Neck Lump

[Plabforum]

Who you are:
You are an FY2 in the GP practice.

Who the patient is:
Allen Porter, 37-year-old male, came to the GP with a complaint of neck swelling.

What you should do:
Talk to the patient, take relevant history, discuss a plan of management and address his concerns.

Approach

D: Hello my name is doctor (name) I am one of the doctors here in the GP practice. Can I confirm your full name and date of birth please?
P: My name is Allen Porter, 8/10/85.
D: And may I call you Allen is that OK?
P: Yes, doctor Allen is fine.
D: Thank you Allen, so what brings you here today?
P: I have recently noticed that I have some swelling.
D: Can you tell me more about it?
P: It’s on my neck.
P1 Swelling analysis: (remember the derma structure very similar)
D: Do you have any idea how it started? Was it ever there before? Onset
P: I think it might have been there before but never that obvious doctor. OR I’m not sure doctor I don’t know.
D: When did you notice it? Duration
P: This morning. (If it has always been there and he l came only recently, ask why
he came now, what changed?)
D: Where exactly is it? Site
P: On the right side of my neck.
D: Have you noticed lumps or swelling anywhere else like in your neck or armpit?
P: No.
D: Can you describe the size of the swelling?
P: Like a coin.
D: Any change in its size ,whether increased or decreased lately?
P: No.
D: Is it painful?
P: No.
D: Does it feel warm when you touch it?
P: No.
D: Does the swelling go away if you press it?
P: No.
D: Does it move when you swallow or stick your tongue out ?
P: Yes/No
D: Any change in the colour of the skin like getting red or dark ?
D: Any coughing up of blood or discharge from the skin on top?
P: No.
D: Any difficulty in breathing or swallowing?
D: Any change in your tone of voice?
P: No, (may say it feels like a lump in the back of my throat (red flag)* )
D: Anything else?
P: No.

DDx

D: Have you hurt yourself by any chance? (Trauma)
P: No.
D: Any fever or flu-like symptoms or cough? (infections)
P: No.
D: Any night sweats? (TB)
P: No.
FLAWS for CANCERS, TB and AIDS
D: Have you noticed any weight loss?
P: No.
D: How is your appetite these days?
P: Good.
D: Do you feel tired these days?
P: No.
D: Any dizziness or heart racing? (Heart failure with neck veins)
P: No.
D: Are you sexually active? (AIDS)
P: Yes.
D: Do you practice safe sex?
P: Yes, my partner uses condoms. (No need to explore sexual hx further)
D: Do you feel hot when others feel the warm or the opposite with cold? (Thyroid)
P: No.

ICE

Extremely Important can cut your history really short and help you with management.

IDEA
D: Any idea what might be the cause of this swelling?
P: Not really doctor. (or might say: Yes doctor I might have cancer)
D: Explore: May I ask you why you think it’s cancer in particular?
P: My father had cancer when I was young.
D: Sorry to hear that. How is he now (show empathy and console him) ?
P: What cancer did your dad have?
D: I can understand why you are thinking of cancer then. I will do my best to get to the bottom of this.

CONCERN
D: Apart from the cancer concern you have, are you worried about anything else?
P: No doctor or (may mention something else that you will have to address in management)

EXPECTATION:
D: Are you expecting anything specific today?
P: I want to know if the swelling is something sinister. (or may say anything he think he needs like biopsy or chemo treatment or radio therapy don’t forget to mention whether needed or not in management and always reassure but be realistic if he has red flags (way too early to say for sure—see the provisional Dx) )

P2

D: Have you ever had similar swellings in the past?
P: No.
D: Have you been diagnosed with any medical condition in the past?
P: No.
D: Are you taking any medications including OTC or supplements?
P: No.
D: Any allergies from any food or medications?
P: No.
D: Any previous hospital stays or surgeries or blood transfusions?
P: No.
D: Has anyone else in your family had cancer, other than your dad?
P: No.

