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Practice case P2-27 · Face-to-face · simulated patient
Sudden groin pain in a 16-year-old
A 16-year-old has been brought to the practice by his mother with severe pain “down below” that started this morning. He has asked to be seen on his own.
Reviewed and kept current
Station family: History, diagnosis and management · 8-minute station · 1 min 30 s reading · Last editorial review: 16 October 2026 · Next scheduled refresh: 11 April 2027.
Candidate instructions
Read this as you would outside the room
You have 1 minute 30 seconds to read, then 8 minutes. Candidates: everything below this section is folded away — leave it closed until you have finished the station.
| Information | |
|---|---|
| Your role | Foundation Year 2 doctor in a general practice, urgent same-day clinic. It is 10:55. Your supervising GP is in the building. The practice has a treatment room, and oral analgesia. |
| Patient | Reuben Adeyemi, 16, sixth-form student |
| Reception note | “Rang at 10:40 — severe pain ‘down below’ since about 8 o’clock this morning, been sick. Mum drove him in; she is in the waiting room. He asked to come in on his own.” |
| Records | No past medical history. No regular medication. No known allergies. Immunisations complete. |
Your task
•
Take a focused history.
•
You may ask for examination findings; they will be read out to you.
•
Explain to Reuben what you think is happening and what needs to happen next, and address his concerns.
Folded away
For the actor and the examiner
1 · Actor script — role player only
Candidates: do not open until you have consulted.
Persona and manner
- Reuben Adeyemi, 16, in the lower sixth doing A-levels; plays football for the school. You live with your mum, Funmi, who is a bus driver, and your younger sister. Polite, embarrassed, and in a lot of pain: you sit forward, keep very still, and speak in short sentences.
- You asked to come in alone because you do not want your mum hearing about “down there”.
How to show the pain
- Sit on the edge of the chair leaning forward with your legs slightly apart; wince when you move; put a hand near your left groin without touching it. Do not writhe — you keep still because moving hurts.
Opening line — say this verbatim
- “It’s my… it’s my left ball, doctor. It just started hurting really badly this morning and it won’t stop.”
Volunteer freely if given the space
- It started at about eight o’clock while you were getting ready for school — sudden, like being kicked. No injury. It has not eased at all in three hours.
- You were sick once on the way here and feel sick now.
- You rang the surgery because you could not sit through lessons.
Only if asked
- Pain: left testicle, spreading into the left groin and the lower tummy. Constant, 9 out of 10. Worse with any movement; lying still with your knees up helps a little. Paracetamol at home did nothing.
- Swelling: yes — it feels bigger and “wrong”, higher up than the other one.
- Previous episodes: if asked directly whether this has happened before, twice in the last year the same testicle hurt badly for twenty minutes and then went off by itself; you never told anyone.
- Urinary symptoms: none — no burning, no going more often, no discharge. No fever, no sore throat, no swollen face or jaw.
- Bowels normal. No injury, no cycling, no heavy lifting. No lump in the groin before today.
- Sexual history — only if asked, and only if the doctor has asked what you would like kept private or has explained that what you say is confidential: you had sex for the first time three weeks ago, with your girlfriend, who is 16 too, with a condom. If the doctor asks without any mention of confidentiality, answer “no” the first time; if they then say that what you tell them stays between you unless someone is at serious risk, tell them.
- Mum: she knows you have “a pain in your stomach”. You do not want her told about the sex. You are happy for her to know you are ill and to come with you to hospital — if the doctor asks.
Impact on daily life — today and this week (only if asked)
- You have a mock exam tomorrow and a football match on Saturday.
- Mum had to leave her shift to bring you — she will lose pay.
- You are frightened of needing an operation and of what your friends would say.
Ideas, concerns and expectations
- Idea: “Is it something I caught?” — you think it may be an infection from having sex.
- Concern: that you will have to tell your mum about the sex; that your testicle is damaged; that you will be “cut open”.
- Expectation: antibiotics and painkillers so you can go home.
Cues to deliver, timed
- Minute 2: “Please don’t tell my mum what we talk about.” (Say this once, whatever the doctor has said so far.)
- Minute 4, if the doctor has not yet said that you need to go to hospital straight away: “Can you just give me some antibiotics? I can’t miss my mock tomorrow.”
- Minute 6, if the doctor is still taking history or arranging a scan: “It’s getting worse, doctor.”
