Cases/Ear, Nose and Throat

Man Who Wants A Camera Test for A Lump Feeling in His Throat — Free SCA Practice Case

Man who wants a camera test for a lump feeling in his throat

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Initial Introduction

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

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•Catch early cues

Data Gathering

History, ICE & Diagnosis

Clinical Management

Diagnosis, Plan & Decisions

Safety Net

Follow-up & Close

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Materials for Candidate

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Patient Profile

Full Name

Imran Bhatti

Age

45 years

Consultation Type

Video

Age

Situation

Video Consultation. Routine appointment booked by the patient.

Reason for Encounter

"Feeling of something stuck in my throat for two months. Would like a camera test."

Medical Records

●PMH: Plantar fasciitis, right foot, 2024 (resolved).
●Medications: None.
●Allergies: NKDA.
●Social: Quantity surveyor for a housebuilder. Never smoked. Does not drink alcohol.
●Previous investigations: None of the upper gut or throat.

Recent Notes

●NHS Health Check, 14 months ago: BP 126/78. Weight 89 kg, BMI 28.7. Advised on diet and physical activity. No consultations since.

Patient Script

For the friend playing the patient role

Character Overview: You are Imran Bhatti, a 45 year old quantity surveyor for a housebuilder. You live with your wife Sana and your daughters Zara, 14, and Hana, 9. For about two months you have had a feeling of something stuck in your throat, like a bit of food or a tablet that has not gone down. It started a week or so after the funeral of Phil, a 58 year old site manager who trained you when you joined the firm nine years ago and became a good friend. Phil died of cancer of the food pipe about three months ago. You visited him in the hospice the week before he died, when he could not even swallow his own spit, and you cannot get that picture out of your head. Phil had a camera test that found the cancer, and you have booked this appointment to ask for the same test. You are polite and practical. You sound tired and a little tense, and your voice catches when you talk about Phil.

Opening Sentence: "Thanks, doctor. For about two months I've had a sort of blockage in my throat, like a tablet that hasn't gone down properly. It won't shift. I wanted to ask about getting one of those camera tests, to have a proper look down there."

History if Asked (Data Gathering Phase)

●What it feels like: "Like a bit of food that hasn't gone down, or a tablet stuck halfway. It doesn't hurt. It's just there."
●Where it is (if asked): "Right in the middle, low down, just above where my top shirt button is. It's not on one side."
●When it started: "About two months ago. It was a week or so after a funeral, actually."
●Pattern and eating: "It's not there all the time. Some evenings it nags at me for hours, other days I hardly notice it. When I'm eating a meal I don't notice it. It's in between meals, when I'm just sitting there."
●What makes it worse (if asked): "Evenings, when I'm sat still. Meetings. And when I think about Phil, it's like it tightens up."
●Better, and checking it (if asked): "Eating, and when I'm busy on site. I keep swallowing to see if it's still there. Dozens of times a day, probably, even in meetings. I haven't tried anything for it."
●Phil (if asked who Phil was or what happened to him): "Phil was a site manager. He trained me up when I joined, nine years ago, and we got close. He'd had indigestion for years and bought stuff from the chemist. Then his food started sticking, sandwiches first, then even soup. He lost about two stone. He put off seeing the doctor for three months. They did the camera within a fortnight and it had already spread. He died about three months ago. He was 58."
●Visiting Phil (if asked): "I saw him in the hospice the week before he died. He couldn't swallow his own spit. I can't get that out of my head."

Ideas, Concerns, Expectations

Gating note: Imran does not raise any of the following himself. 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 thinks something is growing in his food pipe, the way it did for Phil. He has had heartburn for a year and he knows Phil had indigestion for years before his diagnosis, so he has put the two together. "Honestly? I think there's something growing in there. Phil had indigestion for years, and I've got heartburn, and now this. That's how his started."
●Concerns: His main fear is leaving Sana and the children the way Phil left his family. "Phil left it too late. I'm not doing that. I've got two kids." If the doctor explores further, a quieter worry comes out: "Sana thinks it's work stress. I haven't told her I think it's cancer. I don't want to frighten her."
●Expectations: He wants the same camera test Phil had, arranged now. "I want the test Phil had. If it comes back clear, I can stop thinking about it."

