CASE INFORMATION

Case ID: SEB-2025-12
Case Name: Michael Carter
Age: 42
Gender: Male
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: S78 (Sebaceous Cyst)

COMPETENCY OUTCOMES

Competency Domain	Competency Element
1. Communication and Consultation Skills	1.1 Engages effectively with the patient to assess symptoms and concerns 1.3 Explains the nature, causes, and treatment options for sebaceous cysts 1.5 Uses shared decision-making regarding management, including watchful waiting vs. intervention
2. Clinical Information Gathering and Interpretation	2.1 Conducts a structured history and physical examination to confirm the diagnosis 2.3 Differentiates between sebaceous cysts and other skin lumps (e.g., lipomas, abscesses, malignancies)
3. Diagnosis, Decision-Making and Reasoning	3.1 Identifies key clinical features of sebaceous cysts 3.5 Recognises indications for excision, drainage, or referral
4. Clinical Management and Therapeutic Reasoning	4.2 Provides appropriate first-line management based on cyst size, symptoms, and risk of infection 4.5 Discusses procedural options including incision and drainage vs. complete excision
5. Preventive and Population Health	5.1 Advises on wound care, infection prevention, and recurrence risk
6. Professionalism	6.1 Provides reassurance while addressing patient concerns about malignancy
7. General Practice Systems and Regulatory Requirements	7.1 Documents examination findings and management plan clearly 7.2 Ensures appropriate follow-up if intervention is performed
8. Procedural Skills	8.1 Demonstrates safe and effective minor surgical skills if excision is performed
9. Managing Uncertainty	9.1 Addresses patient concerns regarding recurrence, scarring, and potential malignancy
10. Identifying and Managing the Patient with Significant Illness	10.1 Recognises when a skin lump requires further investigation (e.g., suspicious features for malignancy)

CASE FEATURES

Middle-aged male presenting with a painless lump on the upper back that has been growing slowly over the past six months.
No redness, warmth, or discharge, but the patient is concerned it might be cancer.
Examination reveals a mobile, non-tender, dome-shaped subcutaneous lump with a central punctum.
Needs education on benign nature of sebaceous cysts and management options.

INSTRUCTIONS

Review the following patient record summary and scenario.
Your examiner will ask you a series of questions based on this information.

You have 15 minutes to complete this case.

The time for each question will be managed by the examiner.
The time allocation for each question is roughly as follows:

Question 1 – 3 minutes
Question 2 – 3 minutes
Question 3 – 3 minutes
Question 4 – 3 minutes
Question 5 – 3 minutes

PATIENT RECORD SUMMARY

Patient Details

Name: Michael Carter
Age: 42
Gender: Male
Gender Assigned at Birth: Male
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

Nil known

Medications

Nil regular medications

Past History

No history of skin cancer, infections, or prior cysts

Social History

Works as a mechanic, often exposed to oily environments
Married, no significant family history of skin conditions or malignancies

Family History

No family history of melanoma, skin cancers, or cystic conditions

Smoking

Non-smoker

Alcohol

Drinks occasionally on weekends

Vaccination and Preventative Activities

Up to date with routine health screenings

SCENARIO

Michael Carter, a 42-year-old mechanic, presents with a painless lump on his upper back that has been growing slowly over six months. He denies any pain, redness, or discharge, but is worried that it could be cancer.

On examination, there is a 3 cm, mobile, non-tender, dome-shaped subcutaneous lump with a visible central punctum. There are no signs of infection or surrounding inflammation.

Michael is seeking advice on what the lump is, whether it is dangerous, and whether he needs it removed.

EXAMINATION FINDINGS

General Appearance: Well, no acute distress
Vital Signs:

Temperature: 36.8°C
Heart Rate: 72 bpm
Blood Pressure: 126/78 mmHg
Respiratory Rate: 14 breaths per minute

Skin Examination:

Location: Upper back
Size: ~3 cm in diameter
Consistency: Soft to firm, non-tender, mobile
Appearance: Dome-shaped, well-circumscribed, with a central punctum
No overlying skin ulceration, erythema, warmth, or drainage

EXAMINER ONLY INFORMATION

QUESTIONS

Q1. What aspects of history and examination are critical in assessing this patient’s sebaceous cyst?

