Telephone Consultation · Intermediate · Respiratory

Telephone Call About Confusion in Elderly Patient

Practise this PLAB 2 telephone consultation station on Respiratory Sepsis. 8-minute voice AI simulation with feedback on all 3 marking domains.

Clinical scenario

You are an on-call GP receiving a telephone call from Margaret Wilson, the daughter of Mr Thomas Wilson, an 83-year-old man living independently. Margaret is calling because her father seems confused and unusually lethargic today. He lives alone but Margaret visits regularly. Please assess the situation over the telephone, establish risk of serious illness, and arrange appropriate management. This is a TELEPHONE consultation - you cannot examine the patient directly.

Background notes: PMH: COPD (mild-moderate, FEV1 55% predicted, on inhalers), Type 2 diabetes (diet/metformin controlled), Hypertension (on amlodipine)

What this station tests

  • Triaging urgency by telephone: identifying new confusion plus signs of sepsis as a medical emergency requiring 999, not a GP home visit
  • Gathering clinical information through a third party: directing Margaret to check specific things (temperature, respiratory rate, mobility, sputum colour) to compensate for not being able to examine
  • Considering the differential for acute confusion in an elderly patient: respiratory sepsis (most likely), UTI, hypoglycaemia (diabetic), subdural (on anticoagulant), dehydration
  • Making a clear disposition decision and communicating it confidently: telling the daughter an ambulance is needed without hedging
  • Providing practical instructions while waiting for the ambulance: what to do, what not to do, when to re-escalate

How to use your 8 minutes

  • 0-1 min — Introduction: Introduce yourself and confirm patient identity. Explain purpose and check they can talk. Verify phone number for callback.
  • 1-3 min — Gather Information: Take focused history. Compensate for lack of visual cues with explicit questions about severity.
  • 3-5 min — Assessment: Summarise findings. Share working assessment. Identify any red flags requiring face-to-face review.
  • 5-7 min — Management Plan: Discuss management. Clear instructions. Ensure patient has means to follow plan (medications, transport to hospital).
  • 7-8 min — Safety Netting: Explicit safety netting (patient cannot see your expressions). When to call back, when to go to A&E. Confirm understanding.

Consultation approach

The opening

Telephone consultation stations test your ability to assess clinical urgency without seeing the patient. The candidate must compensate for missing visual information by asking explicit, structured questions through the caller. Margaret Wilson, 55, is calling about her 83-year-old father Thomas, who is confused and lethargic today. He lives alone. Start by establishing who you are speaking to and the urgency: 'Thank you for calling, Margaret. I can hear you're worried. Can you tell me exactly what you've found when you arrived today?' Begin triaging immediately.

Core approach

Gather information through Margaret systematically. Thomas was fine yesterday evening by phone. Today he is confused (not recognising Margaret initially, asking what day it is, repeating questions), still in pyjamas (unusual for a man who is normally dressed by 9am), and lethargic. New confusion in an elderly person is a medical emergency until proven otherwise.

Assess for sepsis features through Margaret. Ask her to check: 'Does he feel hot to touch?' (yes, forehead is warm). 'Is he breathing faster than normal?' (yes, seems to be breathing quickly). 'Can he walk to the bathroom?' (struggling, unsteady). 'Has he had a cough recently?' (yes, coughing more the past few days, especially at night). 'Any coloured sputum?' (yes, greenish). These features, new confusion plus fever plus tachypnoea plus productive cough in a patient with COPD, strongly suggest respiratory sepsis.

Check his medications: inhalers (adherent), amlodipine, metformin, apixaban. The metformin is relevant because hypoglycaemia is a differential for acute confusion in a diabetic patient. Ask if there is a glucometer available. The apixaban tells you he has AF, which is relevant background.

Assess for other causes of acute confusion: urinary symptoms (could indicate UTI with sepsis), falls or head injury (subdural in a patient on apixaban), medication changes, alcohol (he does not drink). Has he eaten and drunk normally today (dehydration)?

This patient needs a face-to-face assessment urgently. The combination of new confusion, fever, tachypnoea, and productive cough in an 83-year-old with COPD and diabetes is high-risk.

Closing and safety netting

The key decision in a telephone consultation is disposition: can this wait for a GP visit, or does this need 999? For Mr Wilson, the answer is 999. New confusion with signs of sepsis (fever, tachypnoea) in an elderly, comorbid patient is a medical emergency. Tell Margaret clearly: 'Margaret, based on what you have described, I am concerned your father may have a serious chest infection that is making him confused. I think we need to call an ambulance to get him to hospital for assessment and treatment. This is the safest option.'

Give Margaret instructions while waiting: keep him comfortable, do not give any new medications, offer small sips of water if he can swallow safely, note what medications he has taken today. If he deteriorates (stops responding, breathing becomes very laboured, or he collapses), call 999 again.

