History Taking · Foundation · Respiratory

Sudden Breathlessness After Immobility

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

Clinical scenario

You are an FY2 doctor in the Medical Assessment Unit. Ms Sarah Campbell, a 47-year-old woman, has presented with acute-onset breathlessness and pleuritic chest pain. She had a long-haul flight from Australia three days ago and has been relatively immobile since returning home. Please take a focused history, perform appropriate examination, and discuss initial management.

Background notes: PMH: nil chronic disease. Last took OCP 4 years ago (stopped due to headaches). Appendectomy aged 16. Immunisations up to date

What this station tests

  • Building the clinical probability of PE systematically: flight history, immobility, acute pleuritic symptoms, calf discomfort, Wells score components
  • Actively asking about leg symptoms: the right calf tightness is a concurrent DVT indicator that the patient may not connect to her chest symptoms
  • Initiating anticoagulation before imaging in high-probability cases: treating empirically when clinical suspicion is strong and CTPA may be delayed
  • Excluding competing differentials: pneumonia (no fever), pneumothorax (atypical), musculoskeletal (breathlessness present), and ACS (pleuritic, not heavy)
  • Clear communication of a blood clot diagnosis to a frightened patient: explaining PE and its treatability in lay terms

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

PE should be considered in any patient with acute-onset breathlessness plus pleuritic chest pain, especially with identifiable risk factors for venous thromboembolism. The candidate's role is to build the clinical probability, not to diagnose. Ms Campbell is 47, presenting with sudden breathlessness and right-sided pleuritic chest pain three days after a long-haul flight from Australia. Open with: 'Ms Campbell, tell me what happened and when it started.' The flight history combined with acute pleuritic symptoms should immediately raise PE on your differential.

Core approach

The pain started suddenly yesterday evening while sitting watching TV. It is sharp, right-sided, worse on deep inspiration and coughing, with no radiation. Associated severe breathlessness, palpitations, feeling faint, and a dry cough. No haemoptysis. These features, acute onset, pleuritic, unilateral, with dyspnoea and tachycardia, are the classic PE presentation.

Build the VTE risk profile. She flew from Australia three days ago (24-hour flight with stopover): prolonged immobility is a major risk factor. Since returning she has been relatively immobile at home (unpacking, resting on sofa). Previous OCP use stopped 4 years ago due to migraines. Ask specifically about her right calf: she will report it feels 'tight and achy,' which raises the possibility of concurrent DVT. This is a critical finding that candidates must actively elicit, as she may not connect her leg to her chest.

Assess using Wells score components: clinical signs of DVT (right calf tenderness, score 3), PE as likely or more likely than alternative diagnosis (yes, score 3), heart rate over 100 (likely, score 1.5), immobilisation or recent surgery (recent long-haul flight, score 1.5), previous DVT/PE (none). Even without the full score, clinical probability is intermediate to high.

Exclude competing differentials. Pneumonia: no fever, no productive cough, no preceding illness. Pneumothorax: possible but typically presents in tall, thin young men with sudden onset. Musculoskeletal: not reproducible on palpation, associated breathlessness makes this unlikely. ACS: sharp and pleuritic rather than heavy and central, no cardiac risk factors.

PMH: nothing significant. No regular medications. No allergies. Non-smoker, moderate social drinker. ICE: she is terrified it might be a heart attack. She also wonders about a blood clot given the flight.

Closing and safety netting

For suspected PE, the management plan must be clearly communicated. 'Ms Campbell, based on your symptoms, the timing after your flight, and the discomfort in your calf, I am concerned about a blood clot that may have travelled to your lung. This is called a pulmonary embolism. We need to do some urgent tests.' Name the investigations: CTPA (the definitive scan), blood gases, ECG, bloods including D-dimer (though with high clinical suspicion, CTPA is indicated regardless), and an ultrasound of her right leg.

