Persistent Sore Throat, Lymphadenopathy, and Abdominal Pain — Free SCA Practice Case
Teenager with persistent sore throat, lymphadenopathy, and abdominal pain
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
Liam Connor
Age
17 years
Consultation Type
VideoAge
17
Situation
Video Consultation.
Reason for Encounter
"Patient complaining of a severe sore throat that is getting worse over the last 5 days. He also has swollen glands and now mentions a stomach ache."
Medical Records
- ●PMH: Mild childhood asthma.
- ●Medications: Salbutamol inhaler PRN.
- ●Allergies: Penicillin (Mother states he had a mild rash as a toddler, never formally tested).
Recent Notes
- ●Nil significant. Usually fit and well. Plays rugby for the county youth team.
Patient Script
For the friend playing the patient role
Character Overview: You are Liam. You are a 17-year-old Sixth Form student. You are usually energetic and sporty, but right now you look completely washed out, pale, and sweaty. Your throat is agonizing. You are trying to act tough, but you are secretly terrified. You have been Googling your symptoms, and because your uncle died of lymphoma (blood cancer) a few years ago after finding "lumps in his neck," you are convinced you have cancer. You will not volunteer this fear unless the doctor explicitly asks what you are worried about.
Opening Sentence: "Hi Doctor. My throat is absolutely killing me. It's been five days and it's just getting worse. I've got these massive lumps in my neck, I'm sweating constantly, and since yesterday, my stomach has been really aching too."
History if Asked (Data Gathering Phase)
- ●The Throat (Ruling out Quinsy/Airway compromise):
- ●"It feels like swallowing glass. I can drink water, but eating solid food is too painful."
- ●"No, I can open my mouth fully. My voice just sounds a bit weird and nasally."
- ●If asked about drooling or difficulty swallowing saliva: "No, I can swallow fine — it just really hurts."
- ●If asked whether the pain is worse on one side: "It's pretty bad both sides, maybe slightly worse on the right."
- ●The Abdominal Pain (The Splenomegaly Clue):
- ●"It's a dull, heavy ache on the left side, just under my ribs."
- ●"It hurts a bit more if I take a really deep breath or twist my body."
- ●"No vomiting, my bowels are normal."
- ●Systemic Symptoms:
- ●"I am so tired. I slept for 14 hours last night and I still feel exhausted. I feel feverish and sweaty."
ICE — Ideas, Concerns, Expectations The patient does not volunteer any of this unprompted. These responses surface only if the candidate directly explores the patient's perspective.
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Ideas: Liam has Googled his symptoms and believes the swollen glands, sweats, and fatigue point to lymphoma. This belief is anchored by his uncle's death from lymphoma, which also started with "lumps in the neck." He does not have any alternative explanation in mind — as far as he is concerned, the symptoms match cancer and nothing else.
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Concerns: His deepest fear is that he has the same cancer that killed his uncle. He is also frightened by how rapidly he has deteriorated — he went from being a fit, active rugby player to barely being able to get out of bed in under a week. He is worried about what this means for his future.
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Expectations: He wants the doctor to take his symptoms seriously and run proper tests — specifically blood tests. He wants a clear answer about whether it could be cancer. If reassured it is not cancer, he wants to know exactly what it is and how quickly he can get back to normal, especially for rugby.
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If the doctor asks: "What are you worried this might be?" or "Have you looked up your symptoms?"
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Reaction (The Reveal): You drop your tough-guy act and look panicked. "Well... yeah, I did look it up. It said swollen glands and night sweats can be Lymphoma. My uncle died from that. With these lumps in my neck and feeling so weak... do I have cancer, Doctor?"
If Asked — Medical History and Medications The patient does not volunteer this information unprompted. These responses are for use if the candidate asks about past medical history, medications, or allergies.
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Asthma / Salbutamol inhaler: "Yeah, I've got a blue inhaler somewhere — I've had it since I was a kid. Honestly, I hardly ever use it. Maybe a couple of puffs before a match if it's really cold, but I haven't needed it for ages. It doesn't bother me at all normally."
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Penicillin allergy: "My mum says I'm allergic to penicillin — apparently I came out in a rash when I was really little, like a toddler. I've never had it since so I don't really know what would happen. I've never been tested for it or anything."
