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Practice case P2-09 · Face-to-face · simulated patient

Explaining a liver scan result

A 54-year-old restaurant owner has come for the results of his liver scan. The scan shows cirrhosis.

Reviewed and kept current

Station family: Breaking bad news / explaining a long-term condition · 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 gastroenterology outpatient clinic. Your registrar has asked you to explain the results; a consultant hepatology appointment is booked for two weeks’ time.
Patient	Mr Vikram Sharma, 54, restaurant owner
Background	Referred by his GP with abnormal liver blood tests, six months of tiredness and abdominal bloating.
Results in front of you	Ultrasound: coarse, nodular liver; spleen 14 cm; a trace of free fluid; no focal lesion; portal vein patent. Transient elastography: liver stiffness 21 kPa — consistent with cirrhosis. Bloods: platelets 118 ×10⁹/L (150–400), bilirubin 28 µmol/L (under 21), albumin 36 g/L (35–50), INR 1.1, ALT 62 U/L (under 41), HbA1c 58 mmol/mol. Hepatitis B and C negative; ferritin and transferrin saturation normal; autoantibodies and immunoglobulins normal.
Records	Type 2 diabetes (metformin), hypertension (ramipril). BMI 33. Alcohol recorded by GP as “social”.

Your task

•

Explain the results to Mr Sharma.

•

Explore the possible causes with him.

•

Explain what happens next and what he can do himself.

•

Address his concerns. No examination is required.

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

Vikram Sharma, 54. You run a family restaurant with your wife Meena; two children at university.
Warm, talkative, proud, hopeful. You are expecting something minor.

Opening line — say this verbatim

“Doctor, they said my liver scan wasn’t quite normal. It’s nothing serious, is it?”

Volunteer freely if given the space

You have been tired for about six months — “work stress”.
Your trousers are tighter; you feel bloated.
Your GP mentioned “a bit of fat on the liver” years ago.

Only if asked

Alcohol — first answer: “I drink socially.” If asked kindly and specifically what, how much and how often: whisky with customers most evenings, three or four doubles (50 ml each), six nights a week, for about twenty years. No morning drinking, no shakes. “I’ve never been drunk in my life.”
Diabetes for eight years; you have put on about 12 kg in ten years; you eat late at night after service.
No yellow eyes or skin, no vomiting blood, no black stools, no confusion or sleeping in the day and waking at night. Your ankles swell a little in the evenings. You bruise a bit easily.
No tattoos, transfusions or injected drugs. No family history of liver disease.
You take a herbal “liver tonic” that you buy online, and ibuprofen about once a week for your knee.
Paracetamol occasionally.

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

You are exhausted by the end of service and have started napping in the office.
Meena has taken over the accounts; you worry about who will run the business.
Hospitality is your whole social life — “every deal is done over a drink”.

Ideas, concerns and expectations

Idea: fatty liver — common, nothing much.
Concerns (after the news): “Isn’t cirrhosis what alcoholics get?” — shame; liver failure; cancer (“a friend of mine died of liver cancer”); dying before the children are settled; “Did I do this to myself?”
Expectation: a tablet to fix it; to be told it is reversible.

Cues to deliver, timed

If you have not been told the result by minute 3: “Please — just tell me what it shows.”
On hearing the word cirrhosis: silence, then — “But I’m not an alcoholic.”
Minute 5: “Will I need a transplant?”
If told to stop alcohol: “Completely? Even at a wedding?”

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

If the true alcohol intake has not come out: “I should be honest with you. It’s more than social. It’s every night with the customers.”
If it has: “There’s a herbal tonic I buy online for the liver. Should I carry on with it?”

