MD Acumen · PLAB 2 OSCE / CPSA course · free practice resources
Practice case P2-26 · Face-to-face · simulated patient
“There was blood in the toilet” — a 64-year-old man
A 64-year-old retired painter and decorator has booked an appointment because he has twice noticed his urine was red. He thinks his aspirin may be to blame.
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 can do a urine dipstick during the consultation. |
| Patient | Mr Roy Pemberton, 64, retired painter and decorator |
| Reason for appointment | Booked by telephone: “Blood in his water — twice. Wonders if it’s the aspirin.” |
| Records | Hypertension: amlodipine 5 mg daily. Coronary stent 2019: aspirin 75 mg daily, atorvastatin 80 mg daily. Ex-smoker — 40 a day for 35 years, stopped eight years ago. Last blood pressure 142/86; eGFR 74 mL/min/1.73 m² a year ago. No known allergies. |
Your task
•
Take a focused history.
•
You may ask for examination findings and a urine dipstick result; they will be read out to you.
•
Tell Mr Pemberton what you think is going on, and agree a management plan with him.
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
- Roy Pemberton, 64, retired painter and decorator — forty years in the trade, mostly house interiors, some industrial work spraying in the early days. Married to Christine; three grown-up children; a keen allotment man. Plain-spoken, a bit sheepish about “making a fuss”, and inclined to explain things away.
- You are not in pain and you look well.
Opening line — say this verbatim
- “There was blood in the toilet, doctor — twice now. I reckon it’s the aspirin thinning my blood, but the wife made me come.”
Volunteer freely if given the space
- The first time was about three weeks ago: your water was pink-red the whole way through, with no pain. It cleared by the next day. You put it down to the beetroot from the allotment.
- Then last Thursday it happened again — darker red, a couple of small clots, again no pain — and it has been clear since.
- You feel fine otherwise.
Only if asked
- Where in the stream: the whole stream, start to finish, both times. Clots: a couple, small, the second time. Pain: none — no burning, no pain in the back or side, no colic.
- Urinary symptoms: you get up twice a night and the stream is slower than it was — “that’s my age”. No burning, no urgency, no dribbling, no trouble starting. Never been treated for a water infection.
- Fever, shivers: no. Weight: if asked directly, your trousers are looser — you think you have lost nearly nine pounds — about four kilos — over the summer without trying; you put it down to the allotment. Appetite fine. No tiredness beyond the usual, no night sweats, no bone pain, no cough.
- Smoking: forty a day for thirty-five years; stopped eight years ago after the stent. Alcohol: a couple of pints at the weekend.
- Work: if asked what you did for a living or about chemicals at work, you painted and decorated for forty years — in the 1980s you spray-painted machinery and vehicles in a workshop with “not much in the way of masks”, and you stripped old paint with solvents for years.
- Medicines: aspirin 75 mg every morning since the stent; amlodipine; the statin. No blood thinners other than aspirin; no over-the-counter painkillers. No new medicines, no rifampicin, no foods other than beetroot that colour the urine.
- Family: your father had “kidney trouble” in his eighties — you are not sure what. No one with bladder cancer that you know of.
- Travel: never outside Europe. No injury. No recent heavy exercise.
Impact on daily life — home and work (only if asked)
- You have been checking the toilet every time you go, and you have stopped drinking your evening tea so you do not have to look.
- Christine is frightened; you have been short-tempered with her and with the grandchildren.
- You have put off a coach holiday you had booked for next month “in case”.
Ideas, concerns and expectations
- Idea: the aspirin — or the beetroot — or “my prostate, like the chap on the next allotment”.
- Concern: that it is cancer, because of the smoking; and — said only if asked directly what worries you — that you would be told to stop the aspirin and have another heart attack.
- Expectation: a water test and perhaps to be told to stop the aspirin.
Cues to deliver, timed
- Minute 2: “It’ll be the aspirin, won’t it? Shall I just stop it?” (If the doctor agrees that it is the aspirin, you relax and ask nothing more.)
- Minute 4, if cancer has not been raised by either of you: “The chap on the next allotment had blood in his water and it was just his prostate.”
