. I always preferred to wait for few seconds for the examiner to respond to this,and luckily for me, all the 15 examiners did respond back and we went further with checking of my GMC number.
Remember, your station actually starts after this initial intro with the examiner. Try and avoid the mistake of turning to the patient directly and starting with your station straight to save time!!! The examiner needs to confirm first that he is marking the correct candidate.
After settling with the examiner, you need to turn to the patient and confirm first that you are talking to the right person. Make sure u remember the patient's name (esp. the surname). In case of any doubt, ask the examiner if could have a look at the question once again, just before you turn to the patient and start with your station.
Introduction with the patient is slightly different from how you u introduced yourself to the examiner. Usually the question wud specify, that you are an SHO in a particular department and u introduce yourself accordingly.
Introduction with patient is important as these simulators might sometimes refuse talk to you at all. The logic is, why should anyone discuss their personal problems with a stranger. The patient doesnt know who you are till you introduce yourself to her!!!
Be clear and sufficiently loud throughout the station as the aim is to get the true and best grade you deserve. The conversation between you and the patient is intended for the examiner to hear.
My first station was a young 28 year old lady with lower abdominal pain. The station clearly asked NOT TO EXAMINE, take RELEVANT history and discuss differential diagnosis with the examiner.
After checking her identity and introducing myself I started with how was she feeling today. She went direct on the topic that she having this pain and pointed at her right iliac fossa. So I went on asking about the 'pain' history first, then the associated symptoms. The diagnosis of 'appendicitis' which had flashed in my mind after her pointing to right iliac fossa, soon disappeared as no other associated symptoms matched. Rather, on further probing she gave a positive history of purulent vaginal discharge and the presence of IUCD as well. She also gave a positive history of unprotected sex coinciding with the onset of her abdominal pain. She also had a previous history of 2 abortions in last one year and a previous history of chlamydia vaginal infection as well.
I quickly finished up with the entire history taking format, thanked her and turned to the examiner for the second part of the question. The DDs I put forth as PID, STD, Mittleschmerz (her LMP was jus 2 weeks back), Ectopic pregnancy and lastly acute appendicitis. I also gave reasons of why I thought these as to be the probable diagnoses. Added that I wud like to do further investigations, bell rang and me out of the cubicle after thanking the examiner.
Long station, I should say! Try and wrap up things fast so that you finish both parts of the question well within the time provided. Always, finish the complete format for history taking. It will always lead to the diagnosis. Dont stick to the first clue the patient provides (for this station, was the Right Iliac Fossa). Always expand further thinking of other possibilities depending on the age of the patient and the nature of pain.
Here was a patient just after a small attack of myocardial infarction, ready for discharge. The question clearly stated that the patient is OBESE and I was supposed to give him advice for life style modifications.
Now, post MI life style modification is quite a common station and usually we are supposed to counsel the patient on his food habits, smoking, alcohol, work, sex, driving as well as medications. However, as the question hinted directly at him being OBESE, I preferred to focus my counselling accordingly.
After introducing myself with the examiner and the patient and investing some time over general questions to create a good rapport, I went on to advise him regarding loosing weight. He seemed reluctant to carry on with advices I gave him regarding food modifications and daily exercise regimen. But all I was supposed to do was to inform him of the benefits of following the advices and then leave it upto him if he actually wanted to follow or not. After a quick discussion over obesity, I switched over to his smoking habits and drinking habits.
Overall the discussion was good, although very long especially when the simulator seemed reluctant at every advice I suggested; but it was nothing different from what we usually have to face in day-to-day practice.
Also, the most important points in this station were:
1. Do not forget to give advice on loosing weight. The question mentioned that straight! Most candidates who lost this station started with the general advices on Post MI life style modifications and by the time they thought of talking on obesity, bell went off.
2. Never pester a patient that You SHOULD loose weight (or any other advice). You can only suggest him of the best possible options. Leave it on him to choose what he thinks best for him. Why the simulator was showing reluctance on each n every advice the candidates were giving him, was only because they were testing if we know the art of suggesting the patient about everything we want to, yet not forcing anything on them.
This was young lady recently diagnosed with Idiopathic epilepsy and started on carbamezepine. She has come for follow up and has poorly controlled fits. Talk to her and give relevant advice.
After initial formalities with the examiner and the patient, I confirmed if she is actually being diagnosed with the condition and prescribed a medicine. Asked her if she knows how to take it and if she is actually complying with the directions of her consultant and taking the medications regularly. Then she came out with the real problem, that because she is working, she keeps forgetting to take the medications. I offered her a couple of simple methods to help her with this 'forgetting issue' and told her the importance of taking the medications regularly.
