History Taking · Advanced · Psychiatry

Weight Loss and Body Concerns

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

Clinical scenario

You are an FY2 doctor in general practice. Sofia Bergmann, a 19-year-old university student, has attended with her mother following concern about weight loss. She has lost 12 kilograms over the past six months. Please take a focused history regarding eating, weight, and body image, assess physical health risk, and discuss management.

Background notes: PMH: Nil significant, Menarche age 13, Periods regular until 4 mths ago (now amenorrhoeic)

What this station tests

  • Medical risk assessment at low BMI: bradycardia, postural hypotension, electrolyte disturbance, QTc prolongation
  • Engaging a resistant patient: focus on physical symptoms (palpitations) not weight or eating behaviour
  • Distorted body image: she thinks she is overweight at BMI 15-16, do not confront directly
  • Eating disorder service referral: specialist, not generic psychiatry
  • BEAT charity as the primary support resource for patients and families

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

Anorexia nervosa assessment requires the candidate to build rapport with a patient who does not believe she is unwell, assess medical risk (which can be life-threatening), and involve the family sensitively. Sofia is 19, brought by her mother. She is resistant and minimising. Open with: 'Sofia, I know you did not want to come today. Can you tell me how things have been from your perspective?'

Core approach

Engage with Sofia first, not her mother. She does not think she has a problem. She thinks she is overweight (distorted body image) despite a BMI of approximately 15 to 16. She is restrictive: eating very small amounts, avoiding fats and carbohydrates, exercising excessively. She counts calories obsessively. Ask about: food intake in a typical day, exercise pattern, use of laxatives or vomiting, menstrual history (amenorrhoea is common with severe restriction).

Assess medical risk. At BMI <16, she is at significant physical risk. Check for: bradycardia (HR <50), postural hypotension, hypothermia, peripheral cyanosis. Electrolyte disturbance (hypokalaemia if purging). QTc prolongation (arrhythmia risk). Muscle wasting. Lanugo hair. She mentions palpitations (likely from electrolyte disturbance or bradycardia).

Psychological assessment. Distorted body image. Fear of weight gain. Self-worth tied to weight. Mood: often low and anxious in AN. Any self-harm? Perfectionist traits. Control as a theme (food restriction as the one thing she can control).

Closing and safety netting

Medical: urgent bloods (FBC, U&E including magnesium and phosphate, LFTs, TFTs, glucose, bone profile). ECG (QTc). If any medical instability (severe bradycardia, electrolyte disturbance, BMI <13): medical admission. Referral to eating disorder service (specialist, not generic psychiatry).

Communicate with care. Do not confront her body image directly ('you are underweight' will trigger resistance). Instead: 'I am worried about the palpitations and I want to make sure your heart is safe.' Focus on her physical symptoms as the entry point, not her weight or eating behaviour.

Involve her mother sensitively. Sofia may not want her mother in the room. Respect this but explain: 'Your mum is clearly very worried. Would you be willing to let me share some information with her?' BEAT (eating disorder charity) for both Sofia and her mother. Safety net: 'If you feel faint, develop chest pain, or cannot keep any food down, come to A&E immediately.' Follow-up within 1 week.

How examiners mark this station

Examiners will focus on the thoroughness and structure of your history taking for anorexia nervosa. 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 (Primary focus)

Scores well: Eating pattern assessed. BMI calculated. Medical risk screened (HR, BP, electrolytes, ECG). Purging behaviours asked. Menstrual history. Psychological assessment.

Costs marks: Not assessing medical risk. Not checking eating pattern. Not asking about purging.

Domain 2 (Primary focus)

Scores well: Urgent bloods and ECG. Eating disorder service referral (not generic psychiatry). Medical admission criteria known. BEAT signposted. Safety netting for cardiac symptoms.

Costs marks: No medical investigations. Generic psychiatry referral. No safety netting.

Domain 3 (Primary focus)

Scores well: Engaging Sofia directly. Using physical symptoms as entry point. Not confronting body image. Respecting her autonomy while involving mother sensitively. BEAT for family support.

Costs marks: Confronting body image. Speaking only to mother. Being directive. Not engaging the patient.

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. Confronting body image directly: telling her 'you are dangerously underweight' triggers resistance and disengagement
  2. Not assessing medical risk: BMI <16 with palpitations could indicate life-threatening electrolyte disturbance or arrhythmia
  3. Speaking only to the mother: Sofia is 19 and the patient, she must be engaged directly even if she is resistant

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 anorexia nervosa history in this PLAB 2 station?

Anorexia nervosa assessment requires the candidate to build rapport with a patient who does not believe she is unwell, assess medical risk (which can be life-threatening), and involve the family sensitively. Sofia is 19, brought by her mother. She is resistant and minimising.

What are examiners marking in this anorexia nervosa station?

Marks are won for: Eating pattern assessed. BMI calculated. Medical risk screened (HR, BP, electrolytes, ECG). Purging behaviours asked. Menstrual history. Psychological assessment. Marks are lost for: Not assessing medical risk. Not checking eating pattern. Not asking about purging.

What is the most common mistake candidates make in this anorexia nervosa station?

Confronting body image directly: telling her 'you are dangerously underweight' triggers resistance and disengagement. Another frequent error: Not assessing medical risk: BMI <16 with palpitations could indicate life-threatening electrolyte disturbance or arrhythmia.

How do I prepare for this station if I have not managed anorexia nervosa in clinical practice?

This station rewards process over personal experience. The skill being assessed: Engaging a resistant patient: focus on physical symptoms (palpitations) not weight or eating behaviour. The written guidance on this page covers the full approach, and practising the consultation aloud builds the fluency the examiner is listening for.

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