If the doctor summarises and asks whether you want to add anything
- If the weight loss has not come out: “There is one thing — my trousers are hanging off me. I’ve lost nearly nine pounds — about four kilos — this summer and I wasn’t trying. Christine noticed.”
- If it has: “Thirty-five years of fags — this is my own fault, isn’t it?”
How to respond to the doctor
- If the doctor says the aspirin is not the cause and should be continued, and that you will be referred to the hospital to be checked: you are worried but accept it — “How long will that take?”
- If the doctor says you are being referred on the suspected-cancer pathway, which aims to tell you within about four weeks whether or not it is cancer, and that most people referred this way do not turn out to have it: you take it in and ask what you should tell Christine.
- If the doctor says it is probably the aspirin, or the prostate, and suggests stopping the aspirin or “seeing how it goes”: you agree readily — and the examiner notes it.
- If told to stop the aspirin: “But the heart doctor said never to stop it.”
- If the doctor promises you will “have a scan next week” or that “it will turn out to be nothing”: you ask them to put it in writing — and the examiner notes it.
- If asked how you are feeling: you say you are scared, and that you blame yourself for the smoking.
Do not
- Volunteer the weight loss, the spray-painting or your fear of cancer unless asked — or invited to add anything (apart from the timed cues).
- Say “bladder cancer” before the doctor has raised cancer.
- Argue about the referral once it has been explained.
Findings to give the candidate — only if asked for
Give each finding only when the candidate asks for it or says they would examine that part. The dipstick result is given only if the candidate asks for a dipstick.
General: looks well; no pallor. BP 148/88, pulse 76 regular, temperature 36.8 °C. Weight 84 kg (88 kg a year ago in the record). Abdomen: soft, non-tender; no mass; no loin tenderness on either side; bladder not palpable. Digital rectal examination, if asked, having explained and offered a chaperone: prostate moderately enlarged, smooth, symmetrical, not hard or nodular. Urine dipstick, if asked: blood 3+, leucocytes negative, nitrite negative, protein trace, glucose negative. Genitalia, if asked: 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 | Haematuria characterised, smoking and red flags covered, dipstick and examination asked for; one of the occupational history, the aspirin discussion, the prostate examination or the impact missing. | Correct working diagnosis and a suspected-cancer referral with the aspirin continued; one of the MSU, bloods, explanation of cystoscopy or the safety-net missing. | Warm and clear; the aspirin explanation a little lecturing, or the “own fault” cue handled awkwardly. |
| 2 | A urinary-symptom history with no risk factors; weight loss not asked about; or accepts the beetroot explanation for the first episode without probing the second. | Refers, but attributes the bleeding to the prostate or the aspirin in the explanation; or waits for the MSU result before deciding; or offers a “routine” urology referral. | Pleasant but formulaic; the cancer question dodged with “let’s not worry yet”; the allotment neighbour cue missed. |
| 1 | Accepts “blood in the water” and a dipstick; little history. Or unsafe: accepts the aspirin as the explanation and takes no further history, or never establishes whether the blood was visible or painful. | Antibiotics for a presumed infection and “come back if it happens again”; no referral. Or unsafe: tells him to stop the aspirin and see whether the bleeding settles; or reassures him that it is his prostate or the aspirin and makes no referral; or promises a scan next week or that it will be nothing. | Dismissive (“it’s your age”) or alarming (“this is probably cancer”); he leaves confused about the aspirin. Or unsafe: agrees that the smoking makes it his own fault; or frightens him with a certainty of cancer; or ridicules the beetroot idea. |
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 | Asks about the bleeding, jumps to the dipstick and then back to the history; no summary before the plan. |
| 2 · Issues | Key issues or priorities not recognised | Treats the station as “prostate symptoms in an older man” and does not recognise that the task is to act on unexplained visible haematuria as a possible cancer. |
| 3 · Time | Poor time management | Long discussion of the prostate and PSA; the bell goes before the referral has been explained or the aspirin question answered. |
| 4 · Findings | Abnormal findings or results, or their implications, not identified | Told “forty a day for thirty-five years” and “spray-painted machinery” and does not connect them with the bleeding; told the weight is down 4 kg and says nothing; dipstick 3+ blood with no leucocytes or nitrite read as “a bit of infection”. |