How to respond to the doctor

If the doctor is non-judgemental about alcohol: you become honest. If you feel blamed or lectured: you minimise — “a couple, now and then”.
If the doctor says flatly that it cannot be cured, with no hope offered: deflated — “So that’s it, then.”
If the doctor explains that the scarring is permanent but that the damage can be stopped from getting worse, that many people live well for years when the causes are dealt with, and that the specialist team will look after you: engaged — “Tell me what I need to do.”
If asked about support to stop drinking: “I can stop. I just never had a reason.” You accept a referral if it is offered without judgement.
If the doctor has not told you what to look out for, ask: “What should I watch for?”

Do not

Volunteer the real alcohol intake or the herbal tonic unless asked specifically or invited to add anything.
Ask detailed questions about transplant — accept “that is for much later, if ever; the specialists will advise”.

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 Checks what he already knows and expects before giving the result Causes explored without judgement: alcohol quantified (about 40 units a week), diabetes and weight, viral risks, herbal and over-the-counter medicines Red flags of decompensation: jaundice, vomiting blood or black stools, confusion, increasing abdominal or leg swelling ICE (expects “fatty liver”; shame, fear of cancer and of dying) and impact — exhaustion, the business, a social life built around alcohol	☐	☐	☐	☐	/4
2 · Clinical management skills Recap, then plain words: cirrhosis — advanced scarring — with early back-pressure (low platelets, large spleen, trace of fluid); summary and check before the plan Cause, with reasoning: fatty liver from diabetes and weight plus* alcohol; viral, iron and autoimmune causes already excluded; no cancer seen on the scan* Plan: consultant clinic in 2 weeks; varices check (camera test or beta-blocker — consultant decides); 6-monthly ultrasound; stop alcohol completely, with support; stop the tonic and ibuprofen Safety-net: vomiting blood, black stools, sudden confusion or marked drowsiness → 999; yellow skin or eyes, fever with abdominal pain, rapidly swelling abdomen or legs → same-day help · Follow-up: hepatology clinic in 2 weeks; nurse specialist number	☐	☐	☐	☐	/4
3 · Interpersonal skills Warning shot; allows silence; responds to shame and “I’m not an alcoholic” Non-judgemental and culturally aware about alcohol, food and family Honest but hopeful: permanent scarring, progression can be halted Chunks and checks; asks what he will tell Meena	☐	☐	☐	☐	/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.

