History Taking · Foundation · Respiratory

Daytime Somnolence and Snoring

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

Clinical scenario

You are an FY2 doctor in a GP surgery. Mrs Patricia Chen, a 52-year-old woman, has come to see you with a six-month history of excessive daytime sleepiness, loud snoring, and her husband has witnessed her stopping breathing during sleep. Please take a focused history and discuss your initial assessment and management plan.

Background notes: PMH: Hypertension, Hypothyroidism, Obesity

What this station tests

  • Taking a structured sleep history: daytime somnolence severity (Epworth score estimation), witnessed apnoeas, snoring character, nocturia, morning headaches, unrefreshing sleep
  • Identifying the driving safety issue: nearly falling asleep at the wheel requires immediate DVLA notification and advice to stop driving until treated
  • Recognising hypothyroidism as a contributing factor: undertreated hypothyroidism can cause or worsen OSA, and TFTs must be checked
  • Explaining CPAP practically: what the machine does, how it works, setting realistic expectations about treatment
  • Assessing functional impact: work performance, driving safety, relationship (husband sleeping in spare room), morning headaches

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

Sleep apnoea stations test whether the candidate can take a sleep history that goes beyond 'do you snore?' The key features to elicit are witnessed apnoeas, excessive daytime somnolence with functional impact, and associated risk factors (obesity, hypertension, hypothyroidism). Mrs Chen is 52, presenting with six months of extreme daytime tiredness, loud snoring, and her husband has witnessed her stopping breathing during sleep. Open with: 'Tell me about the tiredness and what's been happening at night.' Let her describe the impact before you formalise the sleep history.

Core approach

The daytime somnolence is severe and functionally significant. She describes overwhelming tiredness, 'eyelids like lead,' nodding off in afternoon meetings, and critically, nearly falling asleep at the wheel driving home. This last detail has driving safety and DVLA implications that must be addressed. She needs multiple coffees to function, has morning headaches 3 to 4 times weekly, and wakes feeling unrefreshed. Estimate her Epworth Sleepiness Scale score through targeted questions: napping during meetings, car journeys, after meals. Her score is approximately 14 to 16 (moderate to severe).

The night-time history must come from the patient and ideally from the bed partner's observations. Her husband reports loud snoring every night (loud enough to make him move to the spare room), witnessed apnoeas (he has seen her stop breathing), and gasping arousals. She herself reports nocturia (2 to 3 times nightly), unrefreshing sleep, and morning headaches. Ask about sleeping position: symptoms typically worse supine.

Assess risk factors. BMI is elevated (obese), she has hypertension and hypothyroidism. Hypothyroidism is particularly relevant: it can cause or worsen OSA, and she should have recent TFTs checked. Ask about neck circumference (>40cm in women increases risk). Alcohol use (worsens OSA). Sedating medications.

ICE: She initially thought she was just tired from work stress. A friend mentioned sleep apnoea. She is worried about the driving incidents and about needing a machine to sleep. She wants to know if weight loss alone would fix it.

Closing and safety netting

Explain the suspected diagnosis: 'Mrs Chen, based on what you and your husband have described, the snoring, the breathing pauses, the extreme daytime sleepiness, and your risk factors, I strongly suspect you have a condition called obstructive sleep apnoea. When you sleep, the muscles in your throat relax and temporarily block your airway, causing you to stop breathing briefly and then wake with a gasp.'

Investigations: refer for a sleep study (polysomnography or home sleep testing). Check TFTs (her hypothyroidism may be contributing). Baseline bloods including HbA1c (OSA increases insulin resistance).

Address driving immediately. 'I need to raise an important safety point. You mentioned nearly falling asleep at the wheel. If you have excessive daytime sleepiness that makes you unsafe to drive, you must stop driving and notify the DVLA until this is assessed and treated.' This is uncomfortable but essential.

Discuss treatment options: CPAP is first-line for moderate to severe OSA (explain what it is practically), weight loss is the most important modifiable factor (target 10% reduction), positional therapy (avoid sleeping on back), and avoiding alcohol before bed. Safety net: 'Until you have had the sleep study and started treatment, please do not drive if you feel drowsy.' Follow-up after sleep study results.

How examiners mark this station

Examiners will focus on the thoroughness and structure of your history taking for obstructive sleep apnoea. 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: Comprehensive sleep history: Epworth estimation, witnessed apnoeas, snoring severity, nocturia, morning headaches. Risk factor assessment: BMI, hypothyroidism, hypertension, neck circumference, alcohol, medications. Driving safety assessment. Functional impact on work and relationships.

Costs marks: Superficial sleep history ('do you snore?'). Not asking about witnessed apnoeas. Not assessing daytime somnolence severity. Not asking about driving.

Domain 2: Clinical Management Skills (Secondary focus)

Scores well: Referral for sleep study. TFTs check. DVLA advice and driving restriction. Treatment explanation: CPAP, weight loss, positional therapy, alcohol avoidance. Appropriate safety netting about driving until treated.

Costs marks: No sleep study referral. Not checking TFTs. Not addressing DVLA. Not explaining CPAP. No driving safety advice.

Domain 3: Interpersonal Skills (Throughout)

Scores well: Explaining OSA in plain terms. Addressing driving restriction with sensitivity (she needs her car for work). Discussing CPAP without making it sound unbearable. Responding to her concern about weight loss as a standalone treatment honestly.

Costs marks: Using 'obstructive sleep apnoea' without explanation. Delivering DVLA advice insensitively. Dismissing her weight loss question. Not acknowledging impact on her husband.

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 driving safety. Mrs Chen nearly fell asleep at the wheel. This is a red flag for DVLA notification and an immediate safety issue. Candidates who take the sleep history but do not address driving demonstrate a gap in patient safety awareness.
  2. Not checking thyroid status. She has known hypothyroidism. If undertreated, this can cause or exacerbate OSA. Candidates who do not ask about her levothyroxine dose and recent TFTs miss a potentially modifiable factor.
  3. Focusing only on CPAP without discussing weight loss. Weight loss is the most important modifiable risk factor for OSA. CPAP treats the symptoms; weight loss can treat the cause. Candidates who present CPAP as the only option miss the lifestyle component.

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 obstructive sleep apnoea station?

Sleep apnoea stations test whether the candidate can take a sleep history that goes beyond 'do you snore?' The key features to elicit are witnessed apnoeas, excessive daytime somnolence with functional impact, and associated risk factors (obesity, hypertension, hypothyroidism). Mrs Chen is 52, presenting with six months of extreme daytime tiredness, loud snoring, and her husband has witnessed her stopping breathing during sleep.

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

Strong performances show: Comprehensive sleep history: Epworth estimation, witnessed apnoeas, snoring severity, nocturia, morning headaches. Risk factor assessment: BMI, hypothyroidism, hypertension, neck circumference, alcohol, medications. Weak performances: Superficial sleep history ('do you snore?'). Not asking about witnessed apnoeas. Not assessing daytime somnolence severity. Not asking about driving.

What is the biggest pitfall in this obstructive sleep apnoea station?

Not asking about driving safety. Mrs Chen nearly fell asleep at the wheel. This is a red flag for DVLA notification and an immediate safety issue.

How should I prepare for obstructive sleep apnoea if I have never seen it in practice?

Structure beats experience here. Focus on identifying the driving safety issue: nearly falling asleep at the wheel requires immediate DVLA notification and advice to stop driving until treated. 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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