History Taking · Intermediate · Respiratory

Recurrent Breathlessness and Wheeze

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

Clinical scenario

You are an FY2 doctor in a general practice clinic. Mrs Emma Fletcher, a 34-year-old woman, has attended with recurrent episodes of breathlessness and wheezing over the past six weeks. She has not had significant respiratory disease before. Please take a focused respiratory history, assess for features of asthma, perform appropriate examination and investigations, and discuss initial management including inhaler technique and an asthma action plan.

Background notes: PMH: Hay fever (seasonal, controlled with antihistamines), Eczema (mild, childhood history, currently clear). No previous respiratory disease

What this station tests

  • Establishing the variable, episodic pattern of asthma: symptom-free intervals between episodes, identifiable triggers, and nocturnal symptoms
  • Assessing the atopic triad: hay fever, eczema history, and family history of asthma as supporting evidence for the diagnosis
  • Distinguishing new-onset adult asthma from COPD (no smoking), cardiac wheeze (no orthopnoea), and anxiety-related dyspnoea (physical triggers, audible wheeze)
  • Explaining preventer versus reliever inhalers at the first consultation: establishing the concept before the patient starts treatment
  • Identifying occupational and environmental triggers: school environment, pet dog, dust exposure during cleaning

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

New-onset wheeze in an adult requires the candidate to establish the pattern of variable airflow obstruction that distinguishes asthma from COPD, cardiac wheeze, or anxiety-related dyspnoea. The key features are episodic symptoms with identifiable triggers, symptom-free intervals, and an atopic background. Mrs Fletcher is 34, presenting with six weeks of recurrent breathlessness and wheezing. She has no previous respiratory disease. Open with: 'Tell me about these episodes of breathlessness. What happens and when?' Let her describe the pattern before directing your questions.

Core approach

Establish the episodic, variable pattern. She has had 5 to 6 episodes over six weeks, each lasting 20 minutes to an hour, settling with rest. Episodes are triggered by exercise (running), night-time (woke from sleep), and cleaning (dust). They come on over minutes, not suddenly, and involve chest tightness, breathlessness, and audible wheeze. No continuous symptoms between episodes. This variability is the hallmark of asthma: symptoms come and go, with symptom-free periods between.

Assess the atopic background. Mrs Fletcher has hay fever (seasonal, controlled with antihistamines) and a childhood history of eczema. Her mother and grandmother both have asthma. This personal and family history of atopy is strongly supportive of an asthma diagnosis. Ask about occupational triggers: she is a primary school teacher (exposure to infections, allergens in the school environment). Does she have pets? She has a dog (potential allergen). Ask about home environment: carpets, damp, dust.

Exclude competing diagnoses. No productive sputum, no fever (not infection). No orthopnoea or ankle swelling (not cardiac failure). Symptoms are not exercise-limited to a fixed exertion threshold (not cardiac). No smoking history (not COPD). No acid reflux worsening symptoms (not GORD-related cough). Screen for anxiety: episodes are not associated with panic, and she can identify physical triggers.

ICE: She wonders if it could be asthma given her family history, but also considers stress or anxiety. She is worried it might be something serious. She wants to know what it is and whether she can continue running.

Closing and safety netting

For a new asthma diagnosis, the closing must include confirmation of the suspected diagnosis, initial investigations, and a practical management plan. 'Mrs Fletcher, the pattern you describe, episodes of breathlessness and wheeze that come and go, triggered by exercise, dust, and happening at night, combined with your family history of asthma and your hay fever, strongly suggests asthma.'

Investigations: peak flow measurement today (baseline), spirometry with reversibility testing, and a peak flow diary for 2 to 4 weeks (morning and evening readings to demonstrate variability). Bloods including eosinophil count if available.

Initial management: start with a short-acting bronchodilator (salbutamol inhaler) for symptom relief, and if diagnosis is confirmed, a regular low-dose inhaled corticosteroid (preventer) will be needed. Teach inhaler technique at this first consultation. Explain the concept of preventer versus reliever: 'The preventer reduces the inflammation in your airways every day. The reliever opens your airways quickly when you have symptoms.' Reassure her she can continue running with appropriate management. Explain an asthma action plan will be developed once the diagnosis is confirmed. Safety net: 'If you have an episode where you cannot speak in full sentences or your reliever inhaler is not helping, call 999.'

How examiners mark this station

Examiners will focus on the thoroughness and structure of your history taking for asthma. 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: Establishing episodic, variable symptoms with trigger identification. Atopic history (personal and family). Environmental and occupational exposure assessment. Exclusion of COPD, cardiac failure, and anxiety. Complete medication and allergy history.

Costs marks: Not establishing the episodic pattern. Missing atopic background. Not asking about triggers (exercise, night, dust, pets). Not excluding alternative diagnoses.

Domain 2: Clinical Management Skills (Secondary focus)

Scores well: Appropriate investigations: peak flow today, spirometry referral, peak flow diary. Correct initial management: SABA for relief, ICS planned as preventer. Preventer versus reliever explanation. Inhaler technique teaching. Asthma action plan concept introduced. Safety netting for severe exacerbation.

Costs marks: No investigations planned. Prescribing inhalers without explaining preventer versus reliever. No inhaler technique. No safety netting for acute attack.

Domain 3: Interpersonal Skills (Throughout)

Scores well: Addressing her concern about whether she can continue running (yes, with management). Explaining asthma as a manageable condition. Exploring her family history connection and what it means for her. Checking understanding of inhaler use.

Costs marks: Being alarmist about asthma. Not addressing her exercise concern. Using jargon ('bronchodilator', 'inhaled corticosteroid') without plain language. Not checking understanding.

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 establishing the episodic pattern. Asthma is defined by variable airflow obstruction. Candidates who document 'breathlessness and wheeze for six weeks' without clarifying that she has symptom-free periods between episodes fail to distinguish asthma from a continuous process like COPD or heart failure.
  2. Missing the atopic background. Her personal history (hay fever, childhood eczema) and family history (mother and grandmother with asthma) are the strongest non-spirometric evidence for asthma. Candidates who do not ask about these miss the most supportive diagnostic features.
  3. Not teaching inhaler technique. Starting an inhaler without demonstrating technique is a missed opportunity. Poor inhaler technique is the commonest cause of treatment failure in asthma. Even mentioning technique briefly scores on Domain 2.

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 asthma history in this PLAB 2 station?

New-onset wheeze in an adult requires the candidate to establish the pattern of variable airflow obstruction that distinguishes asthma from COPD, cardiac wheeze, or anxiety-related dyspnoea. The key features are episodic symptoms with identifiable triggers, symptom-free intervals, and an atopic background. Mrs Fletcher is 34, presenting with six weeks of recurrent breathlessness and wheezing.

What are examiners marking in this asthma station?

Marks are won for: Establishing episodic, variable symptoms with trigger identification. Atopic history (personal and family). Environmental and occupational exposure assessment. Exclusion of COPD, cardiac failure, and anxiety. Marks are lost for: Not establishing the episodic pattern. Missing atopic background. Not asking about triggers (exercise, night, dust, pets). Not excluding alternative diagnoses.

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

Not establishing the episodic pattern. Asthma is defined by variable airflow obstruction. Candidates who document 'breathlessness and wheeze for six weeks' without clarifying that she has symptom-free periods between episodes fail to distinguish asthma from a continuous process like COPD or heart failure.

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

Structure beats experience here. Focus on assessing the atopic triad: hay fever, eczema history, and family history of asthma as supporting evidence for the diagnosis. 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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