MD Acumen · PLAB 2 OSCE / CPSA course · free practice resources
Practice case P2-29 · Colleague conversation · simulated ward nurse · then simulator at the bedside
“He’s just not right, doctor” — day three after bowel surgery, the ward nurse calls you
It is two in the morning. You are the doctor covering the surgical wards. A staff nurse telephones about a 67-year-old man who had bowel surgery three days ago and is now feverish, fast and hypotensive. You will take the call, then go to the bedside.
Reviewed and kept current
Station family: Acute care — a call from the ward, then the bedside · 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 covering the surgical wards overnight. The surgical registrar, Miss Farrell, is in theatre with an emergency case and can be reached by phone; the critical-care outreach team and the medical emergency team are called through switchboard on 2222. |
| Patient | Mr Stan Kowalski, 67, retired plumber. Day 3 after a laparoscopic anterior resection for a sigmoid cancer, with a pelvic drain and a urinary catheter still in. Hypertension (amlodipine). Weight 82 kg. No known allergies. Antibiotic prophylaxis at surgery only; regular paracetamol and oral morphine as needed since the pain pump came down yesterday. |
| The call | Staff Nurse Josh Reid: “Sorry to bother you, doctor. It’s Mr Kowalski in bay 3. He’s just not right — he’s spiked a temperature and his heart rate’s up, and his pressure’s dropped.” |
| Set-up | The first part of the station is the telephone call: the nurse is at the ward, you are elsewhere. When you say you are on your way, you will be told that you have arrived; a manikin or a colleague on a couch is the patient, the nurse stays with you and does what you ask, and you will be told each finding as you assess it. Time is compressed: you will be told when simulated time has passed. |
Your task
•
Take the telephone call: find out what you need to know and give the nurse clear instructions for the next ten minutes.
•
At the bedside, assess and begin to treat Mr Kowalski. Say aloud everything you do, give or ask for.
•
When the registrar rings back, hand over to her.
Folded away
For the actor and the examiner
1 · Actor script — role player only
Candidates: do not open until you have consulted.
How to run this station
- Use three people if you can: the role player is Staff Nurse Josh Reid and also voices Mr Kowalski; the examiner reads the findings, announces the time and marks. With two, the role player gives the findings “as the monitor”; the examiner scores time to oxygen and fluids, cultures before the antibiotic, when the registrar was called and the SBAR handover.
- Part 1 — the telephone call (about 2½ minutes). Sit back to back or across the room; speak as if on the phone. Give observations only as they are asked for. When the doctor says they are coming, say “Thank you — I’ll get things ready” and then: “You’ve arrived on the ward.”
- Part 2 — the bedside (about 3½ minutes, 2:30–6:00). Drugs and fluids are “given” by the doctor saying the drug, dose, route and rate aloud; you repeat the order back and say “Running” or “Given”. If asked for the antibiotic by name, ask “What dose, doctor, and have you checked his allergies?” and do as told. If asked for cultures, say “Taking them now — before the antibiotic?” and take them.
- Part 3 — the handover (last 1½ minutes). About 6:00, say “Miss Farrell’s on the phone for you.” Listen as the registrar would, say “Understood”, and ask one question: “Is he going to need a scan or theatre tonight, do you think?”
Persona and manner — Staff Nurse Josh Reid
- An experienced night staff nurse, calm and organised, with one healthcare assistant and twenty-two patients. Worried about Mr Kowalski; you have looked after him for three nights and “he’s not been like this”.
- You answer what you are asked, accurately and without padding. You do not volunteer a diagnosis, and you never say “sepsis”, “leak” or “peritonitis” yourself. If asked “what do you think is going on?” say “That’s why I rang you, doctor — he’s not right.”
- You do what you are asked promptly and repeat each instruction back (“Oxygen on — what saturation do you want?”). If an instruction is vague (“give him some fluids”), ask “How much and how fast, doctor?”
