History Taking · Intermediate · Neurology

Episodes of Neurological Symptoms

Practise this PLAB 2 history taking station on Multiple Sclerosis. 8-minute voice AI simulation with feedback on all 3 marking domains.

Clinical scenario

You are an FY2 doctor in GP surgery. Miss Emma Thompson, a 28-year-old woman, presents with a three-week history of blurred vision in her left eye and recent pins and needles in her feet. She describes previous episodes of numbness that resolved spontaneously. Please take a detailed history to investigate possible demyelinating disease and discuss initial management.

Background notes: PMH: Anxiety disorder (well-controlled)

What this station tests

  • Establishing dissemination in time: actively asking about previous neurological episodes that the patient dismissed as minor (leg numbness, hand tingling)
  • Recognising optic neuritis: painful unilateral visual loss with pain on eye movement as a classic MS presenting feature
  • Establishing dissemination in space: different anatomical locations (optic nerve, spinal cord, peripheral nerves) affected at different times
  • Communicating a suspected serious neurological diagnosis with honesty but without premature certainty: naming MS as a possibility without diagnosing it
  • Excluding MS mimics: requesting B12, folate, syphilis serology, HIV, and coeliac screen alongside MRI

How to use your 8 minutes

  • 0-1 min — Introduction: Introduce yourself, confirm identity, open question. 'What's brought you in today?'
  • 1-4 min — Systematic History: Presenting complaint detail (SOCRATES for pain, timeline, severity). Systems review. PMH, medications, allergies.
  • 4-6 min — Context and ICE: Social history (smoking, alcohol, occupation, living situation). Family history. Ideas, Concerns, Expectations.
  • 6-7 min — Summary and Plan: Summarise findings back to patient. Share differential/working diagnosis. Outline investigation and management plan.
  • 7-8 min — Closing: Safety netting with specific red flags. Arrange follow-up. Check for questions.

Consultation approach

The opening

Suspected MS requires the candidate to demonstrate the concept of dissemination in space and time through careful history. The presenting symptoms alone are not enough: the candidate must actively ask about previous neurological episodes that the patient may have dismissed or never reported. Miss Thompson is 28, presenting with three weeks of blurred vision in her left eye and one week of pins and needles in both feet. She mentions previous episodes of numbness that resolved. Open with: 'Tell me about the vision problem and the tingling, and when these started.' But your real target is the previous episodes.

Core approach

Characterise the current symptoms. Left eye vision blurred for 3 weeks, gradually worsening, affecting her whole visual field. Crucially, she has pain behind the left eye on eye movement. This combination, painul unilateral visual loss with pain on eye movement, is optic neuritis. Her optician has already suggested 'possible inflammation of the optic nerve.' Right eye is normal. Bilateral pins and needles in both feet for one week: electric tingling, 'fizzing' sensation, slightly unsteady when walking.

Now establish dissemination in time. This is where candidates score or fail. Ask about previous neurological episodes. Six months ago: right leg numbness (thigh and shin) lasting 3 weeks, then complete resolution. She did not seek medical attention and attributed it to sleeping wrong. Two months ago: tingling in left hand and forearm lasting 2 weeks, then resolution. She put it down to a trapped nerve.

These three separate episodes (leg numbness, hand tingling, and now optic neuritis plus foot paraesthesia) involving different anatomical areas (optic nerve, spinal cord, peripheral) at different times demonstrate dissemination in space and time, meeting McDonald criteria for MS.

Ask about other MS features: fatigue (the commonest MS symptom, present and severe), bladder symptoms (urgency starting recently), heat sensitivity (worse in hot bath, suggesting Uhthoff's phenomenon), and cognitive changes. Screen for mood: she has anxiety disorder, which is well-controlled, but the emerging symptoms are amplifying her health anxiety. Her colleague was recently diagnosed with MS, which is why she is connecting the dots.

Closing and safety netting

Communicating a suspected MS diagnosis requires honesty without premature certainty. 'Emma, the combination of your eye symptoms, the tingling in your feet, and importantly the previous episodes of numbness that came and went, suggests we need to investigate for a condition that affects the nervous system. The pattern of symptoms appearing in different parts of the body at different times is something we take seriously.'

Do not diagnose MS in this consultation. She needs urgent neurology referral, MRI brain and spinal cord, blood tests to exclude mimics (B12, folate, syphilis, HIV, coeliac), and potentially lumbar puncture. Name the concern if she asks: 'One possibility is multiple sclerosis, and the MRI will help us determine that. But there are other conditions that can cause similar symptoms, which is why we need the blood tests too.'

Acknowledge her anxiety. She is already thinking MS because of her colleague. Respond honestly: 'I understand this is frightening, especially given your colleague's diagnosis. If it is MS, there are now very effective treatments that can significantly reduce relapses and slow progression. The most important thing is getting the right diagnosis.' Safety net: urgent neurology referral, return if vision worsens significantly or new weakness develops.