| 5 · Examination | Physical examination or use of instruments not competent | Does not ask for examination findings, or asks for a prostate examination without explanation or a chaperone; does not ask for a dipstick, or asks and does not interpret it. |
| 6 · Diagnosis | Working diagnosis or differential diagnoses not correct | “It’s probably your prostate” or “the aspirin can do that”; bladder cancer never named; no reasoning given for or against infection, stones or the prostate. |
| 7 · Management | Management plan not reflecting current best practice | Antibiotics and “come back if it happens again”, or “stop the aspirin and see”; no suspected-cancer referral; nothing said about clots, retention, fever or what to do if no letter arrives; no review booked. |
| 8 · Rapport | Rapport and sensitivity to the patient’s feelings and concerns not shown | Agrees “It’ll be the aspirin, won’t it?” to keep him happy; or answers “Thirty-five years of fags — this is my own fault, isn’t it?” with “well, yes”. |
| 9 · Listening | Verbal and non-verbal cues not used; poor active listening | Misses “Shall I just stop it?” and the allotment neighbour cue; never invites him to add anything, so the weight loss is never mentioned. |
| 10 · Language | Language or explanations not understandable; understanding not checked | “You’ve got frank haematuria so you meet the NG12 criteria for a two-week-wait urology referral — they’ll do a flexi cystoscopy and a CT urogram to exclude TCC.” |
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 1.6.4: refer people using a suspected cancer pathway referral for bladder cancer if they are aged 45 and over and have unexplained visible haematuria without urinary tract infection, or visible haematuria that persists or recurs after successful treatment of urinary tract infection; or aged 60 and over with unexplained non-visible haematuria and either dysuria or a raised white cell count. Rec 1.6.6 makes the same visible-haematuria referral for renal cancer. Rec 1.6.5: consider non-urgent referral for people aged 60 and over with recurrent or persistent unexplained urinary tract infection. (All [2015]; the 2025–26 updates did not change the urological recommendations.)
- NG12 rec 1.6.2: consider a PSA test and digital rectal examination to assess for prostate cancer in men with any lower urinary tract symptoms, erectile dysfunction or visible haematuria; rec 1.6.3 and table 2 give the age-specific PSA thresholds for men with symptoms (60 to 69: more than 4.5 micrograms/litre), and rec 1.6.1 refers a prostate that feels malignant. A PSA test is offered with an explanation of what the result can and cannot tell him, not done by default.
- “Suspected cancer pathway referral” (NG12, Terms used) means the person receives a diagnosis or ruling out of cancer within 28 days of urgent GP referral — NHS England’s 28-day Faster Diagnosis Standard, operational standard 80% from March 2026 (previously 75%). NICE CKS (Urological cancers — recognition and referral, revised August 2025) adds that the referral should be made within 1 working day, that the person should be told they are being referred to a cancer service and that most people referred do not have cancer, and that safety-netting should cover what to look out for and when to return. Do not promise an appointment date, a scan or a result.
- NICE NG12 (last updated 15 April 2026) refers unexplained visible haematuria without UTI at 45 and over (recs 1.6.4 and 1.6.6) and makes no exception for people taking aspirin, other antiplatelets or anticoagulants: a drug that thins the blood does not explain the bleeding, so the haematuria stays unexplained and he is investigated regardless. The 2008 Renal Association/BAUS consensus statement, which first set this out in the UK, has been withdrawn by BAUS and replaced by NG12; local urology services hold current practice. A dipstick of fresh urine negative for both leucocytes and nitrite makes UTI unlikely (otherwise send an MSU); other causes of red urine are beetroot, rifampicin and myoglobin; exercise and menstruation are transient causes. Everyone who meets the NG12 criteria is referred to urology for imaging and cystoscopy, whatever else is on the medication list.
- Initial investigations in primary care alongside the referral (usual UK practice; NG12 does not require them before referral): blood pressure; plasma creatinine and eGFR; urine for albumin:creatinine ratio if a glomerular cause is possible; MSU for culture; full blood count. None of these should delay the referral, and a normal result does not cancel it. Mr Pemberton’s eGFR was 74 a year ago and his blood pressure today is 148/88 on amlodipine 5 mg — a recheck and home readings are reasonable at the follow-up visit.