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General health: "I'm usually really fit — I never get ill. I can't remember the last time I went to the doctor before this. This is completely out of the blue."
Social History and Lifestyle Impact Volunteered naturally in conversation when the candidate explores Liam's daily life, or woven into other answers where relevant.
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Occupation / daily life context: Liam is in Year 12 (Lower Sixth), studying PE, Biology, and Psychology at A-level. Rugby is the centre of his life — he plays flanker for the county youth team and has been training three or four times a week alongside weekend matches. He is hoping for a sports scholarship or a place on a university rugby programme. His social life revolves around his teammates.
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Lifestyle impact of the condition: "I haven't been to school all week — I literally can't get out of bed before midday. I missed training on Tuesday and Wednesday, and the coach has already messaged asking if I'm going to make Saturday. I can't even eat properly — I've been living off soup and smoothies because I can't swallow anything solid. My mates came round yesterday and I had to tell them to leave after twenty minutes because I was so knackered. I've never felt this bad in my life."
If Asked — Associated Symptoms The patient does not volunteer these details unprompted. These are for use when the candidate directly asks about specific symptoms.
- ●If asked about a rash: "No, I haven't noticed any rash or spots anywhere."
- ●If asked about a headache: "Yeah, I've had a bit of a headache on and off — nothing as bad as the throat though."
- ●If asked about jaundice or yellowing of the skin/eyes: "No, I don't think so — no one's said I look yellow."
- ●If asked about bruising or bleeding easily: "No, nothing like that."
- ●If asked about weight loss: "I don't know — I haven't weighed myself, but I've barely eaten for five days so probably a bit."
- ●If asked about night sweats specifically: "Yeah, I've been waking up drenched. I had to change my t-shirt twice last night."
- ●If asked about joint or muscle pain: "My whole body aches, but I think that's just because I feel so rough. No specific joint pain or swelling."
- ●If asked about a cough: "No, no cough."
- ●If asked about difficulty breathing or shortness of breath: "No, breathing is fine. Just the throat and the tiredness."
- ●If asked about ear pain: "A little bit — it kind of aches when I swallow, like it shoots up to my ear. But it's mostly the throat."
- ●If asked about nosebleeds: "No, no nosebleeds."
- ●If asked about sexual activity or kissing contacts: "Erm... yeah, I was seeing someone a few weeks ago. We were together at a party about three weeks back." (Slightly embarrassed but honest if asked directly.)
- ●If asked about recent travel abroad: "No, I haven't been anywhere — just school and rugby."
- ●If asked about contact with anyone unwell: "Not that I know of, but there's always stuff going round at school."
- ●If asked about alcohol or drug use: "I had a few beers at that party a few weeks ago, but nothing mad. No drugs or anything."
- ●If asked about lumps or swelling anywhere else (axillae, groin): "I don't think so — I've only noticed the ones in my neck. They're massive though."
Responses to Management (The Negotiation Phase)
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If the Doctor dismisses the cancer fear too quickly ("Don't trust Google"): Reaction: Defensive. "But my uncle had exactly this! How can you be sure it's not cancer without doing tests?"
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If the Doctor diagnoses Glandular Fever (Infectious Mononucleosis): Reaction: "The kissing disease? Oh right. So I just need antibiotics to clear it up quickly?" (Testing if the doctor will inappropriately prescribe antibiotics for a viral illness.)
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If the Doctor advises AGAINST playing sports (The Major Conflict): Reaction: Highly distressed. "Wait, what? No, I have the county rugby final this Saturday! I'm the captain, the scouts are coming to watch. I have to play! I'll take strong painkillers, just tape me up. Can't I just play this one game?"
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If the Doctor explains the risk of splenic rupture: Reaction: Shocked but starting to listen. "Wait — my spleen could burst? Like, actually burst? What would happen?" (This is the key moment for the candidate to explain the danger clearly and compassionately, helping Liam understand why contact sport is genuinely dangerous.)
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If the Doctor asks you to come in for an examination and blood tests: Reaction: "Yeah, I can get my mum to drive me down. Will you check my stomach? It really feels heavy."
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If the Doctor discusses amoxicillin and the risk of a rash in glandular fever: Reaction: "So even if I wasn't allergic to penicillin, you still couldn't give me that antibiotic? That's weird — why would it cause a rash?" (Opportunity for the candidate to demonstrate knowledge of the characteristic amoxicillin-EBV rash.)