- You also speak for Mr Kowalski when he is addressed: short, breathless, frightened phrases — “My belly’s… agony, doctor… worse than after the op… am I all right?”
Opening line — say this verbatim
- “Sorry to bother you, doctor. It’s Mr Kowalski in bay 3 — the anterior resection from Monday. He’s just not right. He’s spiked a temperature and his heart rate’s up, and his pressure’s dropped. Can you come?”
Volunteer freely if given the space
- He said about an hour ago that his tummy pain was “different — worse”; he has had his paracetamol and one dose of oral morphine at midnight, which did not help much.
- “He looks grey, doctor. He wasn’t like this at ten o’clock.”
Only if asked
- Observations and trend: give each one only when it is asked for — see the findings box (it includes the ten o’clock set). If asked for the NEWS2 score: “It’s 9. It was 1 at ten o’clock.” If the doctor asks you to add it up with them, do so.
- Urine: catheter still in; 40, 20 and 15 mL in the last three hours — “I was going to flush it.”
- Drain: if asked what is in it — “It’s gone brown and it smells. It was pink yesterday.” 150 mL since midnight.
- Abdomen: if asked on the phone — “It looks bigger, and he doesn’t like me touching it.” He has not opened his bowels or passed wind since surgery; he vomited once at midnight.
- Chest: no cough; a bit breathless.
- Access, drugs, allergies: one cannula in the left hand from theatre; no allergies on the chart; no antibiotics since the single dose in theatre; amlodipine given this morning; paracetamol and oral morphine as above. No blood thinner apart from the daily injection for clots.
- What has been done: nothing yet except the observations — “I rang you straight away.” If asked whether anyone else has been called: “No. Shall I?”
- Bloods, history, resuscitation status: this morning’s results are on the system (findings box); no blood gas yet; hypertension only; for full escalation.
- As Mr Kowalski, only if asked: the pain started to change about two hours ago — all across the lower tummy, constant, worse when he moves; he feels sick and “shivery”; no chest pain; no calf pain; frightened — “Is it the cancer?”
Impact on daily life — as Mr Kowalski (only if asked)
- Mr Kowalski lives with his wife, Teresa, who has just had a hip replacement and does not drive; his daughter has been staying to help. He was told he could go home on day five.
- He is terrified of “going back under” and of a bag — the surgeon mentioned a stoma as a possibility if things went wrong.
- He asks whether someone can ring Teresa, and then asks that they wait until morning so she is not frightened.
Ideas, concerns and expectations — the nurse, and then the patient
- Nurse — idea: “Is it a chest thing? He’s been lying flat.” Concern: that he will crash before the doctor gets there; that the doctor will say “just do a chest X-ray and I’ll see him in the morning”. Expectation: that the doctor comes now and tells you what to do while you wait.
- Patient — idea: the cancer; concern: another operation and a stoma, and Teresa at home; expectation: to be told honestly what is happening.
Cues to deliver, timed
- Minute 1 (on the phone), if the doctor has not asked for a full set of observations: “Do you want all his obs, doctor? I’ve got them in front of me.”
- Minute 2 (on the phone), if the doctor has given no instructions: “What do you want me to do while you’re on your way?”
- Minute 2½: whatever has happened, “You’ve arrived on the ward.”
- Station minute 4 (about 90 seconds after arrival on the ward), if no fluid has been started: say unprompted — “He’s gone very pale, doctor. Pressure’s 84 over 50 and he’s drowsy.” Give the deterioration findings.
- About 45 seconds after the first bolus is started: “That’s fifteen minutes — the first bag’s through.” Give the post-bolus findings as he is reassessed. If nothing is reassessed within 20 seconds: “Shall I do his obs again?”
- About 45 seconds after the second bolus: “Second bag’s through.” Give the second set.
- Minute 5, if the registrar has not been called: “Do you want me to bleep Miss Farrell, or the outreach team?”
