Cases/Respiratory Health

Man Told His CT Scan Found A Small Lung Nodule — Free SCA Practice Case

Man told his CT scan found a small lung nodule

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12:00

Golden Minute

Initial Introduction

•Introduce yourself

•Ask an open question — "How can I help you today?"

•Listen — don't interrupt

•Catch early cues

Data Gathering

History, ICE & Diagnosis

Clinical Management

Diagnosis, Plan & Decisions

Safety Net

Follow-up & Close

12:00

Golden Minute

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Materials for Candidate

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Patient Profile

Full Name

Bryn Ainsley

Age

60 years

Consultation Type

Telephone

Age

Situation

Telephone Consultation, booked by the patient.

Reason for Encounter

"I've read my scan report online and it says there's a nodule in my lung."

Medical Records

●PMH: Hypertension. Hypercholesterolaemia. Right renal colic 10 days ago.
●Medications: Amlodipine 5 mg OD, atorvastatin 20 mg nocte.
●Allergies: NKDA.
●Social: Facilities manager at a leisure centre. Ex smoker, 34 pack years, stopped 9 years ago.

Results (CT KUB, 10 days ago, requested by urgent treatment centre)

2 mm non obstructing right renal calculus. Incidental 6 mm solid nodule, right lower lobe, smooth margin, no calcification. Recommend CT thorax in 3 months.

Patient Script

For the friend playing the patient role

Character Overview: You are Bryn Ainsley, a 60 year old facilities manager at a leisure centre. You look after the buildings, the pool plant and a team of six, and you are on your feet most of the day. You live with your wife Shirley, who works as a dental receptionist, and your daughter Heather, who is 31 and lives ten minutes away. About ten days ago you had a sudden, terrible pain in your right side and went to the urgent treatment centre, where you were given a CT scan for a kidney stone. You passed the stone five days ago and have been fine since. Three days ago the scan report appeared on the NHS app, and you have read it more times than you can count. It says there is a small nodule in your lung and that a repeat scan is advised. You looked it up and you are convinced it is cancer, and you want it cut out before it spreads. You are a practical man who solves problems, so sitting and waiting is almost impossible for you. You speak quickly when you are anxious, you go quiet and flat when your father comes up, and you soften once you feel properly listened to. You are an ex smoker and quietly blame yourself.

Opening Sentence: "Hello doctor. I had a scan for a kidney stone and the report says there's a nodule in my lung. I've looked it up and I'm sure it's cancer, so I'd like it taken out as soon as possible, please."

History if Asked (Data Gathering Phase)

●The scan and the stone: "About ten days ago I got a sudden pain in my right side, so bad I was sick. They did a scan at the urgent treatment centre. I passed the stone five days ago and I've had no pain, no fever and no blood since. Then three days ago the report came up on the app and it also mentions a nodule in my lung. Nobody has spoken to me about it."
●What the report says: "A six millimetre nodule at the bottom of my right lung, smooth edges, and it says they recommend a repeat scan of the chest in three months. That's what I want to ask you about, because three months is a long time to wait."
●Cough: "No. I had a smoker's cough years ago but it went within a year of stopping. I haven't had a cough lately, no."
●Coughing up blood or phlegm: "No blood, ever. No phlegm."
●Breathing and chest pain: "My breathing is fine. I walk about four miles most days, up hills, and I'm not breathless. No chest pain, no wheeze, and my voice is normal."
●General health: "I feel well in myself. My weight has been steady at about 14 stone for years. Appetite is normal. No night sweats, no fevers, no bone pain, no headaches, no lumps anywhere."
●Smoking: "Twenty a day from when I was 17 until I was 51, so 34 years. I stopped nine years ago with patches from the chemist and Shirley nagging me. I haven't had a single one since and I don't vape."
●Alcohol: "A couple of pints at the weekend, about six units a week. Nothing in the week."
●Previous problems: "High blood pressure and cholesterol, both on tablets. I've never had cancer, TB or any lung problem, and I've never had a chest X ray or scan that I can remember before this one."
●Exposures: "Nothing that I know of. The leisure centre was built about 30 years ago, so I've never been near asbestos. I haven't worked in any dusty trade."
●Family history: "My dad died of lung cancer 22 years ago, aged 66. He smoked. From his scan to the funeral was five months. My mum is 86 and well."
●Fitness: "I'm fit. I can climb four flights of stairs at work without stopping. My blood pressure was fine at my last check."