Start treatment while awaiting results if clinical suspicion is high. Anticoagulation with a treatment-dose LMWH or DOAC should be initiated before CTPA if there will be a delay. This is important: candidates who wait for imaging before treating in a high-probability case demonstrate inadequate urgency.

Reassure her: 'PE is very treatable. The blood thinner medication we start today will prevent the clot from growing and allow your body to break it down.' Address her concerns about her children and work. Safety net: 'If your breathing suddenly worsens, you feel faint, or you cough up blood, tell the nursing team immediately.' She will need admission for monitoring and CTPA.

How examiners mark this station

Examiners will focus on the thoroughness and structure of your history taking for pulmonary embolism. 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 VTE risk assessment: flight, immobility, OCP history, calf symptoms. Wells score components identified. Active questioning about leg symptoms. Exclusion of pneumonia, pneumothorax, ACS, and musculoskeletal causes.

Costs marks: Not asking about calf symptoms. Not assessing VTE risk factors. Not calculating or estimating clinical probability. Not excluding competing diagnoses.

Domain 2: Clinical Management Skills (Primary focus)

Scores well: Correct investigation: CTPA as definitive imaging, not relying on D-dimer alone. Initiating anticoagulation before imaging. Appropriate additional investigations (ABG, ECG, leg USS). Correct safety netting for deterioration. Understanding of treatment pathway.

Costs marks: Ordering D-dimer as the only investigation. Not starting anticoagulation. Not requesting CTPA. Not admitting the patient. Vague management plan.

Domain 3: Interpersonal Skills (Throughout)

Scores well: Clear explanation of PE in lay terms ('blood clot that has travelled to your lung'). Addressing her fear of a heart attack. Reassuring about treatability. Acknowledging impact on her family and work. Calm, confident manner matching the clinical urgency.

Costs marks: Using 'pulmonary embolism' without explanation. Not addressing her cardiac anxiety. Being overly alarming. Not acknowledging her family concerns.

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 calf symptoms. Ms Campbell's right calf feels 'tight and achy' but she may not mention it unless asked specifically about her legs. This concurrent DVT finding increases the clinical probability of PE significantly and is a commonly missed history point.
  2. Waiting for CTPA before starting anticoagulation. In a patient with high clinical probability of PE, treatment-dose anticoagulation should be started while awaiting imaging. Candidates who say 'we will do a scan and then decide' demonstrate inadequate urgency for a potentially life-threatening condition.
  3. Relying on D-dimer in a high-probability patient. D-dimer is useful for excluding PE in low-probability patients. In a patient with acute pleuritic pain, dyspnoea, recent flight, and calf symptoms, clinical probability is intermediate to high and CTPA is indicated directly. Candidates who order 'just a D-dimer' show misunderstanding of the diagnostic pathway.

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 pulmonary embolism history in this PLAB 2 station?

PE should be considered in any patient with acute-onset breathlessness plus pleuritic chest pain, especially with identifiable risk factors for venous thromboembolism. The candidate's role is to build the clinical probability, not to diagnose. Ms Campbell is 47, presenting with sudden breathlessness and right-sided pleuritic chest pain three days after a long-haul flight from Australia.

What are examiners marking in this pulmonary embolism station?

Marks are won for: Systematic VTE risk assessment: flight, immobility, OCP history, calf symptoms. Wells score components identified. Active questioning about leg symptoms. Marks are lost for: Not asking about calf symptoms. Not assessing VTE risk factors. Not calculating or estimating clinical probability. Not excluding competing diagnoses.

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

Not asking about calf symptoms. Ms Campbell's right calf feels 'tight and achy' but she may not mention it unless asked specifically about her legs. This concurrent DVT finding increases the clinical probability of PE significantly and is a commonly missed history point.

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

This station rewards process over personal experience. The skill being assessed: Actively asking about leg symptoms: the right calf tightness is a concurrent DVT indicator that the patient may not connect to her chest symptoms. 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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