- Minute 6, whatever has happened: “Miss Farrell’s on the phone for you — she’s just scrubbed out.” Listen to the handover as the registrar; say “Understood. I’ll be ten minutes,” and ask “Is he going to need a scan or theatre tonight, do you think?”
- Safety challenges, once each: an antibiotic named without a dose or an allergy check — “What dose, doctor, and have you checked his allergies?”; an antibiotic ordered before cultures — “Before the cultures, doctor?”; a litre of fluid ordered “stat” — “A litre straight off? He’s 67 with a heart rate of 118 — how fast do you want it?” (do as told after the challenge); morphine ordered for the pain before anything else — “Before we’ve sorted his pressure?”
If the doctor summarises (on the phone, or hands over) and asks whether you want to add anything
- If the drain has not been asked about: “One thing — his drain’s gone brown and it smells. It was pink yesterday.”
- If it has: “He vomited once at midnight — green. I didn’t think to mention it.”
How to respond — as the nurse
- Clear instructions, one at a time, with amounts and rates: carry them out at once and say so.
- If the doctor asks you to put out a 2222 call or to bleep the registrar or outreach: “What shall I tell them?” Then repeat exactly what you are told. Never supply the word “sepsis” yourself.
- If the doctor says “just do a chest X-ray and I’ll review in the morning”: “I don’t think he can wait till morning, doctor. His pressure’s 96.” If the doctor still does not come: “I’m going to call the outreach team.”
- If the doctor asks you to start oxygen, repeat observations every 15 minutes, put a second cannula in if you can, catch a urine sample, keep him nil by mouth and get the fluids and the sepsis equipment ready: “All of that — on it.”
How to respond — as Mr Kowalski
- If the doctor tells him there is an infection in his tummy and that fluids and antibiotics are being given: frightened but steadier — “Will I need another operation?” Accept an honest “possibly — the surgeon will decide, and she may want a scan first.”
- If nobody explains anything to him: “Somebody tell me what’s going on.”
- If told “you’ll be fine” or “it’s probably just a chest infection”: “It doesn’t feel like my chest.”
Do not
- Start oxygen, fluids, cultures or call anyone until you are asked to (apart from the timed cues).
- Suggest a drug, a dose, a test — or a diagnosis.
- Volunteer the drain, the vomit or the urine output unless asked, or invited to add anything.
Findings to give the candidate — only if asked for
This is a simulation. Give each finding only as the candidate assesses that part of the patient or asks for it — except the time announcements and the minute-4 deterioration, which you say unprompted (see the timed cues). On the telephone, give only what is asked for. (Where a separate examiner is present, the examiner reads the findings and announces the time.)
Observations now (on the telephone, in whatever order they are asked for): temperature 38.6 °C, pulse 118 regular, blood pressure 96/58, respiratory rate 26, SpO₂ 94% on air, alert; NEWS2 9 if the candidate asks for the score or works it out. Last set at 22:00: temperature 37.8, pulse 98, BP 118/72, respiratory rate 20, SpO₂ 96%. Urine output 40, 20 and 15 mL in the last three hours. Capillary glucose 7.9 mmol/L. On arrival at the bedside. Airway: talking, clear. Breathing: respiratory rate 26, SpO₂ 94% on air (97% once oxygen is on), reduced air entry at both bases, no crackles or wheeze, no pleuritic pain. Circulation: pulse 118, BP 96/58, capillary refill 4 seconds, peripheries cool, mucous membranes dry; one cannula in the left hand, in since theatre, slightly red at the site. Disability: alert, orientated, in pain; glucose 7.9. Exposure: temperature 38.6; abdomen distended, tender across the lower abdomen with guarding, bowel sounds absent; the pelvic drain has put out 150 mL of brown, offensive fluid since midnight (it was pale pink yesterday); laparoscopic port sites clean and dry; calves soft and non-tender; catheter draining concentrated urine, 15 mL in the last hour. Venous blood gas (if sent): pH 7.31, lactate 3.8 mmol/L, bicarbonate 18 mmol/L, glucose 7.9. Bloods from this morning’s round: Hb 118 g/L, white cells 17.2 × 10⁹/L, CRP 240 mg/L (it was 110 on day 1), creatinine 142 µmol/L (80 before surgery), potassium 4.9 mmol/L. After the first 250 mL bolus: pulse 114, BP 100/60. After the second bolus: pulse 108, BP 106/64, capillary refill 3 seconds; urine 25 mL in the next hour. If no fluid has been given by station minute 4 (about 90 seconds after arrival on the ward): he becomes drowsy and pale — pulse 126, BP 84/50, SpO₂ 92% on air.
