Explain a persistent neck lump and the safety-net to a parent — OSCE

Candidate instructions

You are the paediatric registrar. A 6-year-old boy is referred by his general practitioner with a five-week history of a painless lump in the right side of the neck. It has not changed much in size, he is otherwise well, and there are no red flags on examination, but because it has lasted five weeks you have arranged a neck ultrasound and are reviewing the family. His mother has ten minutes with you and wants to understand: (1) why he is having an ultrasound rather than just a course of antibiotics; (2) what the lump could turn out to be; (3) what to watch for and when to bring him back. Explain with empathy, check understanding, and agree a clear plan. [1]

Encounter

Mother: "He has had this lump in his neck for over a month now. The GP gave him antibiotics for a week and it did not change at all, and now you are sending him for a scan. My neighbour's child had a swollen gland and it just went away on its own — why is my son different?" [1]

Registrar: "I can hear that this has been worrying you for a while, and it is a really fair question. Most swollen glands in children's necks are what we call reactive nodes — the body's normal response to a mild viral infection — and they do go away on their own within a few weeks, just like your neighbour's child. The reason we are doing a scan for your son is a single fact: his lump has been there for five weeks and did not change with the antibiotic. We use a simple rule for neck lumps in children: if a lump has not gone away within about four to six weeks, we want to look at it with an ultrasound to be sure of what it is. That is not because we think it is serious — in a well child like your son it very likely is not — but because looking is the safe thing to do, and antibiotics only help when there is a bacterial infection, which the scan will help us tell." [1] [2]

Mother: "So what could it actually be?" [1]

Registrar: "A few things. It could still be a reactive node that is just taking longer to settle, or a small collection from a low-grade infection — those are the common ones in a child his age. Occasionally a lump like this turns out to be a congenital cyst, which is a kind of pocket that has been there since birth and only becomes noticeable later; those are harmless but often best removed with a small operation to stop them getting infected. There is also a particular kind of slow infection we sometimes see in young children that needs a different kind of treatment. The ultrasound will help us tell these apart. I want to be honest with you that, because it has lasted this long, we are also keeping an eye out for anything more serious, but the fact that he is otherwise completely well is very reassuring." [3] [2]

Mother: "When would I need to bring him back sooner than the follow-up?" [1]

Registrar: "Here is the plan, and I will write it down for you. You will have the ultrasound, and then we will see you back to go through the result together. In the meantime, bring him straight back — even in the middle of the night — if you notice any of these things: if the lump is clearly getting bigger or becomes painful, red or hot; if he gets a fever or starts looking generally unwell; if he is losing weight or getting drenching sweats at night; if he has any difficulty swallowing, breathing or a change in his voice; or if the skin over the lump changes colour. None of those mean it is definitely something serious, but they are the signs we want to know about straight away so we can reassess." [1]

Mother: "So if it gets bigger, or he gets fevers or night sweats, or the skin changes." [1]

Registrar: "Exactly right — you have got it. And one more thing that is worth knowing: there is a particular spot just above the collarbone where any lump is taken more seriously, so if you ever feel anything there, let us know straight away regardless. I will write all of this down with the warning signs and our number. The really positive thing today is that your son is well in himself, and having the ultrasound is exactly the right next step." [1]

Examiner debrief

A strong candidate explains the four-to-six-week rule and why antibiotics did not help in plain language, frames the ultrasound as the safe and proportionate next step rather than alarming the family, gives a balanced and honest differential (reactive node, congenital cyst, low-grade infection, and acknowledging the need to exclude anything serious), and delivers a concrete safety-net that names the red flags (enlargement, pain, fever, weight loss, night sweats, skin change, dysphagia, voice change) and the special alarm of a supraclavicular lump. They use teach-back to confirm the parent has understood the warning signs and provide written information. Pitfalls include dismissing the five-week duration as nothing when it meets the ultrasound threshold, giving a vague safety-net such as come back if worse without naming the red flags, over-promising that it is definitely benign, and failing to mention that a supraclavicular lump is always urgent. [1] [2]