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Practice case P2-08 · Face-to-face · simulated patient

“Nobody is listening” — the angry patient with abdominal pain

Her third visit in two months with stomach pain, fifty minutes late being seen, and furious.

Reviewed and kept current

Station family: Angry patient / history, diagnosis and management · 8-minute station · 1 min 30 s reading · Last editorial review: 19 September 2026.

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 urgent clinic. The clinic is running 50 minutes late. Your supervising GP is available.
Patient	Mrs Emma Roberts, 44, teaching assistant
Reception note	“Stomach pain — 3rd visit. Patient upset at the desk about the wait.”
Records	Eight weeks ago (locum GP): “epigastric discomfort — likely gastritis; advised an antacid.” Three weeks ago (nurse practitioner): “abdominal pain, ?IBS — peppermint oil, diet sheet.” No blood tests on file. No regular medication. No known allergies.
Weight today (healthcare assistant)	61 kg. Recorded as 65 kg four months ago.

Your task

•

Respond to Mrs Roberts’s concerns.

•

Take a focused history; you may ask for examination findings, which will be read out to you.

•

Explain your working diagnosis 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

Emma Roberts, 44, teaching assistant, two teenagers. Your husband moved out five months ago.
You are on your feet, or sitting with your arms tightly folded. Loud, clipped, furious — and underneath it, frightened. You do not swear at or threaten the doctor.

Opening line — say this verbatim

“Fifty minutes I’ve been sat out there. This is the third time I’ve come about this and nobody is listening. Are you going to fob me off as well?”

How the anger behaves

If the doctor apologises sincerely for the wait, lets you speak without interrupting and does not get defensive: your volume drops and you sit down.
If the doctor says “calm down”, explains why the clinic is late, or starts firing closed questions: get louder — “Don’t tell me to calm down!”

Volunteer freely once you are calmer

A burning, gnawing pain at the top of your tummy for three months, getting more frequent — now every day.
The antacid only takes the edge off for half an hour; the peppermint oil did nothing.

Only if asked

The pain comes an hour or two after eating and wakes you at two or three in the morning. Milk, food or an antacid ease it briefly. It does not go through to your back or shoulder; it is not colicky; fatty food makes no difference.
No difficulty swallowing. No vomiting. You have never vomited blood. Your stools are normal — not black, no blood. Bowels unchanged. No yellow skin or eyes, no fevers or sweats.
You are eating smaller meals and skipping some — the pain comes back an hour or two after a proper meal, and you have had little appetite since the separation; your clothes are looser.
Medication: ibuprofen 400 mg two or three times most days for the past four months, bought over the counter for a bad back from lifting at work. “Nobody ever asked.”
Alcohol (only if asked without judgement): since your husband left, a bottle of wine most nights, more at weekends. No morning drinking, no shakes; you went two days without on a school trip with no problems.
You smoke ten a day.
Your mum died of stomach cancer at 58 — “she was told it was indigestion for months.”
Your periods are regular; you have a coil; you are not pregnant.

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

You are awake half the night and exhausted at school; three days off sick this month.
You are snapping at the children and avoiding meals out with friends.
Money is tight since the separation; you cannot afford to lose your job.

Ideas, concerns and expectations

Idea: “It’s not IBS.” Privately you think it is cancer, like your mum.
Concern: stomach cancer — and that being “fobbed off” means it will be found too late.
Expectation: “a camera test” or a scan; to be taken seriously.

Cues to deliver, timed

Minute 2: “My mum was told it was indigestion too.” — then look away.
Minute 4, if alcohol and medicines have not been asked about: “I’m not sleeping, I’m not eating properly… I’m just about holding it together.”

If the doctor summarises and asks whether you want to add anything

If ibuprofen or alcohol has not come up: “There is one thing. I’ve been taking a lot of ibuprofen for my back. And… I’m probably drinking more than I should.”
If both have: “I just keep thinking about my mum.”

