MD Acumen · PLAB 2 OSCE / CPSA course · free practice resources
Practice case P2-23 · Face-to-face · simulated patient
“This mole on my leg has changed”
A 38-year-old landscape gardener has booked a routine appointment about a mole on her leg that she thinks has changed. She would like it “sorted out today”.
Reviewed and kept current
Station family: History, diagnosis and management · 8-minute station · 1 min 30 s reading · Last editorial review: 16 October 2026 · Next scheduled refresh: 11 April 2027.
Candidate instructions
Read this as you would outside the room
You have 1 minute 30 seconds to read, then 8 minutes. Candidates: everything below this section is folded away — leave it closed until you have finished the station.
| Information | |
|---|---|
| Your role | Foundation Year 2 doctor in a general practice. Your supervising GP is available. The practice does not have a dermatoscope. |
| Patient | Ms Hannah Woodcock, 38, self-employed landscape gardener |
| Reason for appointment | Booked online: “Mole on left leg — has changed. Can it be removed?” |
| Records | No past medical history. No regular medication. No known allergies. Non-smoker. Last seen two years ago with a sprained wrist. |
Your task
•
Take a focused history.
•
You may ask for examination findings; they will be read out to you.
•
Tell Ms Woodcock what you think is going on, and agree a plan with her.
Folded away
For the actor and the examiner
1 · Actor script — role player only
Candidates: do not open until you have consulted.
Persona and manner
- Hannah Woodcock, 38, self-employed landscape gardener — outdoors most days, shorts and a vest in summer. Lives with your partner Dev; no children. Practical, cheerful, a little impatient: you have a job waiting and you want this “sorted”.
- You are fair-skinned with reddish-brown hair and freckles; you burn easily and have had several bad sunburns, including blistering on your shoulders as a teenager.
Opening line — say this verbatim
- “This mole on my leg has changed, doctor. Can you just take it off today?”
Volunteer freely if given the space
- The mole is on the outside of your left calf. You have had it “for years” but about three months ago you noticed it looked bigger and darker.
- It itches now and then — you catch it when you shave your legs.
- You have not had it looked at before. You thought it was a sun spot.
Only if asked
- Change in size: yes — it was “a dot” and is now nearer the size of a pencil end. Change in shape: the edge has gone wonky on one side. Change in colour: darker, with a black bit at one edge; it used to be one even brown.
- Itch: yes, on and off for about six weeks. Bleeding, oozing or crusting: no. Pain: no. Any sore that will not heal: no.
- Other moles: lots of small ones on your arms and back; none of the others has changed. No new lumps anywhere; no lump in your groin.
- Sun: you work outdoors all year, often without a hat; you use sunscreen “when I remember”. Several bad sunburns as a child and teenager. Sunbeds: if asked directly, you used them twice a week for about two years in your early twenties — “everyone did”.
- Family: if asked whether anyone in the family has had skin cancer, your older sister Kirsty had “a mole cut out of her back” four years ago and then “had some treatment at the hospital”; you were told it was a melanoma. Keep this back unless asked, or invited to add anything.
- General health: well. No weight loss, no cough, no headaches, no night sweats, no tiredness beyond the usual. Not pregnant. No immunosuppressing medicines; never had a transplant.
- Previous skin problems: none. Never had a mole removed.
Impact on daily life — home and work (only if asked)
- You have started covering the mole with a plaster at work because you keep looking at it.
- You have not been sleeping well for a fortnight — you lie awake and “google moles”, which frightens you more.
- You run your own business: a hospital appointment in the middle of the day means cancelling a client and losing money; “I can’t afford to be off”.
Ideas, concerns and expectations
- Idea: a sun spot or a “mole gone funny” from catching it with the razor.
- Concern: underneath the brisk manner you are frightened it is skin cancer, because of your sister — but you will not say so unless you are asked what worries you, or the sister comes up.
- Expectation: that the GP cuts it off or freezes it today, “like they did my dad’s wart”.
