History Taking · Intermediate · Respiratory

Persistent Cough with Blood in Sputum

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

Clinical scenario

You are an FY2 doctor in primary care. Mr Derek Patterson, a 72-year-old man, has attended requesting a sick note for work. He mentions a persistent cough that has worsened over three months, and today he noticed blood in his sputum. He is a current smoker. Please take a focused respiratory history, assess for red flags suggesting malignancy, and discuss urgent referral to hospital for investigation. This requires a 2-week wait urgent cancer pathway referral.

Background notes: PMH: COPD (mild-moderate, FEV1 58% predicted), Hypertension, Hyperlipidaemia, Gout (occasional). No previous malignancy

What this station tests

  • Recognising the 2-week-wait cancer referral criteria: haemoptysis in a smoker over 40 with persistent cough and constitutional symptoms
  • Actively eliciting red flag features the patient will not volunteer: weight loss, night sweats, appetite loss, and fatigue must be asked about directly
  • Asking about occupational asbestos exposure: a retired bricklayer with 45 years in construction has significant exposure risk, synergistic with smoking
  • Navigating the emotional complexity of a patient whose wife died of lung cancer: he has already experienced this disease from the other side
  • Delivering an urgent referral conversation with honesty: explaining the need for investigation without prematurely diagnosing cancer, while not being evasive if he asks directly

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

Haemoptysis in a smoker over 40 is lung cancer until proven otherwise. The candidate's task is to identify red flag features, assess urgency, and initiate the 2-week-wait cancer referral pathway. Mr Patterson is 72, a current smoker with COPD, presenting with a three-month worsening cough and blood in his sputum today. He came in asking for a sick note, not expecting a serious conversation. Open gently: 'Mr Patterson, before we sort out your sick note, I'd like to hear more about this cough and the blood you noticed today. Can you tell me about it?' Meeting his stated reason for attending (sick note) while redirecting to the clinical priority shows respect for his agenda.

Core approach

The cough has been present for three months, initially dry, now productive, worse in mornings, with daily episodes lasting 10 to 15 minutes. Sputum is sometimes yellowish, sometimes clear. Today: bright red blood mixed with sputum, a small amount but definite. This is haemoptysis and is the immediate red flag.

Screen for other red flag features. He may not volunteer these, so ask directly. Weight loss: 'Now that you mention it, probably lost half a stone to a stone. Trousers are looser.' Night sweats: yes. Loss of appetite: 'Food doesn't interest me much.' Fatigue: 'Tired all the time.' Chest discomfort when coughing. These are constitutional symptoms consistent with malignancy.

Smoking history is critical. He smokes 40 per day and has done for 50 years (100 pack-years, extremely high risk). He has never seriously tried to quit. His wife used to nag him to stop. She died of lung cancer 5 years ago. This detail is emotionally central to the consultation: he has already watched someone die of the disease he is now at risk of. He knows this. He may say 'I keep thinking, am I next?'

Work history: retired bricklayer, 45 years in the building trade. Ask about asbestos exposure: construction workers of his generation had significant exposure. This is an additional lung cancer risk factor (synergistic with smoking). He may not have considered it as relevant.

PMH: COPD (FEV1 58%), hypertension, hyperlipidaemia, gout. Medications: salbutamol, tiotropium, amlodipine, simvastatin, allopurinol.

Closing and safety netting

Delivering a 2-week-wait referral conversation requires honesty without premature diagnosis. 'Mr Patterson, I want to be straightforward with you. Coughing up blood with a cough that has lasted this long, along with the weight loss, in someone with your smoking history, means we need to investigate this urgently. I want to arrange a chest X-ray today and refer you to a lung specialist who will see you within two weeks.' Name what you are concerned about if he asks: 'We need to rule out anything serious, including the possibility of a growth in the lung.'

Do not diagnose lung cancer in this consultation. You are referring for investigation. But do not be evasive if he connects the dots, especially given his wife died of lung cancer. If he says 'You think it's cancer, don't you?', respond honestly: 'I think we need to find out. That is why I am referring you urgently.'

