“It’s just piles, isn’t it?” — a change in bowel habit and blood on the paper

Candidates: do not open until you have consulted.

Persona and manner

• Wendy Harcourt, 63, works three days a week on reception at the local primary school; married to Clive, a retired electrician; two daughters and four grandchildren whom you look after on Tuesdays. Cheerful, chatty, apologetic for “wasting the doctor’s time” — and privately very frightened.
• You are a little pale and you sigh when you sit down.

Opening line — say this verbatim

• “The nurse said my blood was a bit low. It’s just piles, isn’t it? I had them years ago with the girls.”

Volunteer freely if given the space

• For about two months your bowels have been “a bit off” — looser than usual, three or four times a day, where you used to go once in the morning.
• You have seen bright red blood on the paper on and off for about six weeks — and once or twice in the pan, mixed in.
• You have been tired — “flat” — for a couple of months; you put it down to the grandchildren and your age.

Only if asked

• Stools: looser, no proper shape, three or four times a day, sometimes with a feeling you have not finished. No black stool. Mucus: a little, sometimes. No pain passing them. No abdominal pain beyond mild cramps before you go.
• Blood: bright red, on the paper most days and mixed into the stool twice. No pain or lump at the back passage; the piles you had years ago were sore and “came down”, and this is not like that.
• Weight: if asked directly, your clothes are looser and the scales at home say you are about three kilos lighter than at Christmas; you have not been dieting. Appetite normal.
• Tiredness: breathless going up the stairs with the laundry, which is new; no chest pain; no palpitations; no dizziness.
• Diet: a normal mixed diet, including red meat twice a week. No gluten-free diet. No recent travel. No antibiotics.
• Medicines: ramipril only. No aspirin, no ibuprofen or other anti-inflammatory painkillers — “just the odd paracetamol”. No iron tablets.
• Screening: you did the bowel-screening kit two years ago and it came back normal — “so it can’t be anything bad, can it?”
• Family: if asked whether anyone in the family has had bowel cancer or bowel problems, your aunt died of bowel cancer at 70; nobody else. Keep this back unless asked, or invited to add anything.
• Periods: stopped at 51; no bleeding since. No urinary symptoms. No joint pains, mouth ulcers or skin rashes. No previous bowel investigations.

Impact on daily life — home and work (only if asked)

• You have stopped doing the Saturday markets because you need to know where a toilet is.
• You are too tired to have the grandchildren all day on a Tuesday and you have not told your daughter why.
• You have been lying awake, and you have not told Clive about the blood — “he’d only worry”.

Ideas, concerns and expectations

• Idea: piles — the same as after your second daughter; and that the tiredness is “just your age”.
• Concern: that it is bowel cancer, like your aunt — you will say so only if asked what worries you, or once your aunt has come up.
• Expectation: some cream for the piles and iron tablets for the blood count.

Cues to deliver, timed

• Minute 2: “Can you just give me some cream for the piles?” (Said brightly; if ignored, do not repeat.)
• Minute 4, if the family history has not come up and you have not been asked what worries you: look down and say, “My aunt had trouble with her bowels.” 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 aunt’s bowel cancer has not come out: “I should say — my aunt died of bowel cancer. She was seventy. That’s what I keep thinking about.”
• If it has: “If the test comes back clear, does that mean it’s definitely not cancer?”

How to respond to the doctor

• If the doctor explains plainly that your blood count is low because you are short of iron, that in a woman your age who has stopped having periods this usually means blood is being lost from the bowel, and that with the change in your bowels and the bleeding it needs to be checked properly — including a camera test of the bowel — to find the cause, which could be piles but could be something more serious including cancer: you are frightened but grateful for the honesty — “What happens now?”
• If the doctor explains the stool test (a small sample you post back), that a result above the threshold means an urgent hospital referral on the cancer pathway, and that because of the anaemia and the symptoms you will still be referred to the bowel specialists even if the stool test is low: you accept, and ask whether you should tell Clive.
• If the doctor starts iron tablets and explains the side-effects and the recheck: you accept.
• If the doctor asks to do a rectal examination: say “Do I have to? Can it wait?” If the doctor explains why, offers a chaperone and says it is your choice: “All right.” If the doctor gives no choice or does not explain: “No, I’d rather not.” (No findings are then given.)
• If the doctor says it is piles, gives cream and iron and tells you to come back if it carries on; or says the stool test will decide everything and “if it’s negative there’s nothing to worry about”: you agree, relieved — and the examiner notes it.
• If told you “definitely have cancer” or that the hospital will “sort it out next week”: you cry and stop listening.
• If asked what you are most worried about: you say you are scared it is what your aunt had, and that you have not told Clive.

Do not

• Volunteer the weight loss, your aunt’s bowel cancer or your fear of cancer unless asked — or invited to add anything (apart from the timed cues).
• Say “bowel cancer” before the doctor has asked what worries you or your aunt has come up.
• Argue once the plan has been explained kindly.

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 rectal examination findings are given only if the candidate explains the examination, asks her consent and offers a chaperone.

Domain marks — with the key facts that earn a 4 at this station

Domain score (educational construct):

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.

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.

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.