Mark Scheme
Domain 1: Data Gathering and Diagnosis
Domain 2: Clinical Management and Medical Complexity
Domain 3: Relating to Others
Clinical Learning Points
Recognising Infectious Mononucleosis
- ●Infectious mononucleosis (glandular fever) is caused by Epstein-Barr virus (EBV) and is most common in adolescents and young adults. Suspect it in any teenager presenting with the classic triad: severe pharyngitis, cervical lymphadenopathy, and profound fatigue.
- ●The addition of left upper quadrant (LUQ) pain in this age group should immediately raise the possibility of splenomegaly — a key complication of EBV that carries significant management implications.
- ●Night sweats, fever, and marked lethargy (sleeping 14 hours and still exhausted) complete a systemic picture that is characteristic of EBV and should prompt early investigation.
- ●The lymphadenopathy in EBV is typically bilateral cervical, though it may be generalised (axillary, inguinal). Bilateral distribution with pharyngitis strongly favours a reactive/infective cause over malignancy.
Differentiating EBV from Bacterial Tonsillitis and Lymphoma
- ●The clinical picture in this case — bilateral pharyngitis, bilateral cervical lymphadenopathy, LUQ pain, night sweats, and profound fatigue in a 17-year-old — should point away from simple bacterial tonsillitis and towards a systemic viral illness.
- ●Bacterial tonsillitis typically presents with acute unilateral or bilateral tonsillar exudate, high fever, and rapid onset, but without the profound systemic features or LUQ involvement seen here.
- ●Lymphoma — the patient's hidden fear — typically presents with insidious, painless, non-tender lymphadenopathy, often without pharyngitis or fever from the outset. The acute onset with severe sore throat and fever here makes a primary lymphoma presentation far less likely, though blood tests are required to confirm.
- ●Explaining this distinction clearly — with clinical reasoning, not dismissal — is essential to address the patient's cancer anxiety appropriately.
Investigations
- ●FBC: Expect a lymphocytosis with characteristic atypical (activated) lymphocytes. These are the hallmark of EBV on the blood film and are a key diagnostic finding.
- ●Monospot test (Paul-Bunnell / heterophile antibody test): Rapid bedside test for EBV. Note that it may be falsely negative in the first week of illness — if clinical suspicion is high and Monospot is negative, EBV-specific serology (VCA IgM/IgG) can be requested.
- ●Liver function tests (LFTs): Hepatitis occurs in up to 80% of EBV cases, often subclinical. LFTs are mandatory in any case of suspected infectious mononucleosis — not optional. Deranged LFTs influence return-to-sport decisions and may require repeat monitoring.
- ●Face-to-face review is essential in a case managed initially via video: to examine the throat (exclude quinsy), palpate for splenomegaly and hepatomegaly, and assess lymph node characteristics directly.
Antibiotic Avoidance — The Aminopenicillin-EBV Rash
- ●Antibiotics are not indicated in infectious mononucleosis — it is a viral illness and antibiotics will not hasten recovery.
- ●Crucially, amoxicillin and ampicillin (aminopenicillins) cause a widespread, intensely pruritic maculopapular rash in patients with active EBV infection. This occurs in approximately 80–90% of cases and is not a true allergic reaction — it is a poorly understood immune-mediated phenomenon specific to EBV.
- ●This matters because the reflex explanation ("I can't prescribe amoxicillin because of his penicillin allergy") is clinically incomplete. In this case, amoxicillin should be avoided regardless of the allergy status — and any candidate who relies on the allergy label without recognising the EBV-specific contraindication is demonstrating a gap in knowledge.
- ●The documented penicillin allergy (childhood rash, never formally tested) is a separate issue and should be flagged for future formal allergy assessment — but it is not the primary reason antibiotics are being withheld here.
Corticosteroid Prescribing
- ●Oral corticosteroids should not be routinely prescribed for infectious mononucleosis. NICE CKS advises against their routine use for symptom control.
- ●They are reserved for specific, serious complications — most commonly significant tonsillar enlargement causing impending airway compromise — and in such cases, specialist input should be sought.
- ●Candidates who offer prednisolone to help with the sore throat or fatigue are making a common management error.