How to respond to the doctor

If the doctor names your fear, explains why an inflamed stomach lining or an ulcer is more likely — the ibuprofen, the wine, the smoking, the pattern of the pain — says what would make them worry about cancer, and gives a clear plan with a review date and a low threshold for a camera test: “Thank you. That’s the first time anyone has actually explained it.”
If the doctor refuses to discuss a camera test or brushes off the cancer worry: angry again — “So I’m being fobbed off again.”
If the doctor lectures you about drinking: “I didn’t come here to be judged.” If asked kindly about cutting down: “I know. I know I need to.”
If the doctor mentions how to give feedback or complain: “I don’t want to complain. I just want someone to listen.”
If the doctor has not said what to look out for, ask: “And what if it gets worse before then?”

Do not

Swear at, insult or threaten the doctor.
Volunteer the ibuprofen, the alcohol or your mother’s cancer until asked or invited to add anything.

Findings to give the candidate — only if asked for

If the candidate asks to examine you, or asks for observations or examination findings, read these out. Do not offer them otherwise. (Where a separate examiner is present, the examiner reads them.)

Looks tired; not pale, not jaundiced. BP 128/78, pulse 76, temperature 36.8 °C. Abdomen soft; mild epigastric tenderness; no guarding, no mass, no organomegaly, Murphy’s sign negative; no supraclavicular lymphadenopathy. Weight 61 kg (65 kg four months ago).

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 Pain characterised: epigastric, burning, after meals and at night, eased briefly by food and antacids Red flags: difficulty swallowing, vomiting, vomiting blood, black stools, weight loss, jaundice, a mass; asks for examination findings Causes sought: over-the-counter ibuprofen, alcohol quantified without judgement, smoking; mother’s stomach cancer ICE (fears cancer; wants a camera test) and impact — sleep, days off work, the children, money	☐	☐	☐	☐	/4
2 · Clinical management skills Summary and check, then the working diagnosis: dyspepsia from gastritis or a peptic ulcer, driven by ibuprofen, alcohol and smoking; H. pylori to be tested Why not cancer: 44, no dysphagia, vomiting, pallor or mass — but weight loss and family history mean a low threshold; gallstones, pancreatitis and IBS fit less well Plan: stop ibuprofen; bloods; H. pylori test before* a PPI, then full-dose PPI for 4 weeks; alcohol and smoking support; camera test if not settling* Safety-net: vomiting blood, black tarry stools, sudden severe pain or collapse → 999; difficulty swallowing, persistent vomiting or further weight loss → urgent appointment · Follow-up: named review in 2 weeks with results	☐	☐	☐	☐	/4
3 · Interpersonal skills De-escalates: sincere apology for the wait, listens without interrupting, no defensiveness, no “calm down” Finds and names the fear behind the anger — her mother Asks about alcohol without judgement Acknowledges her previous visits; shares the plan; offers the feedback route without hiding behind it	☐	☐	☐	☐	/4
Station total					/12

Examiner's overall judgement (standard-setting only — it does not decide your result): ☐ Unsatisfactory ☐ Borderline ☐ Satisfactory ☐ Good

