History Taking · Foundation · Respiratory

Acute Cough with Fever and Pleuritic Chest Pain

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

Clinical scenario

You are an FY2 doctor in the acute medical unit. Mr Robert Stewart, a 72-year-old man, has come in via ambulance with acute illness. He has high fever, productive cough with rusty sputum, and sharp chest pain on breathing. He appears acutely unwell. Please take a focused history assessing severity, comorbidities, risk factors for serious pneumonia, and discuss initial management and investigations.

Background notes: PMH: COPD, Hypertension, Coronary artery disease, Chronic kidney disease stage 3

What this station tests

  • Rapid severity assessment using CURB-65 components: scoring alongside history, not waiting until after a full history is complete
  • Recognising the classic pneumococcal pneumonia presentation: rusty sputum, high fever, pleuritic chest pain, acute deterioration over hours
  • Identifying the penicillin allergy and its impact on antibiotic choice: this detail directly affects immediate management
  • Managing oxygen targets in COPD: 88 to 92% target rather than 94 to 98% to avoid hypercapnic respiratory failure
  • Addressing cardiac anxiety in a patient with CAD and chest pain: explicitly reassuring him this is pneumonia, not his heart

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 respiratory presentations require rapid severity assessment alongside history. The candidate must demonstrate clinical urgency while still gathering the information needed for safe management. Mr Stewart is 72, arrived by ambulance, febrile (39.8), with productive cough producing rusty sputum and right-sided pleuritic chest pain. He appears acutely unwell. Start by acknowledging his condition: 'Mr Stewart, I can see you are feeling very unwell. I need to ask you some questions to work out the best way to help you. Can you tell me what happened?' Keep the history focused: this is an acute presentation, not a chronic cough.

Core approach

The history reveals a 3 to 4-day prodrome (mild cough, slight temperature) followed by rapid deterioration overnight: high fever (39.8), severe productive cough with rusty sputum, right-sided pleuritic chest pain, and significant breathlessness at rest. Rusty sputum is the classic feature of pneumococcal pneumonia. The pleuritic pain indicates pleural involvement. This is severe community-acquired pneumonia.

Assess severity using CURB-65 components: Confusion (alert and orientated, score 0), Urea (will need blood test), Respiratory rate (likely elevated, assess), Blood pressure (need measurement), age over 65 (yes, score 1). Even before the full score, the clinical picture (ambulance arrival, high fever, breathless at rest, multiple comorbidities) indicates severe CAP requiring hospital admission.

Comorbidities matter significantly for management. Mr Stewart has COPD (on inhalers, sometimes non-adherent), coronary artery disease (stent 5 years ago, on aspirin and bisoprolol), hypertension, and CKD stage 3. The COPD complicates oxygen targets (88 to 92% rather than 94 to 98%), CAD means he may worry this is his heart (address this), and CKD affects antibiotic dosing.

Crucially, check his penicillin allergy. Mr Stewart reports a rash when younger. This changes first-line antibiotic choice: instead of co-amoxiclav, he will need an alternative (respiratory fluoroquinolone or clarithromycin plus another agent). This is a detail that affects immediate management.

Smoking history: 40/day for 35 years, quit 8 years ago. He is an ex-heavy smoker with COPD. ICE: he is terrified this is his heart (chest pain plus CAD history), wants reassurance, and wants to recover quickly.

Closing and safety netting

Explain the diagnosis clearly: 'Mr Stewart, this is a chest infection, specifically pneumonia. The rusty colour in your sputum and the pattern on examination point to a bacterial infection in your right lung. This is not a heart problem.' Address his cardiac anxiety directly, as this will be a significant relief.

Outline management: admission to hospital, IV antibiotics (adjusted for his penicillin allergy), oxygen with careful targets given his COPD, IV fluids, and close monitoring. Blood cultures before antibiotics. Chest X-ray to confirm the diagnosis and assess severity. Regular observations to track his response.

Safety net within the admission: 'You are in the right place. We will monitor you closely. If your breathing worsens significantly or you become confused, the team may need to move you to a higher level of care.' Be honest but reassuring: most patients with pneumonia, even severe, respond well to appropriate antibiotics.

How examiners mark this station

Examiners will focus on the thoroughness and structure of your history taking for community-acquired pneumonia. 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: CURB-65 scoring within the history. Identifying rusty sputum as pneumococcal indicator. Complete comorbidity assessment: COPD (oxygen target implication), CAD (anxiety), CKD (dosing). Checking penicillin allergy. Smoking history with pack-year calculation.

Costs marks: Not assessing severity. Missing the penicillin allergy. Not checking COPD status for oxygen targets. Incomplete comorbidity review.

Domain 2: Clinical Management Skills (Primary focus)

Scores well: Correct admission decision. Appropriate antibiotic choice adjusted for penicillin allergy. COPD-appropriate oxygen targets (88 to 92%). Blood cultures before antibiotics. Investigation plan (CXR, bloods). Fluid management. Clear escalation criteria.

Costs marks: Prescribing penicillin to an allergic patient. Standard oxygen targets in COPD. No blood cultures. Vague management plan. Not recognising severity.

Domain 3: Interpersonal Skills (Throughout)

Scores well: Adapting pace to an acutely unwell patient. Explicitly addressing his cardiac anxiety. Clear, simple explanation of pneumonia versus heart problem. Honest severity assessment while providing reassurance about treatment response.

Costs marks: Taking a leisurely history in an acute presentation. Not addressing the cardiac fear. Using jargon. Not acknowledging that he feels very unwell.

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. Not checking the penicillin allergy before discussing antibiotic treatment. Mr Stewart is penicillin-allergic (childhood rash). First-line severe CAP treatment is typically co-amoxiclav or amoxicillin-based. Candidates who prescribe penicillin-based antibiotics without checking allergies demonstrate unsafe practice.
  2. Using standard oxygen targets in a patient with COPD. Mr Stewart has COPD, and targeting SpO2 94 to 98% risks hypercapnic respiratory failure. The correct target is 88 to 92%. This is a common exam question that differentiates candidates who understand respiratory physiology.
  3. Not addressing the cardiac concern. Mr Stewart has coronary artery disease and right-sided chest pain. He is terrified this is another heart attack. Candidates who diagnose pneumonia correctly but do not explicitly address his cardiac anxiety leave him frightened and score poorly on Domain 3.

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 community-Acquired pneumonia station?

Acute respiratory presentations require rapid severity assessment alongside history. The candidate must demonstrate clinical urgency while still gathering the information needed for safe management. Mr Stewart is 72, arrived by ambulance, febrile (39.8), with productive cough producing rusty sputum and right-sided pleuritic chest pain.

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

Strong performances show: CURB-65 scoring within the history. Identifying rusty sputum as pneumococcal indicator. Complete comorbidity assessment: COPD (oxygen target implication), CAD (anxiety), CKD (dosing). Weak performances: Not assessing severity. Missing the penicillin allergy. Not checking COPD status for oxygen targets. Incomplete comorbidity review.

What is the biggest pitfall in this community-Acquired pneumonia station?

Not checking the penicillin allergy before discussing antibiotic treatment. Mr Stewart is penicillin-allergic (childhood rash). First-line severe CAP treatment is typically co-amoxiclav or amoxicillin-based.

How should I prepare for community-Acquired pneumonia if I have never seen it in practice?

Structure beats experience here. Focus on recognising the classic pneumococcal pneumonia presentation: rusty sputum, high fever, pleuritic chest pain, acute deterioration over hours. 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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