Personal Details:

Name: Mr David Webb

Age: 30

Medical Record:

Past medical history: Fit and well.

Notes:

A 30-year-old man presents with a soft, non-painful lump on the right side of his neck that he first noticed 8 weeks ago.

Task:

1. Take a focused history and address his concerns.

3. Discuss the likely diagnosis and management plan.

Examination findings: Soft, fluctuant, non-tender lump, around 5 cm in size, in the anterior triangle of the neck, no other cervical or axillary lumps or swelling.

Opening Sentence: “Doctor, I’ve got this lump in my neck ”

Open History (to give freely): “I found it about eight weeks ago. It is on the right side of my neck. It’s soft, and it doesn’t hurt, but it seems to be slightly getting bigger. I tried to ignore it, but I can’t stop thinking about my dad. He had lumps, and they spread everywhere.”

ICE (Ideas, Concerns, Expectations):

Ideas: “I think it’s cancer, just like my dad.”

Concerns: “Is it a sign of cancer?”

Expectation: “I need to know what it is. I want you to refer me to a specialist.

How to Act: You are highly anxious and fixated on the idea of cancer due to your family history. You need a lot of reassurance.

More History (only if asked):

You have no other symptoms like weight loss, night sweats, or fever.

This lump is not painful, not red or sore. Apart from feeling slightly bigger in size, there is no other recent change.

You don’t smoke or drink.

You are generally fit and well.

Questions to ask:

But how can you be sure it’s not cancer?

History of the Lump (SOCRATES):

You noticed this lump eight weeks ago. Has it changed in size?

Is it painful? Is it red? Does it weep?

Have you had any other lumps anywhere else?

Associated Red Flag Symptoms (Head & Neck Cancer):

Have you had a persistent sore throat?

Have you noticed any change in your voice, like hoarseness?

Have you had any difficulty or pain when you swallow?"

Have you had any ear pain?

Systemic symptoms

Have you lost any weight? How has your appetite been recently?  

Have you been having any fevers or drenching night sweats?

Risk Factors:

Are you a smoker? How many do you smoke a day, and for how long have you smoked?

Do you drink alcohol? How much would you drink in a typical week?

ICE (Ideas, Concerns, Expectations):

What were your own thoughts about what this lump could be?

You mentioned your wife was worried it was something serious. Was that on your mind too?

What were you hoping I would be able to do for you today?

Acknowledge

David, thank you for coming in. It is completely understandable that you are so worried, given what happened to your father. Let’s talk it through.

(After examination, which would show a soft, fluctuant, non-tender lump in the anterior triangle of the neck)

I’ve examined the lump. It feels very soft and smooth. These features are very reassuring. They are not typical features of a cancerous lump. The most likely diagnosis is a benign (non-cancerous) cyst or a fatty lump, which is harmless.

Addressing and answering the patient’s ICE:

Your main fear is that this is cancer. While we can never be 100% certain without further tests, I want to reassure you that this lump does not have the characteristics of a cancerous lymph node. Cancerous lumps are usually hard, irregular, and grow progressively larger; they don’t tend to change in size. Your age and the fact that you are otherwise completely well also make cancer much less likely.

Next Steps:

However, the rule with any unexplained neck lump that has been present for more than 4 weeks is that it must be investigated properly by a specialist. So, I am going to refer you to the Ear, Nose, and Throat (ENT) team at the hospital. This will be an urgent referral, meaning you should be seen within two weeks.

They will examine you and will likely arrange an ultrasound scan of your neck. This is a simple, painless scan that looks at the lump and confirms if it is a simple fluid-filled cyst. Very rarely, in case they were not fully reassured, they may want to take a small sample from it with a needle, which is called a fine-needle aspiration.

I know the two-week wait for the appointment will be a very anxious time for you. Please try to hold on to the fact that all the signs point towards this being something benign. If you feel you are struggling to cope with the anxiety, please come back and see me.

Do you have any questions at the moment?

If this lump becomes suddenly red or sore, or causes any pain, please let us know

Addressing ideas, concerns, and expectations: Provide strong reassurance based on the clinical features (soft, mobile) that cancer is unlikely. Explain the likely benign diagnosis (cyst). Do not, however, give a 100% guarantee.

The key management step is to make an urgent two-week-wait referral to ENT, as per NICE guidelines for an unexplained neck lump. Explain the investigation pathway (ultrasound and possible FNA) to manage his expectations for the specialist appointment.

What is scenario testing? This case tests the candidate’s ability to manage a patient with significant cancer anxiety. It also tests their knowledge of the NICE guidelines for an urgent head and neck cancer referral. The communication challenge is to balance providing strong reassurance with the need for a serious and urgent investigation, without contradicting oneself.