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 F2 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	Characterises the pain: site, character, timing in relation to food and night waking, relieving factors, radiation, duration and progression Red flags screened explicitly: difficulty swallowing, persistent vomiting, haematemesis, melaena, weight loss, jaundice, fevers or night sweats; asks for examination findings (mass, anaemia, jaundice, lymph nodes) Looks for causes: prescribed and over-the-counter medicines (ibuprofen), alcohol quantified, smoking, stress Family history — her mother’s stomach cancer Uses the records: two previous contacts, no blood tests, 4 kg weight loss ICE: does not believe it is IBS; fears stomach cancer and that delay will be fatal; wants a camera test Impact on daily living: broken sleep, exhaustion at school, days off sick, snapping at the children, money worries since the separation	Summarises the story back to her and checks whether she wants to add anything Working diagnosis with justified differentials: dyspepsia most likely due to gastritis or a peptic ulcer — burning upper abdominal pain after meals and at night, eased by food and antacids, in someone taking regular ibuprofen, drinking heavily and smoking; H. pylori needs testing. Stomach cancer is much less likely at 44 with no difficulty swallowing, no vomiting, no mass and no sign of anaemia — and her weight loss is explained by eating less — but with that weight loss and her mother’s history the threshold for a camera test is low. Gallstones (not colicky, no link to fatty food), pancreatitis (no radiation to the back, no vomiting) and IBS (would not wake her or cause weight loss) fit less well Stops the ibuprofen; paracetamol for her back instead Investigations: blood tests including a full blood count and liver function; an H. pylori test before starting a proton pump inhibitor, then a full-dose PPI for four weeks Explains honestly when an urgent suspected-cancer referral — in practice usually an urgent camera test — is indicated (difficulty swallowing at any age; 55 or over with weight loss and upper abdominal pain, reflux or dyspepsia) and that she will be referred if symptoms persist or anything changes; discusses with the supervising GP Alcohol and smoking: names the amount (roughly 70 units a week) without judgement, agrees a goal to cut down with support, offers the alcohol service and stop-smoking help — the detail can wait for the two-week review Safety-net: vomiting blood or “coffee grounds”, black tarry stools, sudden severe abdominal pain, fainting or collapse → 999; food sticking or difficulty swallowing, persistent vomiting, further weight loss or pain that is getting worse on treatment → urgent same-week appointment — these would change the plan to an urgent camera test. Follow-up: a booked review in two weeks with the same clinician or a named GP — not “come back if no better” — with the blood and H. pylori results, her weight, and how she is getting on without ibuprofen and with cutting down alcohol; treatment reviewed at four weeks; referral for endoscopy if symptoms persist despite treatment or any red flag appears.	Opens with a sincere apology for the wait; sits down, lowers voice, listens without interrupting Does not become defensive, justify the delay or say “calm down” Acknowledges that she has come three times and does not feel heard Finds and names the fear behind the anger — her mother’s death — and responds to it Asks about alcohol and ibuprofen without judgement Offers the practice feedback or complaints route if she wants it — without hiding behind it Shares the plan, invites her view on a camera test, and checks she feels listened to
3	Pain and red flags covered and the fear of cancer elicited; one of NSAID use, alcohol, family history or the impact on work and home missing.	Working diagnosis explained with reasoning and an appropriate plan; one of H. pylori testing before PPI, the alcohol plan, the explanation of endoscopy criteria or a specific follow-up missing.	De-escalates well and is respectful; the fear of cancer acknowledged but not explored, or alcohol handled a little clumsily.
2	Reasonable pain history but red flags incomplete; medicines bought over the counter and alcohol not asked about; her concern emerges only because she volunteers it.	PPI prescribed without stopping the NSAID or testing for H. pylori; diagnosis given without reasoning or differentials; cancer concern not addressed; “come back if no better”.	Polite but defensive or procedural; anger managed by pressing on with questions; limited empathy.
1	Little history — consultation dominated by the argument about waiting; no red-flag screen. Or unsafe: no clinical history taken; or the consultation is terminated because she is angry.	Another antacid or “it’s probably IBS”; no investigations; no safety-net. Or unsafe: continues or prescribes an NSAID; dismisses red-flag enquiry altogether; or refuses to continue the consultation because she is angry.	Argues, justifies or tells her to calm down; she stays angry. Or unsafe: rude, threatens to end the consultation, or belittles her concerns.

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	Starts with closed clinical questions while she is still shouting; no opening, no summary; history, explanation and plan tangled together.
2 · Issues	Key issues or priorities not recognised	Treats the anger as the whole problem — or ignores it completely; does not recognise that the priority is a frightened woman with weight loss whose NSAID use and drinking nobody has asked about.
3 · Time	Poor time management	Most of the station spent on the waiting time and the previous doctors; no diagnosis or plan by eight minutes.
4 · Findings	Abnormal findings or results, or their implications, not identified	Does not register the 4 kg weight loss on the page, the night-time pain, the daily ibuprofen or 70 units of alcohol a week — or does not see their significance.
5 · Examination	Physical examination or use of instruments not competent	Does not ask for examination findings, or is told “mild epigastric tenderness, no mass, not pale, not jaundiced” and cannot use them in the reasoning.
6 · Diagnosis	Working diagnosis or differential diagnoses not correct	“It’s probably IBS / stress”; no working diagnosis of NSAID- and alcohol-related gastritis or ulcer; cannot explain why cancer is less likely or what would make it more likely.
7 · Management	Management plan not reflecting current best practice	A PPI with the ibuprofen left running; no H. pylori test, or tested after starting the PPI; no bloods; alcohol ignored or told to “just stop”; “come back if it’s no better”; nothing said about vomiting blood or black stools.
8 · Rapport	Rapport and sensitivity to the patient’s feelings and concerns not shown	“Please calm down”; explains why the clinic is late; no apology; no recognition that she has been three times.
9 · Listening	Verbal and non-verbal cues not used; poor active listening	Misses “my mum was told it was indigestion too”; misses “I’m just about holding it together”.
10 · Language	Language or explanations not understandable; understanding not checked	“You have dyspepsia; we’ll do an H. pylori stool antigen and start a PPI — you don’t meet the suspected-cancer-pathway criteria for an OGD” — jargon, and no check that she understands or agrees.

