Woman Who Found A Lump Above Her Collarbone — Free SCA Practice Case

Character Overview: You are Ioana Marinescu, a 40 year old driving instructor. You moved to the UK from Romania at 22 and your English is fluent and everyday. You run your own one woman driving school, teaching from half seven in the morning until six, plus Saturday mornings. You live with your husband Andrei, a plasterer who starts early and is usually home by three, and your daughter Daria, 12, and your son Matei, 8. About six weeks ago Matei brought a cold home from school and you caught it. A couple of weeks later the seatbelt started rubbing on a lump just above your left collarbone. It is still there, it doesn't hurt, and you are sure it is a gland left over from the cold. You booked this video call mainly because Andrei keeps nagging you. You are cheerful, quick and practical, and you play things down. Underneath, the weight you have lost without trying bothers you more than you let on, and that only comes out if the doctor makes room for it. Your voice goes quieter when you talk about your children.

Opening Sentence: "Hi, thanks for calling. It's probably nothing, but I've got this lump just above my collarbone, on the left side. I had a stinking cold a few weeks ago and I'm sure it's a gland that just hasn't gone down. My husband's been on at me to get it checked, so here I am."

History if Asked (Data Gathering Phase)

• ●The lump: "Just above my left collarbone, in that little dip, out to the side rather than the middle of my neck. About the size of a grape, maybe a bit bigger. It's firm, like a little rubber ball under the skin. It doesn't hurt, even when I press on it." She found it about a month ago when the seatbelt rubbed on it. "If anything I think it's slightly bigger than when I found it. But I keep poking it, so maybe I'm imagining that."
• ●Other lumps (if asked about her neck, armpits or groin): "No, just this one. I had a feel under my arms after I found it, because you do, don't you, and there was nothing."
• ●The cold: "Matei brought it home from school about six weeks ago. It was gone in about ten days. The cold's long gone. This hasn't budged."
• ●Weight (if asked): "I've lost about six kilos. I was 68 about three months ago and I was 62 on the bathroom scales this week. I'm not dieting. If anything I'm eating more, I'm starving by the evening. I put it down to running around all day."
• ●The itching (if asked about itching, her skin, or anything else that has been bothering her): "Oh, the itching. It started about two months ago. It's everywhere, my legs, my back, my arms. There's nothing on my skin apart from where I've scratched it. It's worst at night." Changing back to her old washing powder made no difference, and three weeks of cetirizine from the pharmacist did nothing. Nobody else at home itches.

Ideas, Concerns, Expectations

Gating note: Ioana does not raise any of the following herself. Each part comes out only when the doctor asks what she thinks is going on, what is worrying her, or what she was hoping for. The second, quieter concern comes out only if the doctor explores her worries further or asks gently about the weight.

• ●Ideas: She is sure the lump is a gland from the cold, maybe with some infection still in it. She thinks the itching is dry skin or the washing powder, and the weight loss is from rushing about. "Glands come up when you've got a cold, don't they? The itching's probably dry skin, and the weight is just me running around after everyone."
• ●Concerns: Her first answer is that she does not want to make a fuss. "Three years ago I had a mole on my leg and I got sent on the urgent cancer referral. It was nothing. I felt such an idiot. I don't want to put everyone through that again over a gland." If the doctor explores further, the real worry comes out, more quietly: "If I'm honest, it's the weight. I've never lost weight without trying in my whole life. When I'm lying awake scratching I do think, what if it's something nasty. Then I think about Daria and Matei."
• ●Expectations: She was hoping to be told it is a gland and given antibiotics to shift it, plus something stronger for the itch. "My sister swears by a steroid cream."

If Asked: Medical History and Medications

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

• ●Health and medicines: "No, I'm healthy. The mole three years ago was completely harmless. Nothing regular, just the cetirizine I tried and the copper coil. No allergies."
• ●Breasts, periods and pregnancy (if asked): "No lumps or changes that I've noticed, Periods are regular, my last one was last week, and I've got the coil."
• ●Family history: "Mum has type 2 diabetes. Dad had a heart attack a few years ago and he's fine now. That's all I know of."

