PLAB 2 Mock Test Feedback :: Ataxia due to N2O Abuse :: Medicine

Mock Date: 14/05/2025

Action Items:

• Practice and Review the case in the OSCE workbench: Click Here

• Read the Mock Feedback Blog:  Click Here

• Additional Resources: Click Here

• Deep Dive into your performance below:

Scenario Summary:

You are an FY2 doctor in a GP Surgery. Your patient, Mr. Roger Marshall, aged 35, presents with lower limb weakness, heaviness, and tiredness in both legs, which has worsened over the last few days. He also reports numbness and tingling in his feet and legs. He is worried about his symptoms and hopes to find out the cause and receive appropriate treatment.

My Performance:

🔍Let’s Deep Dive into your performance:

The Domain-wise evaluation shows areas where you did well and others where you have room to grow. 

• A "Yes" means you covered that point effectively

• A "Partial" indicates that you did some of it well but missed some key details. 

• A "No" means there was an important opportunity that wasn’t addressed.

Don’t worry if you see several areas marked "No" or "Partial"—this is common and simply highlights where you can focus your learning. 

By reflecting on these areas and practicing, you’ll be able to improve and feel more confident in your consultations. Remember, every bit of feedback is an opportunity to grow, and you’re on the right path by taking these steps.

Timestamps are provided to show exactly when during the consultation you covered or missed key points. Reviewing these can help you see how well you're managing your time and where you might need to be more efficient in addressing important areas.

Domain	Point	Timestamp	Response	Remarks
Data Gathering	Confirm the patient's full name and age.	00:22	Yes	You confirmed both name and age at the start of the consultation, which was good.
Data Gathering	Acknowledge and validate the patient's emotions.	05:20	Yes	You expressed empathy effectively with phrases like "This must have been very stressful for you." That helped build rapport.
Data Gathering	Use SOCRATES to elaborate presenting complaint, focusing on site, onset, character, and progression of limb weakness.	00:44, 01:03	Partial	You asked about onset and progression, but did not fully cover site or character of the weakness in enough detail. Next time, ask about the nature of weakness (e.g., heaviness, floppiness), and specific timing like exact duration or time of day.
Data Gathering	Ask about associated symptoms, specifically numbness, tingling, balance issues, or electric shock sensations.	01:49, 02:01	Partial	You asked about balance, tingling, and numbness, but you missed asking about electric shock-like sensations. Consider adding this next time for completeness.
Data Gathering	Screen for red flag symptoms, such as bladder or bowel dysfunction, severe pain, weight loss, or fever.	02:39–02:54	Yes	You covered bladder, weight loss, and fever appropriately.
Data Gathering	Ask about history of trauma or recent infections that might mimic or contribute to neurological weakness.	02:13, 02:20	Yes	You asked clearly about any preceding illness or infection, which was relevant and well done.
Data Gathering	Inquire about past medical history, medications, family history, and allergies.	03:01–03:19	Yes	You covered all these areas systematically.
Data Gathering	Explore lifestyle factors, including diet, exercise, smoking, alcohol, and recreational drug use.	03:25–04:07	Partial	You asked about smoking, alcohol, and diet but missed exercise habits. It’s a small omission but still worth including.
Data Gathering	Inquire about dietary habits, especially veganism or poor nutrition that could contribute to B12 deficiency.	04:43	Yes	You asked clearly about diet and the patient disclosed vegetarianism, well done.
Data Gathering	Explore recreational drug use, especially nitrous oxide, to identify neurotoxic exposure.	04:01	Yes	This was well handled as you followed up with appropriate details after the patient mentioned Vipex use.
Data Gathering	Order relevant investigations: FBC, Vitamin B12, folate, and TFT.	07:44–08:03	Partial	You mentioned FBC and vitamin levels, but didn’t specify folate or TFT. Try to list all relevant tests explicitly.
Data Gathering	Check vitals, general physical examination and neurological examination of the lower limb	06:12	Partial	You mentioned examining general observations and "nerves in your body" but didn’t clearly state a focused neurological exam of the lower limbs. You should have specified gait or limb-specific testing.
Data Gathering	Address the patient's ideas, concerns, and expectations (ICE).	05:36–06:01	Yes	You elicited all parts of ICE thoroughly. Good job!
Management	Explain the diagnosis of sensory ataxia and its implications in layman terms.	—	No	You didn't clearly use or explain the term "sensory ataxia." You discussed B12 deficiency and symptoms well, but naming and explaining the actual condition would have improved clarity.
Management	Describe the condition by name, i.e., “Subacute Combined Degeneration of the spinal cord”, and explain what that means functionally.	—	No	This was missed completely. Next time, include the condition's name and describe its impact on the spinal cord.
Management	Explain that this is likely caused by B12 deficiency, compounded by both vegan diet and nitrous oxide use.	06:30–07:24	Yes	You linked the nitrous oxide use and B12 deficiency well, which was clearly communicated.
Management	Consider advanced investigations, such as MRI spine and nerve conduction studies, if the diagnosis remains uncertain or symptoms persist.	—	No	This was not mentioned. Adding MRI and NCS for unclear or persistent cases would strengthen your plan.
Management	Provide a treatment plan: Stop using nitrous oxide immediately.	07:31	Yes	You advised stopping nitrous oxide clearly.
Management	Start B12 injections (hydroxocobalamin 1 mg) every other day until improvement.	—	No	You did not mention the B12 injection regimen. Make sure to give specific treatment next time.
Management	Delayed treatment can lead to permanent nerve damage, mobility loss, or irreversible spinal cord injury.	—	No	You didn’t warn the patient about risks of delaying treatment. Include this to emphasize urgency.
Management	Seek assistance from seniors	07:37	Partial	You said “we’ll assist you” but did not explicitly state that you'd seek senior advice. Next time, make it clear when you're escalating.
Management	Arrange urgent neurology referral if there is any motor weakness, progression of symptoms, or lack of improvement after initiating treatment.	—	No	You didn’t mention neurology referral at all. This is essential in such cases.
Management	Physiotherapy to help with balance and walking.	—	No	This was not discussed. Physiotherapy could have been included as part of the plan.
Management	Ongoing B12 supplements if a deficiency is confirmed.	—	No	No mention of long-term supplementation. Add this for completeness.
Management	Dietary advice to ensure adequate B12 intake in the future.	—	No	Missed opportunity to give preventive advice regarding diet.
Management	Offer safety netting: Advise the patient to report any worsening symptoms or increased unsteadiness.	—	No	This was not covered. Always give safety netting to avoid medico-legal issues.
Management	Provide follow-up: Schedule follow-up appointments to monitor progress and adjust treatment as needed.	—	No	No mention of follow-up. It’s a key part of good patient care.
Management	Provide educational leaflets on sensory ataxia and vitamin B12 deficiency.	—	No	You didn’t offer any leaflets. Even if not physically available, mention it to show your intent to educate.
Interpersonal Skills	Use sensitive and empathetic language throughout the consultation.	05:16–05:29	Yes	You were warm and empathetic. You responded to the patient’s distress well and provided emotional support.
Interpersonal Skills	Signpost during the consultation to keep the patient informed about the process.	06:09	Partial	You briefly mentioned what you would examine, but did not signpost transitions between history and other sections (like lifestyle or medical history). Signposting helps keep the patient oriented.
Interpersonal Skills	Ensure clear and simple explanations, avoiding medical jargon.	06:30–07:17	Partial	You sometimes used phrases like “inhibit synthesis of vitamin,” which could be unclear. Consider breaking it down even more, e.g., “this gas can damage your nerves by lowering a vitamin that keeps them healthy.”
Interpersonal Skills	Address the patient's concerns and expectations, providing reassurance and support.	05:36–06:01	Yes	You asked about concerns and expectations and reassured the patient, which was well done.
Interpersonal Skills	Explain the potential for full recovery, but also warn about the risk of permanent damage if left untreated.	—	No	You didn’t warn about possible long-term complications or explain prognosis. This is important for shared decision-making.

