PLAB (PSYCHIATRY) Sample Questions Set-7

Categories: U.K. PLAB (Professional and Linguistic Assessments Board)

Question. A 64 year old man has just suffered from a myocardial infarction. Before discharge, he seems to be in a sad mood and avoids eye contact. The nurses report that he has skipped his last two meals. What is the SINGLE best treatment for this man’s condition?

A. Sertraline

B. Risperidone

C. Lithium

D. Amitriptyline

E. Diazepam

 

ANSWER: (a) [For majority of patients with moderate depression, selective serotonin reuptake inhibitors (SSRIs) are considered first-line. If the question gives you options of SSRIs, sertraline would be the best answer to pick as sertraline has a good safety profile with patients with myocardial infarction. The other antidepressants have not been studied enough in context of myocardial infarction however citalopram has gained popularity and is also considered safe for use in patients with depression with a history of myocardial infarction.

Guidelines to choosing the right antidepressant: Selective serotonin reuptake inhibitors (SSRIs) are used as first-line antidepressants in routine care because they are as effective as tricyclic antidepressants and less likely to be discontinued because of side-effects; also because they are less toxic in overdose.

Which SSRI to prescribe: i. Guidance suggests that we choose a generic SSRI (eg, citalopram, fluoxetine, paroxetine, or sertraline) when treating an individual with antidepressants for the first time. ii. Fluoxetine is the antidepressant of choice for children and young people. It is the only antidepressant licensed for this use.

In summary: SSRI’s are the first line. Remember these 4 drugs for PLAB 1:

i. Citalopram

ii. Fluoxetine

iii. Paroxetine

iv. Sertraline

Fluoxetine for young people]

 

Question. A 62 year old man who was admitted for surgery 3 days ago suddenly becomes confused. His attention span is reduced. He is restless and physically aggressive and picks at his bed sheets. What SINGLE aspect of the patient’s history recovered in his notes is most likely to aid in making the diagnosis?

A. Chronic alcohol consumption

B. Previous head trauma

C. Psychiatric history of generalized anxiety disorder

D. Psychiatric history of obsessive compulsive disorder

E. Mild cognitive impairment

 

ANSWER: (a) [Abstinence from alcohol in the hospital can cause delirium tremens which is noted here by his sudden confusion, restlessness and physical aggressiveness.

Delirium tremens:

i. Delirium tremens usually begin 24-72 hours after alcohol consumption has been reduced or stopped.

ii. Seen in chronic alcoholics

iii. The symptoms/signs differ from usual withdrawal symptoms in that there are signs of altered mental status. These can include hallucinations (auditory, visual, or olfactory), confusion, delusions, severe agitation. Seizures can also occur. A common scenario would be a chronic alcoholic who is admitted for an operation where that patient would have to be abstinent from alcohol. A few days after being abstinent, he or she would start having symptoms of an altered mental status which include hallucinations.]

 

Question. A 38 year old woman with episodes of mania followed by depression was started on medication. Improvement was seen and she no longer complains of these episodes. What is the SINGLE most likely medication that she was started on?

A. Fluoxetine

B. Lithium

C. Lorazepam

D. Haloperidol

E. Amphetamine

 

ANSWER: (b)

 

Question. A 62 year old retired school teacher has had a repair of strangulated femoral hernia 3 days ago. She has become agitated, aggressive and confused over the past 12 hours. She has developed auditory hallucinations. Her blood tests show:

Haemoglobin 129 g/L

Mean cell volume (MCV) 112 fL

Gamma-glutamyl transferase (GGT) 120 u/L

Alkaline phosphatase (ALP) 110 iu/L

 

What is the SINGLE most appropriate management?

 

A. Vitamin B12

B. Lorazepam

C. Intravenous morphine

D. Clozapine

E. Thiamine

 

ANSWER: (b) [Abstinence from alcohol in the hospital can cause delirium tremens. The chronic alcoholism is supported by high MCV and GGT here. The GGT result is more useful than the MCV result as a “red flag” to raise the suspicion that the person is drinking too much. Symptoms fit delirium tremens. Seizures can be seen in delirium tremens. It is unlikely to be Wernicke’s encephalopathy or Korsakoff’s psychosis as in PLAB they would usually have a triad of confusion, ataxia and ophthalmoplegia. Diazepam or chlordiazepoxide is used frequently to manage uncomplicated withdrawals however for delirium tremens the first line is Lorazepam (previously this was chlordiazepoxide). As these patients are also thiamine deficient, they would require parenteral and/or oral thiamine eventually however the more immediate treatment here would be lorazepam which is a fast-acting benzodiazepine. If deficiency of thiamine continues, it will cause Wernicke’s encephalopathy and later on can lead to Korsakoff’s syndrome.]