Acknowledge Margaret's anxiety: 'I know this is frightening. You have done the right thing by calling. The hospital team will be able to examine him properly and start treatment.' Ask her to bring his medication list to hospital. Offer to call the ambulance service yourself if she would prefer. Document the consultation thoroughly.

How examiners mark this station

Examiners will assess all three domains, with particular attention to how you compensate for the lack of visual cues. Domain 1 (Data Gathering) focuses on your ability to take a thorough history remotely. Domain 2 (Clinical Management) assesses the clarity of your management plan and quality of safety netting. Domain 3 (Interpersonal Skills) assesses your telephone communication skills.

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

Scores well: Systematic telephone assessment: directing the caller to check specific features (temperature, respiratory rate, mental state, mobility). Differential diagnosis for acute confusion: sepsis, UTI, hypoglycaemia, subdural, dehydration. Medication check including metformin (hypoglycaemia risk) and apixaban (bleeding risk).

Costs marks: Passive history taking ('tell me what's wrong'). Not directing Margaret to check specific features. Not considering hypoglycaemia in a diabetic patient. Not assessing sepsis features.

Domain 2: Clinical Management Skills (Primary focus)

Scores well: Correct 999 disposition for suspected sepsis. Clear instructions while waiting for ambulance. Appropriate safety netting for deterioration. Asking Margaret to bring medication list to hospital. Offering to call the ambulance directly.

Costs marks: Arranging GP home visit instead of 999. No clear instructions while waiting. No deterioration plan. Not recognising the urgency.

Domain 3: Interpersonal Skills (Primary focus)

Scores well: Calm, clear communication with an anxious daughter. Acknowledging her worry and affirming she did the right thing by calling. Explaining the reasoning for 999 without causing panic. Practical and supportive throughout.

Costs marks: Being dismissive of Margaret's concerns. Causing unnecessary alarm. Not explaining why an ambulance is needed. Cold or procedural tone inappropriate for a worried family member.

Common examiner feedback (and how to fix it)

Did not gather sufficient information to make an adequate assessment of the patient's condition

Fix: Ask explicitly about things you would normally observe: 'Can you describe the rash for me?', 'How severe is the pain on a scale of 1-10?', 'Are you able to walk around?'

Did not provide adequate safety netting

Fix: Be very specific: 'If you develop X, Y, or Z, go directly to A&E or call 999.' Confirm the patient has understood and can access care if needed.

Common mistakes in this station

  1. Arranging a GP home visit instead of calling 999. An 83-year-old with new confusion, fever, tachypnoea, and productive cough has probable respiratory sepsis. A GP home visit means hours of delay. This patient needs hospital assessment urgently. Candidates who underestimate the severity demonstrate inadequate telephone triage skills.
  2. Not directing Margaret to check specific clinical features. Over the phone, you cannot examine. Candidates who say 'he sounds unwell, bring him in' without asking Margaret to check whether he is hot, how fast he is breathing, or whether he can walk miss the opportunity to triage accurately.
  3. Not considering hypoglycaemia. Thomas is diabetic on metformin. Acute confusion in a diabetic patient could be hypoglycaemia, which is rapidly reversible. Candidates should ask if a glucometer is available or if he has eaten today. Missing this is a patient safety issue.

Resitting PLAB 2?

If telephone consultation stations have been difficult, remember that you must compensate for the lack of visual cues with explicit verbal checking. Describe what you would normally observe, ask about severity in concrete terms, and provide very clear safety netting since the patient cannot see your facial expressions.

Example opening

Hello, am I speaking with [patient name]? Could I confirm your date of birth please? My name is Dr [Name], I'm calling from [surgery/hospital]. Is this a good time to talk? Are you somewhere private?

Frequently asked questions

What is the best way to structure a respiratory sepsis consultation over the phone?

Telephone consultation stations test your ability to assess clinical urgency without seeing the patient. The candidate must compensate for missing visual information by asking explicit, structured questions through the caller. Margaret Wilson, 55, is calling about her 83-year-old father Thomas, who is confused and lethargic today.

Where are marks won and lost in this respiratory sepsis station?

Examiners reward: Systematic telephone assessment: directing the caller to check specific features (temperature, respiratory rate, mental state, mobility). Differential diagnosis for acute confusion: sepsis, UTI, hypoglycaemia, subdural, dehydration. Candidates are penalised for: Passive history taking ('tell me what's wrong'). Not directing Margaret to check specific features. Not considering hypoglycaemia in a diabetic patient.

Where do candidates most often go wrong in this station?

Arranging a GP home visit instead of calling 999. An 83-year-old with new confusion, fever, tachypnoea, and productive cough has probable respiratory sepsis. A GP home visit means hours of delay.

Can I do well in this station without real-world experience of respiratory sepsis?

Structure beats experience here. Focus on gathering clinical information through a third party: directing Margaret to check specific things (temperature, respiratory rate, mobility, sputum colour) to compensate for not being able to examine. 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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