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 | SBAR taken and NEWS2 recognised, instructions given before arrival, structured ABCDE with abdomen and drain examined; one of the lactate, the urine output, the trend or the patient’s own concerns missing. | Sepsis recognised and treated within the hour with cultures first, fluids reassessed, registrar called with a clear SBAR; one of the lactate interpretation, the urine output plan, the differential reasoning or the explanation to the patient thin. | Clear leadership and kind to the patient; the nurse thanked but one challenge brushed aside, or the handover rambling. |
| 2 | Observations collected piecemeal; the abdomen examined only after the nurse mentions the drain; little reassessment; the chest treated as the obvious source without looking further. | Antibiotic and fluids given but the registrar called late or without a clear ask; cultures after the antibiotic; a litre of fluid without reassessment; the drain findings heard but not acted on; the patient told nothing. | Competent but silent — treats the chart, not the man; instructions vague so the nurse has to ask for amounts; handover without structure. |
| 1 | A chest X-ray ordered over the phone and “I’ll see him when I can”; at the bedside, no structure, no lactate, no look at the abdomen. Or unsafe: declines to come, or defers review to the morning with a NEWS2 of 9; or gives morphine for the pain and leaves without addressing the hypotension. | Oxygen and one fluid bolus only; no cultures, no lactate, no antibiotic within the hour; senior not involved; no plan for monitoring. Or unsafe: gives neither fluid nor antibiotic despite a NEWS2 of 9 and a lactate of 3.8; or defers everything to the morning; or sends him for a CT with no fluids, no antibiotic and no senior aware; or gives morphine as the only intervention for a hypotensive, peritonitic patient. | Flustered or brusque; ignores the nurse’s prompts; the patient told nothing. Or unsafe: dismisses the nurse (“it’s probably just his chest — do an X-ray”), is rude to her, or tells the patient “you’ll be fine” when he may be going to theatre. |
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 | Takes the call without structure — asks about the temperature, then the operation, then the temperature again; never says what to do before arriving; at the bedside no recognisable ABCDE and no summary before the handover. |
| 2 · Issues | Key issues or priorities not recognised | Treats this as a feverish post-operative patient needing a chest X-ray; does not see that the tasks are to recognise sepsis from the observations, to start treatment within the hour, and to get a senior to the bedside. |
| 3 · Time | Poor time management | Three minutes on the telephone taking a social history; arrives with two minutes left; the registrar is never called and the handover is never reached. |
| 4 · Findings | Abnormal findings or results, or their implications, not identified | Is told “his pressure’s dropped”, “It’s 9. It was 1 at ten o’clock” and “his drain’s gone brown and it smells” and does not act on any of them; is told the lactate is 3.8 and does not know that it changes the urgency. |
| 5 · Examination | Physical examination or use of instruments not competent | No structured assessment at the bedside — listens to the chest and never examines the abdomen or looks in the drain; does not reassess after the fluid; cannot say what the urine output is. |
| 6 · Diagnosis | Working diagnosis or differential diagnoses not correct | “Probably a chest infection” or “some kind of infection”; sepsis never named; anastomotic leak never considered; no reasoning about why not pneumonia, bleeding or a clot on the lung. |
