You are an FY2 in a GP surgery  

Personal Details:

Name: John Williams

Age: 54

Medical Record:

Past medical history: None.

Notes:

A 54-year-old man presents with a several-month history of nasal blockage and snoring. He is otherwise well.

During the consultation, you are shown a photograph of his nasal passage, which reveals a nasal polyp.

Task:

1. Take a focused history.

2. Explain the finding from the examination (the photo).

3. Discuss the diagnosis and management plan.

Opening Sentence: “Doctor, I’ve had this blocked nose for months now, and it’s driving me mad. My wife says my snoring is terrible.”

Open History (to give freely): “It’s mainly one-sided, my left nostril. It feels constantly blocked. I get a bit of a runny nose with it sometimes. It’s really affecting my sleep.”

ICE (Ideas, Concerns, Expectations):

Ideas: “I don’t know what it could be. A friend of mine had something similar and needed an operation.”

Concerns: “Is it something serious? Is it a tumour?”

Expectation: “I want to know what it is and if there’s a treatment to get rid of it.”

How to Act: You are a straightforward man who is fed up with your symptoms and wants a solution.

More History (only if asked): You have not had any nosebleeds, facial pain, or loss of smell. You are otherwise fit and well.

Social History: Works in the fire service. Non-smoker.

Questions to ask:

“What is a polyp?”

“Will the spray be enough to get rid of it?”

History of Presenting Complaint: You’ve had a blocked nose? How long have you had that for now? Is it on one side or both? Have you had any other symptoms with it, like a runny nose, a reduced sense of smell, or any bleeding? Have you had any pain in your face or any problems with your vision?

Exploring Underlying Atopy: You mentioned you have asthma and hay fever. How well controlled are they at the moment? Are you using your inhalers and allergy tablets regularly?

Red Flag Screening (for malignancy): Have you had any nosebleeds? Any facial swelling or numbness? Any loose teeth or changes in your vision?

ICE (Ideas, Concerns, Expectations): What were your own thoughts about what could be causing this blockage? Your main worry was cancer. What made you think of that?” “What were you hoping we could do for you today?”

Explain the situation, the likely diagnosis or DD:

Thanks for coming in. This sounds very frustrating for you.

(After being shown the photo)

I’ve had a look inside your nose, and I can see what is causing the blockage. You have a small, greyish growth called a nasal polyp. It looks like a small, peeled grape on a stalk. This is a very common, non-cancerous growth of the nasal lining.

Addressing and answering the patient’s ICE:

You were worried this could be something serious, like a tumour. I can reassure you that this has all the typical features of a benign nasal polyp and is not a cancer. They are essentially like a small swelling of the lining inside your nose, a bit like a skin tag.

Next Steps:

The first line of treatment, and what is often very effective, is a steroid nasal spray. This is a spray you use in your nostrils once or twice a day for 8 weeks. The steroid in the spray works to shrink the polyp down over a period of several weeks. It’s very safe as the steroid acts locally in the nose and very little gets into the rest of your body.”

Self-help measures if relevant:

I will prescribe you a course of this spray to use for six to eight weeks. We can then arrange a follow-up appointment to see how much it has improved. For many people, the spray is enough to shrink the polyp and resolve the blockage.”

You asked if the spray will be enough. In most cases, it works very well. If your symptoms don’t improve after a good trial of the spray, or if the polyp is very large, then we would refer you to the Ear, Nose, and Throat (ENT) specialists at the hospital. They can then consider surgically removing it, which is a very straightforward day-case procedure.”

Addressing ideas, concerns, and expectations: Reassure him that the diagnosis is a benign nasal polyp and not cancer. Explain what a polyp is in simple terms (“like a small grape”).

The management is a stepwise plan. 1. Prescribe a trial of a topical steroid nasal spray. 2. Arrange a follow-up appointment to assess the response. 3. Explain the criteria for referral to ENT (failure of medical treatment).

What is scenario testing? This case tests the candidate’s ability to diagnose a common ENT condition from a clinical photograph and history. It requires knowledge of the standard, conservative-first management pathway. The communication challenge is to provide reassurance and explain the treatment plan clearly.