Counselling · Foundation · Respiratory

Sore Throat and Cough for One Week

Practise this PLAB 2 counselling station on Viral Upper Respiratory Tract Infection. 8-minute voice AI simulation with feedback on all 3 marking domains.

Clinical scenario

You are an FY2 doctor in a GP surgery. Miss Emma Thompson, a 24-year-old woman, has attended with a sore throat and cough for one week, expecting antibiotics. She is otherwise well with no concerning features. Please counsel her on the viral nature of her symptoms, explain why antibiotics are not indicated, and discuss self-care measures and when to seek further help.

Background notes: PMH: Mild asthma (well-controlled, occasional inhaler use), Allergic rhinitis

What this station tests

  • Antibiotic stewardship: explaining why antibiotics are not indicated for viral URTI without making the patient feel dismissed
  • Using Centor criteria implicitly: the presence of cough, absence of fever, and absence of exudate reduce the likelihood of streptococcal pharyngitis
  • Providing genuine value when not prescribing: specific self-care advice, natural history education, and clear safety netting give the patient a reason to feel the consultation was worthwhile
  • Managing patient expectations set by family: addressing her mum's advice respectfully without undermining the family relationship
  • Red flag exclusion for serious throat pathology: peritonsillar abscess, epiglottitis, and immunocompromise

How to use your 8 minutes

  • 0-1 min — Introduction: Introduce yourself, establish what patient already knows and understands.
  • 1-3 min — Explain Condition: Explain diagnosis or condition using chunk-and-check technique. Use simple language, avoid jargon.
  • 3-5 min — Management Options: Discuss treatment options. Shared decision-making. Risks, benefits, alternatives.
  • 5-7 min — Address Concerns: Explore and address specific concerns. Check understanding. Discuss lifestyle implications.
  • 7-8 min — Closing: Summarise agreed plan. Safety netting. Arrange follow-up. Written information offer.

Consultation approach

The opening

Antibiotic stewardship counselling tests the candidate's ability to say no to a patient's expectation while maintaining rapport and providing genuine value. The patient expects antibiotics, and the candidate must explain why they are not indicated without making the patient feel dismissed. Miss Thompson is 24, a university student, with a one-week sore throat and cough. Her mum told her to get antibiotics. Open with: 'Tell me about your symptoms and how they have been affecting you.' Address her experience before addressing her expectation.

Core approach

Confirm the viral picture through targeted history. Sore throat for one week, now improving. Dry cough becoming productive of clear or whitish mucus. No fever (she checked). No exudate or white spots on inspection. Can eat and drink. No severe dysphagia, no trismus, no unilateral swelling, no stridor. Sleep disrupted by coughing. These features, gradual onset, no fever, no exudate, cough present (Centor criteria: cough present reduces likelihood of streptococcal infection), are consistent with viral URTI.

Screen for red flags that would change management. No signs of peritonsillar abscess (can open mouth fully, no unilateral swelling). No signs of epiglottitis (no stridor, no drooling). No immunocompromise. Mild asthma is well-controlled and not currently exacerbating. This is a straightforward viral illness in a young, immunocompetent patient.

Now address the antibiotic expectation. Do not start with 'you don't need antibiotics.' Instead, explain what is happening: 'This is a viral infection, which means it is caused by a virus, not bacteria. Antibiotics work against bacteria but have no effect on viruses. Taking antibiotics when they are not needed does not help you recover faster, but it does increase the risk of side effects and contributes to antibiotic resistance.' Address her mum's advice without dismissing it: 'I understand your mum suggested antibiotics, and that is a very common belief. A few years ago, doctors did prescribe antibiotics more freely for sore throats, but we now know this was not helpful and may have caused harm.'

ICE: She expects antibiotics, is frustrated the illness is dragging on, worried it might become pneumonia, anxious about missing classes and exams, and wants to feel better quickly.

Closing and safety netting

Provide genuine value through self-care advice. This is where the consultation earns its worth despite not prescribing. Regular paracetamol and ibuprofen for pain (alternating). Honey and lemon drinks. Adequate hydration. Rest when possible. Salt water gargles for the sore throat. Throat lozenges. Explain the natural history: 'Most sore throats last 7 to 10 days. Yours has been going for a week, so you are likely coming to the end of it. The cough may linger for up to 3 weeks after the sore throat settles, which is normal.'

Address her asthma: 'If you notice your asthma symptoms worsening, your wheeze increasing, or your reliever inhaler not lasting 4 hours, come back as that would need separate treatment.'

Safety net clearly: 'Come back if you develop a high fever, cannot swallow fluids, your neck becomes very swollen on one side, you develop a rash, or your symptoms significantly worsen rather than gradually improving.' Offer a university letter if she needs evidence of attending the GP. She will leave without antibiotics but should leave feeling heard and informed.

