Ethics · Advanced · Medical Error

Swelling and Reduced Urine Output After Throat Infection

Practise this PLAB 2 ethics station on Post-Streptococcal Glomerulonephritis. 8-minute voice AI simulation with feedback on all 3 marking domains.

Clinical scenario

You are an FY2 doctor in a GP surgery. Mr Grant Whitfield, a forty-five-year-old man, has come with his wife because he has developed facial and ankle swelling over the past two weeks. He had a sore throat about four weeks ago that was treated in primary care but his symptoms were not fully investigated at the time. He has been found to have acute kidney injury secondary to post-streptococcal glomerulonephritis. You must explain the delayed diagnosis, the underlying pathology, current management, and prognosis.

Background notes: PMH: Nil significant, no previous hypertension or kidney disease

What this station tests

  • Post-streptococcal GN: oedema, hypertension, cola-coloured urine 1-3 weeks after streptococcal infection
  • Antibiotics do not reliably prevent post-streptococcal GN: honest explanation for the family
  • Complement levels and ASOT as diagnostic investigations
  • Duty of candour: reviewing the original consultation honestly
  • Urgent nephrology referral if renal function significantly impaired

How to use your 8 minutes

  • 0-1 min — Introduction: Introduce yourself. Establish the ethical issue and your role.
  • 1-3 min — Explore Perspective: Listen to patient/relative perspective. Understand their reasoning and concerns.
  • 3-5 min — Ethical Framework: Apply ethical principles: autonomy, beneficence, non-maleficence, justice. Reference relevant guidelines (GMC, Mental Capacity Act).
  • 5-7 min — Negotiate and Plan: Find common ground. Explain your professional obligations. Involve MDT where appropriate. Document plan.
  • 7-8 min — Closing: Summarise agreed position. Outline next steps. Offer further discussion.

Consultation approach

The opening

A patient presenting with complications following a throat infection that was inadequately treated raises questions about whether the original management was appropriate. Mr Whitfield is 45, with swelling and reduced urine output 2 weeks after a throat infection treated with symptomatic relief only. Open with: 'Mr Whitfield, I can see you are unwell. Tell me what has been happening since the throat infection.'

Core approach

Clinical assessment. He has periorbital and ankle oedema, hypertension, dark ('cola-coloured') urine, and reduced urine output. These features 1 to 3 weeks after a streptococcal throat infection suggest post-streptococcal glomerulonephritis. The throat infection 2 weeks ago was treated symptomatically without antibiotics. His wife is angry: she believes antibiotics would have prevented this.

Was the original management appropriate? Post-streptococcal GN can occur even after appropriately treated streptococcal pharyngitis. Antibiotics reduce the duration and transmission of streptococcal infection but do not reliably prevent GN. However, if the original presentation met criteria for antibiotics (Centor score, FeverPAIN) and they were not given, there may be a legitimate concern.

Urgent investigation: urinalysis (haematuria, proteinuria), bloods (U&E for renal function, complement levels C3/C4, anti-streptolysin O titre), BP measurement. If renal function is significantly impaired: urgent nephrology referral.

Closing and safety netting

Explain the likely diagnosis honestly. 'The swelling, dark urine, and high blood pressure suggest your kidneys have been affected by an immune reaction to the throat infection. This is called post-streptococcal glomerulonephritis.' Reassure: 'In adults, this usually recovers fully with supportive treatment.'

Address the wife's concern with duty of candour. 'I understand your concern about whether antibiotics would have prevented this. The evidence suggests that antibiotics do not reliably prevent this kidney complication, but I will review the original consultation to make sure the management was appropriate.' If there was a genuine error: acknowledge it. If not: explain clearly. PALS if they want to complain. Safety net: if urine output drops further or he develops severe headache (hypertensive emergency), attend A&E. Follow-up within 48 hours with blood results.

How examiners mark this station

Examiners will assess your ethical reasoning and interpersonal skills. Domain 2 (Clinical Management) is primary: marks for applying an ethical framework, referencing relevant legislation and guidelines, and reaching a reasoned position. Domain 3 (Interpersonal Skills) is equally weighted: marks for non-judgmental exploration, empathic communication, and negotiation skills. Domain 1 (Data Gathering) assesses your ability to fully explore the situation before forming a view.

Domain 1 (Primary focus)

Scores well: Clinical picture identified. Investigations planned (urinalysis, U&E, complement, ASOT). Original consultation reviewed.

Costs marks: Not recognising GN. Not investigating urgently.

Domain 2 (Primary focus)

Scores well: Urgent bloods. Nephrology referral if needed. Duty of candour about original management. PALS offered.

Costs marks: Delayed investigation. Defensive about original care.

Domain 3 (Primary focus)

Scores well: Honest with wife about antibiotic evidence. Acknowledging her concern. Reviewing original care objectively.

Costs marks: Defensive. Dismissing wife's concern. Not reviewing original consultation.

Common examiner feedback (and how to fix it)

Did not demonstrate adequate ethical reasoning or application of relevant guidelines

Fix: Structure your response around the four ethical pillars (autonomy, beneficence, non-maleficence, justice). Reference specific guidelines (GMC, Mental Capacity Act) where relevant.

Did not sufficiently recognise or respond to the patient's feelings, concerns, or expectations

Fix: Acknowledge the emotional weight of the situation early. Show that you understand why this is difficult before applying ethical reasoning.

Common mistakes in this station

  1. Agreeing that antibiotics would have prevented the complication: the evidence does not support this
  2. Not investigating urgently: post-streptococcal GN with renal impairment needs same-day bloods
  3. Being defensive about the original consultation without reviewing it

Resitting PLAB 2?

If you have found ethics stations difficult, focus on learning a clear ethical framework (the four pillars) and practising how to apply it conversationally rather than reciting principles. Examiners reward candidates who can explore the tension between competing ethical principles while remaining empathic and non-judgmental.

Example opening

Thank you for coming in to speak with me. My name is Dr [Name]. I understand there is something important we need to discuss. Could you tell me your understanding of the situation?

Frequently asked questions

How do I structure my approach to this post-Streptococcal glomerulonephritis consultation?

A patient presenting with complications following a throat infection that was inadequately treated raises questions about whether the original management was appropriate. Mr Whitfield is 45, with swelling and reduced urine output 2 weeks after a throat infection treated with symptomatic relief only.

What does a strong performance look like to the examiner in this station?

Strong performances show: Clinical picture identified. Investigations planned (urinalysis, U&E, complement, ASOT). Original consultation reviewed. Weak performances: Not recognising GN. Not investigating urgently.

What is the biggest pitfall in this post-Streptococcal glomerulonephritis station?

Agreeing that antibiotics would have prevented the complication: the evidence does not support this. Another frequent error: Not investigating urgently: post-streptococcal GN with renal impairment needs same-day bloods.

How should I prepare for post-Streptococcal glomerulonephritis if I have never seen it in practice?

Structure beats experience here. Focus on antibiotics do not reliably prevent post-streptococcal GN: honest explanation for the family. The written guidance on this page covers the full approach, and practising the consultation aloud builds the fluency the examiner is listening for.

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