A PLAB 2 station on MedMock, start to finish

Hello, Mr Walker? Come in and have a seat. I'm Dr Ellis, one of the doctors here at the practice. Could you confirm your full name and date of birth for me, and then tell me what's brought you in today?

Graham Walker, fourteenth of March, 1962. It's a bit awkward, doctor. I've been passing blood in my water. The first time was about ten days ago, and it's happened twice since. The wife made me come in, to be honest.

I'm glad she did, and I'm glad you came. It's exactly the right thing to do. Could you describe what it looks like when it happens?

Red, like rosé wine. The last time there were a couple of little dark stringy bits in it too. It's not every time I go. In between, it looks normal.

Thank you, that's very clear. Those stringy bits sound like small clots. Has there been any pain with it, either when you pass water or in your back or sides?

No, that's the funny thing. It doesn't hurt at all. No burning, nothing in my back.

Any fevers or shivers? And how are your waterworks otherwise? Are you going more often, getting up at night, or has the flow changed?

No fevers. I'm up once or twice most nights, and the stream's weaker than it was. It takes a while to get going. But that's been creeping up for a year or two, and I put it down to my age.

That's useful, thank you. Have you lost any weight without trying, or noticed any change in your appetite or energy?

Weight's about the same, and I'm eating fine. A bit tired, maybe, but that's the getting up at night.

Have you ever had kidney stones, or any kidney, bladder or prostate problems before? And what medicines do you take? In particular, anything that thins the blood, like aspirin?

Never had any trouble like that. I just take one tablet for my blood pressure, amlodipine. Nothing to thin the blood. And no allergies.

Thank you. Do you smoke, and what sort of work have you done over the years?

I smoke, yeah. Twenty a day since I was sixteen, down to about ten now. I worked at the tyre factory for thirty-odd years till it shut. I'm a caretaker at the leisure centre now.

Thank you for being so open. Both of those matter, and I'll come back to them. Before I explain what I think, what's been going through your mind about what this might be?

Honestly? Cancer. A mate of mine from the factory had bladder cancer a few years back, and his started with blood, just like this. And the wife's been worrying herself sick.

That's a completely understandable worry, and I'm glad you've said it out loud. I'll be honest with you. The test today confirms there's blood in your urine, but it shows no sign of infection. Blood in the urine can have several causes, such as a stone, or an enlarged prostate, which could fit with your weaker flow. But at your age, when you can see the blood and there's no infection, we must rule out a growth in the bladder or kidney. So I'm going to refer you urgently to the urology team at the hospital, on what's called the suspected cancer pathway. That doesn't mean we've found a cancer. Most people referred this way turn out not to have one. It means you'll be seen quickly.

Right. So it could be cancer, then. What happens now?

It could be, and that's why we're checking quickly, but there are other possible causes too. Today I'd like to examine your tummy and, if you're happy, your prostate, which means a quick check with a gloved finger in your back passage. I'll take blood tests to check your kidneys and your blood count, and I'd like to talk to you about a blood test for the prostate called PSA, because it has pros and cons. I'll discuss you with the GP supervising me and send the referral today. At the hospital they usually do a camera test to look inside the bladder, using numbing gel, and a scan of your kidneys. The aim is that within four weeks of the referral you'll have had the tests and been told whether or not there's a cancer.

A camera, right. I'll cope. Should I be packing in the smoking, then? Has that got something to do with it?

That's a really good question. Smoking is the biggest avoidable cause of bladder cancer, and some chemicals used in the rubber industry in the past have been linked with it too, so I'll mention your factory work in the referral. Whatever the tests show, stopping is the best thing you can do for your health. Would you like me to refer you to the local stop smoking service? They give you support and nicotine replacement to help with the cravings.

Go on, then. I've tried on my own before and never managed it. The wife'll be pleased.

That's great. While you're waiting, if you ever can't pass water at all, go straight to A&E, because a clot can block the bladder. If you pass a lot of blood or clots, or get a fever, shivers or bad pain in your back, ring us the same day, or 111 if we're closed. You should hear from the hospital soon, and if you haven't heard within a week, ring the surgery and we'll chase it. Just so I know I've explained it properly, what will you tell your wife tonight?

That there's blood in my water but no infection, and because of my age they want it checked quickly at the hospital, with a camera in the bladder and a scan of my kidneys. It doesn't mean it's cancer, most people who get sent don't have it. Bloods today, you're checking my prostate, and I'm packing in the fags with some help. And if I can't wee at all, it's straight to A&E.

That's exactly right, Mr Walker. Is there anything else you'd like to ask before we do the examination and the blood tests?

No, I think that's everything. Thanks for being straight with me, doctor. It's better than sitting at home worrying.