If the doctor summarises and asks whether you want to add anything
- If the previous short episodes have not come out: “It has happened before, actually — twice, for a few minutes, and it went away on its own. I didn’t think it mattered.”
- If they have: “Can my mum come in now? I want her to know what’s happening — just not the other thing.”
How to respond to the doctor
- If the doctor explains plainly that the testicle may have twisted on its blood supply, that this is an emergency because the testicle can be lost within hours, and that you need to go to hospital now where a surgeon will look at it and probably operate today: you are frightened but you agree — “OK. Can Mum come?”
- If the doctor asks whether you want your mum with you and whether you are happy for them to tell her you need to go to hospital, and says the sex will not be mentioned: relieved — yes to both.
- If the doctor says you cannot eat or drink anything from now and explains why (an anaesthetic): you say you had toast at seven and a can of drink at ten.
- If offered pain relief: you accept.
- If the doctor says they will arrange an ultrasound first, or antibiotics and review, or sends you to the emergency department “to be looked at” without ringing ahead or saying it is urgent: you accept — and the examiner notes it.
- If the doctor goes to fetch your mum and tells her about the sex: you go silent and will not answer further questions.
Do not
- Volunteer the earlier short episodes or the sexual history unless asked as scripted — or invited to add anything (apart from the timed cues).
- Use the words “torsion” or “twisted”.
- Say you cannot go to hospital: if the plan is explained, you go.
Findings to give the candidate — only if asked for
Give each finding only when the candidate asks for it or says they would examine that part. If the candidate asks for a urine dipstick or an ultrasound, give the urine result below; say that no ultrasound is available at the practice.
General: pale, sweaty, sitting forward and very still; pulse 104 regular, BP 128/76, temperature 37.1 °C, respiratory rate 18. Abdomen: soft; mild tenderness in the left lower quadrant, no guarding; no hernia at either groin. Scrotum (if the candidate asks to examine, having explained and offered a chaperone): the left testis is swollen, lying high in the scrotum and horizontally, exquisitely tender all over; the epididymis cannot be felt separately; the overlying skin is slightly red; the cremasteric reflex is absent on the left, present on the right; lifting the testis does not ease the pain; the right testis is normal. No urethral discharge. Urine dipstick, if asked (it takes two minutes): clear — no blood, leucocytes or nitrite.
2 · Examiner mark sheet — generic scheme plus the key facts for this case
Domain marks — with the key facts that earn a 4 at this station
| Domain (GMC wording) · key facts for this case | 1 | 2 | 3 | 4 | Score |
|---|---|---|---|---|---|
1 · Data gathering, technical and assessment skills
| ☐ | ☐ | ☐ | ☐ | /4 |
2 · Clinical management skills
| ☐ | ☐ | ☐ | ☐ | /4 |
3 · Interpersonal skills
| ☐ | ☐ | ☐ | ☐ | /4 |
| Station total | /12 |
Domain score (educational construct):
| Score | Descriptor |
|---|---|
| 1 | Unsatisfactory (did not achieve safe FY2 standard) |
| 2 | Borderline (just achieving minimum safe FY2 standard) |
| 3 | Satisfactory (competent and safe FY2 standard) |
| 4 | Good (exceeds FY2 standard) |
This 1–4 domain score and its descriptors are an Acumen educational construct: the GMC publishes the three marking domains and the four-mark maximum, but not the descriptors its examiners use, and it does not publish station mark sheets. See Legal & Regulatory.
Marks are 1 to 4 in each domain; the generic descriptor for each mark is on the mark scheme page, and the structure of the eight minutes is on the 8-minute station page. The full standard for this case is in section 3 and the GMC feedback statements, with examples from this case, are in section 4. The examination findings that the role player gives — only if the candidate asks for them — are at the end of section 1.
3 · Expanded station-specific marking standard — what earns 4, 3, 2 and 1 here
The top row is the full picture of what a competent FY2 could do at this station, including the working diagnosis with its justified differentials, the safety-net and the follow-up; lower rows describe how performance falls away. It is a debriefing aid, not a checklist to recite: nobody says every line in eight minutes, and a 4 is a judgement that the essentials — the italic key facts on the mark sheet — were done well, in plain language and at the patient’s pace. Acumen training standard — the GMC does not publish station mark sheets.
