Fever and Headache — Free SCA Practice Case
Student returning from SE Asia with fever and headache
Station Timer
Golden Minute
Initial Introduction
•Introduce yourself
•Ask an open question — "How can I help you today?"
•Listen — don't interrupt
•Catch early cues
Data Gathering
History, ICE & Diagnosis
Clinical Management
Diagnosis, Plan & Decisions
Safety Net
Follow-up & Close
Five cases are free: a live 12-minute consultation with an AI patient each, marked, and no card.
Materials for Candidate
Please review before starting the consultation
Full Name
Jack Reynolds
Age
21 years
Consultation Type
VideoAge
21
Situation
Telephone or Video Consultation.
Reason for Encounter
"Patient returned from a backpacking trip in Southeast Asia last week. Complaining of high fever, severe headache, and total exhaustion. Attended out-of-hours clinic yesterday where a thick and thin blood film for Malaria was sent."
Medical Records
- ●PMH: Nil significant. Fit and well.
- ●Medications: None.
- ●Allergies: NKDA.
Recent Notes
- ●Yesterday (OOH GP): Temp 39.2°C. Chest clear. Abdo soft. Sent thick/thin film for malaria.
- ●Lab Results (Received this morning): Malaria Rapid Diagnostic Test (RDT) and initial thick/thin blood film: NEGATIVE.
Patient Script
For the friend playing the patient role
Character Overview: You are Jack, a 21-year-old university student. You just got back from a month of backpacking in Thailand and Vietnam. You feel like you've been hit by a truck. Every bone in your body aches, and the headache is blinding. You saw a doctor yesterday who did a malaria test, and the receptionist called this morning to say it was negative. You are secretly terrified because you Googled your symptoms and convinced yourself you have something serious — a tropical infection that can turn life-threatening, and you can't stop catastrophising. You are convinced your blood vessels are going to start leaking and you will bleed internally. You will not volunteer this fear unless the doctor explicitly asks what you are worried about.
Opening Sentence: "Hi Doctor. The receptionist said my malaria test was negative, but I feel absolutely awful. My fever is still 39 degrees, my head is pounding, and I can barely drag myself out of bed. If it's not malaria, what's wrong with me?"
History if Asked (Data Gathering Phase)
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Travel & Exposure History (The Crucial Clues):
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Where/When: "I was in Thailand and Vietnam for four weeks. I got back exactly 6 days ago."
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Mosquitoes: "I got bitten a lot. Mostly during the daytime when we were walking around the cities like Bangkok and Hanoi."
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Prophylaxis: "I didn't take any malaria tablets because the travel clinic said the risk was low in the cities."
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Other Exposures (If asked to rule out other tropical diseases): "I didn't swim in any lakes or rivers (rules out Leptospirosis/Schistosomiasis). No new tattoos, and I didn't sleep with anyone (rules out acute HIV/Hep). I did eat a lot of street food, though (Typhoid risk)."
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The Symptoms:
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Pain: "It's a really strange pain. It feels like my bones are actually breaking, especially my shins and my back."
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Headache: "The headache is right behind my eyes. It hurts when I look side to side."
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Rash: "I noticed a faint, blotchy red rash on my chest this morning, but I thought it was just from the sweating."
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Red Flags (Systemic Screen):
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"No, I haven't had any vomiting or diarrhea."
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"No coughing or shortness of breath."
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"No neck stiffness or sensitivity to light, just the pain behind the eyes."
ICE — Ideas, Concerns, Expectations (Only reveal if the doctor directly explores the patient's perspective — do not volunteer any of this unprompted.)
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Ideas: You aren't sure exactly what's wrong, but you know it's not just a normal flu — the bone pain is too severe and too strange. Since the malaria test came back negative, you've been Googling and have found several possibilities — all of them tropical, all of them sounding serious. You've gone down a rabbit hole and scared yourself.
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Concerns: You are terrified that whatever this is could get suddenly and seriously worse — you've read that some tropical infections can deteriorate rapidly and that people can be fine one moment and critically ill the next. The bone pain and the rash are feeding this fear. You are also worried that because you're at home and not in hospital, nobody will notice if things suddenly get worse overnight. If asked: "Whatever this is — am I going to get worse? Should I actually be in hospital right now?"
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Expectations: You want the doctor to take this seriously and not just tell you to rest and take paracetamol. Ideally you want a blood test to confirm what this is, and you want clear guidance on what warning signs should make you go straight to A&E. You also want to know whether you should be in hospital now rather than waiting at home. If asked: "I just want to know what this actually is, and I want to know what to watch for — like, what would mean I need to get to hospital tonight."
If Asked — Medical History and Medications
- ●Past medical history: "No, nothing really. I've always been healthy — never been in hospital or had anything serious."