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	Confirms identity, checks what he has been told so far and what he is expecting; asks whether he would like anyone with him Alcohol history taken specifically and without judgement — what, how much, how often, for how long (about 40 units a week for 20 years); dependence features Metabolic risk: diabetes duration and control, weight gain, diet and eating pattern Other causes and contributors: viral risks (transfusions, tattoos, injecting), family history, prescribed, over-the-counter and herbal and online remedies, NSAIDs Red flags of decompensation: jaundice, haematemesis or melaena, confusion or reversed sleep pattern, increasing abdominal or ankle swelling, easy bruising ICE: expects “fatty liver”; after the news — shame, fear of liver failure, cancer and dying; hopes for a tablet and reversibility Impact on daily living: exhaustion at work, the business and Meena, a working and social life built around drinking with customers	Recaps why the tests were done; then, after the news and the discussion of causes, summarises and checks whether he wants to add anything — before the plan Gives the diagnosis in plain words: “The scans show cirrhosis — advanced scarring of the liver.” Explains that his liver is still doing its job (albumin and clotting normal) but that there are early signs of back-pressure: low platelets, a large spleen, a trace of fluid Working diagnosis with justified differentials: cirrhosis most likely from two causes acting together — fatty liver linked to diabetes and weight (MASLD) and alcohol at about 40 units a week; viral hepatitis, iron overload and autoimmune liver disease have been excluded by his blood tests; the scan shows no sign of cancer; the herbal tonic may be contributing and should stop What happens next: consultant hepatology clinic in two weeks; a camera test (endoscopy) to look for varices, or a tablet to lower the pressure in those veins instead — the consultant will decide; ultrasound every six months to look for liver cancer early; regular bloods What he can do — three messages: stop alcohol completely, with support offered; stop the herbal tonic and the ibuprofen (paracetamol is the safer painkiller); keep the clinic appointment — diet, vaccines and diabetes go in the letter to his GP Honest prognosis: the scarring is permanent, but dealing with the causes can stop it getting worse and many people stay well for years; transplant is not a question for now Safety-net: vomiting blood, passing black, tarry stools, or sudden confusion, marked drowsiness or slurred speech → 999; yellowing of the skin or eyes, fever with abdominal pain, or a rapidly swelling abdomen or legs → same-day medical attention (the clinic’s advice line, NHS 111 or the emergency department); Meena told what to look for. Follow-up: the consultant hepatology clinic already booked in two weeks — he is encouraged to bring Meena and a list of questions; endoscopy and surveillance ultrasound requested through the team; the liver nurse specialist’s number and Liver UK patient information given; a letter to his GP today covering alcohol support, vaccinations, diabetes review and the medicines to avoid.	Warning shot before the diagnosis; pauses; allows the silence Responds to “I’m not an alcoholic” without argument — separates the amount from the label Non-judgemental about alcohol, food and weight; culturally aware of hospitality, family and traditional remedies Balances honesty with hope; does not over-promise Small chunks; checks understanding after each; avoids jargon (“varices”, “decompensation”, “HCC”) Asks what he will tell Meena and offers to see them together
3	Perception checked, alcohol quantified and ICE elicited; one of the decompensation screen, herbal / over-the-counter medicines or the impact on work and home missing.	Clear diagnosis, causes and specialist follow-up explained; one of varices / cancer surveillance, the medicines advice or the specific safety-net missing.	Empathic and clear; one cue missed (the shame, the transplant question or the social meaning of alcohol).
2	Accepts “social” drinking without quantifying; causes only partly explored; concerns picked up late.	Diagnosis given but causes not explained or attributed to alcohol alone; next steps vague (“the consultant will sort it out”); no safety-net.	Kind but clinical; too much information too fast; the alcohol conversation feels like an accusation.
1	Delivers the result with almost no exploration of his understanding or the causes. Or unsafe: no data gathered; or results given to the wrong person / not checked.	Inaccurate or frightening information (“your liver is failing”), or false reassurance (“it will heal if you cut down”); no plan. Or unsafe: tells him moderate drinking can continue; or recommends NSAIDs; or gives no follow-up and no warning signs.	Abrupt delivery; lecturing; distress not acknowledged. Or unsafe: blames him (“you’ve done this to yourself”) or is dismissive.

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	Announces “you have cirrhosis” in the first sentence, then takes the alcohol history, then returns to the scan; no order of perception → warning → news → emotion → causes → plan.
2 · Issues	Key issues or priorities not recognised	Turns the station into an alcohol lecture, or a diabetes review; does not recognise that the task is to explain a serious diagnosis, its likely causes and the next steps.
3 · Time	Poor time management	A full alcohol and dietary history; surveillance, the clinic appointment and the warning signs never reached.
4 · Findings	Abnormal findings or results, or their implications, not identified	Does not interpret the results on the page — platelets 118, spleen 14 cm and a trace of fluid as early portal hypertension; liver stiffness 21 kPa; normal albumin and INR as preserved function; negative viral and autoimmune screens.
5 · Examination	Physical examination or use of instruments not competent	No examination is required — a candidate who starts looking for spider naevi and ascites loses time that belongs to the explanation.
6 · Diagnosis	Working diagnosis or differential diagnoses not correct	“It’s because of your drinking” — or “it’s just fatty liver”; cannot give a reasoned cause (metabolic plus alcohol) or say what has been excluded.
7 · Management	Management plan not reflecting current best practice	“Try to cut down a bit”; no mention of checking for varices or of six-monthly ultrasound; ibuprofen and the herbal tonic left running; nothing about vomiting blood, black stools or confusion; no follow-up beyond “the consultant will see you”.
8 · Rapport	Rapport and sensitivity to the patient’s feelings and concerns not shown	“You’ve brought this on yourself”; no response to his shame or to “I’m not an alcoholic”; stock sympathy.
9 · Listening	Verbal and non-verbal cues not used; poor active listening	Misses “a friend of mine died of liver cancer” and “will I need a transplant?”; does not notice that he stopped listening after the word cirrhosis.
10 · Language	Language or explanations not understandable; understanding not checked	“Your elastography shows F4 fibrosis with portal hypertension, so you need an OGD for varices and HCC surveillance” — and no check of what he has understood.