If Asked: Medical History and Medications

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

●Other health problems and previous tests: "Nothing really. I had a bad heel a couple of years ago, but that sorted itself out. I've never had a camera test or anything like that, and no thyroid trouble that I know of."
●Medicines: "No tablets at all. Only the minty liquid from the chemist for the heartburn."
●Allergies and family: "None. My dad gets gout, Mum's on tablets for her blood pressure. No cancer in the family that I know of."

Social History and Lifestyle Impact

●Work: Since Phil died, his firm has asked him to take on two of Phil's sites as well as his own, and to finish a big tender that Phil had started, due at the end of next month. "I'm doing Phil's job and mine at the minute. Long days. He started that tender, so I feel like I owe it to him to get it done."
●Sleep (if asked): "Rubbish. It takes me an hour to drop off, and then I'm awake in the early hours, lying there thinking."
●Mood (if asked): "I'm not depressed, if that's what you mean. I still enjoy things, like Zara's netball on a Saturday. I'm just on edge. I haven't played badminton since the funeral." If asked about harming himself: "No. God, no. Nothing like that. I've got the kids."
●Diet, smoking and alcohol: "Four or five coffees a day on site, more since I took on Phil's jobs. I've been picking at biscuits at my desk." Has never smoked. "I don't drink. Never have."
●Home: Lives with Sana and the children. Sana has noticed he is quiet and tired, but he has not told her what he fears.

If Asked: Associated Symptoms

Gating note: Answers are brief and natural. Everything below is negative unless a figure is given.

●Swallowing: Food and drink go down fine ("Bread, steak, the lot"). No pain on swallowing, no food coming back up, no choking or coughing when eating or drinking.
●Weight and appetite: "If anything I've put a few pounds on. My trousers are tighter, not looser. Appetite's the same as ever. Too good, Sana would say."
●Heartburn or indigestion: "I get a burning behind my breastbone, maybe twice a week. It's been going on about a year. It's after a big dinner or a curry, especially if I lie on the sofa straight after. The minty liquid sorts it in ten minutes." It never comes on with exertion, walking or climbing ladders.
●Chest, bleeding and general: No chest pain or racing heart, no vomiting blood, no black stools, no night sweats or fevers.
●Head and neck: No change in his voice ("Sana says I sound the same as always"), no lump or swelling in his neck ("My shirt collars still fit"), no sore throat that will not go away, no pain on one side of the throat or in an ear, no blood in his spit, no breathing difficulty, no cough, catarrh or blocked nose.

Responses to Management (The Negotiation Phase)

●
If the doctor explains that this is a common throat sensation and not a growth, or links it to stress or worry:
- ●Reaction: Unconvinced and a bit defensive. "Then what is it? I can feel it now, while we're talking. And I've never been a nervous person, doctor. I deal with builders all day." If the doctor explains that worry tightens the throat muscles and makes a real feeling more noticeable: "So the worrying makes it tighten, and then I notice it more? I suppose it is worse when I'm thinking about him."
●
If the doctor says a camera test is not needed, or compares his symptoms with Phil's:
- ●Reaction: Pushes back at first. "But Phil had the camera, and that's what found it. If they'd done it sooner he might still be here. Why wouldn't you do it for me?" If the doctor sets Phil's symptoms beside his own, he goes quieter. "I hadn't thought of it like that. His sandwiches were getting stuck. Mine go down fine." If a routine ear, nose and throat referral is offered: "Is that a camera as well? How long's the wait?"
●
If the doctor offers to examine him in person, or asks him to check his own neck or throat on camera:
- ●Reaction: Relieved at an in person check. "Yes, please. When can I come in?" He declines to examine himself. "I'd rather not poke around myself. I'll only work myself up."
●
If the doctor offers tablets for the heartburn, or advice about meals, coffee or weight:
- ●Reaction: Suspicious. "Phil was taking indigestion stuff for ages, and look what happened. How do I know the tablets aren't just covering something up?" Once that is answered: "How long do I take them for? I don't want to be on them for life." He agrees to cut down on coffee and curry if given something specific to aim for.
●
If the doctor arranges an urgent test or referral, or has agreed the plan and he has not yet asked about cancer:
- ●Reaction: After an urgent test or referral, alarm: "So you do think it could be cancer, then?" Once the plan is agreed, quietly: "Can you promise me it's not cancer?" He accepts an honest answer that cancer is very unlikely and that the plan is built to pick up any change.
●
If the doctor offers support, time off or safety netting, or asks how he is coping with Phil's death:
- ●Reaction: His voice catches. "He wasn't even family. Is it normal to be this cut up about someone from work?" About talking therapy: "I'm not really a talking about feelings kind of person. If it helps me sleep, I'll give it a go." About time off: "I don't want time off. I've got Phil's tender to finish." About telling Sana: "Maybe. I just didn't want to say the word out loud." If safety netting is vague: "How would I know? Give me something specific to look out for."

