History Taking · Intermediate · Dermatology

Non-Healing Skin Lesion on the Face

Practise this PLAB 2 history taking station on Basal Cell Carcinoma. 8-minute voice AI simulation with feedback on all 3 marking domains.

Clinical scenario

You are an FY2 doctor in a GP surgery. Mr Edward Dean, a 71-year-old man, has come to see you because he has a lesion on his face that has not healed for several months. It appears raised and pearly with occasional bleeding. Please take a focused history of the lesion and discuss assessment and management.

Background notes: PMH: Hypertension, Mild osteoarthritis

What this station tests

  • Classic BCC features: pearly rolled border, central ulceration, telangiectasia, non-healing, slow-growing
  • Occupational UV exposure as the key risk factor in a retired builder
  • Distinguishing BCC from SCC: BCC is slow-growing with pearly edges; SCC is faster-growing with keratin
  • Excellent prognosis communication: BCC almost never metastasises (<0.1%), curable with treatment
  • 2-week-wait referral for suspected skin cancer per NICE NG12

How to use your 8 minutes

  • 0-1 min — Introduction: Introduce yourself, confirm identity, open question. 'What's brought you in today?'
  • 1-4 min — Systematic History: Presenting complaint detail (SOCRATES for pain, timeline, severity). Systems review. PMH, medications, allergies.
  • 4-6 min — Context and ICE: Social history (smoking, alcohol, occupation, living situation). Family history. Ideas, Concerns, Expectations.
  • 6-7 min — Summary and Plan: Summarise findings back to patient. Share differential/working diagnosis. Outline investigation and management plan.
  • 7-8 min — Closing: Safety netting with specific red flags. Arrange follow-up. Check for questions.

Consultation approach

The opening

A non-healing facial lesion in an elderly man with outdoor occupational history is BCC until proven otherwise. The candidate must identify the clinical features, arrange referral, and reassure about the generally excellent prognosis. Mr Dean is 71, retired builder, with an 8-month non-healing lesion on his face. His daughter brought him. Open with: 'Mr Dean, your daughter mentioned this spot on your face. Tell me about it and how long it has been there.'

Core approach

Characterise the lesion through history. Present for 8 months, slowly growing, initially thought it was a pimple. It has a raised, pearly edge (rolled border), central ulceration (it bleeds occasionally then crusts over), and visible small blood vessels on the surface (telangiectasia). It does not heal. This description is classic nodular BCC.

Risk factors: 71, male, retired builder (decades of outdoor UV exposure), fair skin. Ask about previous skin cancers, sunburn history, and sun protection habits. His occupational history is the key risk factor: chronic cumulative UV exposure over a career in construction.

Distinguish from SCC (which has higher metastatic potential). SCC: typically more rapidly growing, crateriform with keratin plug, may be tender, arises on sun-damaged skin. BCC: slow-growing, pearly rolled edges, telangiectasia, central ulceration, rarely metastasises. The clinical features here favour BCC.

Check regional lymph nodes (neck, pre-auricular). BCC almost never metastasises (<0.1%), but examining lymph nodes is good practice and helps exclude SCC.

Closing and safety netting

Refer via 2-week-wait pathway. 'Mr Dean, this lesion has features that suggest a type of skin growth called a basal cell carcinoma. The good news is that this is the least aggressive type of skin cancer. It grows very slowly and almost never spreads to other parts of the body. But it does need to be removed.' Reassure about prognosis: BCC is curable with treatment in virtually all cases.

Treatment options (the specialist will decide): surgical excision (most common), Mohs surgery (for facial lesions near important structures), cryotherapy, or topical treatment for superficial BCC. Address his concern about facial scarring: the dermatologist will discuss the best approach for his specific location.

Sun protection: hat, sunscreen, avoid prolonged sun exposure. Monitor for new lesions. Safety net: 'If it bleeds heavily, grows rapidly, or you develop any lumps in your neck, come back before your appointment.' Follow-up after dermatology review.

