The Professional and Linguistic Assessments Board (PLAB) test is the main route by which International Medical Graduates (IMGs) demonstrate that they have the necessary skills and knowledge to practice medicine in the UK.

The PLAB Part 1 is a computer-based exam that lasts three hours and ten minutes, with a total of 200 ‘single best answer’ questions.

The GMC website gives the following information about what knowledge is required in order to take the PLAB Part 1 test:

The exam tests your ability to apply knowledge to the care of patients rather than how well you can remember and recite facts.

All questions relate to current best practice – answer them in relation to published evidence and not according to your local arrangements.

Any drugs featured in the exam will be listed in the most recent edition of the British National Formulary (BNF).

You should be aware of the range of equipment routinely available in UK hospitals.

The PLAB Part 1 is run four times a year in the UK and twice a year at a number of overseas centres. The PLAB Part 1 test dates can be found on the GMC website here: www.gmc-uk.org

Sitting practice questions is a great way to prepare for the PLAB Part 1. Here are a few to get you started.

1. A 66-year-old man is reviewed on the coronary care unit 3 days after a myocardial infarction. He states that he feels very breathless. On examination you can hear a pansystolic murmur that is maximal at the lower left sternal edge. What is the SINGLE most likely diagnosis?

A. Mitral regurgitation
B. Mitral stenosis
C. Ventricular septal defect
D. Tricuspid stenosis
E. Dressler syndrome

Show Answer

Answer: C. Ventricular septal defect

Post myocardial infarction ventricular septal defect (VSD) is a rare but serious complication, which may result in cardiac wall rupture. It tends to develop 2-3 days after the myocardial infarction and 85% of patients that develop it will go on to die within 2 months without surgical intervention. The murmur of a VSD is a pansystolic murmur that is maximal at the lower left sternal edge. An accompanying thrill is also often present. 

Dressler’s syndrome is a type of pericarditis that develops 2-10 weeks after a myocardial infarction or cardiac surgery. It is characterised by sharp chest pain that is typically relieved by sitting forwards. A pericardial rub, pulsus paradoxus and signs of right ventricular failure can also be seen.

Mitral regurgitation also causes a pansystolic murmur, however it is best heard at the apex and radiates to the axilla.

Tricuspid stenosis causes an early diastolic murmur, best heard at the lower left sternal edge in inspiration.

Mitral stenosis causes a rumbling mid-diastolic murmur best heart at the apex, in the left lateral position, in expiration with the bell of the stethoscope.

2. A 70-year-old man with poorly controlled hypertension develops sudden visual loss in his right eye. The visual acuity on the right is reduced to hand movements only. Visual acuity on the right is 6/6. On examining his fundi you note engorgement of the retinal veins, disc oedema, multiple flame-shaped haemorrhages and cotton wool spots spread across the entire retina. What is the SINGLE most likely diagnosis?

A. Central retinal vein occlusion
B. Vitreous haemorrhage
C. Central retinal artery occlusion
D. Diabetic maculopathy
E. Wet age-related macular degeneration

Show Answer

Answer: A. Central retinal vein occlusion

Central retinal vein occlusion (CRVO) typically causes painless, unilateral visual loss. The retina has a characteristic appearance that has been likened to a ‘pizza thrown against a wall’. There is engorgement of the retinal veins, disc oedema, multiple flame-shaped haemorrhages and cotton wool spots evident on fundoscopic examination. Hypertension is found in approximately 65% of patients presenting with CRVO and it is most common in patients over the age of 65.

Central retinal artery occlusion (CRAO) also presents with sudden, painless, unilateral visual loss. The appearance of the retina is quite distinct to that of CRVO however, with a pale retina and attenuation of the vessels. There is often a ‘cherry-red spot’ visible at the centre of the macula, which is supplied by the underlying choroid. Examination also frequently reveals an afferent papillary defect.

Vitreous haemorrhage occurs when there is bleeding into the middle chamber of the eye (‘the vitreous’). Causes include proliferative diabetic retinopathy, trauma and retinal detachment. The appearance has been likened to ‘blood within a bloodless gel’ and there is a diffuse red appearance to the retina without the focal flame-shaped haemorrhages that are visible with a CRVO.

Diabetic maculopathy occurs when there is evidence of diabetic eye disease within one disc diameter of the macula.

Wet age-related macular degeneration (ARMD) causes visual loss due to choroidal neovascularisation, which leads to blood and protein leakage below the macula. There can be haemorrhages evident on the retina, however, the appearance is not consistent with the fundus shown in the photo above.

