Glandular fever

  • Candidate Instructions
  • Actor Instructions
  • Mark Sheet
  • Score

Location: You are an F1 junior doctor in A&E working with the ENT team

Patient: Patient has presented to A&E with a sore throat

– Take a focused history from the patient
– After 6 minuets you will be asked a series of questions by the examiner
– Answer any questions that the patient may have

Note to actor: Try to restrain yourself from volunteering to much information – you may do so when prompted (that is, by a specific question, not a general one). If a student is on the wrong line of clinical reasoning do not fuel this line of thinking, state no to the question as being ambiguous may prompt further questioning and does not allow the student to be appropriately tested. The aim of the exercise is to take a focused history; short answers are required.

You are a 17 year old male / female who has attended A&E with a sore throat. This began 5 days ago and has been getting worse. If asked the swelling is on both sides at the back of the throat. It is extremely painful to swallow and you have been spitting out your saliva into a cup. You have had tonsillitis before but nothing as bad as this. If asked you feel extremely tired and have found it extremely difficult to get out of bed and have been unable to attend collage.

You have seen your GP 2 days ago and prescribed some medications but have been unable to swallow the tablets given as they are too big and you cannot even swallow water. If asked you cannot remember what the doctor was treating.

You do not regularly see your doctor about anything and have not had any past operations. You do not take any regular medications and do not have any drug allergies

You do not drink or smoke

Nothing like this runs in your family.

Category Question
Introduction Candidate appropriately introduced themselves with:
Full name
Medical school
Year or grade
Clarifies who they are talking to
Asks patient for preferred name

PC Presenting complaint
Appropriate opening question
Timing – does the pain come and go or is it constant?
Exacerbating and relieving factors

AF Associated features
Fever / night sweats
Recently been in contact with anyone unwell
Recently been in contact with anyone unwell Previously had tonsillitis

Features requiring admission Features requiring admission
Stridor present
Dehydration or difficulty swallowing fluids
Acute abdominal pain

System review System review
Ear = otalgia, discharge, change in hearing / tinnitus
Nose = rhinnorrhoea, epistaxis

PMH Past medical history
Appropriate past medical history questions
Asks about previous operations

DH Drug history
Asks appropriate questions about past medical history
Asks about any drug allergies

FH Family history
Asks appropriately if there is any family history

SH Social history

ICE Ideas, Concerns, Expectation
Explores ideas, concerns, expectations
Asks patient if they have any questions

Question Examination findings = febrile, looks unwell. Enlarged cervical lymph nodes bilaterally, exudate pharyngitis with soft palate petechiae. Given your history you have taken and the examination findings provided, what are your list of differentials?
Group A streptococcal pharyngitis (bacterial tonsillitis)
Peritonsilar cellulitis
Glandular fever (infectious mononucleosis)
Scarlet fever

Question What blood investigations would you like to do as an F1 doctor in A&E?
Monospot test (or allow glandular fever screen)

Question What would be your diagnosis if a patient being treated for tonsillitis by the GP developed a maculopapular puritic rash after starting amoxicillin?
Glandular fever (infective mononucleosis)

Question What is the cause of infective mononucleosis?
Epstein-Barr virus (EBV)

Question What laboratory test is used to diagnose infective mononucleosis?
Monospot test (glandular fever screen not accepted as an answer)

Question What is your management for this patient with infective mononucleosis?
IV Fluids as patient is unable to swallow. Encourage oral hydration
Analgesia: paracetamol, ibuprofen, codeine PRN
Difflam throat mouthwash
STAT dose of dexamethasone

Question On discharge what advice should the patient be given with regards to infective mononucleosis?
Exclusion from work or school is not necessary.
To return to normal activities as soon as possible. If they are tired, they should tailor their activities to what they can manage comfortably. Bed rest is not normally needed.
To limit spread of the disease, by avoiding kissing and sharing eating or drinking utensils, and to thoroughly clean all items that may have been contaminated by saliva.
To avoid contact or collision sports or heavy lifting for the first month of the illness (to reduce the risk of splenic rupture)