PLAB 2 Clinical History-Taking & Communication 2 — Questions and Answers
Question 1: During a psychiatric history, what does 'MSE' stand for and what does it assess?
- Medical and Surgical Evaluation — assessment of physical health in psychiatric patients
- Mental State Examination — a systematic assessment of appearance, behaviour, speech, mood, affect, thought, perception, cognition, insight, and judgement (Correct answer)
- Mental Safety Enquiry — a risk assessment tool
- Medication Safety Evaluation — checking for psychiatric drug side effects
Correct answer: Mental State Examination — a systematic assessment of appearance, behaviour, speech, mood, affect, thought, perception, cognition, insight, and judgement
The MSE is the psychiatric equivalent of a physical examination. It assesses: Appearance and behaviour; Speech (rate, volume, form); Mood (subjective) and Affect (objective); Thought (form, content — including suicidal ideation); Perception (hallucinations, illusions); Cognition (orientation, memory); Insight; Judgement.
Question 2: A 55-year-old man presents with 3 weeks of low mood. Which specific questions should you ask to assess suicide risk?
- Ask about sleep and appetite only
- Directly ask about suicidal ideation ('Have you had thoughts of harming yourself or ending your life?'), and if present: frequency, intent, plans, means, and protective factors (Correct answer)
- Only use a standardised questionnaire
- Refer to psychiatry without asking about suicide — it is too distressing
Correct answer: Directly ask about suicidal ideation ('Have you had thoughts of harming yourself or ending your life?'), and if present: frequency, intent, plans, means, and protective factors
Directly asking about suicidal ideation does not increase risk — it may provide relief. A complete suicide risk assessment includes: passive ideation ('life not worth living') → active ideation → plan → means → intent → previous attempts → protective factors (family, religion, hope). Risk stratification guides management.
Question 3: Which of the following best describes a 'systematic inquiry' (systems review) in clinical history-taking?
- A review of previous medical records
- Screening questions about symptoms in body systems not already covered, to avoid missing important diagnoses (Correct answer)
- A review of all medications the patient is taking
- An assessment of the patient's social background
Correct answer: Screening questions about symptoms in body systems not already covered, to avoid missing important diagnoses
The systems review (or systematic inquiry) asks brief screening questions about common symptoms in major body systems (cardiovascular, respiratory, GI, neurological, etc.) that haven't already been covered. It serves as a safety net to catch symptoms the patient has forgotten to mention or doesn't connect with their main complaint.
Question 4: A patient presents with headache. Which 'red flag' features require urgent investigation to exclude dangerous causes?
- Bilateral location, onset with stress, and long duration
- Thunderclap onset ('worst headache of life'), associated neurological deficit, fever + photophobia + neck stiffness, waking from sleep, new onset in >50 years, or following head trauma (Correct answer)
- Frontal location, nasal congestion, and facial pain
- Gradual onset, bilateral tension-type, and fatigue
Correct answer: Thunderclap onset ('worst headache of life'), associated neurological deficit, fever + photophobia + neck stiffness, waking from sleep, new onset in >50 years, or following head trauma
Red flags for headache (SNOOP4): Systemic symptoms/signs (fever, weight loss); Neurological symptoms; Onset sudden (thunderclap); Onset after 50; Positional (worse lying down); Papilloedema; Progressive worsening; Prior headache history change. These require urgent investigation (CT, LP) to exclude SAH, meningitis, or intracranial mass.
Question 5: When taking a social history, which four key areas should always be covered?
- Employment, housing, relationships, and hobbies
- Occupation, smoking, alcohol, recreational drugs, living situation, social support, functional status, and relevant travel (Correct answer)
- Income, education, religion, and marital status
- Exercise, diet, sleep, and stress levels
Correct answer: Occupation, smoking, alcohol, recreational drugs, living situation, social support, functional status, and relevant travel
A thorough social history covers: Occupation (current and past — exposure risks, sick leave), Smoking (pack years), Alcohol (units per week — use CAGE or AUDIT if concerned), Illicit drugs, Home situation (who they live with, housing conditions), Social support, Functional status (ADLs), and recent travel (for infectious disease screening).
Question 6: A patient presents with a 6-week history of weight loss, fatigue, night sweats, and a lump in their neck. Which additional history questions are most important?
- Ask about recent stress and diet
- Ask about fever, pruritis, alcohol-induced pain in the lump, family history of malignancy, travel to TB-endemic areas, and full systematic review for malignancy symptoms (Correct answer)
- Ask about hydration and sleep quality only
- Ask about recent viral illnesses only
Correct answer: Ask about fever, pruritis, alcohol-induced pain in the lump, family history of malignancy, travel to TB-endemic areas, and full systematic review for malignancy symptoms
Constitutional B symptoms (weight loss, night sweats, fever) with a neck lump raise concern for lymphoma. Important questions: fever pattern (Pel-Ebstein in Hodgkin's), pruritus, alcohol-induced pain (Hodgkin's), occupational exposures, travel (TB), family history of malignancy, and full systems review for primary malignancy with nodal spread.
PLAB 2 Clinical History-Taking & Communication 2
During a psychiatric history, what does 'MSE' stand for and what does it assess?