3. A 62-year-old female smoker presents with weight loss, dysphagia and intermittent vomiting. On examination you note a mass in the left iliac fossa and can also palpate a fullness in the right iliac fossa. An ultrasound scan is organised, which demonstrates bilateral, solid ovarian masses, with clear well-defined margins. What is the SINGLE most likely underlying diagnosis?

A. Primary ovarian carcinoma
B. Oesophageal carcinoma
C. Gastric carcinoma
D. Benign ovarian tumour
E. Functional ovarian cysts

Show Answer

Answer: C. Gastric carcinoma

This patient has Krukenberg tumours, which are also known as carcinoma mucocellulare. Krukenberg tumors are ovarian malignancies that have metastasized from a primary site. The commonest source if gastric adenocarcinoma, which would fit with the history of weight loss, dysphagia and intermittent vomiting.

Other primary malignancies that can act as the primary for a Krukenberg tumour include:

  • Colorectal carcinoma
  • Breast cancer
  • Lung cancer
  • Contralateral ovarian carcinoma
  • Cholangiocarcinoma

 

Ultrasound usually reveals a solid, well-defined ovarian mass, which is frequently bilateral. Further evaluation by CT scan or MRI can be helpful. Biopsy will confirm the diagnosis, with mucin-secreting ‘signet-rings’ being seen on histological examination.

4. You review a 45-year-old woman with a history of polyuria and polydipsia. You suspect a diagnosis of type 2 diabetes mellitus. Select from the list of options below the single result that is most consistent with a diagnosis of diabetes mellitus.

A. A random plasma glucose of 10.5 mmol/l
B. A fasting plasma glucose of 6.5 mmol/l
C. A 2 hour OGTT glucose concentration of 7.5 mmol/l
D. An HbA1c of 50 mmol/mol
E. An HbA1c of 6.2%

Show Answer

Answer: D. An HbA1c of 50 mmol/mol

According to the 2011 WHO recommendations HbA1c can now be used as a diagnostic test for diabetes providing that stringent quality assurance tests are in place and assays are standardised to criteria aligned to the international reference values, and there are no conditions present which preclude its accurate measurement.

An HbA1c of 48 mmol/mol (6.5%) is recommended as the cut off point for diagnosing diabetes. A value of less than 48 mmol/mol (6.5%) does not exclude diabetes diagnosed using glucose tests.

If using glucose tests the following are diagnostic of diabetes mellitus:

  • A random venous plasma glucose concentration > 11.1 mmol/l 
  • A fasting plasma glucose concentration > 7.0 mmol/l
  • A two hour plasma glucose concentration > 11.1 mmol/l two hours after 75g anhydrous glucose in an oral glucose tolerance test (OGTT)

 

In the following circumstances HbA1c is not appropriate for the diagnosis of diabetes mellitus:

  • ALL children and young people
  • Patients of any age suspected of having Type 1 diabetes
  • Patients with symptoms of diabetes for less than 2 months
  • Patients at high diabetes risk who are acutely ill (e.g. those requiring hospital admission)
  • Patients taking medication that may cause rapid glucose rise e.g. steroids, antipsychotics
  • Patients with acute pancreatic damage, including pancreatic surgery
  • In pregnancy
  • Presence of genetic, haematologic and illness-related factors that influence HbA1c and its measurement

5. A 44-year-old businessman returns from a trip to West Africa with headaches and intermittent fevers. Thick and thin films are sent to the lab and a diagnosis is made of malaria. The patient is started on treatment, but his condition deteriorates and he develops jaundice, renal failure and haemoglobinuria. What is the SINGLE most likely causative organism?

A. Plasmodium falciparum
B. Plasmodium ovale
C. Plasmodium vivax
D. Plasmodium malariae
E. Plasmodium knowlesi

Show Answer

Answer: A. Plasmodium falciparum

Malaria is an infectious disease transmitted by female of the Anopheles genus of mosquito. It is a parasitic infection caused by the genus Plasmodium. Five species are recognized as causing disease in humans; Plasmodium falciparum, Plasmodium ovale, Plasmodium vivax, Plasmodium malariae and Plasmodium knowlesi.

The classic symptom of malaria is the malarial paroxysm, a cyclical occurrence of a cold phase, where the patient experiences intense chills, a hot stage, where the patient feels extremely hot and finally a sweating stage, where the fever declines and the patient sweats profusely. On examination the patient may show signs of anaemia, jaundice and have hepatosplenomegaly without evidence of lymphadenopathy.

Haemoglobinuria and renal failure following treatment is suggestive of blackwater fever, which is caused by Plasmodium falciparum. An autoimmune reaction between the parasite and quinine causes haemolysis, haemoglobinuria, jaundice and renal failure. This can be fatal.

 

 


Thank you to the joint editorial team of www.plabprep.co.uk for this ‘Exam Tips’ post.

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