| 7 · Management | Management plan not reflecting current best practice | Antibiotic after the cultures have been forgotten, or with no dose and no allergy check; a litre of fluid without reassessment, or no fluid at all; no lactate; registrar called only when the nurse asks “Do you want me to bleep Miss Farrell, or the outreach team?”; nothing said about what the nurse should do if he worsens, or how often to repeat the observations. |
| 8 · Rapport | Rapport and sensitivity to the patient’s feelings and concerns not shown | Curt with the nurse (“just give me the obs”); says nothing to a frightened man who thinks his cancer is back; answers “Will I need another operation?” with “Don’t worry about that now.” |
| 9 · Listening | Verbal and non-verbal cues not used; poor active listening | Does not hear “He’s just not right”, “I was going to flush it” or “It doesn’t feel like my chest”; never asks the nurse whether there is anything else, so the vomit and the drain are never mentioned; talks over the registrar. |
| 10 · Language | Language or explanations not understandable; understanding not checked | “Give him a stat bolus and some pip-taz, he’s probably got an AL” — no amounts, an abbreviation, and jargon the nurse cannot act on; and to the patient: “you’re septic from a dehisced anastomosis.” |
5 · Examiner points of fact and guidelines
Points of fact the examiner should have to hand
- NEWS2 (Royal College of Physicians, 2017): six physiological parameters each scored 0–3 — respiratory rate (12–20 scores 0; 21–24 scores 2; 25 or more scores 3; 9–11 scores 1; 8 or less scores 3), oxygen saturation on scale 1 (96% or more 0; 94–95% 1; 92–93% 2; 91% or less 3), supplemental oxygen (2 points), systolic blood pressure (111–219 scores 0; 101–110 scores 1; 91–100 scores 2; 90 or less, or 220 or more, scores 3), pulse (51–90 scores 0; 91–110 scores 1; 111–130 scores 2; 131 or more, or 40 or less, scores 3; 41–50 scores 1), consciousness (alert 0; new confusion, voice, pain or unresponsive 3) and temperature (36.1–38.0 scores 0; 38.1–39.0 scores 1; 39.1 or more scores 2; 35.1–36.0 scores 1; 35.0 or less scores 3). Mr Kowalski at 02:00: respiratory rate 26 (3) + SpO₂ 94% (1) + air (0) + systolic 96 (2) + pulse 118 (2) + alert (0) + 38.6 °C (1) = 9. Trigger thresholds: 1–4 low (ward nurse review, 4–6-hourly observations); 3 in any single parameter — urgent review by a ward doctor; 5–6 medium — a key threshold: urgent review by a clinician competent in acute illness, observations at least hourly; 7 or more high — emergency response by a team with critical-care competencies, continuous monitoring. (Band-to-points mapping checked against the RCP charts and executive summary; reproduce the colour chart itself when teaching.)
- NICE NG253, Suspected sepsis in people aged 16 or over (published 19 November 2025, which replaced the adult part of NG51; last updated 23 September 2026): in acute hospital settings grade the risk of severe illness or death from sepsis using the history, the examination and NEWS2 (rec 1.6.1); a score of 7 or more suggests high risk, 5–6 medium, 1–4 low, 0 very low; a single parameter scoring 3 needs a high-priority review by an FY2 or above to decide the level of risk (1.6.2). Treat as higher risk if there is mottling, a non-blanching rash, cyanosis, or deterioration or lack of improvement since the last score (1.6.3–1.6.4). Recalculate NEWS2 every 30 minutes at high risk, hourly at medium, every 4–6 hours at low (1.6.5), and whenever the patient changes (1.6.6).
