“I’ve had a stinking sore throat and I’m wiped out for weeks — just give me antibiotics?”

In a YOUNG ADULT, a prolonged severe SORE THROAT with profound FATIGUE, fever, tender (especially POSTERIOR cervical) LYMPHADENOPATHY, tonsillar enlargement/exudate, and sometimes splenomegaly, hepatitis or palatal petechiae, is INFECTIOUS MONONUCLEOSIS (glandular fever), usually EBV — the fatigue and posterior cervical nodes helping distinguish it from simple tonsillitis. Confirm with the MONOSPOT/heterophile antibody test and FBC (atypical lymphocytes), checking LFTs (EBV hepatitis is common), and remember the monospot can be FALSELY NEGATIVE in the first week (repeat or use EBV-specific serology, and offer an HIV test if negative in a mononucleosis-like illness, BHIVA/BASHH/BIA 2020). Explain it is VIRAL — antibiotics do NOT help and are not indicated — with SUPPORTIVE management (rest, fluids, analgesia/antipyretics, saltwater gargles), resisting the antibiotic request with a clear explanation. A classic pitfall: AVOID AMOXICILLIN/ampicillin, which causes a florid maculopapular RASH in EBV (and is not needed anyway; penicillin V would be used if a genuine coexisting bacterial tonsillitis required treatment). Critically, glandular fever causes SPLENOMEGALY and the spleen can rupture, so advise AVOIDING CONTACT/COLLISION SPORTS and heavy lifting for at least 4 weeks from the start of symptoms and until reviewed (NICE CKS; longer while the spleen is enlarged), checking the spleen face to face — hence no rugby — and warn of sudden severe left-upper-quadrant/abdominal or shoulder-tip pain (splenic rupture, an emergency). The hidden agenda is the wish for antibiotics and a fast return to sport; explain kindly why both must wait, give realistic recovery expectations (fatigue can linger), and safety-net for airway compromise (severe swelling, difficulty swallowing/breathing), splenic rupture, dehydration, and a prolonged/atypical course (persistent lymphadenopathy/weight loss prompting re-review).