Who you are:
You are an F2 in GP surgery.Who the patient is:
Mrs. Martha, aged 41, presented to the clinic with a skin lesion
on her shoulder.What you are required to do:
Please talk to the patient, take focused history, discuss different options of management and address her concerns.
Doctor: What brought you to the hospital?
Patient: I have a lesion on my right shoulder. I want it to be removed. (P1)
D: That is fine. We will assess you first and see what can be done.
P: Ok.
D: Can you tell me more about the lesion please. OPEN Q
P: I’ve had it for years.
D: When did you first notice it? Duration
P: I can’t remember it was years ago.
D: May I know the size of the lesion?
P: It’s about 2 x 3 cm.
D: What shape is it?
P: Round.
D: Have you noticed any change in its size since it started?
P: Yes it’s getting bigger.
D: Have you noticed any change in its shape since it started?
P: I am not sure.
D: Have you noticed any change in its colour since it started?
P: It’s been getting darker the past few months.
D: What is the colour of the lesion?
P: Brown/black.
D: Is it painful?
P: No/Yes, it has been recently.
D: Is it itchy?
P: It was not itchy before, but now it is.
D: Any bleeding or discharge from the lesion?
P: No/ Yes it’s been bleeding a little recently.
D: Have you noticed any ulcer on the lesion?
P: No.
D: Have you got any idea how the lesion started?
P: No.
D: Do you have any other skin lesion anywhere else?
P: No.
FLAWS
D: Any fever recently?
P: yes / no
D: Any lumps or swelling in your neck or armpit?
P: No.
D: Have you noticed any weight loss recently?
P: No.
D: How is your appetite these days?
P: Good.
D: Do you feel tired these days?
P: No.
D: Any other problem?
P: No.
D: Any dizziness or heart racing?
P: No.
P2+maftosa
D: Have you been diagnosed with any medical condition in the past?
P: No.
D: Any previous skin conditions?
P: No.
D: Are you currently taking any medications, over-the-counter drugs or supplements?
P: No.
D: Any long-term steroids or antibiotics?
P: No.
D: Any allergies from any food or medications?
P: No.
D: Any previous hospital stays or surgeries?
P: No.
D: Has anyone in the family been diagnosed with any medical condition?
P: No.
D: Anyone with any skin problems or any skin cancer in the family?
P: No.
D: What do you do for a living? Occupation
P: I’m a gardener and I also sell fruit and vegetables in the market.
D: Any long-term exposure to sun or tanning sessions? Sun exposure is Very important.
P: Yes, I’m in the sun all day for my work.
DESAS
D: Do you smoke?
P: Yes/No.
D: Do you drink alcohol?
P: Occasionally.
D: Tell me about your diet?
P: It’s a good diet.
D: Could you please tell me about your home condition?
P: I live in a house with my partner.
D: Does the lesion affect your day-to-day activities?
P: No.
D: Have you got any particular concern for the lesion to be removed now?
P: I have my wedding coming up and my wedding dress won’t cover it. It looks ugly.
Also, it gets stuck in my dress and is quite uncomfortable.
D: Oh dear! That sounds horrible. I understand how it must be frustrating for you.
ALWAYS REFLECT ON THE PATIENT.
EXAMINATION
D: I would like to check your vitals and examine your lesion if that’s OK? I would like to send for some initial investigations as well including routine blood tests.
D: Have you got any idea what the lesion could be?
P: Well I thought it was a mole but since it started changing I’m not sure any more.
Management:
Diagnosis:
Best case - Worst case scenario So far based on what you have told me it might be something as benign as a mole. However, from my assessment we found out that (mention any positive findings what so ever that are red flags). So I am a bit worried that your lesion might be something more sinister like melanoma.
Unfortunately, this is a type of cancer of the skin, but it’s still too early to say for sure. PAUSE
We will refer you to a dermatologist and team of doctors (multi-disciplinary team) who will do the necessary tests and confirm the diagnosis and start treatment depending upon the condition.
We will refer you to the specialist in 2 weeks time.
Senior.
Investigation:
- Routine bloods
- Excisional biopsy: They may remove it and send it for testing to check whether it’s cancerous.
- Wide local excision: If cancer is confirmed, you’ll usually need another operation, most often carried out by a plastic surgeon, to remove a wider area of skin. This is to make absolutely sure that no cancerous cells are left behind in the skin. We call it WLE.
- Depending on the depth and the size. Other tests and scans might be needed to find out if it has spread to another area of your body. CT, MRI or PET or taking samples from nearby Lymph nodes (sentinel LN biopsy)
- If you don’t have melanoma, you do not need any further tests or treatment.
Treatment
Surgery is the main treatment for melanoma. Other treatments include:
− Immunotherapy
− Chemotherapy
− Radiotherapy
Specialist:
- Multidisciplinary team: If you have melanoma skin cancer you’ll be cared for by a team of specialists that should include a skin specialist (dermatologist), a plastic surgeon, a specialist in radiotherapy and chemotherapy (oncologist), an expert in tissue diseases (pathologist) and a specialist nurse.
- When helping you decide on your treatment, the team will consider:
− the type of cancer you have
− the stage of the cancer (its size and how far it has spread)
− your general health - Your treatment team will recommend what they believe to be the best treatment option, but the final decision will be yours.
Safety netting
If you experience any bleeding, difficulty in breathing, come to us immediately. RED FLAGS for MELANOMA are often a new mole or a change in the appearance of an existing mole. Signs to look out for include a mole that’s:
• getting bigger
• changing shape
• changing colour
• bleeding or becoming crusty
• itchy or sore
Follow up
After your treatment, you’ll have regular follow-up appointments to check whether:
− there are signs of the melanoma coming back.
− the melanoma has spread to your lymph nodes or other areas of your body.
− there are signs of any new primary melanomas.
Help and support
Being diagnosed with melanoma can be difficult to deal with. You may feel shocked, upset, numb, frightened, uncertain, and confused. These types of feelings are natural. Some people prefer to talk to people outside their family. There are several UK-based charities that have specially trained staff you can speak to on a free helpline:
− Macmillan Cancer Support
− Melanoma UK