She also asked if we could change the medications, as the fits are anyway not controlled. I advised her on this as well and also ruled out other causes for uncontrolled fits (viz skipping meals, less sleep, bright light, watching TV for long, loud music and the rest).
I finished this one just at 4 30 bell and all three of us sat together looking at each other for the next 30 seconds.
Here was a young guy and the question said that he had been abusing opioid, but now he wants to quit. Talk to him.
I went ahead with the initial formalities and first went in accordance with the questionnaire to confirm if he is actually dependent. The usual questions about what he was abusing, which route, for how long, from where he gets the drug and money to get it. He said that he started with sniffing n now he was injecting direct into his veins. The very next question was, if he is aware of the needle exchange programme. Thankfully, he said yes and we went ahead with further questions determining tolerance, compulsion and any prob with the law.
Once his dependence was confirmed I talked about the de addiction centres and how exactly it will help him out with his habit. He was happy and I asked if he had any more concerns to be answered.
Cool station! wrapped up by thanking him and the examiner.
This was a teenager with recently diagnosed with asthma. The question clearly said that the patient is not aware that he has asthma. Tell him about the diagnosis and address his concerns.
This was a cool young guy called Sam. I started the main part of station telling him the cause of his breathlessness and that we think its asthma and asked him if he knew anything about the condition. He said yes, but wanted to know more. I explained the basic mechanism of the disease and went ahead talking on allergens and ways he could identify and avoid them. I went further talking about the type of medications we would put him on. Also told him how important is to keep people informed about his condition. His main concern was if he would be able to play hockey as he was joining the hockey team that summer. I told him that we will have to see how u respond to the medications and also, if exertion is a precipitating factor for him.
He was happy n convinced towards the end and I myself left the cubicle satisfied.
This was the usual telephonic conversation regarding a patient who had collapsed in the post op ward. He was operated for hemi colectomy in the morning. TPR chart was given and I was supposed to discuss this with the consultant on phone.
Traditional station, and I did nothing more than what was taught at the coaching centre. After confirming whum I was talking to and introducing myself, I told the consultant about the patient's condition straight from the question, interpreted the TPR chart and told him about his previous as well as present readings. The examiner at this point asked me, 'What exactly u think is going on with this patient?' I talked about my provisional diagnosis with valid reasons based on the chart provided. Then went ahead with immediate resuscitation, investigations and informing the theatre as well the anaesthetist. Wrapped up by requesting him to come down and have a look at the patient and decide on further management.
Went smooth! finished just in time!
This was a young lady diagnosed who had a cervical smear done and dyskaryosis (Grade III/IV) was observed. Counsel her regarding colposcopy and further treatment options.
Went ahead with telling her first about the smear results and told her why we need to do colposcopy at this point. Went further describing the colposcopy process and told her about spotting, and also how we gonna proceed further once her colposcopy results are available. Talked about LLETZ and further follow up smears required.
Again I should say, a very familiar station. Tackled the same way I learnt during my mock tests.
Now this was examination of the thyroid. The question also said to discuss the findings with the examiner as you go ahead with the examination.
I went ahead first with examination of the gland proper and then with the general examination. That way I could finish the main part of question (ie examination of thyroid) with cool head and also had enough time left towards the end to carry out a fast general examination.
It was a colloid goitre and lobes were bilaterally enlarged.
For a station like this:
1. Do not forget to tell the patient that u will be going behind him to carry out the examination.
2. Do not forget to do the special tests to check for opthalmoplegia, lid lag and exopthalmos.
3. Ask for a stethoscope to ausculate for an bruit. I was provided with one and I carried out with ausculation and commented that no bruit heard over the gland.
4.Do not forget to check for tremor, moist hands and pulse rate while doing general examination. Talk about sleeping pulse rate.
This was a young lady with pain in her left elbow. Do relevant examination, tell the patient about the diagnosis and talk to her about further management of the condition.
Ufff! I actually hate examination stations. Wish I could escape from such stations. First thyroid and then this.
Anyway, the lady was quite co operative and gave me hint straight away about Lateral epicondylitis. I quickly finished up with the elbow joint examination ending with the special tests. Then we sat and told her about the diagnosis and what exactly it is. Asked her about her profession and stressed on the importance of rest. Told her about the pain killers. Asked her that further treatment would depend on how she responds to this and we need to see her again in few weeks time to determine whats best for her.
