Cases/Ear, Nose and Throat

Unilateral Blood-stained Nasal Discharge — Free SCA Practice Case

Man with unilateral blood-stained nasal discharge

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

Gerald Finch

Age

73 years

Consultation Type

Telephone

Age

Situation

Telephone Consultation.

Reason for Encounter

"For a couple of months I've been getting blood in the mucus from my nose and the back of my throat, and it's happening more often. I think my blood thinner might be behind it — should I stop it?"

Medical Records

●PMH: Atrial fibrillation. Hypertension. Benign prostatic hyperplasia.
●Medications: Apixaban 5 mg BD, amlodipine 10 mg OD, ramipril 5 mg OD, bisoprolol 2.5 mg OD, tamsulosin 400 micrograms OD.
●Allergies: NKDA.
●Recent results (routine apixaban monitoring, 7 months ago): FBC normal (Hb 14.2 g/dL, platelets 250). U&E normal (creatinine 85, eGFR 76). Calculated creatinine clearance 89 mL/min.

Patient Script

For the friend playing the patient role

Character Overview: You are Gerald, a 73-year-old retired postman who lives alone (your wife died ten years ago). You are stoical and a bit reluctant to make a fuss — you have put off calling. You have smoked heavily for most of your life. You are focused on the blood thinner as the likely cause and are half-hoping to be told to stop it. You will mention the weight loss only if asked. You are cooperative and will accept what the doctor advises.

Opening Sentence: "Morning, Doctor. For the last couple of months I've been spitting up mucus with streaks of blood in it — feels like it's draining from the back of my nose. It's getting more frequent. I reckon it's the apixaban thinning my blood too much. Do you think I should stop it?"

History if Asked (Data Gathering Phase)

●The blood: "It's mucus coming from the back of my nose down into my throat, and when I spit it out there are streaks of dark red blood in it. Two or three times a week now. Last time was a couple of days ago. Not gushing — just streaks."
●Which side: "Now you ask — it's mostly the right side of my nose that feels blocked and stuffy, and that's the side the bloody mucus seems to come from."
●The apixaban: "I've been on it about five years for my irregular heartbeat, no bother with it until now. I take all my tablets as I should."
●Weight (only volunteered if asked): "I have lost a bit of weight, actually — maybe half a stone, a stone over the last six months. Wasn't trying to. My trousers are loose."
●Smoking: "I've smoked around 25 a day since I was a young man — fifty-odd years. I know, I know."

ICE — Ideas, Concerns, Expectations

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

●Ideas: Gerald thinks the apixaban is thinning his blood too much, or that he has a minor sinus problem. He has not connected the one-sided symptoms, the weight loss, and his smoking. "I've got it in my head it's the blood thinner, or maybe a touch of sinus trouble. I hadn't thought beyond that."
●Concerns: He is worried about the blood itself, mainly because he knows the apixaban increases bleeding risk. He has not consciously entertained the possibility of cancer, though he is uneasy. "It's the bleeding that worries me, being on the thinner. I try not to think too hard about what else it might be."
●Expectations: He wants the cause found and a decision on the apixaban. "I'd like to know what's causing it, and whether I should be stopping that tablet."

If Asked — Medical History and Medications

The patient confirms these details only when directly asked.

●Atrial fibrillation: "Irregular heartbeat, been on the apixaban for it five years."
●Other conditions: "Blood pressure, and my prostate — I'm on a tablet for the waterworks."
●Adherence: "I take everything as prescribed, never miss."
●Previous nosebleeds/sinus problems: "The odd cold over the years, but no real sinus infections, and I've never been a nosebleed person."
●Allergies: "None."

Social History and Lifestyle Impact

Gerald is a retired postman who lives alone since being widowed ten years ago.

●Smoking: "About 25 a day, fifty years. Tried to stop a few times, never managed it."
●Alcohol: "Just the odd one at Christmas or a wedding."
●Living: "On my own since my wife passed. I manage fine."
●Impact: "It's more the worry than anything. And the blocked nose on that side is a nuisance."

If Asked — Associated Symptoms and Red-Flag Screen

The patient answers these only when directly asked.

●If asked to clarify the source (nose vs coughing vs vomiting blood): "It's from the nose and the back of the throat, in the mucus. I'm not coughing it up from my chest, and I'm not being sick."
●If asked about the colour of the blood: "Dark red streaks, mixed in the mucus."
●If asked about unilateral nasal blockage/obstruction: "Yes — the right side's been blocked and stuffy, more than the left."
●If asked about unilateral facial pain, numbness, or cheek swelling: "A bit of dull ache around the right cheek sometimes, no numbness or swelling that I've noticed."
●If asked about visual symptoms (double vision, bulging eye): "No, my eyes are fine."
●If asked about neck lumps: "I've not felt any lumps in my neck."
●If asked about hoarseness or voice change: "No, my voice is normal."
●If asked about difficulty swallowing: "No trouble swallowing."
●If asked about cough, chest pain, breathlessness (haemoptysis screen): "No cough, no chest pain, not short of breath."
●If asked about weight loss and night sweats: "Lost a bit of weight as I said. No night sweats."
●If asked about anaemia symptoms (tiredness, dizziness, palpitations, breathlessness): "I've been a touch more tired, but no dizziness or palpitations."
●If asked about heavy bleeding, black/tarry stools, easy bruising: "No black stools, no big bleeds, no unusual bruising."