- NG253 — high risk (NEWS2 7 or more with suspected infection), rec 1.8.2–1.8.3: an FY2 or above assesses urgently and thinks about alternative diagnoses; venous blood gas including glucose and lactate, blood culture, full blood count, CRP, urea and electrolytes, creatinine, liver function and a clotting screen; consider procalcitonin (added September 2026); broad-spectrum intravenous antibiotics within 1 hour of calculating the NEWS2 score on ward deterioration (1.8.3), after microbiological samples (1.8.1); refer to the senior clinical decision-maker as soon as possible and use judgement about discussing with a consultant. Medium risk (5–6), rec 1.8.16–1.8.20: same bloods; FY2 or above reviews the patient and the lactate within 1 hour; antibiotics may be deferred for up to 3 hours to reach a more specific diagnosis — but if there is evidence of hypoperfusion (lactate over 2 mmol/L, or acute kidney injury) treat as high risk (1.8.20). Low risk (1–4): review within 1 hour; antibiotics may be deferred up to 6 hours. Once the decision to give antibiotics is made, do not delay further.
- NG253 — fluids (2025 recommendations 1.8.4–1.8.9): at high risk give an intravenous fluid bolus without delay (within 1 hour of identifying high risk) unless contraindicated; use an isotonic crystalloid — a balanced solution such as Hartmann’s, or 0.9% sodium chloride if a balanced solution is not available; an initial bolus of 250 mL over 10–15 minutes, further 250 mL boluses as needed up to 1,000 mL in total, reassessing after each; if not improved enough after 1,000 mL, get advice from a senior clinical decision-maker; vasopressors are discussed with critical care (1.8.11). Note the change from the 500 mL bolus in the 2016 guideline. Oxygen (1.10.1): target saturation 94–98%, or 88–92% if at risk of hypercapnic respiratory failure. Escalation (1.8.15): if a high-risk patient has not responded within 1 hour of any intervention, the senior clinical decision-maker attends in person, critical care is involved, and the responsible consultant is informed.
- Source control (NG253 1.11.1–1.11.4): tailor investigations to the history and examination; consider urinalysis and a chest X-ray in everyone; consider imaging of the abdomen and pelvis if no source is found; involve the surgical team early when surgical or radiological intervention may be needed — they seek senior advice on timing and carry it out as soon as possible. The Academy of Medical Royal Colleges’ statement on the initial antimicrobial treatment of sepsis (v2.0, October 2022), which NICE adopted, adds that an adult with a NEWS2 of 5 or more who is likely to need an emergency procedure to control a surgical source should be managed in the NEWS2-7 band: antimicrobials within 1 hour, preferably after blood cultures, urgent review by senior surgical and intensive-care clinicians, and source control within 3–6 hours.
- Antibiotic choice: NG253 (1.9.2, 1.9.7) says use the local antimicrobial policy for an empirical intravenous antimicrobial — for intra-abdominal sepsis after bowel surgery most trusts specify a broad-spectrum regimen covering Gram-negative and anaerobic organisms. The candidate names the local policy drug, checks the dose in the BNF and the allergy history with the nurse, and says both aloud; no brand names. Review and narrow the antibiotic when the source is confirmed or microbiology results are available (1.9.1) — usually by 48–72 hours under local stewardship policy.
- Anastomotic leak is the most feared complication of colorectal anastomosis: reported rates of up to about 30% depending on the definition, with no universally accepted definition or grading system (Rennie and colleagues, Frontiers in Surgery 2024). Most clinical leaks declare themselves in the first postoperative week — typically days 3–7, sometimes later — with new or different abdominal pain, fever, tachycardia, ileus, a raised or rising CRP, and purulent or faeculent drain fluid; grade C leaks present with peritonitis and sepsis and need relaparotomy (washout with a defunctioning ileostomy, or taking down the anastomosis with an end colostomy); grade B leaks are managed with antibiotics and radiological or transanal drainage. The diagnostic test is CT of the abdomen and pelvis with intravenous (and often rectal) contrast; a negative scan does not exclude a leak when the clinical picture is convincing, so the surgeon decides. Risk factors include male sex, smoking, alcohol, steroids, diabetes, a low anastomosis and long operating time. (Timing and management points from published reviews; no UK national guideline specifies them — to confirm against the local colorectal protocol.)
