History Taking · Intermediate · Rheumatology

Persistent Fatigue in a 45-Year-Old Woman

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

Clinical scenario

You are an FY2 doctor in a GP surgery. Mrs Anna Chow, a 45-year-old woman, has come to see you with a complaint of persistent exhaustion lasting nine months. She reports extreme tiredness that is disproportionate to her activity, difficulty concentrating, and muscle pain. She has had numerous investigations already. Please take a focused history to exclude organic causes and discuss your assessment of chronic fatigue syndrome versus other causes.

Background notes: PMH: Glandular fever age 20 (recovered normally), Appendectomy age 32, Hay fever in spring

What this station tests

  • Post-exertional malaise as the cardinal feature of CFS/ME: disproportionate worsening after physical or mental exertion, lasting days
  • Making a positive diagnosis rather than a diagnosis of exclusion: CFS/ME is a recognised condition with specific features
  • Validating the patient's experience: acknowledging that normal tests do not mean normal health
  • Pacing rather than graded exercise therapy: NICE no longer recommends GET for CFS/ME
  • Not repeating normal investigations: avoiding over-investigation that reinforces diagnostic uncertainty

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

CFS/ME stations test whether the candidate can make a positive diagnosis after excluding organic causes, validate the patient's experience, and provide a management plan. The challenge is a patient who feels dismissed by previous doctors despite normal investigations. Mrs Chow is 45, presenting with 9 months of overwhelming fatigue. All investigations are normal. She is frustrated and wants answers. Open with: 'Mrs Chow, I can see this has been going on a long time. Tell me how it is affecting you.'

Core approach

Characterise the fatigue. Duration: 9 months. Onset: around a period of work stress, possibly preceded by a viral illness. Character: overwhelming, disproportionate to activity, not relieved by rest. Post-exertional malaise: any physical or mental exertion makes her worse for days afterward (the cardinal feature of CFS/ME). Cognitive symptoms: 'brain fog,' difficulty concentrating, word-finding problems. Sleep: unrefreshing despite adequate hours. She was previously active and high-functioning.

Confirm that organic causes have been excluded. FBC, TFTs, U&E, LFTs, glucose, ESR/CRP, coeliac screen, B12/folate, cortisol: all normal. If any have not been done, arrange them. Do not repeat tests that have already been normal.

Make the diagnosis positively. 'Mrs Chow, based on the duration of your symptoms, the pattern of post-exertional malaise, the cognitive difficulties, and the normal investigations, this is consistent with a condition called chronic fatigue syndrome or ME.' Frame this as a real diagnosis: 'This is a recognised medical condition, not a diagnosis of exclusion or a way of saying we cannot find anything.'

Validate her experience. She has felt dismissed by previous doctors. 'I understand how frustrating it has been to feel so unwell and be told everything is normal. The investigations are normal because this condition does not show up on blood tests, but that does not mean it is not real.'

Closing and safety netting

Management: pacing is the cornerstone (activity management to avoid boom-bust cycles). Not graded exercise therapy (which NICE no longer recommends for CFS/ME). Pacing means staying within her energy envelope rather than pushing through. Sleep hygiene. Cognitive rehabilitation if brain fog is prominent. Consider referral to a specialist CFS/ME service if available.

Address work: occupational health assessment for workplace adjustments (reduced hours, flexible working, rest breaks). She may need a phased return if she has been off work. Do not recommend she 'push through' as this worsens PEM. Safety net: 'If you develop new symptoms like weight loss, fever, or focal neurological changes, come back as we would need to reconsider.' Follow-up in 4 to 6 weeks.

How examiners mark this station

Examiners will focus on the thoroughness and structure of your history taking for chronic fatigue syndrome. 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: Post-exertional malaise identified as cardinal feature. Duration and onset characterised. Cognitive symptoms documented. Previous investigations reviewed (not repeated). Organic causes confirmed excluded.

Costs marks: Not identifying PEM. Repeating normal tests. Not reviewing previous investigation results. Missing cognitive symptoms.

Domain 2: Clinical Management Skills (Primary focus)

Scores well: Positive CFS/ME diagnosis made with confidence. Pacing recommended (not GET). Sleep hygiene. Occupational health referral. Specialist CFS/ME service referral. Appropriate safety netting for new symptoms.

Costs marks: Recommending GET. Vague management ('try to rest more'). No specialist referral. No occupational support.

Domain 3: Interpersonal Skills (Primary focus)

Scores well: Validating her experience. Framing CFS/ME as a real condition. Acknowledging frustration with previous dismissal. Not repeating the dismissal. Providing a clear diagnosis and plan.

Costs marks: Dismissing as 'nothing wrong.' Suggesting it is psychological. Not validating her frustration.

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. Recommending graded exercise therapy. NICE updated its guidance in 2021 and no longer recommends GET for CFS/ME. Candidates who suggest 'gradually increasing your exercise' demonstrate outdated knowledge.
  2. Dismissing the diagnosis as 'we cannot find anything wrong.' CFS/ME is a positive diagnosis based on specific criteria, not a label for unexplained fatigue. Candidates who present it as 'good news that tests are normal' invalidate the patient.
  3. Repeating investigations that have already been normal. Re-checking TFTs and FBC when they were recently normal wastes resources and reinforces the patient's fear that something has been missed.

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

What is the best way to take a chronic fatigue syndrome history in PLAB 2?

CFS/ME stations test whether the candidate can make a positive diagnosis after excluding organic causes, validate the patient's experience, and provide a management plan. The challenge is a patient who feels dismissed by previous doctors despite normal investigations. Mrs Chow is 45, presenting with 9 months of overwhelming fatigue.

Where are marks won and lost in this chronic fatigue syndrome station?

Examiners reward: Post-exertional malaise identified as cardinal feature. Duration and onset characterised. Cognitive symptoms documented. Previous investigations reviewed (not repeated). Candidates are penalised for: Not identifying PEM. Repeating normal tests. Not reviewing previous investigation results. Missing cognitive symptoms.

Where do candidates most often go wrong in this station?

Recommending graded exercise therapy. NICE updated its guidance in 2021 and no longer recommends GET for CFS/ME. Candidates who suggest 'gradually increasing your exercise' demonstrate outdated knowledge.

Can I do well in this station without real-world experience of chronic fatigue syndrome?

This station rewards process over personal experience. The skill being assessed: Making a positive diagnosis rather than a diagnosis of exclusion: CFS/ME is a recognised condition with specific features. 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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