Cues to deliver, timed
- Minute 2: “Can’t you just freeze it off? I’ve got a client at eleven.” (Said lightly; if ignored, do not repeat.)
- Minute 4, if the sister has not come up and you have not been asked what worries you: look at the mole and say quietly, “My sister had one like this.” If the doctor does not follow it up, say no more.
If the doctor summarises and asks whether you want to add anything
- If your sister’s melanoma has not come out: “Can I tell you something else? My sister Kirsty had a mole cut out of her back four years ago — it was a melanoma. She had to have more treatment afterwards. That’s really why I came.”
- If it has: “Will they take it off there and then? And is it going to be like Kirsty’s?”
How to respond to the doctor
- If the doctor explains plainly that the mole has several features that need a specialist to look at it urgently — change in size, shape and colour, the itch, its size — that this is why they will not cut it out here, and that most people referred this way do not turn out to have cancer: you are shaken but accept it — “OK. How quickly?”
- If the doctor says the hospital will be asked to see you urgently on the suspected-cancer pathway, with the aim of telling you within about four weeks whether or not it is cancer, and tells you what the appointment is likely to involve (a specialist looking at it with a magnifier, probably removing it under local anaesthetic to send to the lab): you ask about work and accept a letter or a plan.
- If the doctor offers to remove it, freeze it, “keep an eye on it” for a few months, or says it is “definitely nothing to worry about”: you accept with relief — and the examiner notes it (excision or freezing is unsafe; “keep an eye on it” is a mark-1 plan).
- If the doctor says “it’s cancer” or “you’ll need the same treatment as your sister”: you become tearful and stop listening.
- If asked how you are feeling about it: you admit you are scared and that you have not told Dev.
Do not
- Volunteer the sunbeds, your sister’s melanoma or your fear of cancer unless asked — or invited to add anything (apart from the timed cues).
- Use the words “melanoma” or “cancer” before the doctor has asked what worries you or the sister has been mentioned.
- Describe the mole in medical terms: say what you see (“a black bit”, “a wonky edge”).
Findings to give the candidate — only if asked for
Give the findings only when the candidate asks to look at the mole or to examine her. Give the lymph-node and whole-skin findings only if the candidate asks for them or says they would examine them.
The lesion (outer side of the left calf): a flat-to-slightly-raised pigmented lesion, 9 mm by 7 mm, asymmetrical, with an irregular, notched edge; two shades of brown with a darker, almost black area at one side; no ulceration, no crusting, no bleeding; no surrounding redness. Other skin, if examined: about twenty small, even, pale-brown moles on the arms and back, all under 5 mm and alike; freckled, sun-weathered forearms and neck; no other lesion that stands out. Lymph nodes, if examined: no palpable nodes in the left groin or popliteal fossa. General: looks well; no weight loss; observations normal.
2 · Examiner mark sheet — generic scheme plus the key facts for this case
Domain marks — with the key facts that earn a 4 at this station
| Domain (GMC wording) · key facts for this case | 1 | 2 | 3 | 4 | Score |
|---|---|---|---|---|---|
1 · Data gathering, technical and assessment skills
| ☐ | ☐ | ☐ | ☐ | /4 |
2 · Clinical management skills
| ☐ | ☐ | ☐ | ☐ | /4 |
3 · Interpersonal skills
| ☐ | ☐ | ☐ | ☐ | /4 |
| Station total | /12 |
Domain score (educational construct):
| Score | Descriptor |
|---|---|
| 1 | Unsatisfactory (did not achieve safe FY2 standard) |
| 2 | Borderline (just achieving minimum safe FY2 standard) |
| 3 | Satisfactory (competent and safe FY2 standard) |
| 4 | Good (exceeds FY2 standard) |
This 1–4 domain score and its descriptors are an Acumen educational construct: the GMC publishes the three marking domains and the four-mark maximum, but not the descriptors its examiners use, and it does not publish station mark sheets. See Legal & Regulatory.
