Cases corner – 34 YEARS OLD WITH A BREAST LUMP


Jane, a 34 year old women, presents with a 2 week history of a right sided breast lump she found incidentally in the shower. The lump is non-tender and mobile. She reports regular menses and is due her next period in 4 days. There is no relevant past medical history or family history of breast cancer. She reports she commonly experiences bilateral mastalgia before her period. On examination you confirm the presence of a 2x2cm mobile lump on the right upper quadrant of her right breast. There is no associated lymphadenopathy.

What should you do next?

  1. Safety net the patient and ask her to come back in two weeks
  2. Reassure the patient and advise her that the if the lump remains after her period to come back for review
  3. Refer the patient for a non-urgent breast referral
  4. Referral the patient along an urgent 2-week-wait breast referral

Cases corner – 21 YEAR OLD WITH ABDOMINAL PAIN AND BLOATING


A 21 year old women presents with new onset symptoms of crampy lower abdominal pain, bloating and increased flatulence. She reports experiencing these symptoms on average 3-4 x a week. Her diet is mainly fast food and can bee erratic since she started university 6 months ago. The symptoms are not related to any particular foods and she is opening her bowels normally with no rectal bleeding. Her weight is normal. No symptoms of fatigue or clinical signs on examination.

What would you do next?

  1. Reassure her that her symptoms are suggestive of IBS with safety netting advice
  2. Order baseline bloods, FBC, U+E, LFT and reassure if normal
  3. Order a CA125 to evaluate her risk of ovarian cancer and a FIT test for low risk colorectal cancer
  4. Organise an abdominal ultrasound scan and Ca125
  5. Offer dietary advice, gut health and recommend a food diary

Cases corner – 62 years old with back pain


Mr K, a 62 year old man, attends with persistent upper back pain for the last 3 months. He denies any other symptoms and denies radiation of the pain. On examination, the pain is elicited on firm pressure over the vertebral body.

What would you do next?

  1. Reassure him and offer safety-netting advice if he deteriorates
  2. Request a full blood count, serum calcium and erythrocyte sedimentation rate (ESR)
  3. Request protein electrophoresis
  4. Request serum immunoglobulins/li>
  5. Refer the patient along a 2-week-wait pathway to haematology

Cases corner – 19 YEARS OLD WITH LYMPHADENOPATHY


Mr X, a 19 year old man, presents to you with a one week history of lumps in his groin. He is otherwise well, denying any fever, sore throat, appetite loss, pain, urethral discharge, urinary frequency or dysuria. On examination you note generalised lymphadenopathy (cervical, axilla and groin). There is no evidence of pharyngitis and his spleen is not palpable.

What would you do next?

  1. Reassure him and offer safety-netting advice if he deteriorates
  2. Request a very urgent full blood count
  3. Request an urgent blood film
  4. Refer the patient along a 2-week-wait pathway to haematology
  5. Refer the patient immediately to hospital

Cases corner – 8 year old boy with a rash


An 8 year old boy presents to you with his mum, with a 2-day history of a spreading rash over his lower limbs. He is otherwise well with no other symptoms. There is no evidence of confusion, neck stiffness, photophobia or fever. He has previously been fit and well and is up to date with his immunisations. His observations are all within the normal range. You examine his lower legs and see the following rash on his feet and legs. Otherwise, the examination is unremarkable.

What would you do next?

  1. Reassure his mum and offer safety-netting advice if he deteriorates
  2. Refer the patient for an urgent full blood count (within 48 hours)
  3. Refer the patient for a full blood count (within 2 weeks)
  4. Consider urgently referring the patient to a specialist within 48 hours
  5. Refer the patient immediately to hospital

Cases corner – 50 years old with thrombocytosis

Mr D, a 50 year old man, attends for his annual health check. He is currently fit and well and his examination is unremarkable. A urine dipstick is negative. You perform routine bloods as part of your assessment. The results of this show an abnormal platelet count of 620 x10⁹/L. His previous blood test 6 months ago, was normal. A repeat 2 weeks later is also raised at 624 x10⁹/L.

What would you do next?

  1. Reassure, as patient is asymptomatic, and safety net if symptoms arise to comeback
  2. Re-book patient for a repeat platelet count in 3 months
  3. Refer for a chest x-ray
  4. Refer under a 2-week-wait pathway to haematology for further investigation

Cases corner – 62 year old with dysuria and urinary frequency

Mrs G, is a 62 year old female, who presents to you with a two month history of urinary frequency and polydipsia. She has also noticed that her clothes feel looser. She is otherwise well in herself with no other symptoms. You perform a random plasma glucose which is 13 mmol/L. You also weigh her and she’s 7 kg lighter than last year (last recorded weight).

What would you do next?

  1. Confirm the diagnosis of diabetes and start treatment
  2. Refer the patient to endocrinologist
  3. Refer the patient along a 2-week-wait pathway
  4. Refer the patient for a CT scan of the pancreas

Cases corner – 65 years old with haematuria

Mrs B, a 65 year old woman, presents to you with a 2 week history of visible haemturia. She denies any other symptoms. Examination is unremarkable, but the blood tests you requested show an iron deficiency anaemia. A urine sample confirms visible haemturia and a culture is negative for infection.


Which cancer is Mrs B at risk of? (more than one may apply)

  1. Bladder
  2. Colorectal
  3. Endometrial
  4. Lung
  5. Renal