Mark Scheme

Domain 1: Data Gathering and Diagnosis

0 / 14 indicators checked+0−0

Positive (0/7)

Negative (0/7)

Domain 2: Clinical Management and Medical Complexity

0 / 22 indicators checked+0−0

Positive (0/11)

Negative (0/11)

Domain 3: Relating to Others

0 / 12 indicators checked+0−0

Positive (0/6)

Negative (0/6)

Clinical Learning Points

The Core Dilemma and the Model Plan

●Imran is 45 and has had a painless lump in the throat feeling for two months, which began after the death of a friend from oesophageal cancer. He asks for the same camera test. The skill is recognising globus, excluding red flags, explaining why the test he wants is not the right one, and treating the fear as seriously as the symptom.
●Model plan: establish the pattern, screen for dysphagia and head and neck warning signs, uncover Phil and the bereavement, name globus as a benign sensation, arrange a face to face neck and mouth examination within a week or two, treat the reflux with lifestyle advice and a time limited acid reducing course, address the checking habit and grief, give a specific safety net and review at four to eight weeks.
●Also acceptable: a routine (not urgent) ear, nose and throat (ENT) referral as a shared decision, explained as not suspecting cancer; lifestyle advice with an alginate first; or Helicobacter pylori test and treat.

What Globus Is, Why It Happens and How It Differs From Dysphagia

●
Globus is the sensation of a lump, tightness or something stuck in the throat when there is no physical lump. It is common: up to 45% of people experience it at some point and it accounts for about 4% of new ENT referrals (British Journal of General Practice (BJGP) practical guide, 2025).
●
The typical picture is painless, in the midline, intermittent, most noticeable on empty swallows between meals, and easing while eating and drinking.
●
The cause is usually multifactorial: tension in the cricopharyngeus muscle at the top of the oesophagus, a more sensitive throat, reflux, and stress, anxiety or grief. Repeated dry swallowing and throat clearing keep the sensation in focus.
●
It is benign and does not turn into cancer, although cancer has to be considered and excluded clinically before the label is applied.
●
Globus is a sensation between meals with normal swallowing of solids and liquids and stable weight. Dysphagia is food or drink sticking or slow to pass, often solids first, with regurgitation, choking or coughing and often weight loss.
●
Ask what happens during a meal. "When I'm eating I don't notice it" points to globus; "my sandwiches get stuck" is what Phil had and needs urgent referral.

Red Flags and Referral Thresholds

●NICE NG12 (suspected cancer, updated April 2026): dysphagia at any age warrants a suspected cancer pathway referral. Persistent unexplained hoarseness or an unexplained neck lump in someone aged 45 or over should prompt consideration of one for laryngeal cancer, which is why Imran's voice and neck matter.
●Red flags specific to globus (BJGP 2025): dysphagia, pain on swallowing, unexplained weight loss, persistent hoarseness, coughing up blood, a neck mass or enlarged nodes, one sided throat pain or earache, and heavy smoking or alcohol use. Many local ENT pathways use hoarseness lasting more than 3 weeks as the trigger.
●Imran has none of these. His reassurance should be explained by their absence, and it must be conditional: if any appear, the plan changes.

Why Examination in Person Matters

●Before globus is called benign, examine the neck for lymph nodes and thyroid swelling, and the mouth and oropharynx for ulcers, masses and tonsil asymmetry.
●This cannot be done reliably on video, and asking him to feel his own neck or show his throat to the camera is not a substitute. A face to face appointment within a week or two is proportionate when the history is reassuring, and an abnormal finding means urgent referral.

