PLAB 2 Case Scenario Summary: Gout Consultation

Summary

This case involved a patient presenting with acute onset pain in the big toe, suspected to be gout. The candidate demonstrated strong clinical knowledge but faced challenges in communication, patient engagement, and time management, which significantly impacted their performance.

Key Points

Data Gathering Issues

Interrupting the patient: The candidate repeatedly cut off the examiner before they could respond.
Pre-scripted questioning: The candidate followed a rigid question list, leading to a robotic interaction.
Lack of open-ended questions: The history-taking was heavily based on closed questions, limiting patient interaction.
Failure to integrate given information: Key details (e.g., sudden pain, location) were already in the candidate brief but were still being re-asked, wasting time.
Missed risk factors: Although some risk factors (alcohol, thiazide use, smoking) were identified, the DVLA risk (patient's inability to press the brake while driving) was not addressed in time.

Management Issues

Over-explaining without patient involvement: The candidate tried to cover all aspects of management without pausing for patient input.
Lack of prioritization: Instead of focusing on the patient’s main concern (pain relief), the candidate attempted to give excessive details.
Missed key lifestyle advice: Important elements like avoiding alcohol, weight loss, exercise, and leg elevation were omitted.
Failure to emphasize safety concerns: The patient, being a taxi driver unable to press the brake, posed a risk to public safety. This should have triggered DVLA notification advice.

Important Considerations

Interpersonal Skills Impact: Interrupting and failing to engage the patient meaningfully can lead to significant mark deductions in PLAB 2.
Avoiding a Scripted Approach: Over-rehearsed interactions make candidates appear unnatural and could lead to penalties.
Time Management: Spending excessive time on history-taking or providing unnecessary information can cost crucial points.

Diagnostic Approach

Recognize key features: Sudden onset, big toe involvement, red, swollen, and painful joint.
Rule out differentials: Septic arthritis (fever, systemic symptoms), rheumatoid arthritis (morning stiffness), osteoarthritis (worse with activity).
Identify risk factors: Alcohol, medications (thiazide diuretics), obesity, previous gout episodes.
Confirm the diagnosis: Clinical presentation is usually sufficient, but joint aspiration can confirm urate crystals if necessary.

Management Plan

Immediate Treatment

Pain relief: NSAIDs (e.g., Naproxen) or Colchicine if NSAIDs are contraindicated.
Rest and elevate the limb.
Apply ice packs to reduce swelling.

Long-term Management

Lifestyle modifications:
- Avoid alcohol (major risk factor).
- Weight loss and regular exercise.
Medication review: Consider adjusting hypertensive medications if thiazides are implicated.
Consider urate-lowering therapy (Allopurinol) for recurrent attacks, but not during an acute episode.

Safety Considerations

DVLA notification: The patient should be advised not to drive until pain subsides.
Follow-up: Monitor urate levels and adjust long-term therapy as needed.

Communication Skills

Active Listening: Allow the patient to complete their responses before asking another question.
Summarization: Begin management by outlining key points and asking the patient what they would like to hear about.
Patient-Centered Approach: Focus on the patient’s primary concern (pain relief), then gradually cover other aspects.

Ethical Considerations

Patient safety: Advising against driving ensures public safety.
Shared decision-making: Engage the patient in treatment choices.
Professionalism: Avoid rehearsed, robotic interactions.

Additional Resources

GMC Good Medical Practice Guidelines.
PLAB 2 Examiner Top Tips:
- Avoid being overly rehearsed.
- Ensure a natural, patient-centered approach.
- Prioritize key issues rather than reciting exhaustive management plans.