| Mark | Domain 1 · Data gathering, technical and assessment skills | Domain 2 · Clinical management skills | Domain 3 · Interpersonal skills |
|---|---|---|---|
| 4 |
|
|
|
| 3 | Onset, severity and the examination findings established and the infection differential screened; one of the previous episodes, confidentiality before the sexual history, or the impact missing. | Correct working diagnosis and immediate transfer by telephone; one of nil by mouth, analgesia, the explanation of the operation or the arrangement with his mother missing. | Kind and clear; confidentiality explained a little late, or the conversation with his mother handled without checking what he wanted said. |
| 2 | A general pain history without the time of onset or the previous episodes; sexual history, if taken, done bluntly; findings asked for without a chaperone or explanation. | Recognises that this may be serious and sends him to the emergency department, but without ringing ahead or stating the urgency. | Competent but impersonal; the plea about his mother answered with “we’ll see”; the urgency delivered abruptly. |
| 1 | Accepts “a pain in my ball” and asks a few closed questions; no examination findings sought. Or unsafe: spends the station on a urine test or a sexual-health history and never establishes the time of onset or the testicular findings. | Treats as an infection with antibiotics and review; or sends him home with painkillers; or asks for an ultrasound and arranges nothing else; no sense of time. Or unsafe: delays transfer to await an ultrasound or urine result, or tells him to come back if it is no better tomorrow. | Embarrassed or embarrassing; avoids the subject; or frightens him with repeated talk of losing the testicle. Or unsafe: promises absolute secrecy, or breaches his confidence to his mother; or mocks or lectures him about sex. |
4 · GMC feedback statements — where underperformance was identified — with case-specific examples
A feedback statement marks where underperformance was identified in the consultation. With PLAB 2 results the GMC may attach any combination of the ten statements to a station — none, one or several. The right-hand column shows what each one looks like at this station. Record the statements that applied in the practice log.
| GMC feedback statement | Underperformance it signals (generic) | Case-specific examples |
|---|---|---|
| 1 · Consultation | Disorganised or unstructured consultation | History taken in no order; the time of onset never pinned down; the plan announced without a summary. |
| 2 · Issues | Key issues or priorities not recognised | Treats the station as a sexual-health consultation and misses that the task is to recognise a time-critical surgical emergency and act within minutes. |
| 3 · Time | Poor time management | Takes a full sexual and social history, asks for a urine dipstick and is still talking when “It’s getting worse, doctor” is said; the hospital has not been rung when the bell goes. |
| 4 · Findings | Abnormal findings or results, or their implications, not identified | Told the testis is high, horizontal and exquisitely tender with an absent cremasteric reflex, and still calls it “probably an infection”; does not ask whether it has happened before. |
| 5 · Examination | Physical examination or use of instruments not competent | Does not ask for scrotal findings, or asks without explaining or offering a chaperone; asks for an ultrasound as the next step. |
| 6 · Diagnosis | Working diagnosis or differential diagnoses not correct | “It’s probably epididymitis — you’re sexually active”; torsion never named as the working diagnosis, or named without saying why it must be assumed. |
| 7 · Management | Management plan not reflecting current best practice | Antibiotics and review tomorrow; or a routine ultrasound request; no telephone call ahead; no nil-by-mouth or analgesia; nothing said about what to do if the pain changes while waiting or if it happens on the other side; no plan to ring him the next day. |
| 8 · Rapport | Rapport and sensitivity to the patient’s feelings and concerns not shown | Avoids eye contact and the subject; answers “Please don’t tell my mum what we talk about” with “we’ll see”; or lectures him about condoms while he is in pain. |
| 9 · Listening | Verbal and non-verbal cues not used; poor active listening | Misses the plea about his mum and “Can you just give me some antibiotics?”; never invites him to add anything, so the earlier episodes are never mentioned. |
| 10 · Language | Language or explanations not understandable; understanding not checked | “This is likely torsion of the spermatic cord with an absent cremasteric reflex — we need urgent scrotal exploration and bilateral orchidopexy, so you’re NBM from now.” |
5 · Examiner points of fact and guidelines
Points of fact the examiner should have to hand
- NICE CKS, Scrotal pain and swelling (last revised April 2026): suspect testicular torsion in any person presenting with acute scrotal pain and/or swelling, before other causes are considered. If a person has sudden-onset scrotal pain and torsion is suspected clinically, arrange emergency hospital admission to urology or paediatric surgery. A history of previous severe, self-limiting episodes suggests intermittent torsion and detorsion.