Social History and Lifestyle Impact

• ●Work: Ioana runs her own driving school on her own and is paid by the lesson. "I've got three pupils with their driving tests in the next two weeks, and they go in my car. If I let them down they could wait months for another test date."
• ●Lifestyle impact: "The itching's the worst bit, honestly. I'm up half the night, so I'm shattered at work, and I wear long sleeves so the pupils don't see the scratch marks."
• ●Smoking, alcohol and drugs: "I smoked about ten a day from 17 until I got pregnant with Matei. I haven't touched one since. Alcohol hardly ever, I'm always driving."
• ●Travel, contacts and relationships (if asked): "Only back to Romania to see my mum at Christmas. Nobody around me with a bad cough or TB, as far as I know. I've been with Andrei sixteen years and nobody else."

If Asked: Associated Symptoms

• ●If asked about fevers: "Not since the cold." About sweats at night: "A few times I've woken up hot, but never soaked." About tiredness: "Tired, but that's the itching keeping me up."
• ●If asked about cough, breathlessness, chest pain, coughing up blood, or swelling of her face, neck or arms: "The cough went with the cold. My breathing's fine, no pain, no swelling."
• ●If asked about trouble swallowing, a hoarse voice, mouth ulcers, earache, nosebleeds, indigestion, tummy pain, bowel change, or her heart racing or feeling hot and shaky: "No, none of that."
• ●If asked about bruising, bleeding, lots of infections, bone pain, yellow skin or eyes, dark urine or pale stools: "No, none of that." If asked about pain in the lump after a drink of alcohol: "I hardly drink, so I couldn't tell you."

Responses to Management (The Negotiation Phase)

• ●If the doctor says the lump needs checking urgently, or suggests waiting a few weeks:
  • ●Reaction: To urgency, she pushes back cheerfully at first. "But it came up after the cold. Can't we give it a couple more weeks?" If the doctor points out that the itching and weight loss started before the cold, she goes quiet: "I hadn't thought of it like that." If the doctor suggests waiting, she is relieved.
• ●If the doctor asks to see or measure the lump on camera, or offers a face to face appointment:
  • ●Reaction: Declines the camera. "You won't see anything on camera, it's under the skin. I'd rather you had a proper feel." About a face to face visit: "When? I've got lessons solid till six." If the reason is explained she makes it work. "I can move my four o'clock if it needs to be today, or I could come first thing before my half seven."
• ●If the doctor says this is an urgent referral to look for cancer, or names a type of cancer:
  • ●Reaction: A pause, then quietly: "So you do think it's something bad." If the doctor explains that most people referred this way do not have cancer but it needs ruling out quickly: "Okay. Okay. Better to know." If the doctor is vague: "Is this the cancer referral thing again? Please tell me straight." If a cancer is named: "What is that, exactly? Is that a blood thing? Is it the sort of thing people get better from?" She wants a plain, honest explanation. If last time comes up: "Last time was nothing. Isn't this the same?" Near the end, quieter: "What do I tell the kids? Daria's twelve, she notices everything."
• ●If the doctor suggests blood tests, an HIV test or a chest X ray:
  • ●Reaction: "Will the blood test tell you if it's something bad? If it comes back normal, can I stop worrying?" About HIV, surprised: "HIV? I've been with Andrei sixteen years." She agrees once told it is routine for anyone with an unexplained lump. About the X ray: "Why my chest? The lump's in my neck." She agrees once it is explained.
• ●If the doctor declines antibiotics or steroids, or suggests something for the itch:
  • ●Reaction: "Not even a course, just in case?" She accepts if she understands why. About steroids: "My sister swears by it, though." She accepts if offered something else. About a treatment for the itch, practical: "Will it make me sleepy? I'm in the car with a learner at half seven. Will I still be groggy in the morning?"
• ●If the doctor explains the next steps, safety nets or what happens at the hospital:
  • ●Reaction: "What will they actually do? Will they cut it out? Will it hurt? And when would I get an answer?" About her pupils' tests: "What if the hospital rings on a test day?" She accepts the hospital comes first. If safety netting is vague: "Worse how? It's a lump, it doesn't hurt. What am I actually meant to be looking out for?" If the doctor does not say what happens if she hears nothing: "And if nobody rings me? Last time I was chasing them." If Andrei coming along is offered, she is grateful: "He'd want to, actually. He's the one who made me ring."