Ideas, Concerns, Expectations

Gating note: Bryn does not raise any of the following himself, apart from wanting it taken out, which is in the opening line. Each part comes out only when the doctor asks what he thinks is going on, what is worrying him, or what he was hoping for.

●Ideas: He believes a nodule is a cancer in its early stage and that it will spread while it is left alone. He thinks the quickest way to be safe is to cut it out. "A nodule is a tumour, isn't it? Just a small one. And they grow."
●Concerns: His father. Bryn remembers how fast it went and he is frightened that the same thing is happening to him. He is also afraid that the repeat scan is the doctors' way of waiting for it to get worse. He blames himself for smoking for 34 years. Shirley and Heather are frightened too, and Heather is trying to be cheerful for his sake. "I watched my dad go in five months. And I did this to myself, didn't I? Thirty four years of cigarettes."
●Expectations: He expected to hear that he would be referred to a lung specialist or surgeon straight away, and that someone would remove it. He also wants to be told for certain whether it is cancer. "Can you get me in with a surgeon? Or at least tell me for sure what it is."

If Asked: Medical History and Medications

Gating note: Bryn answers each of these plainly when the doctor asks about it.

●Medicines: "Amlodipine 5 and atorvastatin 20. Nothing else. I've had a bit of ibuprofen from the chemist since the kidney stone but not for the last few days."
●Allergies: "None."
●Mood and sleep: "I'm sleeping badly. I keep opening the app to read the report again. I know it by heart now, but I can't leave it alone. I'm not depressed. It's just the waiting and the not knowing."

Social History and Lifestyle Impact

●Work: Manages the leisure centre building and a team of six. His deputy, Nigel, is covering while he sorts this out. He could take time off if needed but would rather not.
●Home: Lives with Shirley. Heather lives nearby and calls in most evenings. Shirley was very upset when he read her the report and has asked him to ring the surgery.
●Telling people: He has told Shirley and Heather what the report says.
●Availability: Free this afternoon and tomorrow morning. Prefers a phone call to a visit unless the doctor wants to see him.

If Asked: Associated Symptoms

Gating note: Bryn answers these only when asked. Every one is negative unless stated.

●If asked about hoarseness or difficulty swallowing: "No, my voice is normal and I swallow fine."
●If asked about tiredness: "No more than normal. Work is busy but I'm coping."
●If asked about recent chest infections, fevers or antibiotics: "None for years."

Responses to Management (The Negotiation Phase)

●
If the doctor explains what a nodule is and that most are harmless:
- ●Reaction: Wary at first. "That's what everyone says until it isn't." He accepts a plain explanation, such as a small spot of tissue that can be an old scar or a healed infection, and that scans very often find them in people with no symptoms. He asks "So how likely is it to be cancer? Give me a number." If told that the chance for a nodule this size is low but cannot be called zero, he goes quiet, then says "At least you're being straight with me."
●
If the doctor explains watching with a repeat scan rather than taking it out:
- ●Reaction: Resists. "But if you leave it, it could spread." He accepts when told that the safest approach is to measure it over time, because a nodule that does not grow is very unlikely to be dangerous, that cutting out or sampling a nodule this small carries its own risks, and that the scan sees changes much earlier than he would feel anything. "So the scan is the test. Fair enough. What do you actually do if it has grown?"
●
If the doctor explains what happens next, the scans and who arranges them:
- ●Reaction: Wants clarity. "Who books it? The hospital lost my letter last time." If told the practice will make sure the scan is requested and will check it has been booked, he is reassured: "Can you tell me by when? I want a date I can hold you to." He asks whether it will be a chest X ray. If told a CT is needed because an X ray cannot track something so small, he says "Right, that makes sense."
●
If the doctor talks about his smoking or about the risk of the nodule:
- ●Reaction: Guilty. "I did this to myself." If the doctor responds kindly and praises him for stopping nine years ago, he lifts: "I never thought of it like that." He asks "Is there a lung check for people like me? Shirley saw something about it." If told about the NHS lung screening for people aged 55 to 74 who have smoked, and that it is separate and does not replace the nodule scan, he says "Right, I'll make sure the surgery has my smoking record straight."
●
If the doctor offers a follow up call or an appointment:
- ●Reaction: Relieved. "Yes please. Shirley would want to be on the line." He asks about written information: "Is there something I can show Heather, so I'm not trying to explain it myself?" If offered a leaflet or website, he agrees.
●
If the doctor describes warning signs and what to do:
- ●Reaction: Wants specifics. "Come back if it gets worse? Worse how?" He repeats back clearly when given specific symptoms such as coughing up blood, a cough lasting more than three weeks, losing weight without trying, new breathlessness, chest pain, or a hoarse voice, and told to ring the same week. "And the kidney stone, if the pain comes back with a fever, I come straight in?"