Short station! Finished quite ahead of time!
This was a middle aged man was posted for herniorapphy. However, his routine investigations revealed Hb >8 mg/dl. Talk to the patient and counsel why his surgery needs to be postponed.
This man was not quite happy with the postpontment of his operation date. I explained about his low Hb, when he asked what could have caused this. I then took a short history to rule out causes for anemia in a middle aged man. He didnt give anything positive in the history which could have explained the cause, so I went further saying dat we wud need to do some investigations to find out the cause of his anemia. and then he wanted to know - what investigations. I quickly brushed on the investigations and again stressed on the fact that his anemia needs to be corrected before we can go on with his scheduled surgery. He was sorta satisfied towards the end and I wrapped up by asking if he had any more concerns.
Here was an anxious mother whose baby had a fall and got unconscious. Take a short relevant history and discuss management with the mother.
On reading the question, I wasnt really sure whether it was a head injury station or a station on Non Accidental Injury. I went ahead as usual and elicited the history ruling out the possibility of both non accidental injury as well as head injury. Mother told me dat her baby went 'floppy' after the fall. Next I went ahead with the management part of the questions and discussed it with mother.
In this sort of stations it is important that:
1. You carefully rule out non accidental injury.
2. If its head injury, do not forget to ADMIT the baby.
3. Ensure you are as gentle as possible as these simulators are always tearful.
4. Read carefully, if the question requires you to discuss management with the patient or with the examiner. One of my friend lost this station as she went on to discuss management with the examiner.
Here was a middle aged lady with complaints of diplopia. The question clearly asked carry out relevant examination and DO NOT TAKE ANY HISTORY.
Short station! I carried out the examination of III, IV and VI nerve and complemented it with the examination of the V and VII nerve as well. The patient clearly showed lateral rectus affection (Right). I dunno if the question asked to discuss findings with the examiner but he asked me the diagnosis and probable causes for such a presentation at this age group. Could list only a couple of causes when the bell rang and I went out with a relief.
This was a manniquin station and we were supposed to do venepuncture.
I went ahead like any other manniquin station. Everything went fine till I introduced the needle and kept the vacutainer in position - NO BLOOD!!! God damn! I could see clearly the channels in the manniquin were connected with a bag full of some red fluid. I tried advancing the needle tip a bit, but all in vain!! My vacutainer was still empty. Gosh!!! am messing up with this station!!! Decided to withdraw the needle and give a second try. Withdrew the needle and discared it in the sharps bin, talked about hemostasis and also the second try. Took a new set of needle n swipes and went ahead again at a different site. Introduced the needle, placed vacutainer in position --- but no blood means NO BLOOD AGAIN!!!! 4 30 bell rang! I disposed off the needle, removed tourniquet, talked abt hemostasis and told the examiner that I would tell the patient that I could not complete the procedure and would come later to try again. I also added, that if, I would have completed the procedure, I would have labelled the vacutainer appropriately and sent for investigations.
Thats it!!! Almost ran out of the cubicle at 5 'o' clock bell. :-|
This was Paediatric CPR. The universal precautions were taken and cervical injury already ruled out. We just needed to go ahead with the procedure. Went well and smooth!
This was REST!!!!!!!!!!! 6 minutes in a stretch!!!!! Good time to sit back and relax!
This was again manniquin - Testicular Examination. The question asked only to discuss findings with the examiner and nothing was mentioned if we were also supposed to discuss the diagnosis.
There were two examiners in this station (the 2nd one was observer, I suppose). I carried out with the examination and described 2 swellings. Went ahead with the fluctuation test and asked that I would like a torch and transilluminoscope to carry out transillumination test. No translilluminoscope!! Only pen torch was provided. So I asked If I could dim the lights and carry on with the test. Instead of him saying, 'Assume doctor, its done', the observer went ahead and switched off the light. I carried out with the test and then discussed the findings. 4 30 bell rang and then ........OVER!!!!
PLAB 2 over.... what a relief!!!
I was definitely anxious about my results especially after the way I had messed up with the venepuncture station, but then thank God that I passed! Still wonder what grade I got for that station!!!
So good luck to all you folks taking plab 2 in near future. Its not a difficult exam. Keep your cool and be confident, you will definitely succeed!
Note: If you are benefitted by reading this article, then do not forget to post your own personal experience of PLAB part 2 exam. You can easily post your contribution at RxPG submit page.