5 · Examiner points of fact and guidelines

Points of fact the examiner should have to hand

Cirrhosis is diagnosed here by transient elastography and imaging; NICE NG50 recommends elastography-based testing for people at risk. The scarring is permanent, but treating the cause can halt progression, and well-compensated cirrhosis is compatible with many years of good health.
His liver is still compensated (normal albumin and INR, no jaundice or encephalopathy, no clinically detectable ascites). Low platelets, splenomegaly and a trace of fluid seen only on ultrasound indicate clinically significant portal hypertension. Decompensation means overt ascites, variceal bleeding or overt encephalopathy (Baveno VII consensus); jaundice is often included. Fluid seen only on ultrasound puts him close to the line — hence the hepatology review within two weeks.
NICE NG50 (amended 2023): after diagnosis offer upper GI endoscopy to detect oesophageal varices — unless the person is going to take carvedilol (or propranolol) to prevent decompensation, which NICE says to consider in clinically significant portal hypertension, as here; that choice is the consultant’s. Offer ultrasound (with or without alpha-fetoprotein) every six months as surveillance for hepatocellular carcinoma, and refer to a specialist hepatology service.
Cause: the 2023 nomenclature replaces NAFLD with MASLD (metabolic dysfunction-associated steatotic liver disease). Metabolic risk plus alcohol of 210–420 g a week in men (about 26–52 units; 140–350 g, about 18–44 units, in women) is termed MetALD — two causes acting together. 40 units a week is nearly three times the low-risk guideline of 14.
Alcohol: complete, lifelong abstinence is advised in cirrhosis of any cause. Ask about dependence before advising an abrupt stop; people who are dependent need a supported withdrawal (NICE CG115).
Medicines: avoid NSAIDs (renal failure, bleeding) and unregulated herbal or traditional remedies bought online (some are hepatotoxic or contaminated). Paracetamol is the analgesic of choice, usually at a reduced maximum daily dose.
Nutrition: malnutrition and muscle loss worsen outcomes. Advise regular meals, adequate protein, a late-evening snack and no added salt; do not advise a low-protein diet.
Vaccination (the Green Book): chronic liver disease is an indication for hepatitis A and B, pneumococcal and annual influenza vaccines.
Metformin can usually continue in compensated cirrhosis with normal renal function; the specialists will review diabetes treatment.

Where candidates lose marks at this station

Accepting “I drink socially”.
“You’ve brought this on yourself.”
“If you cut down it will heal.”
Forgetting variceal screening and the six-monthly scan.
Leaving the ibuprofen and the herbal tonic running.
No warning signs and no number to ring.

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) · Clinical imaging
Domain 3 · Clinical and professional capabilities	Communication with patients, relatives and carers · Chronic condition management plans · Health promotion and disease prevention · Investigations: request, interpret, act
Domain 5 · Patient presentations	Fatigue · Abdominal distension
Domain 6 · Conditions	Chronic liver disease (including decompensation and cirrhosis of the liver) · Metabolic dysfunction-associated steatotic liver disease (MASLD) · Alcohol related liver disease
Station family	Explanation, counselling and breaking bad news — Breaking bad news / explaining a long-term condition

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 P2-09

Revision link for this case: acumenprimarycare.com/plab-2-osce/case-09-liver-scan-result

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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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