How examiners mark this station

Examiners will focus on the thoroughness and structure of your history taking for multiple sclerosis. Domain 1 (Data Gathering) carries the most weight: expect marks for systematic coverage of presenting complaint, red flags, PMH, medications, social and family history. Domain 2 (Clinical Management) requires a clear differential, appropriate investigations, and a safe management plan with safety netting. Domain 3 (Interpersonal Skills) is assessed throughout: genuine exploration of ICE, active listening, empathic responses, and clear communication without jargon.

Domain 1: Data Gathering, Technical and Assessment Skills (Primary focus)

Scores well: Optic neuritis identified (painful unilateral visual loss with pain on eye movement). Previous episodes actively elicited (leg numbness, hand tingling). Dissemination in space and time established. Other MS features screened: fatigue, bladder, heat sensitivity. Mimics considered (B12, coeliac).

Costs marks: Not asking about previous episodes. Not identifying optic neuritis. Not establishing the dissemination pattern. Not screening for other MS features.

Domain 2: Clinical Management Skills (Secondary focus)

Scores well: Urgent neurology referral. MRI brain and spine requested. Blood tests for MS mimics (B12, folate, syphilis, HIV, coeliac). Appropriate safety netting for vision deterioration or new weakness. Not diagnosing MS prematurely before investigations.

Costs marks: Not referring urgently. Not requesting MRI. Not ordering mimic-exclusion bloods. Either diagnosing MS definitively or being evasive about the concern.

Domain 3: Interpersonal Skills (Primary focus)

Scores well: Acknowledging her anxiety (amplified by colleague's MS diagnosis). Honest without premature certainty. Providing hope about modern MS treatments. Distinguishing her anxiety disorder from her legitimate clinical concern. Creating space for her to ask questions.

Costs marks: Dismissing her symptoms as anxiety. Being evasive when she asks directly about MS. Not acknowledging her colleague's diagnosis as a source of fear. Being either falsely reassuring or unduly alarming.

Common examiner feedback (and how to fix it)

Did not gather sufficient information to make an adequate assessment of the patient's condition

Fix: Use a consistent framework for every history. After covering the presenting complaint, systematically move through PMH, drug history, social history, family history, and ICE. Keep a mental checklist.

Did not identify the patient's problems and/or did not develop a management plan adequately

Fix: Reserve the final 2 minutes to summarise your findings, share your working diagnosis with the patient, and outline your investigation and management plan including safety netting.

Common mistakes in this station

  1. Not asking about previous episodes. The current symptoms alone (optic neuritis plus foot paraesthesia) suggest a single event. The previous episodes (leg numbness 6 months ago, hand tingling 2 months ago) establish dissemination in time and transform the clinical picture. Candidates who do not ask 'have you had anything like this before?' miss the most important history.
  2. Not asking about pain on eye movement. Painless visual loss has a different differential (compressive lesion, retinal pathology). Painful visual loss with pain on eye movement is optic neuritis, which is the presenting feature of MS in 15 to 20% of cases.
  3. Being either too vague or too definitive about the diagnosis. Saying 'we just need some tests' without explaining the concern is evasive. Saying 'you have MS' before investigations is premature. The correct balance is: 'One possibility is MS, and the tests will help us determine that.'

Resitting PLAB 2?

If you have previously struggled with history taking stations, focus on building a consistent systematic framework that you apply to every case. Practise structuring your history into clear phases (presenting complaint, systems review, PMH, social, ICE) so that even under pressure, you cover all domains. Many resitters lose marks not on knowledge but on organisation and time management.

Example opening

Good morning/afternoon, my name is Dr [Name], I'm one of the doctors here today. Could I confirm your name and date of birth please? Thank you. So, what's brought you in to see me today?

Frequently asked questions

What is the best way to take a multiple sclerosis history in PLAB 2?

Suspected MS requires the candidate to demonstrate the concept of dissemination in space and time through careful history. The presenting symptoms alone are not enough: the candidate must actively ask about previous neurological episodes that the patient may have dismissed or never reported. Miss Thompson is 28, presenting with three weeks of blurred vision in her left eye and one week of pins and needles in both feet.

Where are marks won and lost in this multiple sclerosis station?

Examiners reward: Optic neuritis identified (painful unilateral visual loss with pain on eye movement). Previous episodes actively elicited (leg numbness, hand tingling). Candidates are penalised for: Not asking about previous episodes. Not identifying optic neuritis. Not establishing the dissemination pattern. Not screening for other MS features.

Where do candidates most often go wrong in this station?

Not asking about previous episodes. The current symptoms alone (optic neuritis plus foot paraesthesia) suggest a single event. The previous episodes (leg numbness 6 months ago, hand tingling 2 months ago) establish dissemination in time and transform the clinical picture.

Can I do well in this station without real-world experience of multiple sclerosis?

This station rewards process over personal experience. The skill being assessed: Recognising optic neuritis: painful unilateral visual loss with pain on eye movement as a classic MS presenting feature. Work through the consultation approach above, then rehearse it aloud under the 8-minute time pressure so the structure holds up in the exam.

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