- ●Regular medications: "I don't take anything. No tablets, no inhalers, nothing."
- ●Allergies: "No, no allergies to anything that I know of."
- ●Pre-travel vaccinations/advice: "I went to the travel clinic before I left. They gave me some jabs — I think hepatitis A and typhoid — and they said I didn't need malaria tablets for the cities. They told me to use insect repellent, but honestly I wasn't great at putting it on."
- ●Yesterday's OOH visit: "I went to the out-of-hours clinic yesterday because my temperature was nearly 39.5 and I just felt terrible. The doctor examined me, listened to my chest, pressed on my tummy, and then took some blood for a malaria test. She said if it was negative they'd call me, and the receptionist rang this morning to say it was clear."
Social History and Lifestyle Impact
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Occupation / daily life: You are a third-year geography student at university. You've just come back from your trip and were supposed to be starting revision for end-of-year exams which are in three weeks. You live in a shared student house with two flatmates.
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Lifestyle impact of the condition: "I literally cannot get out of bed. I've missed three days of revision already, and my exams start in three weeks — I can't afford to lose any more time. I tried to sit at my desk yesterday and I couldn't even focus on the screen because the headache behind my eyes was so bad. My flatmates are getting worried because they can hear me shivering through the wall at night, and I've completely lost my appetite — I've barely eaten anything since I got back. I'm supposed to be handing in my dissertation draft next week and I haven't even opened it."
If Asked — Associated Symptoms
- ●If asked about bleeding from gums or nose: "No, nothing like that — no bleeding at all."
- ●If asked about blood in urine or stool: "No, my wee looks normal and I haven't noticed any blood when I go to the loo."
- ●If asked about bruising or small red/purple spots on the skin: "I haven't noticed any bruising, no. The only thing on my skin is that blotchy rash on my chest."
- ●If asked about joint pain or swelling: "My joints ache, but it's more the bones themselves — there's no swelling that I can see."
- ●If asked about muscle pain: "Yeah, my muscles ache all over — it feels like I've done a massive workout, but I haven't done anything."
- ●If asked about appetite or oral intake: "I've barely eaten in three days. I'm drinking water but I have to force myself."
- ●If asked about urine output: "I'm not going as often as normal, and it's quite dark. I know I'm probably not drinking enough."
- ●If asked about abdominal pain: "I haven't had any tummy pain, no. The doctor pressed on my stomach yesterday and it was fine."
- ●If asked about swollen glands: "I haven't noticed any lumps, no."
- ●If asked about rigors or sweating pattern: "The fever comes and goes in waves. I get really cold and shivery, then I break out in a drenching sweat. It's worst at night."
- ●If asked about eye symptoms (redness, discharge): "My eyes feel sore and heavy, but they're not red or sticky or anything."
- ●If asked about sore throat: "No, my throat's fine."
- ●If asked about confusion or drowsiness: "No, my head's clear — it just pounds. I'm exhausted but not confused or anything."
- ●If asked about recent insect bites visible: "Yeah, I've got loads of old mosquito bites on my legs and arms. Most of them have stopped itching now."
- ●If asked about what painkillers taken so far: "I've been taking paracetamol, two tablets every six hours or so. It takes the edge off the temperature for a bit but it doesn't touch the bone pain."
Responses to Management (The Negotiation Phase)
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If the Doctor dismisses the patient's fear of serious deterioration ("You'll be fine at home"):Reaction: Frustrated. "But how do you know? I've read that people can go downhill really fast with these tropical things. What if that happens tonight and my flatmates don't realise? Shouldn't I just be in hospital where someone can keep an eye on me?"
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If the Doctor tells you the single negative malaria test means you definitely don't have malaria:Reaction: "Oh, so I'm completely in the clear for malaria then? The out-of-hours doctor said something about needing three tests?"
Additional Responses to Management
- ●If the Doctor gives vague safety-netting ("just come back if you feel worse"):
- ●Reaction: Unsatisfied. "What does 'worse' mean though? I already feel terrible — how would I know if it was the normal kind of terrible or the kind where I need to call 999? Can you be more specific about what I'm actually watching for?"
- ●If the Doctor suggests antibiotics:
- ●Reaction: Compliant but uncertain. "Okay, I'll take them if you think so — but I did read that most things you catch from mosquitoes are viruses. Would antibiotics actually work?"
- ●If the Doctor advises strong hydration but gives no practical guidance:
- ●Reaction: Confused. "How much are we talking? I've been sipping water but I feel sick at the thought of drinking loads. Is there anything specific I should be drinking — like those rehydration sachets or just water?"
- ●If the Doctor confirms malaria is excluded based on the single negative test:
- ●Reaction: Relieved but then uncertain. "Oh good — so malaria is definitely off the table? The out-of-hours doctor mentioned something about needing more than one test. Does one negative result actually rule it out completely?"
