History Taking · Intermediate · Gastroenterology

Difficulty Swallowing with Progressive Course

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

Clinical scenario

You are an FY2 doctor in the acute medical unit. Mr Henry Booth, a 62-year-old man, has presented with progressive difficulty swallowing over the past 4 weeks. He describes specific difficulty with solid food but not liquids. Please take a focused history to determine if this is mechanical obstruction or motility disorder, assess alarm features, and discuss urgent referral for investigation.

Background notes: PMH: Diabetes, Hypertension, GORD, Smoking history (ex-smoker 5 yrs, 40 pack-years)

What this station tests

  • Distinguishing mechanical from motility dysphagia: solids worse than liquids (mechanical) versus solids and liquids equally affected (motility)
  • Identifying NICE NG12 red flags for urgent upper GI referral: progressive dysphagia, weight loss, age over 50, smoking history
  • Recognising GORD as a risk factor for Barrett's oesophagus and oesophageal adenocarcinoma
  • Communicating an urgent cancer referral without premature diagnosis: explaining the 2-week-wait pathway honestly
  • Practical dietary advice while awaiting investigation: soft foods, small mouthfuls, upright positioning

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

Progressive dysphagia for solids but not liquids is mechanical obstruction until proven otherwise. The candidate must identify alarm features that mandate urgent endoscopy and 2-week-wait referral. Mr Booth is 62, presenting with 4 weeks of progressive difficulty swallowing solids. He has GORD, diabetes, hypertension, and a 40 pack-year smoking history. Open with: 'Mr Booth, tell me about the swallowing difficulty. What exactly happens when you try to eat?' The word 'exactly' pushes beyond vague descriptions.

Core approach

Characterise the dysphagia systematically. Solids are stuck ('catches in lower chest'), requiring water to push food down. Liquids pass more easily. Bread and meat are worst. Sometimes food comes back up. This pattern, progressive solids worse than liquids, localised to the lower chest, worsening over weeks, strongly suggests mechanical obstruction rather than motility disorder (which would affect solids and liquids equally from the outset).

Screen for red flags. Weight loss: 'My clothes are looser.' This is significant and he may not quantify it unless asked directly. Chest pain on swallowing (odynophagia): present. Regurgitation: yes. Duration over 4 weeks with progression: yes. Age over 50: yes. Smoking: 40 pack-years (ex-smoker 5 years). GORD history (Barrett's oesophagus risk). These collectively meet criteria for urgent 2-week-wait referral for suspected upper GI malignancy per NICE NG12.

Differential diagnosis through the history. Oesophageal cancer is the primary concern given age, smoking, GORD, and progressive mechanical dysphagia with weight loss. Benign stricture (from chronic reflux) is possible but cannot be distinguished from malignancy without endoscopy. Oesophageal web or ring: usually intermittent, not progressive. Achalasia: would affect liquids and solids equally. External compression: unlikely without other symptoms.

ICE: He initially thought it was his dentures. He has not connected his symptoms to anything serious. He may be avoiding the possibility of cancer.

Closing and safety netting

Communicate the need for urgent investigation without premature diagnosis. 'Mr Booth, progressive difficulty swallowing that is getting worse over weeks, combined with the weight loss, your smoking history, and your reflux, means we need to arrange an urgent endoscopy to look inside your food pipe. I am referring you on an urgent pathway, which means you should be seen within two weeks.' If he asks whether it is cancer, be honest: 'That is one of the things we need to rule out. The endoscopy will give us the answer.'

Immediate actions: bloods (FBC for anaemia, LFTs, albumin for nutritional status), urgent OGD referral. Dietary advice while waiting: soft, moist foods, eat slowly, small mouthfuls, sit upright during and after meals. Safety net: 'If you cannot swallow liquids, vomit blood, or feel significantly worse, go to A&E immediately.' Arrange follow-up after endoscopy results.

How examiners mark this station

Examiners will focus on the thoroughness and structure of your history taking for oesophageal obstruction. 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: Dysphagia characterised (solids vs liquids, location, progression). Red flags identified (weight loss, duration, age, smoking, GORD). Differential considered through history. Complete PMH and medication review.

Costs marks: Not distinguishing solid from liquid dysphagia. Not quantifying weight loss. Not recognising alarm features. Incomplete history.

Domain 2: Clinical Management Skills (Primary focus)

Scores well: 2-week-wait urgent referral arranged. Appropriate investigations (FBC, LFTs, albumin). Practical dietary advice. Clear safety netting for complete dysphagia or haematemesis.

Costs marks: Not arranging urgent referral. Treating empirically with PPI. No dietary advice. No safety netting.

Domain 3: Interpersonal Skills (Throughout)

Scores well: Honest communication about the need for urgent investigation. Responding to his cancer question directly. Acknowledging that this is worrying. Providing practical support while waiting.

Costs marks: Being evasive about why the referral is urgent. Not addressing his unspoken cancer concern. Being alarmist without providing support.

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 quantifying weight loss. He says 'my clothes are looser' but may not volunteer a number. Candidates who do not ask 'how much weight do you think you have lost?' miss the most important alarm feature for malignancy.
  2. Attributing the dysphagia to GORD without considering malignancy. He has longstanding reflux, and candidates may assume the swallowing difficulty is reflux-related. Progressive mechanical dysphagia with weight loss in a 62-year-old smoker requires cancer exclusion regardless of GORD history.
  3. Not explaining the 2-week-wait pathway. Saying 'we will refer you for a camera test' without explaining the urgency or timeline leaves the patient uncertain about how seriously you are taking his symptoms.

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

How should I structure the oesophageal obstruction history in this PLAB 2 station?

Progressive dysphagia for solids but not liquids is mechanical obstruction until proven otherwise. The candidate must identify alarm features that mandate urgent endoscopy and 2-week-wait referral. Mr Booth is 62, presenting with 4 weeks of progressive difficulty swallowing solids.

What are examiners marking in this oesophageal obstruction station?

Marks are won for: Dysphagia characterised (solids vs liquids, location, progression). Red flags identified (weight loss, duration, age, smoking, GORD). Differential considered through history. Marks are lost for: Not distinguishing solid from liquid dysphagia. Not quantifying weight loss. Not recognising alarm features. Incomplete history.

What is the most common mistake candidates make in this oesophageal obstruction station?

Not quantifying weight loss. He says 'my clothes are looser' but may not volunteer a number. Candidates who do not ask 'how much weight do you think you have lost?' miss the most important alarm feature for malignancy.

How do I prepare for this station if I have not managed oesophageal obstruction in clinical practice?

Structure beats experience here. Focus on identifying NICE NG12 red flags for urgent upper GI referral: progressive dysphagia, weight loss, age over 50, smoking history. 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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