Mark Scheme

Domain 1: Data Gathering and Diagnosis

0 / 16 indicators checked+0−0

Positive (0/8)

Negative (0/8)

Domain 2: Clinical Management and Medical Complexity

0 / 20 indicators checked+0−0

Positive (0/10)

Negative (0/10)

Domain 3: Relating to Others

0 / 14 indicators checked+0−0

Positive (0/7)

Negative (0/7)

Clinical Learning Points

The Core Dilemma and the Model Plan

●Bryn is a 60 year old ex smoker who read an incidental 6 mm lung nodule on the NHS app after a CT for a kidney stone. He is sure it is cancer and wants it removed. The station tests explaining an incidental finding honestly: a small solid nodule is common and usually benign, the risk is low but not zero, and the right response is planned CT surveillance, not surgery.
●The model plan has six parts. Ask what he has read and how he feels. Screen for chest and general symptoms and take a smoking, exposure and family history. Explain what a nodule is in plain words and give an honest, proportionate account of risk. Explain surveillance with a repeat dedicated CT chest at about three months and again at about one year, with discharge if stable. Make sure the scan is actually requested and tracked. Give specific safety netting, support him to stay smoke free and offer a further conversation with his wife included.
●Acceptable alternatives: following the radiologist's three month recommendation exactly, or describing the BTS pathway of scans at three months and one year. Requesting the scan yourself, or confirming that radiology or the urgent treatment centre has done so and tracking it, are both fine. Referral to the local nodule service, or discussing the case with a respiratory physician through advice and guidance, is reasonable if you are unsure, as long as you do not tell him it is cancer. A face to face review is acceptable if he wishes, but nothing in the history requires examination to decide the plan.

What a Pulmonary Nodule Is and How Common It Is

●BTS defines a pulmonary nodule as a focal, rounded opacity of 3 cm or less in diameter, seen on CT. Most are benign: old scars, healed infections, small lymph nodes or granulomas.
●The BTS guideline on pulmonary nodules (Thorax 2015;70 supplement 2) is the national standard for the investigation and management of nodules found incidentally. Risk of malignancy rises with nodule size, spiculation, upper lobe position, age, smoking and pack years, and family history of lung cancer. A smooth margin, no spiculation, a lower lobe position and a size under 8 mm all point towards a low risk. Bryn's smoking history and his father's lung cancer are factors that raise risk, which is why his fear is understandable and why follow up is genuinely needed.
●The CT KUB only images the lung bases, which is one practical reason a dedicated thin section CT chest is the sensible next scan. A chest X ray cannot reliably follow a nodule of this size and should not be used for monitoring.

The BTS Surveillance Pathway

●BTS advises no follow up for solid nodules under 5 mm in maximum diameter, or under 80 cubic millimetres by volume. Solid nodules of 5 mm up to 8 mm in diameter, or 80 up to 300 cubic millimetres, are offered CT surveillance. A nodule of 5 to under 6 mm has a single repeat CT at one year, whereas Bryn's 6 mm nodule falls in the three month and one year group. For nodules of 8 mm or more, or 300 cubic millimetres or more, the Brock model is used, so it is not needed for Bryn.
●For a nodule of 6 mm or more, or 80 cubic millimetres or more, growth is assessed by volume doubling time on repeat CT at three months and at one year, with growth defined as a volume change of 25% or more. A nodule that is stable at one year can be discharged. If growth is assessed from two dimensional diameter measures instead, follow up continues for two years in total.
●Nodules with clear growth, or a short volume doubling time, are referred for further investigation by the lung cancer team, which may include PET CT, image guided biopsy or resection. Nodules that grow slowly may be watched for longer according to patient preference and fitness.
●Bryn's nodule is 6 mm, solid, smooth and has no calcification, so surveillance with repeat CT at three months and one year is the model answer.

