• Candidate Instructions
  • Actor Instructions
  • Mark Sheet
  • Score

Location: Foundation doctor in general practice

Patient: Mrs Summer, a 55 year old, has come into clinic after noticing a lump in her left breast

– Take a focused history from the patient
– After 6 minutes you will be asked a series of questions by the examiner.
– Answer any questions that the patient may have

Note to actor:Try to restrain yourself from volunteering too much information – you may do so when prompted (that is, by a specific question, not a general one). If a student is on the wrong line of clinical reasoning do not fuel this line of thinking, state no to the question as being ambiguous may prompt further questioning and does not allow the student to be appropriately tested. The aim of the exercise is to take a focused history; short answers are required.

You are a 45 year old patient who feels silly about coming into see the GP today. You’re really only here to put your partner’s mind at rest. You’ve noticed a lump in your left breast, it’s been there for about 3 months.

If asked, you think it’s been increasing in size, the shape doesn’t feel smooth and the skin over the top feels different but you are not sure how to describe this. Size is roughly that of a grape. Position is above the nipple. Firm in consistency.

You have not lost any weight that you know of.

If asked you started periods when you were 11 years old and your periods stopped when you were 50.

PMH – none

DH – no regular medications, no known drug allergies

SH – you smoke 30 cigarettes a day, drink a glass of wine at the weekend

FH – mother died of breast cancer aged 65

ICE – you think you are getting older and your breast are changing, you are concerned that this is happening on one side only.

If the candidate appears to have finished early remind them how long is left at the station and enquire if there is anything else they would like to ask, or whether they have finished. If they have finished, please remain silent and allow the candidate that time for reflection.

Category Question
Introduction Candidate appropriately introduced themselves with:
Full name
Clarifies who they are talking to
Asks patient for preferred name

PC Presenting Complaint - Breast Lump
Size (grape size)
Consistency (firm)
Margins (indistinct)
Surface (irregular)

Red Flags
Sudden increase in lump size
Skin changes
Nipple inversion
Blood Stained Nipple discharge
Back pain
Shortness of breath

Systemic Symptoms
Weight loss
Low energy

Factors Affecting Risk of Breast Cancer
Pregnancy history
Breastfeeding history
Age of menarche & menopause
Past and current use of hormone replacement and oral contraceptive pills
Family history of breast or ovarian cancer
Previous breast cancer / DCIS
Alcohol Excess

PMH Past medical history

DH Drug history
No regular medications
No known drug allergies

SH Social history
Alcohol – wine at weekend
Smoking – 30/day
Job – receptionist
Living situation – lives with partner

FH Family history
Family history appropriately explored – mother died of breast cancer

Explores ideas, concerns, expectations, feelings
Asks patient if they have any questions

Question What is your management plan for this patient given you are in general practice?
Urgent referral / 2-week wait referral
To breast clinic

Question How would you fully assess any patient with a breast lump?
Mentions "Tripple Assessment"
Clinical examination
Imaging: USS / mammography
Tissue sample: core biopsy / fine needle aspiration