Cases/Ear, Nose and Throat

Persistent Sensation of A Lump in His Throat — Free SCA Practice Case

Man with a persistent sensation of a lump in his throat

Station Timer

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

Materials for Candidate

Please review before starting the consultation

Patient Profile

Full Name

Daniel Osei

Age

39 years

Consultation Type

Video

Age

Situation

Video Consultation.

Reason for Encounter

"I've had this feeling of a lump in my throat for a few weeks and I can't shake the worry that it's cancer. I think I need a scan."

Medical Records

●PMH: Nil significant.
●Medications: None.
●Allergies: NKDA.
●Recent contact: No recent consultations.

Patient Script

For the friend playing the patient role

Character Overview: You are Daniel, a 39-year-old accountant. You are usually level-headed, but the last few weeks have been very stressful and you are anxious and preoccupied. You have a persistent sensation of a lump in your throat that has convinced you something serious is going on. You are articulate and will ask directly for a scan. You are frightened rather than demanding, and you respond well to being taken seriously.

Opening Sentence: "Hi Doctor. For about a month now I've had this constant feeling of a lump in my throat, like something's stuck. It's really playing on my mind — I keep thinking it's cancer. I was hoping you could arrange a scan to check."

History if Asked (Data Gathering Phase)

●The sensation: "It's a feeling of something stuck in my throat, more or less all the time when I'm not eating. Weirdly, it's fine when I'm actually eating or drinking — no problem swallowing food at all."
●Swallowing: "That's the strange thing — food and drink go down completely normally. It's when my throat's empty that I notice the lump feeling most."
●Throat clearing: "I catch myself clearing my throat and swallowing all the time, even with nothing there. My partner keeps telling me to stop doing it."
●Timing and triggers: "It's worse when I'm stressed, and I've been under a lot of stress lately. Better when I'm distracted or relaxed."
●What he thinks it is: "I've read things online and now I'm convinced it's throat cancer or something. That's why I want a scan."

ICE — Ideas, Concerns, Expectations

The patient does not volunteer this information unprompted. These responses surface only when the candidate directly explores his perspective.

●Ideas: Daniel believes the lump sensation is a sign of cancer. He has not connected it with the intense stress he is under. "In my head, a lump that won't go away means cancer. I haven't really thought about anything else it could be."
●Concerns: His overriding concern is a serious diagnosis, amplified by the fact that his partner has just been diagnosed with cancer — which has left him frightened and hypervigilant about his own body. "My partner's just been diagnosed with cancer a few weeks ago, and I think it's made me terrified that something's wrong with me too. I can't switch the worry off."
●Expectations: He wants a scan or referral to rule out cancer and will be uneasy if simply told he is fine without any assessment. "I really want a scan to be sure. I don't think I'll settle until something's been checked properly."

If Asked — Medical History and Medications

The patient confirms these details only when directly asked.

●Past health: "I'm normally fit and well. No medical problems, no operations."
●Reflux: "I get a bit of heartburn now and then, especially lately, but nothing major."
●Medications: "Nothing regular."
●Allergies: "None."
●Family history: "No family history of throat or neck cancer that I know of."

Social History and Lifestyle Impact

Daniel is an accountant. He lives with his partner, who was recently diagnosed with cancer.

●Work: "I'm an accountant. It's been full-on, and honestly with everything going on at home I've made a couple of mistakes at work recently — I've been pulled up on it, which has added to the stress."
●Home: "My partner's just had this cancer diagnosis and is waiting for treatment. It's turned everything upside down. I'm trying to hold it together."
●Smoking and alcohol: "I don't smoke. I barely drink — the odd glass."
●Impact: "I'm not sleeping well, I'm on edge all the time, and this throat thing has become the focus of all my worry."

If Asked — Associated Symptoms and Red-Flag Screen

The patient answers these only when directly asked.

●If asked whether the sensation is constant or intermittent: "It comes and goes, but it's there a lot of the time. It's not there when I'm eating." (Intermittent, eased by eating — typical of globus.)
●If asked about difficulty swallowing (dysphagia): "No — no trouble swallowing food or drink at all."
●If asked about pain on swallowing (odynophagia): "No, it doesn't hurt to swallow."
●If asked about a lump or swelling in the neck: "No, I've felt around and I can't feel any lump in my neck."
●If asked about voice change or hoarseness: "No, my voice is completely normal."
●If asked about weight loss: "No, my weight's steady."
●If asked about night sweats: "No night sweats."
●If asked about coughing or coughing up blood: "No cough, no blood."
●If asked about heartburn / acid reflux: "A bit of heartburn recently, and sometimes a sour taste, especially when I've been stressed and eating late."
●If asked about postnasal drip / catarrh: "Maybe a little bit of mucus at the back of the throat sometimes, nothing much."
●If asked about smoking, alcohol, occupational voice strain: "Don't smoke, hardly drink, and I don't strain my voice for work."

