History Taking · Foundation · Respiratory

Progressive Cough and Breathlessness in Immunocompromised Patient

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

Clinical scenario

You are an FY2 doctor in the A&E department. Marcus Johnson, a 34-year-old man, has come in with a two-week history of progressive dry cough and increasing shortness of breath. He mentions he is unwell with night sweats. Please take a focused history exploring his immune status, exposure risks, and severity of presentation, and discuss initial investigations and management considerations.

Background notes: PMH: Not disclosed initially - undiagnosed or undisclosed HIV/immunosuppression; on no regular medications (or patient not forthcoming)

What this station tests

  • Recognising the PCP presentation pattern: insidious dry cough, progressive dyspnoea, night sweats in a young adult, distinct from acute bacterial pneumonia or TB
  • Asking about HIV status directly and sensitively: the clinical pattern mandates this question, and avoiding it is a clinical failure
  • Taking a relevant sexual history: number of partners, condom use, MSM status, done with sensitivity and clinical justification
  • Distinguishing PCP from TB and bacterial pneumonia: tempo (subacute vs acute), cough character (dry vs productive), and constitutional symptom pattern
  • Communicating a diagnosis that implies underlying immunocompromise without making assumptions or causing stigma

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

When a young patient presents with progressive respiratory symptoms and constitutional features, the candidate must consider immunocompromise even if it is not volunteered. The combination of insidious dry cough, progressive dyspnoea, and night sweats in a 34-year-old should trigger questions about HIV status, regardless of how uncomfortable the candidate finds them. Marcus is 34, presenting with two weeks of worsening dry cough and breathlessness, with night sweats. He has not seen a GP because he thought it would pass. Open with: 'Marcus, tell me about what's been happening over the past two weeks.'

Core approach

The presentation is characteristic of PCP: insidious onset (not acute like bacterial pneumonia), progressive dry cough over two weeks, dyspnoea that started on exertion and is now present at rest, night sweats drenching his clothing, fatigue, and weight loss. This tempo and pattern, subacute, progressive, dry, with constitutional symptoms, is the classic PCP signature. Bacterial pneumonia presents acutely with productive cough and high fever. TB presents more insidiously but over weeks to months with productive cough.

The critical history is immune status. Ask about HIV directly: 'Have you ever been tested for HIV?' Marcus may be reluctant initially. He may be already diagnosed and non-adherent to antiretroviral therapy, or he may be undiagnosed. Either way, the candidate must ask sensitively but directly. Do not dance around it. 'I ask because the pattern of your symptoms, a slowly progressive dry cough with night sweats in someone your age, can sometimes be associated with a weakened immune system. An HIV test would be an important part of working out what is going on.'

If he discloses HIV: ask about antiretroviral therapy (he may have stopped months ago), most recent CD4 count (PCP typically occurs below 200), and whether he was on PCP prophylaxis (co-trimoxazole). If he has not been tested: recommend testing as part of the workup, with his consent.

Screen for other opportunistic infection features: oral thrush (suggests low CD4), skin lesions, visual changes (CMV retinitis), diarrhoea, neurological symptoms. Take a sexual history if appropriate: number of partners, condom use, MSM status. This requires sensitivity but is clinically essential.

Screen for TB risk: contact history, travel, occupation. Exclude bacterial pneumonia: no purulent sputum, no acute high fever, no rigors.

Closing and safety netting

Communicating a likely PCP diagnosis requires acknowledging the underlying HIV question without making assumptions. 'Marcus, the pattern of your symptoms, progressive dry cough, breathlessness at rest, and night sweats, suggests an infection called Pneumocystis pneumonia, which typically occurs when the immune system is weakened. We need to do some urgent tests: blood tests including an HIV test with your consent, a chest X-ray, blood oxygen levels, and possibly a CT scan.'

Immediate management: oxygen if hypoxic, IV access, blood cultures and sputum samples. He will need admission. Treatment for PCP is high-dose co-trimoxazole. If severely hypoxic (PaO2 below 9.3 kPa), adjunctive steroids improve survival.

