History Taking · Intermediate · Gastroenterology

Chronic Abdominal Pain with Bowel Symptoms

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

Clinical scenario

You are an FY2 doctor in primary care. Mr Walter Tucker, a 34-year-old man, has come to see you with a long history of abdominal pain, bloating, and changes in bowel habit. He has undergone multiple investigations which have been inconclusive. Please take a focused history and discuss a management approach based on NICE guidelines for IBS.

Background notes: PMH: Anxiety disorder

What this station tests

  • Making a positive IBS diagnosis using Rome IV criteria: not a diagnosis of exclusion but a pattern-based positive diagnosis
  • Framing normal investigations as confirmatory rather than dismissive: 'we have found that your bowel functions in a particular way' rather than 'we can't find anything wrong'
  • Explaining the gut-brain axis without invalidating physical symptoms: stress worsens symptoms through a real physiological mechanism, not imagination
  • Providing a concrete management plan: dietary (low FODMAP), pharmacological (antispasmodics, amitriptyline), and psychological (CBT, hypnotherapy) as NICE-recommended options
  • Addressing patient frustration with previous medical experiences: validating his experience while providing a new, clear framework

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

IBS stations test whether the candidate can make a positive diagnosis using Rome IV criteria rather than treating IBS as a diagnosis of exclusion. The challenge is providing confident reassurance to a frustrated patient who has had multiple investigations and still feels unheard. Mr Tucker is 34, presenting with years of abdominal pain, bloating, and variable bowel habit. Multiple investigations (colonoscopy, CT, faecal calprotectin, coeliac screen) have all been normal. Open with: 'Mr Tucker, I can see you've had a lot of tests. Tell me how these symptoms are affecting your life right now.'

Core approach

Confirm the IBS pattern using Rome IV criteria. Recurrent abdominal pain at least 1 day per week for at least 3 months, associated with defecation (pain improves after bowel movement), change in stool frequency (varies from twice daily to every other day), and change in stool form (alternating hard and loose). Pain is crampy, diffuse, worse with stress and certain foods (spicy, fatty, coffee). Bloating is significant, worse in evenings, better after passing wind. No nocturnal symptoms (this is important: nocturnal diarrhoea suggests organic disease). No weight loss. No blood. No fever.

The normal investigations are actually the diagnosis. Colonoscopy, CT, faecal calprotectin, and coeliac screen are all normal. This excludes IBD, cancer, and coeliac disease. Combined with positive Rome IV criteria, this is IBS. Frame it as a positive diagnosis: 'IBS is a real, recognised condition. It is not that we cannot find anything: we have found that your bowel is functioning in a particular way.'

Explore the gut-brain axis. He has anxiety disorder (8 years). IBS and anxiety are strongly linked through the gut-brain connection. Stress demonstrably worsens his symptoms. This is not 'all in his head,' but his nervous system is amplifying normal gut signals. Frame this connection without invalidating his physical symptoms.

He is frustrated with previous doctors who he feels have dismissed him. Acknowledge this: 'I understand you feel you haven't been given a clear answer. I want to change that today.'

Closing and safety netting

Provide a concrete management plan rather than dismissing with 'it's just IBS.' Dietary: consider a trial of the low FODMAP diet (ideally with dietitian support), reduce caffeine, regular meals, adequate fibre (soluble fibre like ispaghula husk, not insoluble like bran which can worsen symptoms). Pharmacological: antispasmodics (mebeverine or hyoscine butylbromide) for pain, loperamide for diarrhoea-predominant episodes, osmotic laxatives for constipation-predominant episodes. If first-line fails: low-dose amitriptyline (10 to 30mg at night) has good evidence for IBS pain through central modulation.

Address the gut-brain axis: CBT and gut-directed hypnotherapy have NICE-recommended evidence for IBS. Managing his anxiety disorder may improve his gut symptoms. This is not dismissing his symptoms as psychological: it is treating a real physiological pathway.

Safety net: 'If you develop blood in your stool, unintentional weight loss, night-time symptoms that wake you, or if your symptoms change significantly from this pattern, come back as that would need re-evaluation.' Arrange dietitian referral and follow-up in 6 weeks.

How examiners mark this station

Examiners will focus on the thoroughness and structure of your history taking for irritable bowel syndrome. 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: Rome IV criteria confirmed. Negative red flags documented (no blood, no weight loss, no nocturnal symptoms). Normal investigation results incorporated into diagnosis. Gut-brain connection explored. Dietary triggers identified. Anxiety disorder relationship assessed.

Costs marks: Not using Rome IV criteria. Not checking for red flags. Not acknowledging the normal investigation results. Not exploring the anxiety connection.

Domain 2: Clinical Management Skills (Primary focus)

Scores well: Stepped management plan: dietary (low FODMAP, fibre guidance), pharmacological (antispasmodics first-line, amitriptyline second-line), psychological (CBT, hypnotherapy as NICE-recommended). Dietitian referral. Clear safety netting for red flag development. Follow-up plan.

Costs marks: No management plan. Vague dietary advice. Not knowing pharmacological options. Not mentioning CBT or hypnotherapy. No safety netting.

Domain 3: Interpersonal Skills (Primary focus)

Scores well: Validating his frustration with previous doctors. Positive framing of the diagnosis. Explaining the gut-brain axis without invalidation. Providing hope through a concrete plan. Empowering him with dietary tools.

Costs marks: Dismissing with 'it's just IBS.' Suggesting symptoms are psychological. Not acknowledging his frustration. No concrete plan.

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. Presenting IBS as a diagnosis of exclusion. Saying 'all your tests are normal so it must be IBS' is dismissive. IBS should be diagnosed positively using Rome IV criteria, with investigations confirming the absence of organic disease. The framing matters enormously for the patient's acceptance of the diagnosis.
  2. Suggesting the symptoms are psychological. The gut-brain axis is a physiological pathway, not a dismissal. Candidates who say 'it might be related to your anxiety' without explaining the mechanism risk the patient feeling invalidated and disengaged.
  3. Not providing a concrete management plan. 'Try to manage your stress and eat better' is not a management plan. Specific dietary advice (low FODMAP), named medications (mebeverine, amitriptyline), and NICE-recommended therapies (CBT, hypnotherapy) demonstrate competence.

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 an irritable bowel syndrome history in PLAB 2?

IBS stations test whether the candidate can make a positive diagnosis using Rome IV criteria rather than treating IBS as a diagnosis of exclusion. The challenge is providing confident reassurance to a frustrated patient who has had multiple investigations and still feels unheard. Mr Tucker is 34, presenting with years of abdominal pain, bloating, and variable bowel habit.

Where are marks won and lost in this irritable bowel syndrome station?

Examiners reward: Rome IV criteria confirmed. Negative red flags documented (no blood, no weight loss, no nocturnal symptoms). Normal investigation results incorporated into diagnosis. Candidates are penalised for: Not using Rome IV criteria. Not checking for red flags. Not acknowledging the normal investigation results. Not exploring the anxiety connection.

Where do candidates most often go wrong in this station?

Presenting IBS as a diagnosis of exclusion. Saying 'all your tests are normal so it must be IBS' is dismissive. IBS should be diagnosed positively using Rome IV criteria, with investigations confirming the absence of organic disease.

Can I do well in this station without real-world experience of irritable bowel syndrome?

Structure beats experience here. Focus on framing normal investigations as confirmatory rather than dismissive: 'we have found that your bowel functions in a particular way' rather than 'we can't find anything wrong'. Use the domain breakdown on this page to target your preparation, then practise the station aloud so your structure survives exam pressure.

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