You are an FY2 in a GP surgery
Personal Details:
Name: Brian Smith
Age: 68
Medical Record:
Past medical history: None.
Regular medication: None.
Allergies: None known.
Notes:
A 68-year-old man presents with a lesion on his back that he has had for 30 years. His wife has urged him to get it checked, as he thinks it has become darker recently. He is a keen swimmer and is annoyed by his appearance.
When the candidate offer examination, the examiner will give you a photograph of a classic seborrhoeic keratosis.
Task:
1. Take a focused history of the skin lesion.
2. Discuss the management options
Opening Sentence: “Doctor, my wife has been nagging me for years to get this thing on my back looked at. I’ve had it for ages.”
Open History (to give freely): “I think I’ve had it for about 30 years. It’s never really bothered me, no pain or itching. But I think it’s got a bit darker recently, and the wife is worried it’s something sinister. To be honest, I’m just sick of the sight of it. I go swimming a lot, and I feel like people are staring at me.”
Cues to give: “If it’s nothing to worry about, can I just get it removed anyway?”
ICE (Ideas, Concerns, Expectations):
Ideas: “I don’t know what it is. The wife thinks it’s cancer because it’s got darker.”
Concerns: “Is it skin cancer?”
Expectation: “I want to know what it is, and I want to get it removed.”
How to Act: You are a bit gruff and nonchalant, but underneath, you are slightly anxious. Your main motivation for wanting it removed is cosmetic.
More History (only if asked): The lesion has grown very slowly over 30 years. It has a rough, warty surface. There has been no bleeding, ulceration, or sudden change in size. You are otherwise fit and well.
Social History: You are retired. You swim three times a week.
Questions to ask:
“Are you sure it’s not cancer?”
“How can you remove it?”
History of the Lesion: You’ve come in about a mole on your back. When did you first notice it? Has it changed since you first saw it? If so, how? Has it got bigger, changed shape, or changed colour? Has it ever been itchy, or has it ever bled?
Skin Cancer Risk Assessment: Have you ever had a cancerous mole removed in the past? Do you have a family history of skin cancer? Do you burn easily in the sun? Did you have a lot of sun exposure or sunburns over the years?
ICE (Ideas, Concerns, Expectations): What were your own thoughts on what this lesion could be?
Your main worry was skin cancer. What made you concerned about that?
What were you hoping I would do for you today?
Explain the likely diagnosis:
Hi, thanks for coming in. Let’s have a look at this lesion on your back.
(After examining/viewing the photo)
Based on its appearance – the way it looks ‘stuck on’, its warty surface, and the fact you’ve had it for so long – this is a classic example of a seborrhoeic keratosis. It’s a very common, completely harmless skin growth that people tend to get as they get older. Think of it like a skin tag or a barnacle. It is absolutely not a skin cancer.”
Addressing and answering the patient’s ICE:
Your wife was right to be concerned about a change in colour, as that can sometimes be a sign of skin cancer. However, the other features are all very reassuring and typical of this harmless growth. It’s very common for them to get darker over time.”
Next Steps:
You asked if you could have it removed, even though it’s harmless. The answer is yes, but not on the NHS. Because it is a benign lesion and not causing any medical problems, removal is considered a cosmetic procedure. Therefore, we cannot refer you for removal on the NHS. You would need to see a private dermatologist or a skin specialist in a private clinic.”
Other options
If you are really keen to have it done, then there are options to explore, but these are all private. These include removing it, or cryotherapy, where it is frozen off with liquid nitrogen. It’s a very quick and simple procedure.
Safety netting
While this lesion is harmless, it’s always a good idea to keep an eye on your skin. If you notice any new moles or any existing ones that change rapidly in size, shape, or colour, or start to bleed or itch, then you should always come and get them checked out.
Addressing ideas, concerns, and expectations: Provide a clear, confident, and reassuring diagnosis. Directly address the cancer concern. Manage his expectation that he can have it removed on the NHS by clearly explaining the policy on cosmetic procedures.
The management is providing reassurance and information. Explain the options for private removal (excision or cryotherapy). Provide general skin cancer safety netting advice.
What is scenario testing? This case tests the candidate’s ability to diagnose a common benign skin lesion and differentiate it from melanoma. The main challenge is managing the patient’s request for removal by explaining the boundary between NHS and private treatment in a clear and fair way, without being obstructive.