Handle the HIV conversation with care. If he discloses or accepts testing: 'This is the right thing to do. If HIV is confirmed, there are excellent treatments available that can bring the virus under control and protect your immune system.' Safety net: 'You need to stay in hospital for treatment. Your breathing could worsen before it improves, and we need to monitor you closely.' Acknowledge that this is a lot to process.

How examiners mark this station

Examiners will focus on the thoroughness and structure of your history taking for pneumocystis 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: Recognising the PCP pattern from symptom tempo and character. Asking about HIV status directly. Taking a sexual history. Screening for other opportunistic infections (oral thrush, skin lesions, visual changes). Excluding TB and bacterial pneumonia. Checking CD4 count and ART adherence if HIV known.

Costs marks: Not asking about HIV. Not taking a sexual history. Treating as CAP without considering immunocompromise. Not screening for other opportunistic infections.

Domain 2: Clinical Management Skills (Primary focus)

Scores well: Appropriate urgent investigation plan: HIV test, CXR, ABG/SpO2, sputum, blood cultures. Recognising need for admission. Knowledge of PCP treatment (high-dose co-trimoxazole) and adjunctive steroids for severe hypoxia. Correct safety netting about clinical trajectory.

Costs marks: Sending the patient home with antibiotics. Not requesting an HIV test. Not recognising the need for admission. No knowledge of PCP treatment.

Domain 3: Interpersonal Skills (Primary focus)

Scores well: Asking about HIV with sensitivity and clinical justification. Non-judgmental approach to sexual history. Providing hope about HIV treatment if disclosed. Acknowledging that this is a lot to process. Creating a safe space for disclosure.

Costs marks: Avoiding the HIV question. Being judgmental about sexual history. Making assumptions about the patient. Delivering the potential HIV diagnosis insensitively.

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 HIV. A 34-year-old with progressive dry cough, dyspnoea, and night sweats needs an HIV test. Candidates who attribute the presentation to 'viral infection' or 'atypical pneumonia' without considering immunocompromise miss the most important diagnosis. The HIV question must be asked, not assumed.
  2. Being too indirect about the HIV question. Saying 'have you been unwell recently' or 'do you take any medications' and hoping the patient volunteers HIV status is not adequate. The clinical presentation demands a direct question: 'Have you ever been tested for HIV?'
  3. Treating this as straightforward community-acquired pneumonia. The presentation is wrong for CAP: insidious onset (not acute), dry cough (not productive), progressive over weeks (not days), night sweats (suggesting systemic rather than localised infection). Candidates who prescribe amoxicillin and send the patient home miss a life-threatening diagnosis.

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 pneumocystis pneumonia history in this PLAB 2 station?

When a young patient presents with progressive respiratory symptoms and constitutional features, the candidate must consider immunocompromise even if it is not volunteered. The combination of insidious dry cough, progressive dyspnoea, and night sweats in a 34-year-old should trigger questions about HIV status, regardless of how uncomfortable the candidate finds them. Marcus is 34, presenting with two weeks of worsening dry cough and breathlessness, with night sweats.

What are examiners marking in this pneumocystis pneumonia station?

Marks are won for: Recognising the PCP pattern from symptom tempo and character. Asking about HIV status directly. Taking a sexual history. Marks are lost for: Not asking about HIV. Not taking a sexual history. Treating as CAP without considering immunocompromise. Not screening for other opportunistic infections.

What is the most common mistake candidates make in this pneumocystis pneumonia station?

Not asking about HIV. A 34-year-old with progressive dry cough, dyspnoea, and night sweats needs an HIV test. Candidates who attribute the presentation to 'viral infection' or 'atypical pneumonia' without considering immunocompromise miss the most important diagnosis.

How do I prepare for this station if I have not managed pneumocystis pneumonia in clinical practice?

Structure beats experience here. Focus on asking about HIV status directly and sensitively: the clinical pattern mandates this question, and avoiding it is a clinical failure. 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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