Marks are 1 to 4 in each domain; the generic descriptor for each mark is on the mark scheme page, and the structure of the eight minutes is on the 8-minute station page. The full standard for this case is in section 3 and the GMC feedback statements, with examples from this case, are in section 4. The examination findings that the role player gives — only if the candidate asks for them — are at the end of section 1.
3 · Expanded station-specific marking standard — what earns 4, 3, 2 and 1 here
The top row is the full picture of what a competent FY2 could do at this station, including the working diagnosis with its justified differentials, the safety-net and the follow-up; lower rows describe how performance falls away. It is a debriefing aid, not a checklist to recite: nobody says every line in eight minutes, and a 4 is a judgement that the essentials — the italic key facts on the mark sheet — were done well, in plain language and at the patient’s pace. Acumen training standard — the GMC does not publish station mark sheets.
| Mark | Domain 1 · Data gathering, technical and assessment skills | Domain 2 · Clinical management skills | Domain 3 · Interpersonal skills |
|---|---|---|---|
| 4 |
|
|
|
| 3 | Lesion history and risk factors covered and the lesion examined; one of the sunbeds, family history, nodes or the impact missing. | Correct working diagnosis and a suspected-cancer referral; one of the explanation of the pathway, the reasoning against the differentials, the family history in the letter or the safety-net missing. | Warm and clear; the sister cue picked up late, or the explanation of the pathway a little rushed. |
| 2 | Describes the mole but does not characterise the change, or no risk-factor history; nodes and other skin not considered. | Refers, but “routinely” or “to be on the safe side” with no reasoning; or cannot say why it should not be removed here; or offers dermoscopy without training. | Pleasant but formulaic; the sister cue missed; her request to remove it dismissed with “we don’t do that here”. |
| 1 | A glance at the mole and a decision; little history. Or unsafe: does not look at the lesion at all, or accepts “a sun spot” without asking what has changed. | Reassures and asks her to come back if it changes; or treats as an irritated mole with a cream; no referral. Or unsafe: offers to excise, shave or freeze the lesion in the practice; or tells her it is definitely cancer, or definitely not. | Dismissive (“it’s only a mole”) or frightening (“this looks like cancer”); she leaves unsure what is happening. Or unsafe: mocks or laughs at the request to freeze it off; or tells her she will need the same treatment as her sister. |
4 · GMC feedback statements — where underperformance was identified — with case-specific examples
A feedback statement marks where underperformance was identified in the consultation. With PLAB 2 results the GMC may attach any combination of the ten statements to a station — none, one or several. The right-hand column shows what each one looks like at this station. Record the statements that applied in the practice log.
| GMC feedback statement | Underperformance it signals (generic) | Case-specific examples |
|---|---|---|
| 1 · Consultation | Disorganised or unstructured consultation | Describes the mole and starts talking about referral within a minute; no history of change, no risk factors, no summary before the plan. |
| 2 · Issues | Key issues or priorities not recognised | Treats the task as “remove or reassure”; does not recognise that the station tests recognition of a suspicious pigmented lesion and the correct urgent pathway. |
| 3 · Time | Poor time management | Five minutes on sun protection and sunscreen factors; the bell goes before the referral has been explained. |
| 4 · Findings | Abnormal findings or results, or their implications, not identified | Hears “bigger and darker”, “a black bit” and the edge that has “gone wonky” and does not put them together; does not ask the size or whether it itches; does not ask about her sister when she says “My sister had one like this.” |
| 5 · Examination | Physical examination or use of instruments not competent | Does not ask to see the lesion, or looks at it and does not describe it; never mentions the groin nodes or the rest of her skin. |
| 6 · Diagnosis | Working diagnosis or differential diagnoses not correct | “It’s probably just a mole that’s been irritated”; or refers without saying why; no differential — benign naevus, seborrhoeic keratosis, the other skin cancers — reasoned against. |