DESA:

A few questions about your lifestyle now
D: Do you smoke?
P: Yes/No if yes explore (how many packs, for how long)
D: Do you drink alcohol?
P: Yes/No (if yes explore how much for how long, ever tried to calculate the
units)
D: And can you talk to me about your diet?
P: I try to eat healthy.
D: Do you do any form of exercise?
P: Yes/No

Examination

D: Thanks for being so patient with my questions. I would like to examine you now to check your vitals, do a GPE and examine your neck. Is that OK?

If the Examiner doesn’t give you any findings, don’t pause start the management right away and don’t waste your time!!

Examiner may hand you a note with the findings. If not, look for it around and if you don’t find it, carry on and please don’t ask the examiner.

• Swelling is 1x1 cm, hard and fixed.

Provisional Diagnosis

Best and worst case scenarios.
D: Well Allen I suspect that you may have swollen neck glands. While it can be caused by simple conditions, best-case scenario it could just be a common cold or ear or throat infection. Worst case scenario it could also be caused by something worse and more sinister.
When we examined your swelling it was hard and fixed. Considering your father’s history and your concern as well, we would need to do further investigations to exclude the possibility of something as serious as cancer I am afraid to say. However, it is still way too early to say for sure what is
going on. Thank you for coming at this stage you have done right thing.

You can add any positive red flag sx from the hx as well but be brief and simple.

Management:

1. I will refer you urgently to an ear nose throat specialist as a Fast track referral within two weeks
2. Senior
3. Investigations: We will send for some initial investigations like routine bloods and infection markers.
   4- When you go to the specialist, they will do further investigations and imaging as well like an ultrasound for the swelling, maybe an MRI or CT scan as well to assess the area around the swelling more. If it is very suspicious, the throat specialist might also take a sample from the swelling for analysis depending on his decision.

D: How do you feel about that?
P: I’m trying to process it all doctor, I am even more worried now.
D: Let me apologise if I have got you more concerned but as I mentioned it is still way too early and it could be anything so we will have to wait for the
results of the investigations. And rest assured that you will have a meeting with a team of dedicated doctors called a multi-disciplinary team (MDT). They
will discuss your treatment options and start the required treatment at once without any delays. In the meantime, don’t panic, like I said, it could be a cold. Stay positive.
P: Yes doctor.
D: Would you like to know more about treatment options ?
P: Yes.
D: If it is cancer, then the treatment depends not only on the type, size, position and stage of cancer but also your overall health.

• We have surgical options for resection of some tumors.
• Chemotherapy and Radiotherapy may be required as well to extend the quality of life.

Indication for referral:

• Swollen glands are getting bigger, or they have not gone down within 2 weeks.
• They feel hard or fixed (as in this case here).
• Night sweats or high fever (feeling hot and shivery) for more than 3 or 4 days.
• Swollen glands with no other signs of illness or infection.
• Swollen lymph glands just above or below the clavicle (aka collarbone: the bone that runs from your breastbone to each of your shoulders) .

Symptomatic treatment if needed depending on Sx:

• Painkillers
• Anti-sickness.etc

Safety net:

− Flaws
− Difficulty swallowing
− Difficulty breathing
− Hoarseness of voice
− Coughing bloods

[Plabforum]

• Anxiety and patient has swelling on neck for past 2 weeks
• Family history of cancer
• Lymph node enlargement
  — Explain lymph nodes are common
  — Explain that the most common cause is infection
  — Most lymph node enlargement goes away after 6 weeks, you have had it for 2 weeks
  — If it doesn’t resolve then we will refer you to ENT for investigation
• Blood test now to ensure nothing else is going on
• After 2 weeks and it is still there please come back and we will make urgent referral
• ENT
  — Chat
  — Examine
  — Inv: CXR, FNA, CT chest, MRI, Biopsy
• HE HAS ANXIETY IF YOU SAY IT IS CANCER YOU WILL FAIL

[Plabforum]

You are FY2 in GP.
Mr. William Harding, aged 35, has come to you with a neck swelling.
Please talk to him, assess him and address his concerns.

