History Taking · Intermediate · Respiratory

Chronic Cough with Constitutional Symptoms

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

Clinical scenario

You are an FY2 doctor in a community health clinic. Mrs Amara Patel, a 48-year-old woman, has come to see you with a persistent cough lasting six weeks. She describes progressive symptoms including night sweats, weight loss, and fatigue. Please take a focused history exploring risk factors, contact history, constitutional symptoms, and discuss initial investigations for TB screening.

Background notes: PMH: Type 2 Diabetes, Hypertension, no immunosuppression reported

What this station tests

  • Recognising the TB clinical pattern: chronic productive cough plus constitutional symptoms (night sweats, weight loss, fatigue) in a patient with multiple risk factors
  • Systematic risk factor assessment: recent immigration from endemic country, healthcare worker exposure, overcrowded household, diabetes, and contact history
  • Infection control awareness: advising work exclusion from a care home and explaining the need for household and workplace contact tracing
  • Requesting appropriate investigations: three sputum samples for AFB, GeneXpert, chest X-ray, and HIV test
  • Sensitive communication about a stigmatised and notifiable disease: explaining TB without causing shame while addressing practical implications for work and family

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

TB should be considered in any patient with cough lasting more than three weeks combined with constitutional symptoms, especially if risk factors are present. The candidate's task is to identify the clinical pattern, assess transmission risk, and initiate the diagnostic pathway. Mrs Patel is 48, a healthcare assistant in a nursing home, presenting with a six-week cough, night sweats, weight loss, and fatigue. Open with: 'Mrs Patel, tell me about this cough and how you've been feeling generally.' The constitutional symptoms, not just the cough, should drive your differential.

Core approach

The cough started six weeks ago, initially dry, now productive of yellow-green sputum, worse in mornings, persistent daily. No haemoptysis. The constitutional features are the diagnostic signal: night sweats (drenching, three weeks, waking to change clothing), significant weight loss (6 to 8kg in four weeks, clothes feeling loose), overwhelming fatigue, and reduced appetite. This combination, chronic productive cough plus night sweats plus weight loss plus fatigue, is the classic TB presentation.

Assess risk factors systematically. Mrs Patel has multiple: she is a healthcare assistant in a nursing home (occupational exposure to respiratory pathogens), she emigrated from India 18 months ago (high TB-burden country), she lives in a household of 10 people (overcrowding increases transmission), and she has type 2 diabetes (2 to 4-fold increased TB risk). Ask about contact history: has anyone in the care home or household had TB or chronic cough? Ask about BCG vaccination status. Ask about HIV risk (TB and HIV co-infection is important to consider).

Exclude other differentials. Lung cancer: possible but less likely at 48 with no smoking history (ask). Lymphoma: possible with B symptoms but less likely without lymphadenopathy. Bacterial pneumonia: would present more acutely and respond to standard antibiotics.

Assess transmission risk. She works in a care home with vulnerable residents. She lives with 10 family members including children. If TB is confirmed, contact tracing will be needed in both settings. She is worried her employers will react badly if it is contagious.

Closing and safety netting

Explain the working diagnosis sensitively: 'Mrs Patel, the combination of your cough, weight loss, night sweats, and the fact that you recently moved from India and work in healthcare means we need to test you urgently for tuberculosis. TB is treatable with antibiotics, but we need to confirm it quickly.' Avoid alarming her but do not minimise.

Investigations: urgent chest X-ray (looking for apical infiltrates, cavitation), three sputum samples for acid-fast bacilli smear and culture (early morning samples on consecutive days), GeneXpert MTB/RIF for rapid molecular diagnosis, and blood tests including HIV test (with consent). Refer to the local TB service.

Address her work concern: 'Until we have results, it would be safest for you to stay away from work to protect the residents. This is a precaution, not a punishment.' Discuss contact tracing: household contacts and care home contacts will need screening. Safety net: 'If you develop breathlessness, cough up blood, or feel significantly worse, come to A&E immediately.' Explain that TB treatment involves a long course of antibiotics (typically 6 months) but is very effective when completed.

How examiners mark this station

Examiners will focus on the thoroughness and structure of your history taking for pulmonary tuberculosis. 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: Constitutional symptom assessment: quantifying weight loss, characterising night sweats, documenting timeline. Systematic TB risk factors: immigration, occupation, household contacts, diabetes, BCG status. Asking about contact history in care home and household. Considering HIV co-infection.

Costs marks: Treating the cough in isolation without assessing constitutional symptoms. Not asking about country of origin or occupation. Not exploring household contacts. Not considering HIV.

Domain 2: Clinical Management Skills (Primary focus)

Scores well: Correct investigation pathway: CXR, three sputum samples for AFB, GeneXpert, blood tests, HIV test. Referral to TB service. Advising work exclusion. Explaining contact tracing. Knowledge of treatment duration (6 months). Appropriate safety netting.

Costs marks: Prescribing standard antibiotics without TB investigations. Not requesting sputum samples. Not advising work exclusion. No mention of contact tracing. Not referring to TB service.

Domain 3: Interpersonal Skills (Throughout)

Scores well: Explaining TB without stigma. Addressing her work concern directly and compassionately. Framing work exclusion as a precaution, not a punishment. Reassuring that TB is treatable. Being sensitive about immigration-related risk factors.

Costs marks: Making her feel blamed for having TB risk factors. Being insensitive about work exclusion. Not addressing her concern about her employer's reaction. Using language that stigmatises TB.

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 assessing TB risk factors. A 48-year-old healthcare worker from India with constitutional symptoms has a high pre-test probability for TB. Candidates who treat this as a routine chest infection without asking about country of origin, occupation, and contacts miss the diagnosis.
  2. Not advising work exclusion. Mrs Patel works in a nursing home with vulnerable elderly residents. Candidates who do not address the infection control implications demonstrate a gap in public health awareness.
  3. Forgetting to request an HIV test alongside TB investigations. TB-HIV co-infection is clinically important and changes management. HIV testing should be offered to all patients with suspected TB.

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 pulmonary tuberculosis history in PLAB 2?

TB should be considered in any patient with cough lasting more than three weeks combined with constitutional symptoms, especially if risk factors are present. The candidate's task is to identify the clinical pattern, assess transmission risk, and initiate the diagnostic pathway. Mrs Patel is 48, a healthcare assistant in a nursing home, presenting with a six-week cough, night sweats, weight loss, and fatigue.

Where are marks won and lost in this pulmonary tuberculosis station?

Examiners reward: Constitutional symptom assessment: quantifying weight loss, characterising night sweats, documenting timeline. Systematic TB risk factors: immigration, occupation, household contacts, diabetes, BCG status. Candidates are penalised for: Treating the cough in isolation without assessing constitutional symptoms. Not asking about country of origin or occupation. Not exploring household contacts.

Where do candidates most often go wrong in this station?

Not assessing TB risk factors. A 48-year-old healthcare worker from India with constitutional symptoms has a high pre-test probability for TB. Candidates who treat this as a routine chest infection without asking about country of origin, occupation, and contacts miss the diagnosis.

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

This station rewards process over personal experience. The skill being assessed: Systematic risk factor assessment: recent immigration from endemic country, healthcare worker exposure, overcrowded household, diabetes, and contact history. 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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