How examiners mark this station

Examiners will assess your ability to explain viral upper respiratory tract infection and its management in a patient-centred way. Domain 2 (Clinical Management) and Domain 3 (Interpersonal Skills) are equally weighted and primary. Expect marks for accurate information delivery, shared decision-making, chunk-and-check technique, and addressing the patient's specific concerns. Domain 1 (Data Gathering) is assessed through how well you establish the patient's baseline understanding and elicit their concerns.

Domain 1: Data Gathering, Technical and Assessment Skills (Supporting)

Scores well: Confirming the viral picture: timeline, absence of fever, absence of exudate, presence of cough. Red flag exclusion: no abscess, no epiglottitis, no immunocompromise. Checking asthma status. Centor criteria applied implicitly.

Costs marks: Not examining or asking about red flag features. Not checking asthma status. Superficial history that does not confirm the viral picture.

Domain 2: Clinical Management Skills (Primary focus)

Scores well: Correct decision not to prescribe antibiotics with clear rationale. Specific self-care advice: paracetamol/ibuprofen, honey, gargles, hydration. Natural history education (7 to 10 days for sore throat, cough may linger 3 weeks). Asthma-specific safety netting. Clear return criteria for red flags.

Costs marks: Prescribing antibiotics for a viral URTI. No self-care advice. No natural history explanation. No safety netting. Not addressing asthma.

Domain 3: Interpersonal Skills (Primary focus)

Scores well: Addressing her expectation without dismissing it. Respecting her mum's advice while correcting it. Explaining the rationale for not prescribing in a way that educates rather than refuses. Acknowledging her frustration about missing classes. Providing a university letter.

Costs marks: Dismissing her request for antibiotics without explanation. Being condescending. Dismissing her mum's advice. Not acknowledging the impact on her studies and work.

Common examiner feedback (and how to fix it)

Did not provide adequate explanation or plan to the patient

Fix: Use chunk-and-check: deliver one concept, check understanding, then move to the next. Offer all relevant treatment options with risks and benefits before helping the patient decide.

Did not sufficiently recognise or respond to the patient's feelings, concerns, or expectations

Fix: Before and during counselling, explicitly ask what concerns the patient most. Respond to emotional cues with empathic statements before continuing with information.

Common mistakes in this station

  1. Starting with 'you don't need antibiotics.' This triggers defensiveness. Candidates who explain what the illness is (viral) before explaining what it is not (bacterial) have a much better chance of the patient accepting the decision. Lead with diagnosis, not refusal.
  2. Not providing adequate self-care advice. If the patient leaves with nothing, she feels dismissed. Specific, practical self-care (paracetamol/ibuprofen alternating, honey, salt water gargles, hydration) gives her a treatment plan even without a prescription. This is the difference between a good and poor consultation.
  3. Dismissing her mum's advice. Saying 'your mum is wrong' undermines a family relationship. Candidates who contextualise it ('doctors used to prescribe antibiotics more often, but evidence has shown this was not helpful') respect the source while correcting the information.

Resitting PLAB 2?

If counselling stations have been a challenge, the most common issue is information overload: delivering too much clinical detail without checking understanding. Practise the chunk-and-check technique until it becomes automatic. Remember that shared decision-making, not lecturing, is what scores highly in Domain 3.

Example opening

Hello, my name is Dr [Name]. I understand you've come in today to discuss [topic]. Before I explain things, could you tell me what you've been told so far, so I know where to start?

Frequently asked questions

What is the best way to structure this viral upper respiratory tract infection counselling consultation?

Antibiotic stewardship counselling tests the candidate's ability to say no to a patient's expectation while maintaining rapport and providing genuine value. The patient expects antibiotics, and the candidate must explain why they are not indicated without making the patient feel dismissed. Miss Thompson is 24, a university student, with a one-week sore throat and cough.

Where are marks won and lost in this viral upper respiratory tract infection station?

Examiners reward: Confirming the viral picture: timeline, absence of fever, absence of exudate, presence of cough. Red flag exclusion: no abscess, no epiglottitis, no immunocompromise. Candidates are penalised for: Not examining or asking about red flag features. Not checking asthma status. Superficial history that does not confirm the viral picture.

Where do candidates most often go wrong in this station?

Starting with 'you don't need antibiotics.' This triggers defensiveness. Candidates who explain what the illness is (viral) before explaining what it is not (bacterial) have a much better chance of the patient accepting the decision. Lead with diagnosis, not refusal.

Can I do well in this station without real-world experience of viral upper respiratory tract infection?

Structure beats experience here. Focus on using Centor criteria implicitly: the presence of cough, absence of fever, and absence of exudate reduce the likelihood of streptococcal pharyngitis. 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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