Points of fact the examiner should have to hand

1. NICE NG12 (Suspected cancer: recognition and referral, last updated 15 April 2026), rec 1.3.1 [2023]: offer quantitative faecal immunochemical testing (FIT), using one of the two analysers NICE recommends, to guide referral for suspected colorectal cancer in adults with an abdominal mass, a change in bowel habit, iron-deficiency anaemia, aged 40 and over with unexplained weight loss and abdominal pain, aged under 50 with rectal bleeding and unexplained abdominal pain or weight loss, aged 50 and over with unexplained rectal bleeding, abdominal pain or weight loss, or aged 60 and over with anaemia even without iron deficiency. FIT should be offered even if the person has previously had a negative FIT through the NHS bowel cancer screening programme. People with a rectal mass, an unexplained anal mass or anal ulceration do not need FIT before referral is considered (recs 1.3.5–1.3.6).
2. NG12 rec 1.3.2: refer adults using a suspected cancer pathway referral for colorectal cancer if they have a FIT result of at least 10 micrograms of haemoglobin per gram of faeces. Rec 1.3.3: for people who have not returned a sample or whose FIT is below 10, safety-netting processes should be in place, and referral to an appropriate secondary care pathway should not be delayed if there is strong clinical concern of cancer because of ongoing unexplained symptoms. Rec 1.3.4: consider whether the person needs help to return the sample. These recommendations are adapted from NICE HealthTech guidance HTG690 (formerly DG56, published 24 August 2023; the recommendations are unchanged).
3. “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%). The FIT result usually takes a few days. Do not promise an appointment date, a colonoscopy date or a result.
4. NICE CKS, Anaemia — iron deficiency (last revised July 2026): anaemia is a haemoglobin below 120 g/L in non-pregnant women over 15 and below 130 g/L in men; check ferritin in all anaemic people with an MCV below 95 fL; a serum ferritin below 30 micrograms/L confirms iron deficiency (ferritin can be falsely normal with inflammation — her CRP is 3). A diagnostic trial of iron should not be used in men or post-menopausal women, who are at higher risk of occult gastrointestinal bleeding and malignancy and need investigation. Refer all men and post-menopausal women with iron-deficiency anaemia to gastroenterology unless there is overt non-gastrointestinal bleeding; post-menopausal women with a haemoglobin below 100 g/L, and men below 120 g/L, are investigated more urgently. Urgent suspected-cancer referral if the FIT is 10 or more.
5. Treatment (CKS, July 2026): do not wait for investigations before prescribing iron, unless colonoscopy is imminent; ferrous sulfate 200 mg (65 mg elemental iron) once daily, or ferrous fumarate or gluconate, continued for three months after the deficiency is corrected; alternate-day dosing or an alternative oral preparation if not tolerated; modified-release and multi-nutrient combinations are not recommended. Recheck the full blood count within four weeks — the haemoglobin should rise by about 20 g/L over three to four weeks — then at two to four months; refer if the rise is under 20 g/L at two to four weeks. Warn about black stools, constipation and nausea, and about safe storage around grandchildren (accidental overdose can be fatal).
6. Coeliac disease: NICE NG20 rec 1.1.1 — offer serological testing to people with unexplained iron, vitamin B12 or folate deficiency; the laboratory tests total IgA and IgA tissue transglutaminase first (rec 1.2.2); the person must be eating gluten daily for at least six weeks for the test to be valid (rec 1.1.4) and should not start a gluten-free diet before specialist confirmation (recs 1.1.3–1.1.4). A positive result is a gastroenterology referral in its own right (CKS).
7. NHS bowel cancer screening (nhs.uk): a home FIT kit every two years for people aged 50 to 74 in England. A normal screening result is reassuring about that sample at that time; it is not a test for symptoms, and NG12 explicitly says to offer a symptomatic FIT regardless of a previous negative screening FIT. A family history of colorectal cancer (here an aunt) belongs in the referral letter; CKS asks for people aged 50 and over with marked anaemia or a significant family history of colorectal carcinoma to be referred to gastroenterology even if coeliac disease is found.
8. Differentials to reason about: haemorrhoids (bright red blood on the paper, often with anal discomfort or a lump; rarely cause anaemia and do not cause a change in bowel habit — a small haemorrhoid in a 63-year-old with anaemia is a coincidence until proved otherwise); diverticular disease (can bleed, usually painlessly and in larger amounts); inflammatory bowel disease (diarrhoea with blood and mucus, weight loss — possible at any age); coeliac disease (iron deficiency with or without bowel symptoms); upper gastrointestinal loss (NSAIDs, peptic ulcer — she takes none and has no dyspepsia); dietary deficiency (unlikely on a mixed diet). Red flags: weight loss, abdominal or rectal mass, tenesmus, anaemia, family history.
9. What the hospital is likely to do (NHS England timed colorectal pathway; local practice): a colonoscopy, or CT colonography where colonoscopy is unsuitable, usually within the 28-day aim; if the lower bowel is normal in a post-menopausal woman with iron deficiency, upper-gastrointestinal endoscopy is considered. Describe this as the usual sequence, not a promise. Tell her most people referred on the pathway do not have cancer (NG12 patient-support recommendations), without saying that she will not.

Where candidates lose marks at this station

• “It’s just your piles” — cream and iron.
• “Your screening test was normal, so it can’t be cancer.”
• A FIT sent with “if it’s negative, nothing to worry about”.
• Never asking about her aunt, her weight or NSAIDs.
• A rectal examination requested without explanation, consent or a chaperone.
• Starting iron with no plan to recheck the blood count — or waiting for the colonoscopy before starting it.

Guidelines for this station

• NICE NG12 — Suspected cancer: recognition and referral — lower gastrointestinal tract cancers (recs 1.3.1–1.3.6)
• NICE HTG690 (formerly DG56) — Quantitative faecal immunochemical testing to guide colorectal cancer pathway referral in primary care
• NICE CKS — Anaemia: iron deficiency (investigations, referral, treatment, monitoring)
• NICE NG20 — Coeliac disease: recognition, assessment and management
• NHS — Bowel cancer screening (who is invited and how the FIT kit works)
• NHS England — National cancer waiting times monitoring dataset guidance (28-day Faster Diagnosis Standard)

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 P2-39