D: How can I help?
P: I have noticed swelling on my neck.
D: Tell me more about it?
P: What would you like to know?
D: When did you notice it?
P: This morning.
D: Where exactly is it?
P: On my right side of the neck
D: What is the size of the swelling?
P: Like a coin
D: Has the swelling increased in size?
P: No
D: Does it feel warm when you touch it?
P: No
D: Did you hurt yourself?
P: No
D: Does the swelling go away if you press it?
P: No
D: Is it painful?
P: No
D: Is the swelling moving on deglutition or tongue protrusion?
P: Yes/No
D: Any discharge?
P: No
D: Have you got any idea how the swelling started?
P: No
D: Any lumps or swelling in your neck or armpit?
P: No
D: Anything else?
P: No
D: Any fever or flu like symptoms?
P: No
D: Any night sweats (TB)
P: No
D: Did you notice any weight loss?
P: No
432
D: How is your appetite these days?
P: Good
D: Any dizziness or heart racing?
P: No
D: Do you feel tired these days?
P: No
D: Are you sexually active?
P: Yes
D: Do you practice safe sex?
P: Yes, my partner uses condoms
D: Have you been diagnosed with any medical condition in the past?
P: No
D: Are you taking any medications including OTC or supplements?
P: No
D: Any allergies from any food or medications?
P: No
D: Any previous hospital stay or surgeries?
P: No
D: Has anyone else in the family been diagnosed with any medical condition?
P: Dad died because of cancer.
D: Do you smoke?
P: Yes/No
D: Do you drink alcohol?
P: yes/No
D: Tell me about your diet?
P: I try to eat healthy.
D: Do you do physical exercise?
P: Yes/No

I would like to check your vitals, do GPE and examine your neck.
I would like to send for some initial investigations including routine blood tests.

Examiner:
Swelling is 1x1 cm, hard and fixed.

Swollen glands are usually caused by common illnesses like cold, ear or throat problems. In some cases, it could be serious as well. You have told us that your father died because of cancer, so we suspect your condition could be a serious one as your swelling is hard and fixed.

We need to do further investigations to make sure what exactly is going on. We need to do more blood tests and refer you to a specialist. The specialist and a team of doctors (multidisciplinary team) 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. They may consider doing a biopsy of swollen gland and other investigations.
If it is cancer, then the treatment depends not only on the type, size, position and stage of cancer and also your overall health. We have surgical options for resection of some tumours. But in some cases, we have to give chemotherapy and radiotherapy to extend the quality of life.

Management (refer to specialist)

• Your swollen glands are getting bigger, or they have not gone down within 2 weeks
• They feel hard or do not move when you press them
• You’re having night sweats or have a very high temperature (you feel hot and shivery) for
  more than 3 or 4 days
• You have swollen glands and no other signs of illness or infection
• You have swollen lymph glands just above or below your collarbone (the bone that runs
  from your breastbone to each of your shoulders)

DDs
Infections
Cancers
Autoimmune conditions

[Plabforum]

Patient Profile and Scenario Setup

1. Age:
   • Definitely more than 24 years old
   • Typically around 28-30 years old
   • Sometimes up to 40 years old
   • Note: If less than 25, same-day referral is required
2. Gender: Male
   • Reason: Nasopharyngeal cancer is more common in males
3. Presenting complaint: Neck lump
4. Additional background information:
   • Patient has been diagnosed with anxiety in the past Note: This is included to test decision-making. Do not let this influence proper assessment and communication.
   • Family history: Father and mother had leukaemia Note: This is included as a distraction. Do not let it influence your diagnosis.
   • Smoking history: Patient smokes a lot, more than 10 years Important: Smoking is a serious risk factor for head and neck tumours
5. Scenario setup:
   • The presenting complaint (neck lump) is written outside the room
   • You have 1.5 minutes to prepare differentials before entering

