PLAB MLA CPSA — Teaching Resources

Phase 1 — Read & Prioritise: The brief says "assess risk" — this means the examiner expects you to ask directly about suicidal ideation, intent, and plan. This is not optional. Candidates who avoid direct questioning about suicide will score poorly regardless of how good the rest of the consultation is.

Phase 2 — Rapport & Exploration: Start with open questions about how things have been. Allow the patient to tell their story. Explore the timeline: "When did things start to feel this way?" Screen for core depressive symptoms: low mood, anhedonia, sleep disturbance, appetite change, concentration, fatigue, guilt, hopelessness. PHQ-9 criteria structure this efficiently.

Phase 3 — Risk Assessment: Transition directly: "Sometimes when people feel this low, they have thoughts about not wanting to be here. Have you had any thoughts like that?" If yes: "Have you thought about how you might do that?" (assesses plan). "Have you done anything to prepare?" (assesses intent). "Do you have access to means?" Assess protective factors: social support, dependents, engagement with services. This direct questioning is what the examiner is looking for — and what most candidates avoid.

Phase 4 — Plan & Safety-Net: If low to moderate risk: agree a safety plan, offer GP follow-up within one week, consider IAPT self-referral or NHS Talking Therapies, discuss antidepressant options if PHQ-9 suggests moderate-severe depression. If high risk: same-day crisis team referral. Safety-net concretely: "If you feel unable to keep yourself safe at any point, go to A&E or call 999." Do not leave the consultation without an explicit follow-up plan and safety-net.

Common errors that lose marks: Avoiding direct suicide questioning. Using euphemisms instead of clear language. Not assessing protective factors. Not documenting a clear risk level. Not arranging specific follow-up with a named timeframe.

Phase 1 — Read & Prioritise: Telephone station + headache = the examiner is testing your ability to exclude life-threatening causes (SAH, meningitis, space-occupying lesion) without the benefit of physical examination. Your history must be systematic enough to risk-stratify remotely. The migraine history is there to tempt you into premature reassurance.

Phase 2 — Structured History: SOCRATES for headache characterisation. Then the critical discriminators: "Was this the worst headache of your life?" (SAH). "Did it come on suddenly — like a thunderclap?" (SAH). "Do you have neck stiffness, photophobia, or a rash?" (meningitis). "Any weakness, visual changes, or confusion?" (stroke/SOL). "Any fever?" (infection). "Any recent head injury?" Only after red flags are excluded can you explore the migraine pattern.

Phase 3 — Remote Clinical Reasoning: If red flags present: 999 ambulance. If red flags absent and pattern matches known migraine: advise acute management (triptan if prescribed, simple analgesia, dark room, hydration). The examiner rewards the demonstration that you have systematically excluded danger before managing the likely diagnosis.

Phase 4 — Safety-Net (Critical in Telephone Stations): "If the headache becomes the worst you've ever had, or you develop neck stiffness, a rash, confusion, weakness, or visual changes — call 999 immediately." Arrange follow-up: "If this hasn't settled in 48 hours, call back for a face-to-face appointment." Telephone stations demand more explicit safety-netting than face-to-face stations because you cannot examine the patient.

Common errors that lose marks: Diagnosing migraine without excluding red flags. Failing to adapt communication for telephone (no visual cues — must be more explicit). Over-reassuring based on the migraine history without systematic screening. Weak safety-net without specific return criteria.