History Taking · Intermediate · Respiratory

Breathlessness Following Cholecystectomy

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

Clinical scenario

You are an FY2 doctor in the acute medical unit. Ms Heather Blackwell, a 56-year-old woman, presents with acute onset breathlessness and chest pain four days post-laparoscopic cholecystectomy. Please take a focused history, assess for PE, discuss investigations and anticoagulation management.

Background notes: PMH: Gallstones (symptomatic, had cholecystectomy 4 days ago), Hypertension, Obesity, Menopause

What this station tests

  • Recognising post-surgical PE: acute onset breathlessness with pleuritic pain on day 4 post-operatively, with identifiable VTE risk factors
  • Asking about VTE prophylaxis: whether prophylactic anticoagulation and compression stockings were used post-operatively
  • Distinguishing PE from post-operative atelectasis (wrong timeline, no pleuritic pain) and pneumonia (no fever, no productive cough)
  • Addressing the patient's misattribution: she thinks something went wrong with the surgery, and correcting this while explaining what PE is
  • Managing weight-related guilt: she feels responsible for needing surgery because of her weight, and this needs sensitive handling

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 breathlessness in the post-operative period should prompt consideration of PE, atelectasis, pneumonia, and cardiac causes. The timing (day 4 post-surgery) and the acute onset are the key clinical clues. Ms Blackwell is 56, presenting with sudden breathlessness and chest pain four days after laparoscopic cholecystectomy. She was recovering well until this morning. Open with: 'Ms Blackwell, I can see you're breathless. Tell me exactly what happened this morning.' The acuity of her presentation should set the pace of your history.

Core approach

The onset was sudden this morning: acute breathlessness at rest and sharp, right-sided chest pain worse on inspiration. The pain is not where her surgical wounds are (an important distinction she will make). No cough, no fever, no leg swelling or calf pain. She felt dizzy when first standing up. Before this morning, she was recovering normally from surgery.

Build the VTE risk profile. Recent surgery (4 days post-cholecystectomy), age 56, obesity (BMI 32), hypertension, menopause. Ask specifically about VTE prophylaxis: was she given prophylactic anticoagulation post-operatively? Was she wearing compression stockings? This is clinically important and a common exam question: if prophylaxis was inadequate, it changes the context of the PE.

Assess Wells score components. No obvious DVT signs (no calf swelling), but PE is the most likely diagnosis given the clinical picture (score 3). Recent surgery (score 1.5). Heart rate likely elevated (score 1.5 if >100). Clinical probability is at least intermediate.

Exclude competing differentials. Post-operative atelectasis: usually develops days 1 to 2, associated with reduced breath sounds and low-grade fever, not pleuritic pain. Pneumonia: no fever, no productive cough, wrong timeline. Cardiac: she worries about a heart attack (her father died of one), but the pleuritic nature and right-sided location are not typical for ACS.

ICE: She thinks something went wrong with the surgery. She worries about internal bleeding and about her heart. She feels guilty about needing surgery ('if I had managed my weight better'). She is frightened.

Closing and safety netting

Explain your assessment clearly: 'Ms Blackwell, I do not think this is related to your surgery going wrong. The pattern of your symptoms, sudden breathlessness and sharp chest pain worse on breathing, four days after an operation, makes me concerned about a blood clot in your lung. This is called a pulmonary embolism and it is a recognised risk after surgery.'

Address her specific fears: this is not a heart attack, and it is not a surgical complication in the sense that something went wrong. PE is a known risk of surgery that is managed with blood-thinning treatment.

Investigations: CTPA (definitive imaging), blood gases, ECG, bloods including troponin. Start anticoagulation empirically if clinical suspicion is high and CTPA will be delayed. Leg ultrasound if any calf symptoms develop.

Reassure about treatment: 'PE is very treatable with blood-thinning medication. Most people recover fully.' Address her weight-related guilt sensitively but do not dwell on it. Safety net: 'If your breathing suddenly worsens or you feel faint, tell the nursing team immediately.' She will need admission for monitoring and anticoagulation.

How examiners mark this station

Examiners will focus on the thoroughness and structure of your history taking for pulmonary embolism. 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: Acute onset characterisation. VTE risk factor assessment including prophylaxis check. Wells score estimation. Distinguishing PE from atelectasis and pneumonia. Checking for DVT symptoms. Complete surgical history including post-operative mobility.

Costs marks: Not considering PE. Not asking about prophylaxis. Not assessing VTE risk factors. Accepting atelectasis without challenge.

Domain 2: Clinical Management Skills (Primary focus)

Scores well: CTPA as definitive investigation. Empirical anticoagulation if high clinical suspicion. Appropriate additional investigations (ABG, ECG, troponin). Admission for monitoring. Clear safety netting for deterioration.

Costs marks: Not requesting CTPA. Waiting for imaging before treating. Sending patient home. No safety netting.

Domain 3: Interpersonal Skills (Throughout)

Scores well: Correcting her misattribution (not a surgical complication). Addressing her cardiac anxiety (not a heart attack). Handling weight-related guilt sensitively. Clear explanation of PE in lay terms. Reassurance about treatability.

Costs marks: Not correcting her belief that surgery went wrong. Reinforcing weight guilt at a vulnerable moment. Not addressing her cardiac anxiety. Using jargon without explanation.

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 asking about VTE prophylaxis. Whether she received post-operative anticoagulation and compression stockings is clinically relevant and a common exam question. Candidates who do not ask this miss an important assessment point.
  2. Attributing symptoms to post-operative atelectasis without considering PE. Atelectasis typically develops on days 1 to 2 and presents with reduced breath sounds and mild fever, not acute pleuritic chest pain on day 4. Candidates who accept atelectasis without considering PE may miss a life-threatening diagnosis.
  3. Not addressing her guilt about weight. Ms Blackwell feels she caused her own illness by being overweight. Candidates who ignore this emotional dimension or reinforce it ('weight loss would help') at the wrong moment demonstrate poor interpersonal skills.

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 pulmonary embolism history in this PLAB 2 station?

Acute breathlessness in the post-operative period should prompt consideration of PE, atelectasis, pneumonia, and cardiac causes. The timing (day 4 post-surgery) and the acute onset are the key clinical clues. Ms Blackwell is 56, presenting with sudden breathlessness and chest pain four days after laparoscopic cholecystectomy.

What are examiners marking in this pulmonary embolism station?

Marks are won for: Acute onset characterisation. VTE risk factor assessment including prophylaxis check. Wells score estimation. Distinguishing PE from atelectasis and pneumonia. Marks are lost for: Not considering PE. Not asking about prophylaxis. Not assessing VTE risk factors. Accepting atelectasis without challenge.

What is the most common mistake candidates make in this pulmonary embolism station?

Not asking about VTE prophylaxis. Whether she received post-operative anticoagulation and compression stockings is clinically relevant and a common exam question. Candidates who do not ask this miss an important assessment point.

How do I prepare for this station if I have not managed pulmonary embolism in clinical practice?

Structure beats experience here. Focus on asking about VTE prophylaxis: whether prophylactic anticoagulation and compression stockings were used post-operatively. 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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