| 7 · Management | Management plan not reflecting current best practice | Offers excision or cryotherapy in the practice, or “let’s review it in three months”; no suspected-cancer referral; nothing said about what to do if it bleeds or grows, or if no letter arrives; no follow-up arranged. |
| 8 · Rapport | Rapport and sensitivity to the patient’s feelings and concerns not shown | Brisk and transactional; “Can you just take it off today?” answered with “no, we don’t do that”; her fear never acknowledged. |
| 9 · Listening | Verbal and non-verbal cues not used; poor active listening | Misses “Can’t you just freeze it off?” and “My sister had one like this”; never invites her to add anything, so the family history is never mentioned. |
| 10 · Language | Language or explanations not understandable; understanding not checked | “Your lesion scores 8 on the weighted 7-point checklist so you meet the NG12 criteria for a USC referral for melanoma; they’ll do dermoscopy and an excision biopsy for histology.” |
5 · Examiner points of fact and guidelines
Points of fact the examiner should have to hand
- NICE NG12 (Suspected cancer: recognition and referral, last updated 15 April 2026), rec 1.7.1: refer people using a suspected cancer pathway referral for melanoma if they have a suspicious pigmented skin lesion with a weighted 7-point checklist score of 3 or more. Major features, 2 points each: change in size, irregular shape, irregular colour. Minor features, 1 point each: largest diameter 7 mm or more, inflammation, oozing, change in sensation. Ms Woodcock scores 8.
- NG12 rec 1.7.2: refer using a suspected cancer pathway referral if dermoscopy suggests melanoma; rec 1.7.3: consider the same referral for a pigmented or non-pigmented lesion that suggests nodular melanoma; rec 1.7.4: consider it for a lesion that raises the suspicion of squamous cell carcinoma; recs 1.7.5–1.7.6: a lesion suggesting basal cell carcinoma is a non-urgent referral unless delay matters because of site or size (all [2015], unchanged in the 2025–26 updates, which concerned upper-GI, myeloma, ovarian, endometrial and non-site-specific symptoms).
- “Suspected cancer pathway referral” is defined in NG12 (Terms used) as the person receiving a diagnosis or ruling out of cancer within 28 days of urgent GP referral — the NHS England 28-day Faster Diagnosis Standard. NHS England’s cancer waiting times guidance sets the operational standard at 80% from March 2026 (previously 75%); “urgent” in NG12 means within 2 weeks. The appointment is not guaranteed to fall within 2 weeks, and the pathway is a target, not a promise — explain it as the aim. NICE CKS Melanoma (July 2022) still describes the pathway as an appointment within 2 weeks and suggests considering referral for any major 7-point feature or any ABCDE feature; the later NG12 rule (score of 3 or more; 28-day aim) is the one used here.
- NICE CKS Melanoma (last revised July 2022): take the history (when first noticed; change in shape, size or colour; ulceration, itch, bleeding), examine in good light, look for the “ugly duckling” that differs from the person’s other moles, examine the whole skin including the scalp, and palpate the regional lymph nodes if the lesion is suspicious. A dermatoscope should be used only by a primary care professional who has had appropriate training. Do not biopsy in primary care if melanoma is suspected or the diagnosis is uncertain — refer urgently; excision in primary care should be avoided.
- NICE NG14 (Melanoma: assessment and management, updated 27 July 2022), rec 1.3.1: all pigmented lesions referred for assessment are examined with dermoscopy by trained professionals; rec 1.3.3: an atypical lesion that does not need excision at first presentation is photographed and reviewed at 3 months. Management after diagnosis depends on the Breslow thickness of the excised lesion; sentinel node biopsy is considered from 0.8 mm with high-risk features (recs 1.4.3–1.4.4) — detail for the specialist, not for this consultation.
- CKS lists what the referral should contain when there is no local pigmented-lesion form: how long the lesion has been present; change in size, colour and shape; symptoms; site, size, elevation, description (irregular margin, irregular pigmentation, ulceration); palpable nodes; risk factors. Once the decision to refer is made, the referral should be sent within 1 working day (NG12 rec 1.16.8).