Initial Assessment

1. Opening question: “How may I help you?”
   Expected patient response: “I have a lump in my neck.”

History Taking
Use the MES approach: Morphology, Evolution, Symptoms

1. Morphology
   • Location: “Which side is the lump on? Left side or right side?”
   • Size: “How big is that?” “Can you compare it? Is it the size of a grape? Or smaller
     than that? The size of a pea? Or somewhere in between?”
   • Consistency: “How is the consistency? Is it a soft lump?” “Does it feel like it’s filled
     with fluid?”
   • Shape: “How is the margin? Is it smooth?” “Does it have an irregular shape or regular
     shape?”
   • Mobility: “Is it moving? Or is it attached to underlying tissue or overlying skin?”
2. Evolution
   • Onset: “When did you notice it?”
   • Progression: “Since then till now, is it getting bigger? Smaller? Same size?”
   • Changes with position or activity: “Does it change when you change your position?
     For example, when you lie down?” “Does it change when you cough or sneeze?”
     “Does it change when you swallow or drink something? When you eat something?”
     “Does it move when you move your tongue?”
3. Symptoms
   • General symptoms: “Does it have any symptoms at all?” “Is it painful?” “Any
     numbness? Tingly sensation?” “Any redness? Any swellings around?”
   • Thyroid-related: “Have you had any thyroid problem in the past?”
   • Mouth and throat: “Any ulcers in your mouth?” “Any wound in your tongue?” “Any
     ulcers on your lips?” “Any problem with your teeth? Any teeth decay?” “Any problem
     with your swallowing?” “Any throat pain?” “Any voice changes?”
   • Nasal: “Any problem with your smell? Finding it okay? Any changes in your smell?”
     “Any bleeding from the nose?” “Any growth in the nose?”
   • Respiratory: “Any problem with your breathing?” “Cough? Shortness of breath?”
   • Lymph node-related: Ask about TB and HIV
   • Leukaemia symptoms: “Any bruises?” “Any anaemia symptoms?”
   • Lymphoma symptoms: “Any weight loss?” “Any back pain?” “Any night sweats?”

Risk Factors

• Smoking: “How long have you been smoking?” “How much do you smoke?”
  Note: Smoking is the main risk factor for head and neck tumours

Physical Examination
Note: In PLAB 2, examination findings are usually provided on paper
Typical findings for suspected cancer:
• Lymph node swelling
• Size: 1x1 centimetre
• Consistency: Fixed mass

Diagnosis and Communication
Suspected diagnosis: Nasopharyngeal tumour (or oro-pharyngeal tumour)
How to communicate the suspicion:
“Unfortunately, I’m sorry to tell you, cancer of this region could present in this way. We
call this naso-oro-pharyngeal tumours. This could be cancer from any of this area - your
nose, your throat, or your mouth. Unfortunately, you do have some risk. That is, you’ve
been smoking for quite a long time, which increases the chances.”

Management and Next Steps

1. Referral:
   o Two-week pathway referral to ENT (Ear, Nose, and Throat) or Head and
   Neck surgeons
2. Investigations:
   o Ultrasound
   o Needle biopsy (no open biopsy)
   o Possible CT scan to locate the original tumour
3. Treatment options:
   o Surgery (mainly for the original tumour)
   o Possible chemotherapy
   o Possible radiotherapy

Important Notes

1. Do not let a patient’s history of anxiety or other mental health issues deter you from
   proper assessment and clear communication about cancer suspicion.
2. Family history of other cancers (like leukaemia in this scenario) should not distract
   you from focusing on the presenting symptom and its most likely causes.
3. Always consider smoking as a significant risk factor for head and neck tumours.
4. The two-week wait referral pathway is crucial for suspected head and neck cancers.
5. Clear communication about the suspicion of cancer is essential, even if it seems
   difficult or uncomfortable.
6. There are three types of lumps to be particularly aware of: breast lump, neck lump,
   and testicular lump.
7. In PLAB 2, if fever is present, it usually indicates an infectious origin, not cancer.

