History Taking · Foundation · Gastroenterology

Liver Disease from Alcohol Misuse

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

Clinical scenario

You are an FY2 doctor in an acute medical assessment unit. Mrs Meera Mirza, a 55-year-old woman, has been brought in via ambulance with jaundice, abdominal pain, and vomiting. She has hepatomegaly and signs of liver disease. She has a long history of heavy alcohol use which she has been minimising. Please take a focused history about her alcohol use, examine her for signs of cirrhosis, discuss her diagnosis, and counsel on treatment and alcohol cessation.

Background notes: PMH: Nil significant

What this station tests

  • Taking an accurate alcohol history from a patient who minimises: graduated questioning, non-judgmental approach, recognising withdrawal symptoms indicating dependence
  • Recognising acute-on-chronic liver disease: signs of cirrhosis (spider naevi, ascites, palmar erythema) with acute decompensation (jaundice, vomiting, fever)
  • Screening for liver disease complications: ascites, spontaneous bacterial peritonitis, variceal bleeding, hepatic encephalopathy
  • Alcohol withdrawal management: Pabrinex and chlordiazepoxide when physical dependence is identified
  • Addressing shame and stigma: framing alcohol dependence as a medical condition while offering support services

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

Alcohol-related liver disease stations test the candidate's ability to take an accurate alcohol history from a patient who is likely to minimise, while remaining non-judgmental and clinically thorough. Mrs Mirza is 55, brought by ambulance with jaundice, abdominal pain, and vomiting. She has hepatomegaly and signs of chronic liver disease. She has been minimising her alcohol intake. Open with: 'Mrs Mirza, I can see you are in pain and feeling very unwell. I need to ask you some questions to help us work out what is happening and get you the right treatment.' Establish trust before probing the alcohol history.

Core approach

Assess the acute presentation. She has been unwell for 2 to 3 weeks with increasing abdominal distension, poor appetite, dark urine, pale stools, and pruritus (suggesting cholestasis). Vomiting this morning prompted the ambulance call. She has severe right upper quadrant pain. Signs of chronic liver disease (spider naevi, palmar erythema, ascites) suggest established cirrhosis with acute decompensation.

Take the alcohol history carefully. She will initially minimise: 'a glass of wine most nights.' When pressed gently: 'maybe a bottle of wine a day, sometimes more.' The actual consumption is likely 40 to 50 units weekly for 15+ years, starting after her divorce. Ask about withdrawal symptoms: morning shakes, anxiety if she does not drink early, sweating. These indicate physical dependence and have immediate management implications (she will need alcohol withdrawal monitoring and possible Pabrinex/chlordiazepoxide).

Do not lecture about alcohol at this point. She is acutely unwell, frightened, and already knows alcohol is the cause. She will move through denial to admission: 'My liver's probably gone, isn't it?' Acknowledge this honestly but without removing hope.

Screen for complications: ascites (abdominal distension), spontaneous bacterial peritonitis (fever plus ascites), variceal bleeding (haematemesis or melaena, none so far), hepatic encephalopathy (confusion, asterixis). PMH: nothing significant otherwise. She lives alone, divorced, children live away. She is socially isolated.

Closing and safety netting

Outline the immediate management. She needs admission, IV access, bloods (LFTs, bilirubin, albumin, PT/INR, FBC, U&E, glucose), blood cultures, and imaging (USS abdomen). Her Maddrey score will determine whether she needs prednisolone for severe alcoholic hepatitis. Alcohol withdrawal protocol: Pabrinex (IV thiamine) and chlordiazepoxide reducing regimen if she has withdrawal symptoms.

Be honest about the diagnosis: 'Mrs Mirza, the jaundice and the swelling in your abdomen are caused by damage to your liver from alcohol. The good news is that the liver has remarkable ability to recover if you can stop drinking, but that requires support and treatment.' Offer alcohol services: addiction specialist, counsellor, support groups. She will be frightened about rehabilitation but also secretly hoping someone will help her stop.

She does not want her family told yet. Respect this but explore: 'Is there anyone you would like us to contact?' Safety net: she is being admitted, so monitoring is built into the pathway. Address her shame: 'Alcohol dependence is a medical condition, not a moral failing. You deserve help with this.'

How examiners mark this station

Examiners will focus on the thoroughness and structure of your history taking for alcoholic hepatitis. 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: Accurate alcohol history through graduated questioning. Withdrawal symptom assessment. Complication screening (ascites, SBP, varices, encephalopathy). Signs of chronic liver disease identified. Social history (isolated, divorced, children away).

Costs marks: Accepting minimised alcohol history. Not assessing withdrawal risk. Not screening for complications. Missing signs of chronicity.

Domain 2: Clinical Management Skills (Primary focus)

Scores well: Admission with appropriate investigations (LFTs, INR, albumin, USS). Maddrey score concept for severe alcoholic hepatitis. Pabrinex and chlordiazepoxide for withdrawal. Alcohol services referral. Accurate prognostic information (liver recovery possible with abstinence).

Costs marks: Not admitting. Incomplete investigations. Not considering withdrawal management. Not mentioning alcohol services. Overly pessimistic prognosis without mentioning recovery potential.

Domain 3: Interpersonal Skills (Primary focus)

Scores well: Non-judgmental approach throughout. Framing alcohol dependence as a medical condition. Respecting her wish not to tell family yet. Acknowledging her shame. Providing hope about liver recovery. Building trust before probing sensitive history.

Costs marks: Being judgmental about drinking. Lecturing during acute illness. Ignoring her shame. Contacting family without permission. Removing hope entirely.

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. Accepting the initial alcohol history at face value. She will say 'a glass of wine most nights.' Her actual consumption is a bottle daily plus spirits. Candidates who do not probe further with gentle, non-judgmental follow-up questions miss the true intake and underestimate her withdrawal risk.
  2. Lecturing about alcohol while the patient is acutely unwell. Mrs Mirza is jaundiced, in pain, and frightened. Now is not the time for a motivational interview about drinking. The priority is acute management and establishing trust. Behaviour change counselling comes later.
  3. Not assessing for alcohol withdrawal risk. If she has physical dependence (morning shakes, anxiety without alcohol), she is at risk of withdrawal seizures and delirium tremens during admission. Candidates who do not ask about withdrawal symptoms miss a patient safety issue.

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 alcoholic hepatitis history in PLAB 2?

Alcohol-related liver disease stations test the candidate's ability to take an accurate alcohol history from a patient who is likely to minimise, while remaining non-judgmental and clinically thorough. Mrs Mirza is 55, brought by ambulance with jaundice, abdominal pain, and vomiting. She has hepatomegaly and signs of chronic liver disease.

Where are marks won and lost in this alcoholic hepatitis station?

Examiners reward: Accurate alcohol history through graduated questioning. Withdrawal symptom assessment. Complication screening (ascites, SBP, varices, encephalopathy). Signs of chronic liver disease identified. Candidates are penalised for: Accepting minimised alcohol history. Not assessing withdrawal risk. Not screening for complications. Missing signs of chronicity.

Where do candidates most often go wrong in this station?

Accepting the initial alcohol history at face value. She will say 'a glass of wine most nights.' Her actual consumption is a bottle daily plus spirits. Candidates who do not probe further with gentle, non-judgmental follow-up questions miss the true intake and underestimate her withdrawal risk.

Can I do well in this station without real-world experience of alcoholic hepatitis?

This station rewards process over personal experience. The skill being assessed: Recognising acute-on-chronic liver disease: signs of cirrhosis (spider naevi, ascites, palmar erythema) with acute decompensation (jaundice, vomiting, fever). 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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