Why Not Remove It, Biopsy It or Send a PET CT

●For a nodule this small, with a low risk of malignancy, the harms of invasive investigation outweigh the benefit. BTS asks for the risk of pneumothorax to be weighed before a transthoracic needle biopsy. Surgery means an operation and anaesthetic for a nodule that is most likely harmless. BTS offers PET CT where the Brock risk is above 10%, which applies to nodules of 8 mm or more and only where the nodule is above the local PET CT detection threshold.
●Surveillance is the test: a nodule that does not grow over time is very unlikely to be dangerous, and CT detects change long before he would feel any symptom. This reasoning should be put to Bryn as the safest way to find out, not as a decision to do nothing.
●An urgent suspected cancer referral is not indicated by a stable looking 6 mm nodule with no symptoms. If he developed a symptom such as coughing up blood, the NICE guideline on suspected cancer (NG12) would apply, with prompt chest imaging or a suspected cancer referral, whatever the nodule scan shows.

Safety Netting and Responsibility for the Follow Up

●Following up an incidental finding is a patient safety issue. The scan may be recommended by a radiologist who is not the requesting clinician, and many follow up scans are missed because nobody takes ownership. BTS does not say who owns an incidental finding. In UK practice it is the requesting service, here the urgent treatment centre, with radiology or a local respiratory nodule service often running the pathway, and a GP who is told of the finding should check and track it. A strong candidate states who will request the scan, records the nodule and the due date in his notes with a recall, and says how and when he will hear.
●Safety netting should be specific: coughing up blood, a cough that lasts more than three weeks, unexplained weight loss, new breathlessness, chest pain, or a hoarse voice should prompt him to ring the same week. For the kidney stone, renal colic with a fever needs urgent assessment because of the risk of an infected obstructed kidney.
●Offering a follow up call, ideally with Shirley on the line, and written information from BTS or the NHS gives the family a source other than the internet.

Communicating Uncertainty and Fear

●The core skill is honesty without alarm. It is wrong to say it is definitely nothing and wrong to say nothing about risk. A good phrase is that most nodules like this are harmless, the chance of cancer in a nodule this size is low but cannot be called zero today, and the scans are how we find out safely.
●Bryn learned about the finding alone, from an app, and his father's death is his reference point. Explore what he thinks and fears before explaining. Name the fear and link the plan to it, for example explaining how his father's illness differs because the nodule was found early and is being measured.
●Avoid jargon such as pulmonary, solid, spiculated or volume doubling time. Use everyday terms such as a small spot on the scan. Ask him to say the plan back to you.

Smoking, Guilt and Lung Screening

●Bryn smoked 20 a day for 34 years and stopped nine years ago, which is a major success. Praise this, advise him to stay smoke free and offer help from the stop smoking service if he is tempted to restart. Do not lecture, because he already blames himself. Stopping lowers the risk of lung cancer and other lung disease, and the benefit continues to grow with time.
●NHS targeted lung cancer screening is being rolled out across England for people aged 55 to 74 who currently smoke or have ever smoked. It is separate from nodule surveillance and does not replace it. He should check that his smoking history is recorded accurately on his GP record so he is invited when screening reaches his area.

Common Mistakes in This Station

●Promising it is not cancer, or telling him it probably is. Both lose trust.
●Giving a numerical risk that cannot be known, or avoiding his question about risk altogether.
●Referring urgently for suspected cancer, or ordering PET CT or biopsy, to satisfy his request for removal.
●Repeating a chest X ray as reassurance or follow up.
●Telling him a scan is advised without saying who will arrange it and when he will hear.
●Missing that he learned of the finding alone and that his father died of lung cancer.
●Lecturing about smoking, or ignoring his guilt.
●Vague safety netting that says only to come back if worse, and forgetting to close the kidney stone loop.

Mapped to the RCGP curriculum topic: Respiratory Health.

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