Why the Camera He Asked For Is Not the Right Test

●There are no national UK guidelines for investigating globus, and local pathways differ. Most patients with a classic history, no red flags and a normal examination need no tests.
●A gastroscopy examines the oesophagus, stomach and first part of the small intestine. It is right for dysphagia, which is why Phil had one, but it is not designed to examine the throat and voice box, and NG12 gives no indication for it in a 45 year old with no dysphagia, weight loss or bleeding. It also carries small risks such as a reaction to sedation and, rarely, bleeding.
●If globus persists despite treatment, is one sided, or red flags appear, the relevant test is flexible nasendoscopy in the ENT clinic. A barium swallow is of limited value and should not be requested to rule out cancer.
●A normal test often does not settle a symptom driven partly by anxiety. A routine ENT referral for reassurance, agreed as a shared decision, is nevertheless defensible.

His Actual Cancer Risk

●About 9,500 people a year are diagnosed with oesophageal cancer in the UK and 43% are aged 75 or over (Cancer Research UK). Risk factors include older age, male sex, long term severe reflux, Barrett's oesophagus, excess weight, smoking and heavy drinking.
●Imran is male and slightly overweight, but has never smoked, does not drink, and has mild intermittent reflux. A colleague's cancer does not change his own risk.
●NICE CG184 does not advise routine endoscopy for Barrett's oesophagus. The British Society of Gastroenterology suggests considering it in chronic reflux with at least three of: age 50 or over, white ethnicity, male sex and obesity. At 45 with a body mass index of 28.7 he has fewer than three.

Managing the Reflux

●NICE CG184 treats uninvestigated reflux as uninvestigated dyspepsia, starting with lifestyle advice: smaller meals, the evening meal 3 to 4 hours before bed, not lying down after eating, less coffee, weight loss, and avoiding triggers such as spicy food.
●Drug options: a full dose proton pump inhibitor (PPI) for 4 weeks, such as omeprazole 20 mg once daily 30 minutes before breakfast; the BJGP guide suggests a 4 to 6 week trial when reflux contributes to globus. Lifestyle advice with an alginate first, or Helicobacter pylori test and treat, are equally valid starts.
●A PPI helps globus only through the reflux, which Imran clearly has. After the trial, step down to the lowest effective dose or as needed use, or stop; never leave it on repeat without review.
●Answer his worry that tablets cover things up: masking matters when alarm features are present, and he has none. If he is later referred for endoscopy, stop the PPI at least 2 weeks beforehand.

Stress, Grief and the Throat

●Explain the loop: worry tightens the throat muscles and focuses attention on the throat, so a real sensation is noticed more, which increases the worry. This validates the symptom rather than dismissing it.
●Advise against habitual throat clearing and dry swallowing, suggest staying hydrated and cutting down caffeine, and describe noticing the urge and moving attention elsewhere.
●People in England can refer themselves to NHS Talking Therapies; bereavement charities such as Cruse can be contacted directly. Grief after the death of a close colleague is normal, and it is worth saying so.
●Anxiety medication is not needed here. NICE CG113 advises against benzodiazepines except briefly in a crisis.
●Check mood, sleep and thoughts of self harm, because bereavement, sleep loss and a heavy workload can tip into depression.

Safety Netting and Follow Up

●Specific changes need assessment within days: food or drink sticking, pain on swallowing, weight loss without trying, a hoarse voice that does not settle, a neck lump, one sided throat or ear pain, or the feeling becoming constant or one sided. These lead to a suspected cancer pathway referral.
●Vomiting blood or black stools needs same day help, and 999 or A&E if he also feels faint, dizzy or unwell. Difficulty breathing or noisy breathing needs 999.
●Review at 4 to 8 weeks to assess the throat, heartburn, sleep and mood, and decide whether the PPI can be stopped. If globus persists, routine ENT referral for nasendoscopy is the next step, and speech and language therapy helps some people.
●Be honest that globus often fluctuates and can last months. Suggest he tells Sana what he fears.

Common Mistakes in This Station

●Arranging a gastroscopy or an urgent cancer referral to settle his worry when he has no referral features, which tells him the doctor also suspects cancer.
●Refusing the camera test without explaining that he meets no referral criteria and that it does not look at the throat.
●Reassuring on video without asking about swallowing, voice change, neck lumps and weight, or without arranging an in person examination.
●Missing the heartburn, or treating it with an open ended PPI and no review.
●Hearing about Phil's death but not his symptoms, so the most persuasive contrast (Phil could not swallow, Imran eats normally) is never used.
●Calling it just stress, which he hears as being told it is in his head, or promising it is definitely not cancer.
●Giving safety netting as "come back if it gets worse".

Mapped to the RCGP curriculum topic: Ear, Nose and Throat.

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