Practical steps: urgent chest X-ray today, 2-week-wait referral to respiratory, blood tests (FBC, calcium, LFTs, renal function). Offer smoking cessation support, but do not make this the focus of a consultation where the man is frightened. Safety net: 'If you cough up more blood, or the amount increases, or you become significantly more breathless, go to A&E.' Offer to arrange his sick note. Ask if there is someone he would like to bring to the hospital appointment.

How examiners mark this station

Examiners will focus on the thoroughness and structure of your history taking for lung cancer. 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: Systematic red flag assessment: haemoptysis, weight loss, night sweats, appetite, fatigue. Smoking history quantified (100 pack-years). Occupational exposure (asbestos, construction). Complete respiratory review distinguishing from COPD exacerbation. Family history of lung cancer (wife).

Costs marks: Not asking about constitutional symptoms. Not quantifying smoking history. Missing asbestos exposure. Not exploring family history of cancer.

Domain 2: Clinical Management Skills (Primary focus)

Scores well: Arranging same-day chest X-ray. Initiating 2-week-wait cancer referral pathway per NICE NG12. Appropriate blood tests (FBC, calcium for paraneoplastic, LFTs, renal function). Clear safety netting for increased haemoptysis. Offering smoking cessation without making it the focus.

Costs marks: Not arranging urgent investigation. Not knowing the 2-week-wait pathway. Treating as COPD exacerbation with antibiotics. No safety netting for haemoptysis.

Domain 3: Interpersonal Skills (Primary focus)

Scores well: Meeting his stated agenda (sick note) before redirecting. Honest without premature diagnosis: explaining urgency without saying 'you have cancer.' Responding to his direct question about cancer with transparency. Sensitivity to his wife's death from lung cancer. Asking if he wants someone at the hospital appointment.

Costs marks: Ignoring his sick note request. Being evasive when he asks about cancer. Not acknowledging his wife's death from the same disease. Launching into smoking cessation lectures when he is frightened. Delivering the referral conversation without empathy.

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 weight loss, night sweats, and appetite. Mr Patterson presents with haemoptysis and a cough. The constitutional symptoms (weight loss, night sweats, fatigue, appetite loss) are present but he will not volunteer them. Candidates who stop at the cough and haemoptysis miss the full picture.
  2. Not asking about asbestos exposure. A 72-year-old retired bricklayer who worked in construction for 45 years has had significant asbestos exposure. Asbestos exposure synergistically increases lung cancer risk with smoking. This is a commonly missed occupational history point.
  3. Being evasive about the reason for urgent referral. Mr Patterson's wife died of lung cancer. He is connecting the dots. Candidates who say 'we just want to check things' without being transparent when asked directly undermine trust. If he asks 'Do you think it's cancer?', he deserves an honest response: 'I think we need to find out.'

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 lung cancer station?

Haemoptysis in a smoker over 40 is lung cancer until proven otherwise. The candidate's task is to identify red flag features, assess urgency, and initiate the 2-week-wait cancer referral pathway. Mr Patterson is 72, a current smoker with COPD, presenting with a three-month worsening cough and blood in his sputum today.

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

Strong performances show: Systematic red flag assessment: haemoptysis, weight loss, night sweats, appetite, fatigue. Smoking history quantified (100 pack-years). Occupational exposure (asbestos, construction). Weak performances: Not asking about constitutional symptoms. Not quantifying smoking history. Missing asbestos exposure. Not exploring family history of cancer.

What is the biggest pitfall in this lung cancer station?

Not asking about weight loss, night sweats, and appetite. Mr Patterson presents with haemoptysis and a cough. The constitutional symptoms (weight loss, night sweats, fatigue, appetite loss) are present but he will not volunteer them.

How should I prepare for lung cancer if I have never seen it in practice?

This station rewards process over personal experience. The skill being assessed: Actively eliciting red flag features the patient will not volunteer: weight loss, night sweats, appetite loss, and fatigue must be asked about directly. Use the domain breakdown on this page to target your preparation, then practise the station aloud so your structure survives exam pressure.

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