- Why not the alternatives: basal atelectasis or pneumonia is the commonest cause of fever on days 1–3 after abdominal surgery, but does not produce guarding, absent bowel sounds, a faeculent drain or a doubling CRP; post-operative bleeding causes tachycardia and hypotension without fever and with a falling haemoglobin; pulmonary embolism causes tachycardia, breathlessness and hypoxia and should be considered in every post-operative deterioration, but fever of 38.6 °C with peritonism points elsewhere; a cannula-site or catheter infection can cause sepsis but not peritonism. Giving opioid analgesia for “pain” before the circulation has been addressed, or treating a chest X-ray rather than the patient, is how these cases are missed.
- Acute kidney injury: creatinine 142 µmol/L from a baseline of 80 is a rise of more than 1.5 times — stage 1 AKI by the KDIGO criteria used in NICE NG148 — and urine output of 40, 20 and 15 mL over three hours in an 82 kg man (about 0.2–0.5 mL/kg/hour) is heading for the NG148 urine criterion (below 0.5 mL/kg/hour for more than 6 hours); both are evidence of hypoperfusion; NG253 1.8.20 says a medium-risk patient with a lactate over 2 or AKI is treated as high risk — Mr Kowalski is already high risk on his NEWS2 of 9. Measure hourly urine output through the catheter, stop nephrotoxic drugs (hold amlodipine while hypotensive; avoid NSAIDs), review the dose of any renally cleared antibiotic, and recheck electrolytes (potassium 4.9).
- Communication: SBAR — Situation, Background, Assessment, Recommendation — is the structure the NHS uses for escalation calls and handovers; the recommendation should be a specific request with a time (“please come now; I think he needs a CT or theatre tonight”). Closed-loop orders: drug, dose, route and rate said aloud, read back by the nurse, and confirmed. The patient has capacity and should be told honestly, briefly and kindly what is happening and what may happen next — including the possibility of an operation and a stoma — without false reassurance (Good medical practice 2024, paragraphs 23, 28–29).
Where candidates lose marks at this station
- “Do a chest X-ray and I’ll see him in the morning.”
- Antibiotic before the cultures — or with no dose and no allergy check.
- A litre of fluid “stat” and no reassessment.
- Never looking in the drain.
- Calling the registrar only when the nurse suggests it.
- Morphine for the pain before the blood pressure.
Guidelines for this station
- NICE NG253 — Suspected sepsis in people aged 16 or over: recognition, assessment and early management (November 2025, updated September 2026)
- NICE NG253 — Managing suspected sepsis in acute hospital settings (risk bands, antibiotics within 1 hour, 250 mL fluid boluses, escalation)
- Royal College of Physicians — National Early Warning Score (NEWS2): charts and clinical response
- Academy of Medical Royal Colleges — Statement on the initial antimicrobial treatment of sepsis, v2.0 (October 2022) (PDF)
- NICE NG148 — Acute kidney injury: prevention, detection and management
- UK Sepsis Trust — clinical tools aligned to NICE NG253 (acute hospital, 16+)
- Rennie O, Sharma M, Helwa N. Colorectal anastomotic leakage: a narrative review of definitions, grading systems and consequences. Frontiers in Surgery 2024
6 · MLA content map tags for this case
| MLA content map | This station |
|---|---|
| Domain 1 · Areas of clinical practice | Perioperative medicine and anaesthesia · Surgery · Acute and emergency |
| Domain 3 · Clinical and professional capabilities | Emergency and acute management plans · Team working · Investigations: request, interpret, act · Managing risk · Using guidelines and evidence |
| Domain 5 · Patient presentations | Post-operative care and complications · Deteriorating patient · Fever · Oliguria/ anuria · Abdominal pain (acute and chronic) |
| Domain 6 · Conditions | Sepsis (including neutropenic sepsis) · Peritonitis · Acute kidney injury |
| Station family | Acute care, ethics and safeguarding — Acute care — a call from the ward, then the bedside |
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 P2-29
Revision link for this case: mdacumen.com/plab-2-osce/case-29-the-ward-nurse-calls-you
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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