You are an FY2 in the acute medical unit
Personal Details:
Name: John Miller
Age: 64
Medical Record:
Past medical history: COPD for 10 years, frequent hospital admissions for chest infections.
Regular medication: Tiotropium inhaler, Salbutamol inhaler.
Allergies: None known.
Notes:
John was admitted to the AMU with an acute exacerbation of his COPD. He reports feeling unwell and persistent shortness of breath, which has been gradually worsening in the last few weeks.
His observation on admissions:
HR 99
Spo2 93
T 37.8
BP 130/70
A chest X-ray has been performed.
Chest X-ray Report: Hilar mass identified in the right lung. Possible mediastinal lymphadenopathy.
Task:
1. Take a focused history of his new symptoms.
2. Break the X-ray result.
3. Discuss the next steps.
Opening Sentence: “Thanks for sorting out my breathing, Doctor. I’m feeling a bit better since I have been given the prednisolone and the antibiotic.”
Open History (to give freely): “For the last few months, I’ve had this awful cough that just won’t go away. It’s much worse than my usual COPD cough. I’ve been coughing up a lot of phlegm, and a few times, I’ve seen blood in it. It’s really scared me.”
Cues to give: “I just haven’t been feeling myself at all lately.”
ICE (Ideas, Concerns, Expectations):
Ideas: “I thought it was just my COPD getting worse, but the blood… I don’t know.”
Concerns: “With my smoking history, I’m worried it’s the worst, you know? Cancer.”
Expectation: “I want you to tell me what’s going on. What did the X-ray show?”
How to Act: You are anxious and fearful, but also resigned. You have suspected this for a while and are now steeling yourself for bad news.
More History (only if asked): You have lost weight without trying over the last few months and have lost your appetite. You also have a feeling of discomfort in your chest. You have a 40-pack-year smoking history and have struggled to quit despite trying. Your father died of lung cancer.
Social History: You are a retired police officer. You live with your wife.
Questions to ask:
“So it is cancer, isn’t it?”
“What happens now?”
“How long have I got?”
Recapping the History (to show you’ve listened): We did the scan because of the symptoms you’ve been having - the cough with blood and the weight loss. You also mentioned you’ve been a long-term smoker.
How are you feeling in yourself since you've been in the hospital? Is there anything in particular you wanted to ask about?
Explain the situation, the likely diagnosis:
John, thank you for telling me about these symptoms. I know this must be very difficult to live with for a long time, especially since it has been getting worse over time. I’ve reviewed your chest X-ray, and I need to be honest with you. The combination of the symptoms you’ve described – the cough with blood, the weight loss – along with the shadow we can see on your X-ray, this highly suggests something serious……. I am afraid it is highly suspicious of lung cancer.”
(Pause here, give him time to react. Use silence.)
Addressing and answering the patient’s ICE:
I can see that this is a terrible thing to hear. You are right to be concerned, and we need to take this very seriously. The most important thing to know is that we don’t have a definitive diagnosis yet. The X-ray shows us there is a problem, but it doesn’t tell us exactly what kind of problem it is.
Next Steps:
The next step is to get a clear diagnosis. To do this, we need to refer you urgently for a CT scan of your chest. This is a more detailed type of X-ray that gives us a 3D picture of your lungs. I will also let the lung specialist know so they can see you with the result of the CT scan.
Occasionally, after they scan, they need a procedure called a bronchoscopy, where a specialist uses a thin, flexible camera to look into your airways and take a small sample, a biopsy, from the mass. This sample is what tells us for certain if it is cancer, and if so, what type.
Self-help measures:
I know you have struggled to stop smoking, but it is more important now than ever. Stopping smoking can improve your fitness for potential treatments. We have a specialist inpatient team who can come and see you today to offer support and medication to help with this.
You asked how long you have. It is impossible and unhelpful for me to guess at that right now, because we don’t have enough information. The answer depends entirely on what the biopsy shows and how far the disease has spread. Our focus right now is on getting those answers as quickly as possible. I have already spoken to my consultant, and we will be referring you to the specialist lung cancer team today. They will guide you through the next steps. This is a very difficult time, and we will support you and your wife every step of the way.
Do you have any questions at the moment? I know it is a lot to take in, so please, if you have any more questions at any time, let us know.
Addressing ideas, concerns, and expectations: Break the news of suspected cancer sensitively but clearly, using a warning shot (“I need to be honest with you”). Acknowledge his fears. Avoid giving a premature prognosis.
Involve a senior, arrange a CT scan and refer to the specialist lung team.
What is scenario testing? This is a core breaking bad news station. It tests the candidate’s ability to deliver a life-changing, suspected diagnosis with empathy and clarity. It also assesses their knowledge of the urgent cancer referral pathway and their ability to manage patient questions about prognosis in an honest but hopeful way.