Feedback Statement Checklist

	Feedback Statements:	Needs Improvement
Consultation	Disorganised / unstructured consultation	✔️
Diagnosis	Does not make the correct working diagnosis or identify appropriate range of differential possibilities	✔️
Examination	Does not make the correct working diagnosis or identify appropriate range of differential possibilities	✔️
Findings
Issues
Management	Does not develop a management plan reflecting current best practice	✔️
Rapport
Listening
Language	Does not use language or explanations that are relevant and understandable to the patient	✔️
Time	Shows poor time management	✔️

Additional Remarks:

Data Gathering:

You followed a logical structure and asked many relevant questions. However, to improve further, ensure you complete all components of SOCRATES, include “electric shock” sensations when assessing neuro symptoms, and don’t forget to ask about exercise. When describing investigations or examinations, be more specific—mention tests like folate, TFTs, and neurological assessment explicitly to show clarity in your plan.

Management:

You explained the connection between nitrous oxide and B12 deficiency well, which is important. However, the rest of the management plan was lacking key elements like naming the condition, urgent referrals, specific treatment (e.g., hydroxocobalamin), and follow-up. Try to organize your plan under headings (diagnosis, treatment, referral, follow-up) to ensure nothing is missed. Use simple but complete language and avoid assuming patients will know the next steps.

Interpersonal Skills:

You showed compassion and addressed the patient’s concerns well. However, be more structured with signposting and ensure explanations are in lay terms throughout. Also, always explain the prognosis clearly—including both positive outcomes and risks—so the patient can fully understand what’s at stake.