5 · Examiner points of fact and guidelines

Points of fact the examiner should have to hand

De-escalation is the first clinical skill here: apologise for what deserves an apology, sit down, lower your voice, let the patient finish, do not justify or argue, and look for the fear underneath the anger.
Uninvestigated dyspepsia (NICE CG184): review medicines that cause it — NSAIDs, aspirin, corticosteroids, bisphosphonates, calcium-channel blockers, nitrates and theophyllines (NICE CG184; NICE CKS); give lifestyle advice; then offer H. pylori “test and treat” or a full-dose PPI for four weeks.
Test for H. pylori with a stool antigen test or a carbon-13 urea breath test. A PPI taken in the previous two weeks (or antibiotics in the previous four) can give a false negative — so test before starting the PPI.
NSAIDs and H. pylori are independent risk factors for peptic ulcer. Pain relieved by food and waking the patient at night is the classical duodenal ulcer pattern.
Suspected oesophageal or stomach cancer (NICE NG12, amended May 2025): a suspected cancer pathway referral for dysphagia at any age, or for people aged 55 or over with weight loss and upper abdominal pain, reflux or dyspepsia — this replaced “urgent direct-access endoscopy”. She does not meet these criteria at 44 — but persistent symptoms despite treatment (NICE CG184), or any red flag, change that. Explaining the criteria is more reassuring than refusing the test.
Detail for the review visit rather than for eight minutes: coeliac serology and urea and electrolytes with the first bloods; H. pylori eradication therapy if positive; physiotherapy for her back; a formal AUDIT and dependence screen.
A 750 ml bottle of 13% wine is about 10 units: a bottle a night is about 70 units a week against a low-risk guideline of 14. Screen with AUDIT-C, ask about dependence (morning drinking, tremor, withdrawal fits), and agree a goal. People who are dependent should not stop suddenly (NICE CG100; assisted withdrawal: NICE CG115) — she has no features of dependence, so cutting down or stopping with support is safe.
Alcohol and weight loss: offer oral thiamine to harmful or dependent drinkers who are malnourished or at risk of malnourishment (NICE CG100).
A patient who is angry is not necessarily making a complaint — but every patient should know how to give feedback or complain if they wish. Offer it; do not hide behind it.
An F2 would discuss a third presentation with weight loss with the supervising GP.

Where candidates lose marks at this station

“Please calm down.”
Explaining why the clinic is running late.
Never asking what she buys over the counter.
Starting a PPI and then testing for H. pylori.
Refusing the camera test without explaining when it would be needed.
“Come back if it’s no better.”

Guidelines for this station

6 · MLA content map tags for this case

MLA content map	This station
Domain 1 · Areas of clinical practice	Gastrointestinal (GI) · General practice and primary healthcare
Domain 3 · Clinical and professional capabilities	Communication with patients, relatives and carers · History, examination and differential diagnosis · Investigations: request, interpret, act · Health promotion and disease prevention · Complexity, uncertainty and prioritisation
Domain 5 · Patient presentations	Abdominal pain (acute and chronic) · Weight loss · Substance misuse
Domain 6 · Conditions	Peptic ulcer disease and gastritis · Gastric cancer
Station family	Acute care, ethics and safeguarding — Angry patient / 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 P2-08

Revision link for this case: acumenprimarycare.com/plab-2-osce/case-08-angry-patient-abdominal-pain

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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.

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