Prompt: How do you differentiate a sebaceous cyst from other skin lumps?
Prompt: What features would raise concern for malignancy?

Q2. Based on the findings, what is your differential diagnosis, and what is your working diagnosis?

Prompt: How do you differentiate sebaceous cysts from lipomas, abscesses, and other lumps?
Prompt: When would you consider imaging or biopsy?

Q3. How would you manage Michael’s sebaceous cyst?

Prompt: What are the options for conservative vs. surgical management?
Prompt: When would incision and drainage be indicated vs. complete excision?

Q4. How would you counsel Michael on his concerns about malignancy?

Prompt: How do you reassure him about the benign nature of sebaceous cysts?
Prompt: What symptoms should prompt review (e.g., rapid growth, ulceration, recurrence)?

Q5. What follow-up plan would you implement?

Prompt: When should he return for review?
Prompt: How would you manage recurrence or complications such as infection?

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Q1: What aspects of history and examination are critical in assessing this patient’s sebaceous cyst?

A structured history and focused examination are essential to confirm the diagnosis of a sebaceous cyst and differentiate it from other skin lesions.

1. History

Onset and duration:
- When was the lump first noticed? Has it changed in size, shape, or symptoms?
Symptoms:
- Any pain, redness, swelling, drainage, or fluctuation (suggestive of infection or abscess formation)?
- Itching, ulceration, or bleeding (suggestive of malignancy)?
Risk factors:
- History of recurrent cysts, acne, or oily skin?
- Occupational exposure to oily environments?
- Previous trauma to the area (can predispose to cyst formation)?
Family history:
- Any family history of multiple sebaceous cysts, lipomas, or skin cancers?
Impact on daily life:
- Is the cyst causing discomfort, interfering with movement, or affecting appearance?

2. Examination

Location & size: Commonly found on the scalp, face, back, and chest.
Shape & consistency:
- Round, well-defined, mobile, firm-to-soft lesion.
- Presence of a central punctum is characteristic.
Signs of infection or malignancy:
- Redness, warmth, tenderness, pus drainage (infected cyst).
- Rapid growth, ulceration, fixation, irregular borders (suspicious for malignancy).
Transillumination test:
- Cysts generally do not transilluminate, differentiating them from fluid-filled lesions.

A thorough history and examination help to confirm diagnosis, exclude differentials, and guide management.

SUMMARY OF A COMPETENT ANSWER

Elicits a detailed history, including onset, growth, symptoms, and risk factors.
Assesses for infection (pain, redness, drainage) and malignancy (ulceration, rapid growth).
Confirms typical examination findings, including a mobile, firm, dome-shaped lump with a central punctum.
Differentiates from lipomas, abscesses, epidermoid cysts, and malignant lesions.

PITFALLS

Failing to assess for signs of malignancy, particularly in older patients or rapidly growing lesions.
Overlooking features of infection, which may require antibiotics or drainage.
Misdiagnosing a lipoma as a sebaceous cyst, which may lead to inappropriate treatment.
Not considering biopsy in an atypical or suspicious lesion.

REFERENCES

MARKING

Each competency area is on the following scale from 0 to 3.

☐ Competency NOT demonstrated
☐ Competency NOT CLEARLY demonstrated
☐ Competency SATISFACTORILY demonstrated
☐ Competency FULLY demonstrated

2. Clinical Information Gathering and Interpretation

2.1 Conducts a structured history and physical examination to confirm the diagnosis.
2.3 Differentiates between sebaceous cysts and other skin lumps.

Competency at Fellowship Level

☐ CLEARLY BELOW STANDARD
☐ BELOW EXPECTED STANDARD
☐ BORDERLINE
☐ AT EXPECTED STANDARD
☐ ABOVE STANDARD