Responses to Management (The Negotiation Phase)

●If the Doctor explains this is likely globus and not cancer: "Globus? So there's no actual lump there? But it feels so real — how can you be sure it's not something serious?" (The tested point is validating that the sensation is real while explaining the likely benign cause, without dismissing him.)
●If the Doctor explains a scan is not needed at this stage: "But I really wanted a scan for peace of mind. Are you sure I don't need one?" (The tested point is explaining, without being dismissive, that with no red flags a scan/referral is not indicated now, while offering examination and a safety net.)
●If the Doctor wants to examine his neck and throat in person: "You want me to come in? What are you checking for?"
●If the Doctor links it to stress: "You think stress could cause a physical feeling in my throat? That seems hard to believe."
●If the Doctor safety-nets: "So what would actually be a warning sign that I do need to be referred?"

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 / 12 indicators checked+0−0

Positive (0/6)

Negative (0/6)

Clinical Learning Points

Globus Sensation (Globus Pharyngeus)

●Globus is a persistent or intermittent sensation of a lump or something stuck in the throat, in the absence of a true structural lesion. It is common and, when there are no red flags, usually benign.
●Characteristic features: eased by eating/drinking, worse when the throat is "empty," associated with frequent throat-clearing and dry-swallowing, and often worse with stress.

Common Contributory Causes

●Gastro-oesophageal reflux disease (GORD) — a frequent contributor.
●Psychological factors — anxiety and stress (prominent here).
●Pharyngeal irritation/inflammation (pharyngitis, tonsillitis, postnasal drip from rhinosinusitis).
●Upper-oesophageal sphincter/motility factors (e.g. cricopharyngeal spasm).

Red Flags — Exclude Before Reassuring

●The safety of reassurance depends on actively excluding red flags: dysphagia (difficulty swallowing), odynophagia (pain on swallowing), a neck lump, persistent hoarseness/voice change, unexplained weight loss, night sweats, and a constant, progressive (rather than intermittent) sensation.
●Risk factors that lower the threshold for referral: smoking and significant alcohol use.

NICE NG12 — Head-and-Neck Cancer Referral

●Consider an urgent suspected-cancer (2-week-wait) referral for: an unexplained persistent neck lump, persistent unexplained hoarseness, persistent unexplained sore throat/odynophagia, or dysphagia — and for laryngeal/oral/thyroid red flags per NG12.
●Persistent, constant globus, or globus with any red flag, warrants urgent ENT assessment (flexible nasoendoscopy).

Examination Matters

●Examine the neck (lymph nodes, thyroid) and the oral cavity/oropharynx. A normal examination supports benign globus; abnormal findings redirect to urgent referral. This is why an in-person assessment is appropriate even when the history is reassuring.

Avoiding Over-Investigation

●In the absence of red flags, a scan or referral is not indicated. Over-referral and unnecessary invasive investigation can increase anxiety and, paradoxically, worsen the symptom.
●Reassurance should be earned by assessment and paired with clear safety-netting, not used as a substitute for it.

Managing Reflux and Vocal Hygiene

●Where reflux contributes, advise lifestyle measures (avoiding late meals, weight, caffeine, alcohol) and consider a trial of a proton-pump inhibitor.
●Vocal hygiene: reduce caffeine, avoid habitual throat-clearing and dry-swallowing (which perpetuate the sensation), and sip chilled water when the urge to clear the throat arises.

Addressing Stress and Health Anxiety

●Stress and health anxiety frequently drive and amplify globus. Acknowledge the stressor (here, a partner's cancer diagnosis), offer talking therapies/CBT, self-help resources, and a short-term fit note where work stress is impacting health — treating the person, not just the throat.

Safety-Netting and Follow-Up

●Advise return if the sensation becomes constant or worsens, or if dysphagia, odynophagia, a neck lump, voice change, or weight loss develops — with clear escalation to referral, and offer follow-up to reassess.

Common Candidate Mistakes in This Case

●Reassuring without excluding red flags: giving reassurance that is assumed rather than earned by a systematic red-flag screen.
●Dismissing the symptom as "just stress": invalidating a real sensation and losing the patient's trust.
●Ordering an unnecessary scan to placate him — or refusing bluntly: failing to navigate the scan request with a clear, kind, guideline-based rationale and a safety net.
●Missing the partner's diagnosis: overlooking the emotional driver that is fuelling the health anxiety.
●Skipping examination: concluding on video without arranging the neck and throat examination that makes benign reassurance safe.

Free MRCGP SCA practice case for GP registrars covering Persistent Sensation of A Lump in His Throat — Ear, Nose and Throat. Includes candidate brief, patient script, marking scheme mapped to the RCGP SCA marking domains, and learning points. Built directly from the RCGP curriculum topic stations listed under "How this might be tested in the MRCGP SCA," part of a free library of 79 SCA practice cases for simulated consultation assessment preparation.

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