Splenic Rupture — The Non-Negotiable Activity Restriction
- ●EBV causes splenomegaly in approximately 50% of cases. An enlarged spleen is vulnerable to rupture following blunt abdominal trauma — such as a rugby tackle. Splenic rupture is a life-threatening surgical emergency requiring emergency splenectomy.
- ●All patients with confirmed or suspected infectious mononucleosis must be advised to avoid contact sport and heavy lifting for a minimum of 4 weeks from symptom onset, and only return when clinically well with medical clearance.
- ●This restriction is non-negotiable regardless of how important the event (county final, scouts, captaincy). The candidate must hold this boundary firmly while acknowledging the significant personal cost to the patient.
- ●This advice must be accompanied by a clear explanation of the mechanism — patients who understand why the restriction exists are far more likely to comply. "Your spleen is enlarged and if someone tackles you directly into your left side, it can rupture — that would be a life-threatening emergency requiring surgery" is the kind of direct, clear communication that works.
- ●Return-to-sport should be guided by clinical assessment and LFT results, not a fixed calendar date alone.
Symptomatic Management
- ●Analgesia: Regular paracetamol and/or ibuprofen are recommended for pain and fever. NSAIDs are effective for throat pain and are not contraindicated unless there is specific reason to avoid them.
- ●Fluids and diet: Adequate fluid intake is essential. Soft foods and cool fluids may help — practical advice that is genuinely useful for a patient who cannot swallow solids.
- ●Rest and activity: Complete bed rest is not required. Patients should rest as their symptoms dictate and gradually increase activity as energy returns. Fatigue may be prolonged.
Recovery Trajectory and Post-Viral Fatigue
- ●Acute symptoms (sore throat, fever) typically resolve within 2–3 weeks, but fatigue can persist for several weeks to months. This is the most functionally disabling aspect of EBV for young people.
- ●A graduated return to school, sport, and normal activities is appropriate as energy allows. Advise patients not to push through excessive fatigue, as this may prolong recovery.
- ●For a Year 12 student with A-level commitments, advising them to inform school of the diagnosis so appropriate adjustments can be made (deadline extensions, reduced timetable) is part of holistic management.
- ●If deranged on initial testing, LFTs should be repeated at follow-up to confirm normalisation before return to strenuous activity.
Safety Netting
Advise the patient (and parent/carer where appropriate) to seek urgent medical attention — via 999 or A&E — if any of the following develop:
- ●Airway compromise: Stridor, significant difficulty breathing, inability to swallow saliva, drooling, or a rapidly worsening "hot potato" voice — indicating tonsillar enlargement causing airway obstruction.
- ●Splenic rupture: Sudden onset of severe LUQ pain or left shoulder tip pain (Kehr's sign — referred pain from diaphragmatic irritation), or sudden onset of dizziness, faintness, or collapse — which may indicate haemorrhage.
- ●Dehydration: Significantly reduced urine output or postural dizziness — particularly relevant given the difficulty swallowing.
Advise avoidance of all strenuous physical activity (not just contact sport) until formally reviewed and cleared.
Common Candidate Errors in This Case
- ●Prescribing antibiotics: Either assuming this is bacterial tonsillitis without adequate history, or capitulating to the patient's expectation that "antibiotics will sort it quickly." Antibiotics are contraindicated — and amoxicillin specifically is doubly so.
- ●Citing the penicillin allergy as the sole reason to avoid amoxicillin: This is a surface-level answer. The EBV-aminopenicillin rash is a separate, important pharmacological phenomenon that all candidates should be able to explain.
- ●Allowing rugby: Caving to pressure ("see how you feel on Saturday" or "maybe if you're feeling better") is a patient safety failure. The risk of splenic rupture is real and the restriction is absolute until medically cleared.
- ●Dismissing the cancer fear without clinical reasoning: "It's definitely not cancer, don't worry about Google" is not adequate. The candidate should explain why the clinical picture is more consistent with infection than lymphoma, and confirm that blood tests will help exclude other causes.
- ●Failing to arrange LFTs: Omitting liver function tests in a case of suspected EBV is a management gap. Hepatitis is common and may be clinically silent — but it has direct implications for activity restriction and follow-up.
Mapped to the RCGP curriculum topic: Haematology.
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