History Taking · Foundation · Gastroenterology

Vomiting Blood

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

Clinical scenario

You are an FY2 doctor in the emergency department. Mr Darren Anderson, a 56-year-old man, has presented via ambulance after vomiting blood at home. He appears unwell and is haemodynamically unstable. This is a time-critical emergency requiring rapid assessment, resuscitation, risk stratification, and immediate specialist involvement. Please take focused history while simultaneously initiating resuscitation.

Background notes: PMH: Alcohol-related cirrhosis, Portal hypertension with known oesophageal varices, Hepatitis C (genotype 1, untreated), Peptic ulcer disease history

What this station tests

  • ABCDE resuscitation alongside history in a life-threatening emergency: two large-bore cannulae, bloods before fluids, crossmatch
  • Distinguishing variceal from non-variceal upper GI bleeding: both possible in a cirrhotic patient, management differs
  • Terlipressin for suspected variceal bleeding: specific pharmacological intervention that reduces portal pressure
  • Prophylactic antibiotics in cirrhotic upper GI haemorrhage: reduces mortality and rebleeding (commonly missed)
  • Restrictive transfusion strategy: target Hb 70-80 g/L in variceal bleeding (over-transfusion worsens portal pressure)

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

Acute upper GI haemorrhage in a patient with known varices is a life-threatening emergency. The candidate must demonstrate ABCDE resuscitation alongside rapid history taking. Mr Anderson is 56, brought by ambulance after vomiting large amounts of bright red blood. He has alcohol-related cirrhosis with known oesophageal varices. He appears unwell and is haemodynamically unstable. This is not a standard history station. Start with: 'Mr Anderson, I can see you are very unwell. I am going to start treating you immediately while I ask some urgent questions.' Act first, history second.

Core approach

Resuscitation takes priority over history. Two large-bore IV cannulae, bloods before fluids (FBC, U&E, LFTs, coagulation, crossmatch for 4 to 6 units), fluid resuscitation with crystalloid. Do not give colloid. If massive haemorrhage, activate the major haemorrhage protocol.

Take a rapid focused history alongside resuscitation. Bleeding: sudden onset, large volume bright red blood (haematemesis, not coffee-ground, suggesting active bleeding). Known varices on propranolol. Known cirrhosis for 12 years. Hepatitis C (untreated). He is still drinking 8 to 10 units daily. Current medications: propranolol (for portal hypertension), lactulose, spironolactone, vitamin K. Not on a PPI (non-compliant). Has previous peptic ulcer disease.

The differential is variceal bleed versus peptic ulcer bleed. In a patient with known varices and active cirrhosis, variceal bleeding is the most dangerous possibility. However, peptic ulcer disease is more common even in cirrhotics. The management pathway differs: variceal bleeding requires terlipressin and endoscopic band ligation; ulcer bleeding requires endoscopic intervention and PPI.

Assess severity: haemodynamic instability (tachycardia, hypotension), volume of haematemesis, signs of hepatic decompensation (encephalopathy, ascites). Calculate Rockall or Glasgow-Blatchford score for risk stratification.

Closing and safety netting

Immediate management: IV terlipressin (for suspected variceal bleed, reduces portal pressure), IV antibiotics (prophylactic, reduces mortality in cirrhotic upper GI bleeds), IV PPI (omeprazole 80mg bolus then infusion, covers peptic ulcer component), urgent endoscopy within 12 hours (ideally within 2 hours if haemodynamically unstable). Transfuse packed red cells targeting Hb 70 to 80 g/L (restrictive strategy improves outcomes in variceal bleeding). Correct coagulopathy.

He is terrified and says 'I am going to die.' Respond with calm competence: 'We are treating you right now. We are giving you medication to reduce the bleeding and we are arranging an urgent procedure to stop it.' Brief, honest, reassuring through action.

This patient needs ICU or high-dependency monitoring. Contact gastroenterology for urgent endoscopy and critical care for monitoring. Document time of onset, volume of blood loss, and resuscitation given.

How examiners mark this station

Examiners will focus on the thoroughness and structure of your history taking for upper gi haemorrhage. 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 (Secondary (resuscitation takes priority))

Scores well: Rapid focused history alongside resuscitation. Establishing variceal risk (known varices, cirrhosis, portal hypertension). Current medications checked. Bleeding volume and haemodynamic status assessed. Risk score attempted.

Costs marks: Prolonged history before treatment. Not establishing variceal history. Not assessing haemodynamic status.

Domain 2: Clinical Management Skills (Primary focus)

Scores well: ABCDE resuscitation. Two large-bore cannulae. Bloods including crossmatch. Terlipressin started. Prophylactic antibiotics. IV PPI. Restrictive transfusion target. Urgent endoscopy arranged. ICU referral.

Costs marks: Delayed resuscitation. No terlipressin. No antibiotics. Liberal transfusion strategy. No endoscopy arranged.

Domain 3: Interpersonal Skills (Adapted to emergency)

Scores well: Calm, competent manner matching the emergency. Brief reassurance through action. Responding to his fear of dying with honesty and support. Maintaining human connection during a clinical emergency.

Costs marks: Ignoring his distress. Being so clinical that the patient feels like an object. Providing false reassurance ('you will be fine') in an unstable situation.

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. Taking a full systematic history before starting resuscitation. This patient is haemodynamically unstable with active bleeding. Candidates who sit down and take a SOCRATES history before establishing IV access and starting fluid resuscitation demonstrate inappropriate prioritisation.
  2. Not giving terlipressin. In suspected variceal bleeding, terlipressin should be started immediately without waiting for endoscopic confirmation. This is a commonly tested pharmacological intervention specific to variceal haemorrhage.
  3. Not giving prophylactic antibiotics. Antibiotic prophylaxis in cirrhotic upper GI bleeding reduces mortality and rebleeding. This is evidence-based and commonly missed by candidates who focus only on the bleeding.

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 upper GI haemorrhage history in PLAB 2?

Acute upper GI haemorrhage in a patient with known varices is a life-threatening emergency. The candidate must demonstrate ABCDE resuscitation alongside rapid history taking. Mr Anderson is 56, brought by ambulance after vomiting large amounts of bright red blood.

Where are marks won and lost in this upper GI haemorrhage station?

Examiners reward: Rapid focused history alongside resuscitation. Establishing variceal risk (known varices, cirrhosis, portal hypertension). Current medications checked. Bleeding volume and haemodynamic status assessed. Candidates are penalised for: Prolonged history before treatment. Not establishing variceal history. Not assessing haemodynamic status.

Where do candidates most often go wrong in this station?

Taking a full systematic history before starting resuscitation. This patient is haemodynamically unstable with active bleeding. Candidates who sit down and take a SOCRATES history before establishing IV access and starting fluid resuscitation demonstrate inappropriate prioritisation.

Can I do well in this station without real-world experience of upper GI haemorrhage?

This station rewards process over personal experience. The skill being assessed: Distinguishing variceal from non-variceal upper GI bleeding: both possible in a cirrhotic patient, management differs. 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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