 

Question. A 20 year old boy is brought by his parents to the emergency department. He is agitated and euphoric. The parents suspect that he has taken drugs. Examination reveals a perforated nasal septum. What is the SINGLE most likely drug that was taken?

A. Heroine

B. Cocaine

C. Ecstasy/MDMA/amphetamine

D. Alcohol

E. Opioids

 

ANSWER: (b) [This is a high yield question in PLAB. The perforated nasal septum is a huge clue that the route of intake is nasally inhaled. In the majority of cases, the answer when you see that term is cocaine. This along with the signs and symptoms of euphoria and agitation points towards cocaine.

Cocaine: Cocaine is an alkaloid derived from the coca plant. It is widely used as a recreational stimulant. The main route of intake is by inhalation as it undergoes rapid ‘first pass’ liver metabolism. The user forms the powder into ‘lines’ and inhales via rolled paper tube (classically, a high denomination bank note). There is increased energy, increased confidence, euphoria, and diminished need for sleep, but with rapid fall-off in effects due to rapid metabolism, leading to repeated use.

The use of cocaine is associated with a wide variety of adverse effects:

Cardiovascular effects:

i. arrhythmias

ii. both tachycardia and bradycardia may occur

iii. hypertension

Neurological effects:

i. seizures

ii. mydriasis

iii. hypertonia

iv. hyperreflexia

Psychiatric effects:

i. agitation

ii. psychosis

Others: effects include necrosis of nasal septum]

 

Question. A 30 year old man complains of episodes of hearing music and threatening voices within a couple of hours of heavy drinking with his friends at a friend’s birthday party. What is the SINGLE most likely diagnosis?

A. Delirium tremens

B. Wernicke’s encephalopathy

C. Korsakoff’s psychosis

D. Alcohol hallucinosis

E. Temporal lobe dysfunction

 

ANSWER: (d) [Alcohol hallucinosis can occur during acute intoxication or withdrawal. It usually appears 12-24 hours after alcohol has stopped. It involves auditory and visual hallucinations, most commonly accusatory or threatening voices. The answer is unlikely to be delirium because of the time frame in which he was drinking alcohol. Delirium tremens usually happen days after alcohol consumption has been stopped and he would need to be a chronic alcoholic. Think of alcohol withdrawal symptoms as a spectrum whereby delirium tremens is the end of the spectrum where the symptoms are severe involving disorientation, tremors, diaphoresis, impaired consciousness and visual and auditory hallucinations. Again, since there are no signs and symptoms of chronic alcohol abuse, it is unlikely to be Wernicke’s encephalopathy or Korsakoff’s psychosis.

ALCOHOL WITHDRAWAL SYMPTOMS:

i. Symptoms typically present about eight hours after a significant fall in blood alcohol levels.

ii. Symptoms peak on day 2 and, by day 4 or 5, the symptoms have usually improved significantly.

iii. Minor withdrawal symptoms (can appear 6-12 hours after alcohol has stopped)

iv. Alcoholic hallucinosis (can appear 12-24 hours after alcohol has stopped).

v. This includes visual, auditory or tactile hallucinations.

vi. Withdrawal seizures (generalized tonic-clonic seizures can appear 24-48 hours after alcohol has stopped).

vii. If withdrawal symptoms continue to increase in severity it could advance to delirium tremens which is characterised by hallucinations that are indistinguishable from reality and associated with severe confusion, disorientation and tremors.]

 

Question. A 21 year old woman has had several sudden onset episodes of palpitations, sweating, nausea and overwhelming fear. On one occasion, she was woken from sleep and feared she was going insane. She has no previous psychiatric disorder. What is the SINGLE most likely diagnosis?

A. Pheochromocytoma

B. Panic disorder

C. Generalized anxiety disorder

D. Agoraphobia

E. Acute stress disorder

 

ANSWER: (b)

 

Question. An 82 year old schizophrenic man is brought to the Emergency Department in an agitated state. He is lashing out violently and throws any equipment around him at the hospital staff. He seems to be hearing voices which are causing him distress. He does not have any intravenous access. Which is a drug of choice in the management of agitation in this man?

A. Haloperidol

B. Diazepam

C. Risperidone

D. Clozapine

E. Clonazepam

 

ANSWER: (a) [In acute psychosis, the drug of choice is haloperidol. It is still considered a first line medication for rapid tranquilization. Haloperidol is a drug of choice for the management of psychotic episodes particularly in the elderly. Diazepam is a long acting benzodiazepine and so should not be used intramuscularly for rapid tranquilisation as it has a prolonged and erratic absorption. Besides, benzodiazepines in general are not recommended in elderly patients. Clonazepam is a long acting benzodiazepine and can only be given orally which makes it inappropriate in this situation.]

 

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