How examiners mark this station

Examiners will focus on the thoroughness and structure of your history taking for basal cell carcinoma. Domain 1 (Data Gathering) carries the most weight: expect marks for systematic coverage of presenting complaint, red flags, PMH, medications, social and family history. Domain 2 (Clinical Management) requires a clear differential, appropriate investigations, and a safe management plan with safety netting. Domain 3 (Interpersonal Skills) is assessed throughout: genuine exploration of ICE, active listening, empathic responses, and clear communication without jargon.

Domain 1: Data Gathering, Technical and Assessment Skills (Primary focus)

Scores well: Classic BCC features identified. Duration and non-healing pattern documented. UV exposure history. SCC distinguished. Lymph nodes checked. Other skin lesions surveyed.

Costs marks: Not identifying BCC features. Not asking about UV exposure. Not checking lymph nodes.

Domain 2: Clinical Management Skills (Primary focus)

Scores well: 2-week-wait referral. Treatment options outlined. Prognosis communicated (excellent). Sun protection advice. Safety netting for rapid change or lymphadenopathy.

Costs marks: Routine referral. Not communicating prognosis. No sun protection. No safety netting.

Domain 3: Interpersonal Skills (Throughout)

Scores well: Reassuring about the excellent prognosis immediately after saying 'skin cancer.' Addressing facial scarring concern. Acknowledging his daughter's role in bringing him. Using clear, non-alarming language.

Costs marks: Alarming without context. Not addressing scarring concern. Using 'cancer' without prognosis.

Common examiner feedback (and how to fix it)

Did not gather sufficient information to make an adequate assessment of the patient's condition

Fix: Use a consistent framework for every history. After covering the presenting complaint, systematically move through PMH, drug history, social history, family history, and ICE. Keep a mental checklist.

Did not identify the patient's problems and/or did not develop a management plan adequately

Fix: Reserve the final 2 minutes to summarise your findings, share your working diagnosis with the patient, and outline your investigation and management plan including safety netting.

Common mistakes in this station

  1. Not recognising the non-healing nature as the key feature. An 8-month lesion that repeatedly crusts and bleeds is not a pimple. Candidates who do not ask about the healing pattern miss the diagnostic clue.
  2. Being overly alarming about a BCC diagnosis. BCC has an excellent prognosis. Candidates who communicate 'skin cancer' without immediately contextualising ('the least aggressive type, almost never spreads, curable') cause unnecessary distress.
  3. Not asking about occupational UV exposure. A retired builder has decades of sun exposure. This is the primary risk factor and should be documented.

Resitting PLAB 2?

If you have previously struggled with history taking stations, focus on building a consistent systematic framework that you apply to every case. Practise structuring your history into clear phases (presenting complaint, systems review, PMH, social, ICE) so that even under pressure, you cover all domains. Many resitters lose marks not on knowledge but on organisation and time management.

Example opening

Good morning/afternoon, my name is Dr [Name], I'm one of the doctors here today. Could I confirm your name and date of birth please? Thank you. So, what's brought you in to see me today?

Frequently asked questions

How do I approach the consultation in this basal cell carcinoma station?

A non-healing facial lesion in an elderly man with outdoor occupational history is BCC until proven otherwise. The candidate must identify the clinical features, arrange referral, and reassure about the generally excellent prognosis. Mr Dean is 71, retired builder, with an 8-month non-healing lesion on his face.

What does a strong performance look like to the examiner in this station?

Strong performances show: Classic BCC features identified. Duration and non-healing pattern documented. UV exposure history. SCC distinguished. Lymph nodes checked. Other skin lesions surveyed. Weak performances: Not identifying BCC features. Not asking about UV exposure. Not checking lymph nodes.

What is the biggest pitfall in this basal cell carcinoma station?

Not recognising the non-healing nature as the key feature. An 8-month lesion that repeatedly crusts and bleeds is not a pimple. Candidates who do not ask about the healing pattern miss the diagnostic clue.

How should I prepare for basal cell carcinoma if I have never seen it in practice?

This station rewards process over personal experience. The skill being assessed: Occupational UV exposure as the key risk factor in a retired builder. Use the domain breakdown on this page to target your preparation, then practise the station aloud so your structure survives exam pressure.

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