History Taking · Foundation · Infectious Diseases

Fever After Travel - Returned Traveller with Cyclical Fever

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

Clinical scenario

You are an FY2 doctor in a GP surgery. Louis, a 32-year-old man, has returned from a two-week trip to West Africa and presents with fever, chills, and malaise for the past five days. Please take a focused travel history, assess for malaria and other tropical infections, and discuss urgent investigation.

Background notes: PMH: Healthy, no chronic conditions

What this station tests

  • Fever in returned traveller from endemic area = malaria until proven otherwise: this is the cardinal rule
  • Prophylaxis history: which drug, compliance, whether completed the course after return
  • Three negative films needed to exclude: a single negative film does not rule out malaria
  • Severe malaria features: confusion, jaundice, dark urine, AKI, pulmonary oedema requiring immediate hospital admission
  • Not prescribing empirical antimalarials in primary care: species identification and hospital management required

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

Fever in a returned traveller from a malaria-endemic area is malaria until proven otherwise. This is a medical emergency that requires same-day blood films. Louis is 32, returned from Ghana 5 days ago with fever, chills, and malaise. Open with: 'Louis, fever after travel to West Africa is something we treat as urgent. Tell me about the trip and when the symptoms started.'

Core approach

Travel history is critical. Two weeks in Ghana (West Africa, high Plasmodium falciparum risk). Activities: conservation work, outdoor exposure. Malaria prophylaxis: did he take it? What drug? Was he compliant? Many travellers stop prophylaxis early or take it inconsistently. Mosquito prevention: did he use nets, repellent, long sleeves?

Symptom pattern. Fever for 5 days, cyclical (rigors, sweating, then relative wellness before next cycle), headache, myalgia, malaise. The cyclical pattern is classic for malaria but may not be present with falciparum (which can cause continuous fever). Nausea, vomiting, diarrhoea may also occur. No neck stiffness (excludes meningitis). No rash (excludes many viral causes). No respiratory symptoms.

Assess severity. Any confusion (cerebral malaria)? Jaundice (haemolysis)? Dark urine (haemoglobinuria, blackwater fever)? Severe anaemia symptoms? Breathlessness (pulmonary oedema)? Reduced urine output (AKI)? These indicate severe falciparum malaria requiring immediate hospital admission.

Closing and safety netting

This cannot be managed in primary care. Arrange urgent hospital referral for thick and thin blood films (the diagnostic test). Three negative films 12 to 24 hours apart are needed to exclude malaria. Do not wait for results before referring if clinically suspicious.

'Louis, I am sending you to hospital now for blood tests to check for malaria. Malaria from West Africa can be serious if not treated quickly, but with the right treatment it is completely curable.' If falciparum confirmed: IV artesunate for severe, oral artemisinin-based combination therapy (ACT) for uncomplicated.

Do not prescribe empirical antimalarials in primary care. Hospital assessment with confirmed diagnosis and species identification is required. Safety net: 'If you develop confusion, jaundice, dark urine, or become very drowsy before reaching hospital, call 999.' He should go now, not after lunch.

How examiners mark this station

Examiners will focus on the thoroughness and structure of your history taking for malaria. 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: Travel history (destination, duration, activities). Prophylaxis assessment (drug, compliance). Symptom pattern (cyclical fever). Severe malaria features screened. Other tropical differentials considered.

Costs marks: Not taking travel history. Not checking prophylaxis. Not screening for severe features. Diagnosing as viral illness.

Domain 2: Clinical Management Skills (Primary focus)

Scores well: Urgent hospital referral for blood films. Not prescribing empirical antimalarials. Three films to exclude. Severe malaria safety netting. Immediate action (go now, not later).

Costs marks: Managing in primary care. Prescribing empirical treatment. Accepting single negative film. Delayed referral.

Domain 3: Interpersonal Skills (Adapted to urgency)

Scores well: Explaining why this is urgent without causing panic. Reassuring about curability with treatment. Clear instruction to go now. Practical safety netting for transit.

Costs marks: Being casual about the urgency. Not explaining why he needs to go immediately. Not providing safety netting.

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 as a viral illness. A 32-year-old returned from Ghana with fever is not 'probably just a virus.' Falciparum malaria can kill within 24 hours if untreated. Candidates who reassure and send home with paracetamol risk a fatality.
  2. Accepting a single negative blood film as exclusion. Three negative films 12 to 24 hours apart are required. Candidates who accept one negative film may miss early parasitaemia.
  3. Starting antimalarials in primary care. Species identification determines the treatment regimen. Candidates who prescribe chloroquine or ACT without confirmed diagnosis and species may give the wrong treatment.

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 a malaria history in PLAB 2?

Fever in a returned traveller from a malaria-endemic area is malaria until proven otherwise. This is a medical emergency that requires same-day blood films. Louis is 32, returned from Ghana 5 days ago with fever, chills, and malaise.

Where are marks won and lost in this malaria station?

Examiners reward: Travel history (destination, duration, activities). Prophylaxis assessment (drug, compliance). Symptom pattern (cyclical fever). Severe malaria features screened. Other tropical differentials considered. Candidates are penalised for: Not taking travel history. Not checking prophylaxis. Not screening for severe features. Diagnosing as viral illness.

Where do candidates most often go wrong in this station?

Treating as a viral illness. A 32-year-old returned from Ghana with fever is not 'probably just a virus.' Falciparum malaria can kill within 24 hours if untreated. Candidates who reassure and send home with paracetamol risk a fatality.

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

Structure beats experience here. Focus on prophylaxis history: which drug, compliance, whether completed the course after return. 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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