- ●If the Doctor safety-nets well but does not mention the defervescence window:
- ●Reaction: Confused. "So if my temperature comes down over the next day or two, that's a good sign, right? Does that mean I'm on the mend?"
- ●If the Doctor gives a good overall management plan but does not address prognosis or recovery timeline:
- ●Reaction: Anxious. "Realistically, how long am I going to feel like this? We're talking about days, right — not weeks? My exams are in three weeks. Is there any chance I'll be okay by then?"
Mark Scheme
Domain 1: Data Gathering and Diagnosis
Domain 2: Clinical Management and Medical Complexity
Domain 3: Relating to Others
Clinical Learning Points
Recognising Dengue Fever in a Returning Traveller
- ●Aedes aegypti is the primary vector for dengue: it is a daytime biter that thrives in urban environments — distinguishing it from the nocturnal Anopheles mosquito responsible for malaria. Daytime bites in Bangkok or Hanoi strongly favour dengue over malaria as the working diagnosis.
- ●Incubation period: 4–10 days. This is the critical window for dengue to present after return, and aligns precisely with Jack's timeline (returned 6 days ago).
- ●Classical triad: Sudden high fever, severe retro-orbital headache (pain behind the eyes, worse on lateral gaze), and intense myalgia/arthralgia — the hallmark 'breakbone' pain, often worst in the shins and lower back. A transient macular/maculopapular rash typically appears on days 2–5.
- ●The combination of urban SE Asia travel, daytime mosquito bites, correct incubation period, retro-orbital headache, breakbone pain, and early rash constitutes a highly suggestive clinical picture that should lead to a confident working diagnosis of probable dengue.
Ruling Out Malaria: The Three-Film Rule
- ●A single negative malaria Rapid Diagnostic Test (RDT) or thick/thin blood film does not exclude malaria. Parasitaemia fluctuates with the fever cycle and may be below the detection threshold at any single time point.
- ●UKHSA guidance requires three negative thick and thin blood films taken over three consecutive days (at least 12–24 hours apart) before malaria can be confidently excluded in a febrile returning traveller.
- ●This rule applies regardless of whether the patient received malaria chemoprophylaxis or was told the risk in their destination was low.
- ●Missed malaria is the most dangerous diagnostic error in this scenario — it carries significant morbidity and mortality and must be actively excluded in parallel with investigating for dengue.
Broadening the Tropical Differential: Exposure-Guided Screening
- ●Dengue is the leading diagnosis here, but a structured exposure history allows confident exclusion of other tropical infections:
- ●Typhoid (Enteric fever): Street food and untreated water exposure — investigate with blood cultures
- ●Leptospirosis / Schistosomiasis: Freshwater swimming or wading — no exposure reported here
- ●Acute HIV / Hepatitis B/C: New sexual contacts, tattoos, or piercings — denied
- ●The absence of freshwater exposure, new sexual contacts, or blood-borne risk behaviours meaningfully narrows the differential and should be explicitly documented.
- ●Typhoid remains a possibility given heavy street food consumption, even with prior typhoid vaccination (which is not 100% protective) — blood cultures are essential.
The Three Phases of Dengue and Why the 'Recovery' is the Danger Zone
- ●Dengue follows a predictable three-phase pattern. Understanding this is essential for safe monitoring and accurate safety-netting:
- ●Febrile Phase (Days 1–3): High fever, viraemia, severe myalgia/arthralgia, and headache. Platelet count may begin to fall.
- ●Critical Phase (Days 3–7) — defervescence: The fever breaks — but this is paradoxically the most dangerous period. Increased capillary permeability causes plasma leakage, which can lead to haemoconcentration, pleural effusions, and circulatory compromise (Dengue Haemorrhagic Fever / Dengue Shock Syndrome).
- ●Recovery Phase (Days 7–10): Plasma reabsorption, platelet recovery, gradual clinical improvement.
- ●Key FBC markers of progression toward severe dengue: Rising haematocrit (haemoconcentration) and rapidly falling platelet count (thrombocytopenia). Serial FBC monitoring is central to inpatient and SDEC management.
Primary Versus Secondary Dengue Infection: Contextualising the Haemorrhagic Risk
- ●There are four dengue serotypes (DENV-1 to 4). Primary infection (first-ever dengue, any serotype) typically causes uncomplicated dengue fever and confers lifelong immunity to that serotype.
- ●Severe dengue (DHF/DSS) is predominantly a complication of secondary infection with a different serotype, when pre-existing heterotypic antibodies enhance viral uptake into immune cells (antibody-dependent enhancement).
- ●For a young, previously healthy traveller with no prior dengue exposure — as is almost certainly the case here — the risk of severe dengue in a primary infection is substantially lower than in endemic populations.