- Risk factors for melanoma (CKS, NG14 context): fair skin that burns, red or fair hair, many or atypical moles, intermittent intense sun exposure and blistering sunburn (especially in childhood), sunbed use, outdoor occupation, immunosuppression, a previous skin cancer and a family history of melanoma. CKS advises routine referral of people at greatly increased risk (giant congenital naevus; three or more family members with melanoma) — one affected sister does not meet that threshold, but it belongs in the referral letter and in her record.
- Sun protection advice for an outdoor worker (CKS): avoid burning; clothing and a hat that shades the face, neck and ears; shade between 11 am and 3 pm; sunscreen of at least SPF 15 with 4-star UVA protection (SPF 30 or more compensates for thin application), applied liberally and reapplied; no sunbeds. Advise people to seek help for a mole showing any ABCDE feature — Asymmetry, Border irregularity, Colour variation, Diameter over 6 mm, Evolving — or one that itches, bleeds, crusts or looks inflamed.
- What to say about the hospital visit: a specialist examines the lesion with a dermatoscope and, if it remains suspicious, removes the whole lesion with a narrow margin under local anaesthetic for histology; further surgery and any other treatment depend on the result. Most people referred on the pathway do not have cancer (NG12 rec 1.14.1 asks that this is explained), but no one can say in advance that a given lesion is benign — do not promise an outcome either way.
Where candidates lose marks at this station
- Agreeing to “just take it off” — or freezing it — in the practice.
- Looking at the mole without asking what has changed.
- “It’s probably just a sun spot — come back if it changes.”
- Never asking about family history, sunbeds or the groin.
- Referring “urgently” without being able to say why, or what happens next.
- Promising the result: “it’ll be fine” — or “this is cancer”.
Guidelines for this station
- NICE NG12 — Suspected cancer: recognition and referral — skin cancers (recs 1.7.1–1.7.7)
- NICE NG12 — Terms used in this guideline (suspected cancer pathway referral; urgent; 28 days)
- NICE CKS — Melanoma (assessment, referral, prevention)
- NICE NG14 — Melanoma: assessment and management
- NHS England — National cancer waiting times monitoring dataset guidance (28-day Faster Diagnosis Standard)
6 · MLA content map tags for this case
| MLA content map | This station |
|---|---|
| Domain 1 · Areas of clinical practice | Dermatology · Cancer |
| Domain 3 · Clinical and professional capabilities | History, examination and differential diagnosis · Investigations: request, interpret, act · Using guidelines and evidence · Communication with patients, relatives and carers · Managing risk |
| Domain 5 · Patient presentations | Skin lesion · Pruritus |
| Domain 6 · Conditions | Malignant/ pre-malignant skin lesions (including Bowen disease, malignant melanoma, basal cell carcinoma, squamous cell carcinoma) · Benign skin lesion (including melanocytic naevi, epidermal cyst, dermatofibroma, seborrheic keratosis, actinic keratosis) |
| Station family | History, diagnosis and management — History, diagnosis and management |
7 · My marks and reflection — practice log form
Record your three domain marks, your station total, the GMC feedback statements that applied (where underperformance was identified), and what you will keep and change. The form is already labelled with this case and its web address; a copy of your entry is emailed to you, so your practice log builds up in your inbox and can be downloaded.
Record my marks and reflection for P2-23
Revision link for this case: mdacumen.com/plab-2-osce/case-23-a-mole-that-has-changed
Independence & scope. Independent, formative training material from MD Acumen Ltd. Not affiliated with, endorsed by, or delivered on behalf of the General Medical Council. The GMC does not publish its station mark sheets: every mark scheme and descriptor on these pages is an Acumen training tool calibrated to the GMC's published marking domains, feedback statements and the MLA content map. Practice scores are not a prediction of examination performance. Clinical content reflects UK guidance at the date of editorial review — always check the current guideline. All patients are fictional. This course never provides, and will never ask you to share, real GMC exam content — full regulatory statement: Legal & Regulatory.
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