History Taking · Intermediate · Haematology

Bone Pain and Fatigue in a 72-Year-Old Woman

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

Clinical scenario

You are an FY2 doctor in a GP surgery. Mrs Wendy Murphy, a 72-year-old woman, has come to see you with progressive bone pain, fatigue, and recurrent infections over the past two months. She appears pale and unwell. Please take a focused history and discuss your initial assessment.

Background notes: PMH: Hypertension, Cholecystectomy (age 45)

What this station tests

  • Connecting the CRAB features: Calcium, Renal impairment, Anaemia, and Bone disease as the myeloma constellation
  • Recognising recurrent infections as immunoparesis: abnormal plasma cells crowding out normal immune function
  • Appropriate urgent investigations: protein electrophoresis, immunoglobulins, serum free light chains alongside standard bloods
  • Screening for myeloma emergencies: spinal cord compression (leg weakness or numbness) and severe hypercalcaemia
  • Communicating the need for urgent investigation without premature diagnosis while not being evasive about the cancer concern

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

Bone pain, fatigue, and recurrent infections in an elderly patient should raise suspicion for multiple myeloma. The candidate must connect these seemingly unrelated symptoms through the underlying diagnosis. Mrs Murphy is 72, presenting with 2 months of progressive bone pain (back, hips, ribs), fatigue, and three infections in 2 months. She appears pale and unwell. Her daughter insisted she come. Open with: 'Mrs Murphy, I can see you have not been feeling yourself. Tell me about all the symptoms you have noticed.'

Core approach

The symptom triad is bone pain, anaemia (fatigue, pallor), and recurrent infections (immunoparesis). Add hypercalcaemia features if present: confusion, thirst, polyuria, constipation. Renal impairment may also be present. The mnemonic CRAB captures it: Calcium elevation, Renal impairment, Anaemia, Bone disease.

Characterise the bone pain. Dull, constant, deep bone ache (not joint pain), worst in the morning, not improved by movement (distinguishing from OA). Back, hips, and ribs. No preceding trauma. This pattern of widespread bone pain without trauma in a 72-year-old with anaemia and infections is highly suggestive of myeloma.

The recurrent infections are the second clue. Three infections in 2 months (two chest infections, one UTI) suggests immunoparesis: the abnormal plasma cells crowd out normal immune function. Ask about antibiotic courses, whether infections resolved slowly, and whether she has needed repeated treatments.

Screen for complications. Any confusion (hypercalcaemia)? Increased thirst or urination? Numbness or weakness in legs (spinal cord compression from vertebral collapse)? Foamy urine (proteinuria from renal involvement)?

ICE: She fears cancer (her husband died of prostate cancer). She hopes it is something simple. She wants to get back to her church activities.

Closing and safety netting

Arrange urgent investigations today. FBC (anaemia), U&E (renal function), corrected calcium, serum and urine protein electrophoresis (paraprotein band), immunoglobulins, serum free light chains, LDH, beta-2 microglobulin. If strongly suspicious, arrange skeletal survey or whole-body low-dose CT.

Do not diagnose myeloma in this consultation, but do not be evasive. 'Mrs Murphy, the combination of bone pain, tiredness, and frequent infections needs urgent investigation. I am arranging blood tests today that will help us understand what is causing all of these symptoms together.' If she asks about cancer, respond honestly: 'That is something we need to check for.' Refer urgently to haematology.

Safety net: 'If you develop confusion, severe bone pain, or weakness or numbness in your legs, go to A&E immediately.' Spinal cord compression from vertebral collapse is a myeloma emergency. Arrange follow-up within 1 week for results. Ask if she wants her daughter present for the results discussion.

How examiners mark this station

Examiners will focus on the thoroughness and structure of your history taking for multiple myeloma. 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: CRAB features identified. Bone pain characterised (deep, constant, non-traumatic). Recurrent infections documented. Hypercalcaemia features screened. Spinal cord compression screened. Complete PMH including husband's cancer.

Costs marks: Treating symptoms in isolation. Not screening for complications. Not connecting bone pain, anaemia, and infections.

Domain 2: Clinical Management Skills (Primary focus)

Scores well: Urgent investigations including protein electrophoresis and free light chains. Skeletal survey or CT planned. Urgent haematology referral. Spinal cord compression safety netting. Follow-up within 1 week.

Costs marks: Standard bloods only. No protein electrophoresis. No urgent referral. No spinal cord compression warning.

Domain 3: Interpersonal Skills (Throughout)

Scores well: Honest about the need for urgent investigation. Responding to cancer concern with sensitivity (husband's death). Not being evasive but not prematurely diagnosing. Offering daughter's presence for results. Acknowledging impact on her active lifestyle.

Costs marks: Being evasive about cancer possibility. Not acknowledging husband's cancer history. Dismissing her symptoms.

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. Treating the bone pain as osteoarthritis without investigating. Widespread bone pain in a 72-year-old with anaemia and recurrent infections is not OA. Candidates who prescribe painkillers and physiotherapy miss a haematological malignancy.
  2. Not requesting protein electrophoresis. Standard bloods (FBC, U&E, calcium) may be abnormal but are not diagnostic. Serum protein electrophoresis and serum free light chains are the specific investigations for myeloma. Candidates who order standard bloods only miss the diagnostic test.
  3. Not screening for spinal cord compression. Myeloma causes vertebral collapse which can compress the spinal cord. Candidates who do not ask about leg weakness, numbness, or bladder/bowel symptoms miss a potential emergency.

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 multiple myeloma station?

Bone pain, fatigue, and recurrent infections in an elderly patient should raise suspicion for multiple myeloma. The candidate must connect these seemingly unrelated symptoms through the underlying diagnosis. Mrs Murphy is 72, presenting with 2 months of progressive bone pain (back, hips, ribs), fatigue, and three infections in 2 months.

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

Strong performances show: CRAB features identified. Bone pain characterised (deep, constant, non-traumatic). Recurrent infections documented. Hypercalcaemia features screened. Spinal cord compression screened. Weak performances: Treating symptoms in isolation. Not screening for complications. Not connecting bone pain, anaemia, and infections.

What is the biggest pitfall in this multiple myeloma station?

Treating the bone pain as osteoarthritis without investigating. Widespread bone pain in a 72-year-old with anaemia and recurrent infections is not OA. Candidates who prescribe painkillers and physiotherapy miss a haematological malignancy.

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

This station rewards process over personal experience. The skill being assessed: Recognising recurrent infections as immunoparesis: abnormal plasma cells crowding out normal immune function. 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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