- ●Communicating this distinction to the patient provides accurate, evidence-based reassurance without falsely minimising the need for monitoring. It directly addresses the haemorrhagic dengue fear in a clinically meaningful way.
Investigations
- ●The following should be arranged via urgent same-day referral:
- ●Repeat thick and thin malaria films (day 2 and 3 will be needed even if today's is negative)
- ●Dengue NS1 antigen — detectable from day 1 of illness; most sensitive in the first 5 days
- ●Dengue IgM/IgG serology — IgM becomes detectable from around day 5; useful alongside NS1
- ●FBC — platelet count and haematocrit are the key prognostic markers
- ●LFTs — transaminitis (elevated AST/ALT) is common in dengue and helps confirm the diagnosis
- ●U&Es — assess renal function and hydration status
- ●Blood cultures — to exclude concurrent bacteraemia or enteric fever (typhoid)
- ●CRP — non-specific but useful to assess systemic inflammatory burden
- ●Note: dengue NS1 is the investigation of first choice in the early febrile phase. Serology alone may be falsely negative in the first few days.
Safe Prescribing and Medication Rules
- ●Paracetamol (1g up to four times daily) is the only safe antipyretic and analgesic in suspected dengue.
- ●NSAIDs and aspirin are strictly contraindicated — ibuprofen, naproxen, and diclofenac impair platelet function and increase gastric mucosal bleeding risk, creating serious danger in the context of dengue-related thrombocytopenia. This is a patient safety-critical point.
- ●Candidates must be prepared to challenge and correct their own advice if they have suggested ibuprofen — the patient in this station is scripted to flag this error. Recognising and correcting a prescribing error within a consultation is a positive indicator.
- ●There is no antiviral treatment for dengue. Management is entirely supportive.
Hydration and Fluid Management
- ●Adequate fluid intake is a cornerstone of dengue management. High fever causes significant insensible fluid losses, and poor oral intake accelerates the risk of dehydration and haemoconcentration.
- ●Advise regular small volumes of water, oral rehydration solution, or clear fluids throughout the day. Dark urine and reduced urine output are signs of inadequate hydration and should prompt urgent reassessment.
- ●In this case, the patient reports three days of poor intake and dark urine — these findings independently support the need for same-day hospital review rather than home management.
Urgent Referral: When and Where
- ●Any febrile returning traveller with a suspected or confirmed tropical infection warrants same-day referral to secondary care — do not manage in primary care alone.
- ●Appropriate referral destinations: Same Day Emergency Care (SDEC), Acute Medicine, or Infectious Diseases, depending on local pathways.
- ●Indications for same-day referral in this case: suspected dengue in the febrile phase, poor oral intake, dark urine, inability to self-care at home, and the need for serial malaria films and dengue-specific investigations.
- ●Admission is required if any warning signs are present (see below).
Safety Netting: Red Flag Symptoms Requiring Immediate Emergency Care
- ●Advise the patient to call 999 or attend A&E immediately if any of the following develop:
- ●Persistent vomiting — inability to keep fluids down
- ●Severe or worsening abdominal pain
- ●Any mucosal bleeding — bleeding gums, nosebleeds, blood in vomit, urine, or stool
- ●New bruising or petechial/purpuric spots on the skin
- ●Feeling faint, dizzy, or lightheaded on standing
- ●Confusion, extreme drowsiness, or unusual restlessness
- ●Marked deterioration in how he feels overall
- ●The defervescence window (days 3–7 of illness) is the highest-risk period — explain that feeling better as the fever drops does not mean the danger has passed. This is when plasma leakage is most likely to occur and when vigilance must be highest.
- ●In a telephone or video consultation, consider asking the patient to write down these warning signs, or offer to send a written summary — verbal recall when unwell is unreliable.
Public Health: Notifiable Disease
- ●Both dengue fever and malaria are statutory notifiable diseases in the UK.
- ●The diagnosing clinician must notify the local Health Protection Team (UKHSA) upon confirmed diagnosis. Notification does not need to wait for formal laboratory confirmation if clinical suspicion is high.
- ●Awareness of the notification pathway is expected of an ST3 managing a tropical infection in primary care.
Holistic Management: Academic and Psychosocial Impact
- ●Recovery from uncomplicated dengue typically takes 1–2 weeks from symptom onset, though post-viral fatigue and malaise may persist for several weeks beyond.
- ●For a student with imminent exam deadlines and a dissertation submission, acknowledging the academic impact and signposting university mitigating circumstances / extenuating circumstances procedures is part of holistic, person-centred management.
- ●This is not a peripheral concern — it is directly relevant to the patient's wellbeing and to demonstrating person-centred care in the SCA.
Mapped to the RCGP curriculum topic: Infectious Disease and Travel Health.
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