Responses to Management (The Negotiation Phase)

●Direct question the patient asks: "So — should I stop the apixaban or not?" (The tested point is explaining that with only minor streak bleeding and no signs of major blood loss the apixaban should generally be continued, because it prevents stroke in AF, while the cause of the bleeding is investigated.)
●If the Doctor explains an urgent ENT referral is needed: "A specialist? Within two weeks? That sounds serious — what are you worried about?" (The tested point is honest, non-alarming explanation that the one-sided symptoms, weight loss, and smoking mean a serious cause must be excluded.)
●If the Doctor wants to see him in person first: "Do you need to see me? I thought you might just refer me."
●If the Doctor arranges a chest X-ray: "Why an X-ray of my chest if it's coming from my nose?"
●If the Doctor safety-nets: "What should I do if it gets worse before the appointment comes through?"

Mark Scheme

Domain 1: Data Gathering and Diagnosis

0 / 18 indicators checked+0−0

Positive (0/9)

Negative (0/9)

Domain 2: Clinical Management and Medical Complexity

0 / 18 indicators checked+0−0

Positive (0/9)

Negative (0/9)

Domain 3: Relating to Others

0 / 12 indicators checked+0−0

Positive (0/6)

Negative (0/6)

Clinical Learning Points

The Red Flag Inside a Banal Presentation

●Blood-stained nasal discharge is usually benign (minor trauma, dryness, infection). But unilateral nasal obstruction and unilateral blood-stained discharge — particularly in an older, long-term smoker, and especially with weight loss — is a red-flag picture for sinonasal or nasopharyngeal malignancy.
●The clinical skill is not to be anchored by the patient's (reasonable) "it's the blood thinner" explanation and to recognise the sinister pattern.

Sinonasal / Nasopharyngeal Cancer Red Flags

●Unilateral nasal obstruction, unilateral blood-stained discharge or recurrent unilateral epistaxis, unilateral facial pain/numbness or cheek swelling, and visual symptoms (diplopia, proptosis) should raise concern.
●Risk factors include smoking and certain occupational exposures. These features warrant urgent ENT referral.

NICE NG12 — Urgent Referral Pathways

●Refer urgently (2-week-wait) to ENT for suspected head-and-neck/sinonasal cancer where red-flag features are present.
●Offer an urgent chest X-ray (within 2 weeks) for people aged 40 and over who have ever smoked and report unexplained weight loss (among other features), to assess for lung cancer — hence the chest X-ray here despite the nasal presentation.
●Consider haemoptysis as a separate pathway if the blood proves to be from the chest — clarifying the source is essential.

Clarifying the Source of "Blood"

●Distinguish epistaxis/postnasal bleeding from haemoptysis (coughed from the lower airway) and haematemesis (vomited) — the differential and investigations differ entirely. History (where it comes from, colour, associated cough/vomiting) usually separates them.

Anticoagulation and Minor Bleeding

●A DOAC such as apixaban increases bleeding risk, and patients often assume it is the cause of any bleeding. Minor streak bleeding is not a reason to stop anticoagulation in a patient who needs it for stroke prevention in AF.
●Weigh the small bleeding risk against the substantial stroke-prevention benefit: continue the anticoagulant, investigate the bleeding source, and reassess. Stopping it would be appropriate only for major or uncontrolled haemorrhage or specific clinical circumstances.

Assessing Bleeding Severity and Anaemia

●Gauge severity (streaks vs heavy bleeding), and screen for anaemia (fatigue, breathlessness, dizziness, palpitations) and major haemorrhage (melaena, haemodynamic symptoms, easy bruising).
●Check FBC, renal function, and clotting to assess blood loss and inform anticoagulation.

Why Remote Assessment Is Insufficient

●The nose and neck cannot be examined over the phone. Arrange in-person anterior rhinoscopy/inspection of the nostrils, neck examination, chest auscultation, and observations — even when an urgent referral is already being made.

Communicating a Suspected-Cancer Referral

●Explain honestly that an urgent referral is to exclude a serious cause, while making clear that no diagnosis has been made. Balance candour with reassurance, check understanding, and safety-net — and be mindful of patients facing this alone.

Safety-Netting While Awaiting Referral

●Advise seeking urgent help for heavy bleeding, large-volume haemoptysis, black/tarry stools, faintness, or unusual bruising, and ensure the referral and chest X-ray are tracked so the pathway is not lost.

Common Candidate Mistakes in This Case

●Anchoring on the anticoagulant: attributing the bleeding to apixaban (as the patient does) and missing the malignancy red flags.
●Missing the unilateral pattern and weight loss: failing to elicit the one-sidedness and the minimised weight loss that drive the urgent referral.
●Stopping the apixaban unnecessarily: withdrawing stroke protection for minor bleeding, or failing to answer the patient's direct question with a clear rationale.
●Not arranging the chest X-ray: overlooking the parallel NG12 lung-cancer pathway in a heavy smoker with weight loss.
●Managing entirely by phone: not arranging the in-person examination of the nose, neck, and chest that the presentation requires.

Free MRCGP SCA practice case for GP registrars covering Unilateral Blood-stained Nasal Discharge — 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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