History Taking · Intermediate · Neurology

Elderly Patient Unable to Weight-Bear

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

Clinical scenario

You are an FY2 doctor in the Emergency Department. Mr Ian Sutton, an 81-year-old man, has been brought in by ambulance after a fall at home. He cannot weight-bear on his right leg and is in significant pain. Please take a focused history, perform a brief assessment, and discuss your management plan including investigation and referral.

Background notes: PMH: Hypertension (managed), Type 2 diabetes (managed), Chronic obstructive pulmonary disease (mild), Previous stroke 3 years ago with good recovery

What this station tests

  • Distinguishing mechanical fall from medical event: establishing that he did not feel dizzy, faint, or have palpitations before the fall
  • Considering pathological or insufficiency fracture: the leg 'gave way' under normal loading, suggesting bone fragility rather than trauma
  • Assessing the prolonged lie: 75 minutes on the floor increases risk of pressure injury, rhabdomyolysis, and hypothermia
  • Pre-operative risk assessment: COPD (anaesthetic), diabetes (glucose management), previous stroke (anticoagulation, rehabilitation complexity)
  • Establishing pre-morbid function: baseline mobility determines rehabilitation goals and discharge planning

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

An elderly patient unable to weight-bear after a fall requires rapid assessment of the injury alongside investigation of why the fall occurred. The 'why' is as important as the 'what' because it determines whether this is a mechanical fall or a medical event (syncope, arrhythmia, stroke). Mr Sutton is 81, brought by ambulance after a fall at home, unable to weight-bear on his right leg, in severe pain. Prioritise analgesia: 'Mr Sutton, I can see you are in a lot of pain. Let me get you some pain relief first, and then I need to ask you some questions about what happened.' Do not delay analgesia pending the history.

Core approach

Establish the mechanism. He stood up from bed to go to the bathroom, felt a sudden sharp pain in his right hip, and his leg collapsed. He did not slip, trip, or lose balance. He did not feel dizzy or faint beforehand. No chest pain, no palpitations. This suggests the fracture may have occurred spontaneously with normal loading (pathological or insufficiency fracture) rather than from a fall. This distinction matters: ask about bone health, osteoporosis screening, calcium and vitamin D intake.

Assess the injury. Right hip and groin pain, severe (8 to 9 out of 10), cannot weight-bear at all, leg may be shortened and externally rotated (classic hip fracture sign). He was on the floor for approximately 75 minutes before the ambulance arrived. This prolonged lie increases risk of pressure injury, hypothermia, rhabdomyolysis, and dehydration.

Take a focused PMH. Hypertension, type 2 diabetes (blood glucose management perioperatively), COPD (mild, anaesthetic implications), previous stroke 3 years ago (anticoagulation status, rehabilitation complexity). His medications need checking: is he on anticoagulants (affects surgical timing), steroids (bone health), diabetic medications (perioperative management)?

Assess his pre-morbid function: was he independently mobile before this? Yes, using a stick but managing well. This baseline determines rehabilitation goals. He lives with his wife in a bungalow (no stairs, which is helpful for rehabilitation). ICE: he knows it is a fracture, is terrified of surgery and losing independence, worried about burdening his wife.

Closing and safety netting

Confirm the likely diagnosis: 'Mr Sutton, based on what you have described and the way your leg is positioned, I believe you have fractured your hip. We need an X-ray to confirm this, and you will almost certainly need an operation to fix it.'

Outline the pathway: X-ray, bloods (FBC, U&E, clotting, group and save, glucose), ECG (pre-operative), chest X-ray. He should be seen by the orthopaedic team and ideally operated on within 36 hours (NICE hip fracture standard). Address his anaesthetic concern (COPD): 'The anaesthetist will assess you and choose the safest option, which may be a spinal anaesthetic rather than a general.'

Explain rehabilitation: 'Most people are up and moving with support within a day or two of surgery. The physiotherapists will work with you to get you back on your feet.' Address his fear of dependence: the goal is to return him to his pre-fracture function. Assess and address bone health: if he is not on calcium, vitamin D, and a bisphosphonate, these should be considered. Safety net: pain management will continue. Ask if his wife needs transport to the hospital.

How examiners mark this station

Examiners will focus on the thoroughness and structure of your history taking for hip fracture. 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: Fall mechanism established. Medical causes of fall excluded (no syncope, no cardiac symptoms). Prolonged lie assessed. Comorbidities documented with surgical implications. Pre-morbid function assessed. Medication review including anticoagulation and diabetic medications.

Costs marks: Not establishing fall mechanism. Not excluding syncope or cardiac cause. Not assessing prolonged lie. Incomplete comorbidity assessment.

Domain 2: Clinical Management Skills (Primary focus)

Scores well: Immediate analgesia prioritised. Appropriate investigations (X-ray, bloods, ECG, CXR). NICE 36-hour surgery target mentioned. Orthopaedic referral. Bone health assessment and treatment. Rehabilitation plan discussed.

Costs marks: Delaying analgesia. Incomplete investigations. Not knowing the 36-hour surgery standard. No bone health assessment. No rehabilitation discussion.

Domain 3: Interpersonal Skills (Throughout)

Scores well: Addressing pain as the immediate priority. Reassuring about surgery and rehabilitation. Addressing fear of dependence with realistic goals. Considering his wife's needs (transport, information). Acknowledging the frightening experience of being on the floor alone.

Costs marks: Ignoring his pain. Being alarmist about surgery. Not addressing his fear of losing independence. Not considering his wife's needs.

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. Delaying analgesia while taking the history. An 81-year-old in severe pain from a hip fracture should receive analgesia immediately, not after a 5-minute history. Candidates who say 'let me ask you some questions first' before addressing pain demonstrate poor prioritisation.
  2. Not asking why the fall happened. 'He fell' is not a diagnosis. Did he trip, slip, feel dizzy, have a cardiac event, or did the bone simply give way? The cause of the fall determines secondary prevention and ongoing risk.
  3. Not assessing the prolonged lie. He was on the floor for 75 minutes. This creates additional risks (rhabdomyolysis, pressure injury, dehydration) that must be considered in the management plan. Candidates who treat only the fracture miss these complications.

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 should I structure the hip fracture history in this PLAB 2 station?

An elderly patient unable to weight-bear after a fall requires rapid assessment of the injury alongside investigation of why the fall occurred. The 'why' is as important as the 'what' because it determines whether this is a mechanical fall or a medical event (syncope, arrhythmia, stroke). Mr Sutton is 81, brought by ambulance after a fall at home, unable to weight-bear on his right leg, in severe pain.

What are examiners marking in this hip fracture station?

Marks are won for: Fall mechanism established. Medical causes of fall excluded (no syncope, no cardiac symptoms). Prolonged lie assessed. Comorbidities documented with surgical implications. Marks are lost for: Not establishing fall mechanism. Not excluding syncope or cardiac cause. Not assessing prolonged lie. Incomplete comorbidity assessment.

What is the most common mistake candidates make in this hip fracture station?

Delaying analgesia while taking the history. An 81-year-old in severe pain from a hip fracture should receive analgesia immediately, not after a 5-minute history. Candidates who say 'let me ask you some questions first' before addressing pain demonstrate poor prioritisation.

How do I prepare for this station if I have not managed hip fracture in clinical practice?

Structure beats experience here. Focus on considering pathological or insufficiency fracture: the leg 'gave way' under normal loading, suggesting bone fragility rather than trauma. 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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