CCE-CBD-191

EXAMINER ONLY INFORMATION

QUESTIONS

Q1. What is your differential diagnosis, and what is the most likely diagnosis?

• Prompt: How do you differentiate between reactive, infective, and malignant causes of lymphadenopathy?
• Prompt: What features would raise suspicion for malignancy?

Q2. What are your initial management steps?

• Prompt: What investigations would you order at this stage?
• Prompt: When would you refer for specialist review?

Q3. How would you explain the diagnosis and treatment plan to the patient?

• Prompt: How would you address his concerns about serious illness?
• Prompt: What follow-up plan would you implement?

Q4. What preventive measures can help reduce his risk of recurrent lymphadenopathy?

• Prompt: What lifestyle or vaccination advice is relevant?
• Prompt: When should he seek medical attention for lymph node enlargement?

Q5. What are the red flags that would necessitate urgent imaging or referral?

• Prompt: What clinical features suggest lymphoma or metastatic disease?
• Prompt: How would you manage a persistent or concerning lymph node?

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Q1: What is your differential diagnosis, and what is the most likely diagnosis?

Answer:

Lymphadenopathy can result from infectious, inflammatory, malignant, or other systemic conditions. A structured approach helps differentiate between benign and serious causes.

Differential Diagnoses:

1. Reactive Lymphadenopathy (Most Likely Diagnosis)
   • Key features: Tender, mobile, enlarged node following a recent infection.
   • Recent viral pharyngitis makes this the most probable cause.
2. Bacterial Lymphadenitis
   • Key features: Unilateral, painful, erythematous swelling.
   • Common pathogens: Staphylococcus aureus, Group A Streptococcus.
3. Infectious Mononucleosis (EBV or CMV Infection)
   • Key features: Generalised lymphadenopathy, fatigue, fever.
   • Monospot negative, but EBV serology pending.
4. Tuberculosis (TB) Lymphadenitis
   • Key features: Chronic, non-tender lymphadenopathy with systemic symptoms.
   • No travel history or TB exposure reported.
5. Haematological Malignancy (Leukaemia or Lymphoma)
   • Key features: Painless, persistent lymphadenopathy, B symptoms (fever, weight loss, night sweats).
   • Less likely given tenderness and recent infection, but requires follow-up.

Most Likely Diagnosis:

• Reactive lymphadenopathy post-viral pharyngitis, given recent infection and examination findings.
• Requires monitoring and further investigation if persistent.

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Q2: What are your initial management steps?

Answer:

1. Conservative Management (If Clinically Stable)

• Reassure that post-infectious lymphadenopathy is common and usually self-resolves.
• Encourage fluids, rest, and NSAIDs for pain relief.

2. Investigations (If Symptoms Persist Beyond 4 Weeks or Have Red Flags)

• Blood tests:
  • FBC (Leukaemia, infection markers).
  • CRP/ESR (Inflammation or malignancy).
  • EBV/CMV serology.
• Ultrasound if:
  • Node >2 cm, firm, fixed, or growing.
  • Associated with red flag symptoms.

3. Referral Criteria for Specialist Review

• Haematology/Oncology referral if:
  • Persistent lymphadenopathy beyond 6 weeks.
  • B symptoms (weight loss, night sweats, fever).
  • Multiple enlarged lymph nodes.

4. Follow-Up Plan

• Review in 2-4 weeks to reassess resolution.
• Advise immediate return if new concerning symptoms develop.

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Q3: How would you explain the diagnosis and treatment plan to the patient?

Answer:

Diagnosis Explanation:

• “Your enlarged lymph node is most likely due to your recent throat infection. This is called reactive lymphadenopathy and should resolve on its own.”
• “I do not see signs of something more serious at this stage, but we will monitor closely.”

Treatment Plan:

• “You can take ibuprofen or paracetamol for discomfort, and stay well-hydrated.”
• “We will check back in 2-4 weeks to see if it has resolved.”

Safety-Netting:

• “If your lymph node gets larger, becomes hard, or does not resolve in 4-6 weeks, we will investigate further.”
• “If you develop night sweats, weight loss, or persistent fever, return immediately.”

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Q4: What preventive measures can help reduce his risk of recurrent lymphadenopathy?

Answer:

• Good hygiene practices to prevent infections.
• Annual influenza vaccination to reduce viral illnesses.
• Healthy lifestyle: Adequate sleep, hydration, and balanced diet.
• Avoid unnecessary antibiotic use unless bacterial infection confirmed.
• Seek medical attention early if infections persist or worsen.

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Q5: What are the red flags that would necessitate urgent imaging or referral?

Answer:

• Lymph node >2 cm persisting >6 weeks.
• Hard, fixed, or rapidly growing nodes.
• Generalised lymphadenopathy affecting multiple regions.
• B symptoms (weight loss, fever, night sweats).
• Splenomegaly or hepatomegaly on examination.

Management of a Suspicious Lymph Node:

• Ultrasound to assess structure.
• Core needle biopsy if malignancy suspected.
• Urgent haematology referral if persistent or systemic features present.

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SUMMARY OF A COMPETENT ANSWER

• Correctly differentiates between benign, infectious, and malignant causes.
• Recognises reactive lymphadenopathy as the most likely diagnosis.
• Provides clear and structured management with appropriate investigations.
• Offers reassurance while ensuring safety-netting and follow-up.
• Identifies red flags requiring urgent referral.

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PITFALLS

• Over-investigating a clear case of reactive lymphadenopathy too early.
• Missing red flags for malignancy or systemic disease.
• Not explaining the likely benign nature of the condition, causing unnecessary anxiety.
• Failing to arrange follow-up for persistent lymphadenopathy.

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REFERENCES

• 
  RACGP Red Book – Preventive Activities in General Practice
• GP Exams – Painful/enlarged lymph gland(s)

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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

1. Communication and Consultation Skills

1.1 Communication is appropriate to the person and the sociocultural context.
1.2 Engages the patient to gather information about their symptoms, ideas, concerns, and expectations.
1.4 Communicates effectively in routine and difficult situations.

2. Clinical Information Gathering and Interpretation

2.1 Obtains a thorough history relevant to lymphadenopathy.
2.2 Identifies red flag symptoms requiring further investigation.

3. Diagnosis, Decision-Making and Reasoning

3.1 Differentiates between benign, infective, inflammatory, and malignant causes of lymphadenopathy.

4. Clinical Management and Therapeutic Reasoning

4.1 Provides appropriate initial management, including symptomatic treatment.
4.2 Recognises when further investigations or specialist referral is required.

5. Preventive and Population Health

5.1 Provides education on the importance of follow-up for persistent lymphadenopathy.

Competency at Fellowship Level

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