- Risk factors for bladder cancer (Cancer Research UK, bladder cancer risks and causes, reviewed August 2026): smoking causes around half of UK bladder cancers, with up to four times the risk of a non-smoker; workplace chemicals account for about 5% — aromatic amines (dye, rubber and textile industries; some banned in the UK over 50 years ago) and polycyclic aromatic hydrocarbons and mineral oils (combustion, metalworking, aluminium), with a latency of 30 to 40 years or more; long-term bladder irritation (repeated infection, stones, catheters, schistosomiasis), previous pelvic radiotherapy, and a family history. IARC has classed occupational exposure as a painter as carcinogenic to humans (Group 1), with bladder cancer among the cancers (2007 evaluation; Monograph 98); a meta-analysis (Occup Environ Med 2010;67:568) found a relative risk of 1.25 for bladder cancer in painters, 1.28 in studies adjusted for smoking. Occupational history belongs in the referral letter.
- What to tell him about the hospital pathway (NHS England timed urology pathway; CKS): a one-stop haematuria clinic usually performs a flexible cystoscopy under local anaesthetic and imaging of the upper tracts (ultrasound or CT urography, by local protocol) — describe this as what usually happens, and let the hospital give dates. If a tumour is found the next step is usually a resection under general anaesthetic to establish the type and depth; a renal lesion is characterised on CT. Do not speculate on treatment.
- Differentials to name and reason about: urinary tract infection (dipstick negative for leucocytes and nitrite makes it unlikely; MSU still sent); urinary tract calculi (usually colicky loin-to-groin pain, which he does not have); benign prostatic enlargement (can bleed, but is a diagnosis of exclusion after cystoscopy and imaging in a man of 64 with risk factors); glomerulonephritis (cola-coloured urine, proteinuria, raised blood pressure, often after an intercurrent infection); exercise haematuria; drug and food discolouration. Unintentional weight loss is a non-site-specific cancer symptom; NG12 rec 1.13.2 (amended 2026) sets more than 5% in 6 months at 60 and over. His 4 kg (about 4.5% of 88 kg, lost over the summer) is under the 5% threshold on its own, but it adds weight to the urgent referral he already meets under rec 1.6.4.
- Aspirin after a coronary stent: antiplatelet therapy is continued unless a specialist advises otherwise; haematuria is investigated, not managed by stopping it (NG12 ‘unexplained’; urology decides any interruption). If the urologist later needs a procedure, the decision about interrupting antiplatelet therapy is theirs with cardiology input — not a decision for the FY2 in this consultation. Do not advise him to stop it.
Where candidates lose marks at this station
- “It’s probably the aspirin — stop it and see.”
- Antibiotics for a dipstick that shows blood and nothing else.
- Never asking what he did for a living, or how many he smoked.
- Not asking about weight loss — and not hearing it when he says his trousers are loose.
- Waiting for the MSU before referring.
- “You’ll have a scan next week and it’ll be nothing.”
Guidelines for this station
- NICE NG12 — Suspected cancer: recognition and referral — urological cancers (recs 1.6.1–1.6.10)
- NICE NG12 — Terms used in this guideline (suspected cancer pathway referral; 28 days)
- NICE CKS — Urological cancers: recognition and referral
- BAUS — Visible haematuria: initial assessment (lists antiplatelet or anticoagulant use as a history item, not an explanation)
- Cancer Research UK — Bladder cancer: risks and causes
- 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 | Renal and urology · Cancer |
| Domain 3 · Clinical and professional capabilities | History, examination and differential diagnosis · Investigations: request, interpret, act · Using guidelines and evidence · Managing risk · Communication with patients, relatives and carers |
| Domain 5 · Patient presentations | Haematuria · Patient on anti-platelet therapy · Urinary symptoms |
| Domain 6 · Conditions | Bladder cancer · Renal cancer |
| 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 P2-26
Revision link for this case: mdacumen.com/plab-2-osce/case-26-blood-in-the-urine
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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