Things to Avoid

1. Don’t be distracted by the patient’s history of anxiety or family history of leukemia.
2. Don’t avoid clear communication about cancer suspicion due to the patient’s
   anxiety history.
3. Don’t ignore or downplay the significance of smoking history.
4. Don’t perform an open biopsy - needle biopsy is preferred.
5. Don’t delay the two-week referral pathway.
6. Don’t use vague terms when communicating cancer suspicion. Be clear and direct,
   while maintaining empathy.

Sample Dialogue
Doctor: “Hello, how may I help you?”
Patient: “I’ve noticed a lump on the side of my neck.”
Doctor: “I see. Which side is the lump on? Left or right?”
Patient: “It’s on the right side.”
Doctor: “How big would you say it is? Can you compare it to something, like a grape or a
pea?”
Patient: “It’s about the size of a grape, I’d say.”
Doctor: “How does the lump feel? Is it soft or hard?”
Patient: “It feels quite firm.”
Doctor: “Does it have a regular shape? Are the edges smooth?”
Patient: “It seems pretty round and smooth.”
Doctor: “When did you first notice this lump?”
Patient: “I first noticed it about three weeks ago.”
Doctor: “Since you noticed it, has it gotten bigger, smaller, or stayed the same size?”
Patient: “It seems to have stayed about the same size.”
Doctor: “Does the lump change when you swallow or when you move your tongue?”
Patient: “No, it doesn’t seem to move at all.”
Doctor: “Is the lump painful at all? Any numbness or tingling around it?”
Patient: “No, it doesn’t hurt or feel numb. It’s just there.”
Doctor: “Have you noticed any problems with swallowing or any changes in your voice?”
Patient: “No, nothing like that.”
Doctor: “Any problems with your sense of smell or any bleeding from your nose?”
Patient: “No, everything seems normal in that regard.”
Doctor: “Have you been experiencing any unexplained weight loss or night sweats?”
Patient: “No, I haven’t noticed anything like that.”
Doctor: “I understand you’re a smoker. How long have you been smoking?”
Patient: “I’ve been smoking for about 15 years now.”
Doctor: “And how many cigarettes do you smoke per day?”
Patient: “About a pack a day.”
Doctor: “Thank you for all this information. I’d like to examine the lump now if that’s
okay.”
[After examination]
Doctor: “Mr. [Patient’s name], based on our discussion and the examination, I’m a bit
concerned about this lump in your neck. Unfortunately, I’m sorry to tell you, cancer of this
region could present in this way. We call these naso-oro-pharyngeal tumours. This could be
cancer from your nose, throat, or mouth area. Unfortunately, you do have some risk.
You’ve been smoking for quite a long time, which increases the chances.”
Patient: “Cancer? Are you sure?”
Doctor: “At this point, we can’t be certain, but it’s a possibility we need to investigate. I’m
going to refer you to a specialist - an Ear, Nose, and Throat doctor. They’ll be able to do
more detailed tests, including an ultrasound and possibly a needle biopsy of the lump. This
referral will be urgent, and you should be seen within two weeks.”
Patient: “What will happen then?”
Doctor: “The specialist will perform more detailed examinations. They might do an
ultrasound of your neck and a needle biopsy of the lump. If necessary, they might also
arrange a CT scan to get a clearer picture. Based on these results, they’ll be able to
determine if this is indeed a tumour and, if so, where it originated from.”
Patient: “And if it is cancer?”
Doctor: “If it turns out to be a tumour, the main treatment is usually surgery to remove it.
Sometimes, additional treatments like chemotherapy or radiotherapy might be needed. But
let’s not get ahead of ourselves. The first step is to get these tests done and get a clear
diagnosis. Do you have any other questions?”
Patient: “This is a lot to take in. I’m scared.”
Doctor: “I understand this is very worrying news. It’s natural to feel scared. Remember,
we’re taking this seriously and acting quickly to get you the proper care and investigation.
The specialist will be able to give you more detailed information once they’ve done their
tests. Is there anything else you’d like me to explain again?”
[Address any further questions or concerns the patient might have]