History Taking · Intermediate · Gastroenterology

Epigastric Discomfort with Acid Reflux

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

Clinical scenario

You are an FY2 doctor in primary care. Mrs Venetia Peters, a 48-year-old woman, has come to see you with a history of epigastric discomfort and reflux symptoms. She has tried over-the-counter antacids with limited effect. Please take a focused history to investigate the cause and discuss a management approach including the appropriateness of proton pump inhibitor trial and Helicobacter pylori testing.

Background notes: PMH: Hypertension, Obesity

What this station tests

  • Red flag screening in dyspepsia: dysphagia, weight loss, haematemesis, melaena, anaemia, and the age 55 threshold for endoscopy with new-onset dyspepsia
  • NICE dyspepsia pathway: test and treat for H. pylori before empirical PPI, rather than starting PPI directly
  • Identifying modifiable GORD risk factors: smoking (LOS relaxation), obesity (intra-abdominal pressure), dietary timing, and sleeping position
  • Specific lifestyle advice: head of bed elevation (blocks, not pillows), 3-hour gap before lying down, portion sizes, trigger avoidance
  • Appropriate PPI prescribing: full-dose trial for 4 to 8 weeks, then step down to lowest effective dose

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

Dyspepsia and reflux stations test whether the candidate can identify red flag features requiring urgent investigation versus straightforward GORD manageable in primary care. The age threshold matters: first onset of dyspepsia over 55 requires endoscopy. Mrs Peters is 48, with 2 to 3 years of epigastric discomfort and reflux worsening despite antacids. Open with: 'Mrs Peters, tell me about the discomfort and the reflux. What exactly happens and when is it worst?' The word 'exactly' encourages specific description over vague complaints.

Core approach

The symptoms are classic GORD. Burning epigastric discomfort worse after meals (especially fatty), worse in evenings, worse lying flat, with acid regurgitation into the throat, waterbrash (sudden salivation), belching, and heartburn. Symptoms are worse at night and disturb her sleep. Antacids (Gaviscon) provide temporary relief. She has early satiety and bloating but no vomiting, no dysphagia, no weight loss, no haematemesis, no melaena.

Screen for red flags systematically. Age: she is 48, below the 55 threshold for routine endoscopy with new dyspepsia. Dysphagia: none. Weight loss: none. Haematemesis or melaena: none. Anaemia symptoms: none. Palpable mass: examination needed. With no red flags and age under 55, she does not need urgent endoscopy. This is empirical treatment territory.

Identify contributing factors. She smokes 10/day (smoking relaxes the lower oesophageal sphincter and worsens GORD). Obesity (BMI 32, increased intra-abdominal pressure). Fatty diet, eating late, stress at work. Lying flat after eating. Her only medication is lisinopril (not an NSAID, which would be relevant). No alcohol excess.

ICE: She thinks it is reflux like her father. She wants something stronger than antacids. She is worried it might be something more serious. She wants to eat without discomfort.

Closing and safety netting

Management follows the NICE dyspepsia pathway. Step one: lifestyle modifications. Specific advice: raise the head of the bed (blocks under the headboard, not extra pillows), avoid eating within 3 hours of lying down, reduce portion sizes, avoid triggers (fatty and spicy food, caffeine, alcohol), lose weight (target 5 to 10% reduction), and stop smoking (the single most impactful modifiable factor for GORD). Step two: H. pylori testing. Test and treat with urea breath test before starting a PPI. If H. pylori positive, eradication therapy. If negative, trial of full-dose PPI (omeprazole 20mg or lansoprazole 30mg) for 4 to 8 weeks.

Explain the PPI trial: 'This medication reduces the acid your stomach produces. Most people notice significant improvement within 2 weeks. If it works, we can discuss the lowest effective dose for long-term use.' Address her concern: 'At your age and without any warning signs, this is very likely reflux and is highly treatable.'

Safety net: 'If you develop difficulty swallowing, vomiting, unexplained weight loss, blood in your vomit or dark tarry stools, come back urgently as these would require further investigation.' If symptoms persist despite 8 weeks of full-dose PPI, refer for endoscopy. Follow-up in 4 weeks.

How examiners mark this station

Examiners will focus on the thoroughness and structure of your history taking for gord. 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: Classic GORD features identified (postprandial, positional, regurgitation). Red flags systematically excluded. Contributing factors assessed: smoking, obesity, diet, timing, medication review. H. pylori testing planned. NSAID use checked.

Costs marks: Not screening for red flags. Not identifying smoking and obesity as modifiable factors. Not checking NSAID use. Not asking about dysphagia.

Domain 2: Clinical Management Skills (Primary focus)

Scores well: NICE pathway followed: H. pylori test-and-treat, then PPI trial. Specific lifestyle modifications (head of bed, 3-hour rule, smoking). Correct PPI dose and duration (4 to 8 weeks full-dose). Step-down plan. Red flag safety netting. Follow-up at 4 weeks with endoscopy if persistent.

Costs marks: Skipping H. pylori testing. Incorrect PPI prescribing. Vague lifestyle advice. No safety netting. No follow-up plan.

Domain 3: Interpersonal Skills (Throughout)

Scores well: Reassuring based on absence of red flags and age under 55. Addressing her desire for effective treatment. Empowering her with specific lifestyle changes she can start today. Explaining PPI mechanism in plain terms.

Costs marks: Not reassuring despite absence of red flags. Being dismissive ('it's just reflux'). Vague advice. Not addressing her quality of life impact.

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 testing for H. pylori before starting a PPI. The NICE pathway recommends H. pylori test-and-treat as the first step in uninvestigated dyspepsia. Candidates who prescribe a PPI without mentioning H. pylori testing miss a key management step.
  2. Referring for endoscopy when there are no red flags and the patient is under 55. Endoscopy is not indicated for typical GORD symptoms without alarm features in a patient under 55. Candidates who refer prematurely demonstrate over-investigation.
  3. Giving vague lifestyle advice. 'Avoid trigger foods and lose weight' is not specific enough. Candidates who specify raising the head of the bed (blocks under headboard), the 3-hour pre-sleep fasting rule, and smoking cessation as the most impactful single change demonstrate practical clinical knowledge.

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 do I approach the consultation in this GORD station?

Dyspepsia and reflux stations test whether the candidate can identify red flag features requiring urgent investigation versus straightforward GORD manageable in primary care. The age threshold matters: first onset of dyspepsia over 55 requires endoscopy. Mrs Peters is 48, with 2 to 3 years of epigastric discomfort and reflux worsening despite antacids.

What does a strong performance look like to the examiner in this station?

Strong performances show: Classic GORD features identified (postprandial, positional, regurgitation). Red flags systematically excluded. Contributing factors assessed: smoking, obesity, diet, timing, medication review. Weak performances: Not screening for red flags. Not identifying smoking and obesity as modifiable factors. Not checking NSAID use. Not asking about dysphagia.

What is the biggest pitfall in this GORD station?

Not testing for H. pylori before starting a PPI. The NICE pathway recommends H. pylori test-and-treat as the first step in uninvestigated dyspepsia. Candidates who prescribe a PPI without mentioning H. pylori testing miss a key management step.

How should I prepare for GORD if I have never seen it in practice?

This station rewards process over personal experience. The skill being assessed: NICE dyspepsia pathway: test and treat for H. pylori before empirical PPI, rather than starting PPI directly. 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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