- Clinical features (CKS): torsion — usually acute, severe unilateral pain, which may radiate to the groin or lower abdomen; nausea and vomiting; the cremasteric reflex may be abnormal or absent, and the testis may be elevated and lie transversely. Epididymo-orchitis — acute unilateral pain or swelling with fever, dysuria, urethral discharge or parotid swelling; a tender epididymis; pain may be relieved by elevation (Prehn sign) — but a positive Prehn sign does not rule out torsion. Torsion of a testicular appendage — pain and tenderness at the upper pole, sometimes a “blue dot”, systemic upset unlikely.
- CKS reserves urgent scrotal ultrasound for swelling that is not of acute onset; suspected torsion in a person with sudden-onset pain goes straight to emergency admission to urology or paediatric surgery, without imaging first. The NCEPOD review Twist and Shout (2024; patients aged 2–24) found that reviewers judged Doppler ultrasound unnecessary in about one in ten patients and that there were avoidable delays in treatment in over a third; it asks for urgent review by a senior surgical decision-maker and for primary and emergency care staff to be trained to recognise torsion and enact urgent pathways.
- Time matters: NCEPOD cites a systematic review of 1,283 patients in which surgery within six hours of the onset of pain was associated with a 97% chance of saving the testicle, with salvage falling the longer surgery is delayed beyond six to eight hours. In the NCEPOD sample fewer than half of those who kept the testicle, and under one in ten of those who lost it, had surgery within six hours of symptom onset. Reuben’s pain began at 08:00; the practice consultation is at 10:55.
- The operation (BAUS patient leaflet, Scrotal exploration for suspected torsion of the testis; NCEPOD): scrotal exploration under general anaesthetic; the twisted testicle is untwisted and, if viable, stitched in place (orchidopexy); if it is not viable it is removed (orchidectomy); the other testicle is fixed at the same time. A prosthesis can be discussed later. Explain this as what is likely, not as a promise that the testicle will be saved.
- Practical steps in the practice: telephone the on-call surgical team (or 999 where local pathways say so) and state the time of onset; nil by mouth from now because a general anaesthetic is likely — record the time of the last food and drink and tell the receiving team; give analgesia and record what was given and when (oral paracetamol or ibuprofen if that is what is available; the ambulance crew or emergency department can give stronger analgesia); a short handwritten or electronic note goes with him. Do not delay for a urine dipstick, culture or scan.
- Consent at 16 (England and Wales): Family Law Reform Act 1969 section 8 — the consent of a minor who has reached 16 to surgical, medical or dental treatment (including diagnostic procedures and anaesthesia) is as effective as an adult’s, and parental consent is not then required. The Mental Capacity Act 2005 applies from age 16 (section 2(5)). GMC 0–18 years paragraph 25: at 16 a young person can be presumed to have the capacity to consent; paragraph 29: encourage young people to involve their parents in important decisions, but usually abide by any decision they have the capacity to make; paragraph 31: parents cannot override the competent consent of a young person.
- Confidentiality (GMC 0–18 years, paragraphs 42–52): the same duties of confidentiality apply to young people as to adults; ask for consent before sharing identifiable information with parents; disclose without consent only where there is an overriding public interest (risk of death or serious harm to the young person or others), where it is required by law, or in the best interests of a child who lacks the maturity to decide. A 16-year-old’s consensual, protected sex with a girlfriend who is also 16 is not a reason to breach his confidence (GMC 0–18 years paragraphs 57–62 on sexual activity: consider the partner’s age and any sign of exploitation); record what was discussed and what was agreed about his mother. GMC Confidentiality (2017) and Good medical practice (2024) carry the same principles.
- Sexually active 16-year-old — for the surgical team and the follow-up: epididymo-orchitis in a sexually active adolescent is usually chlamydial or gonococcal, so the surgical team may ask about sexual activity when the testicle is explored (CKS asks that the need for STI testing is assessed where epididymo-orchitis is suspected); tell Reuben why and ask his agreement to share it. A later, separate appointment about sexual health and contraception is good practice and can be offered confidentially.
Where candidates lose marks at this station
- Asking for an ultrasound before anything else.
- “You’re sexually active, so it’s probably an infection” — antibiotics and review.
- Never asking what time the pain started.
- A sexual history taken without a word about confidentiality — he answers “no”.
- Sending him to the emergency department without ringing ahead or saying it is urgent.
- Fetching his mother and telling her everything.
Guidelines for this station
- NICE CKS — Scrotal pain and swelling: scenario, testicular torsion (revised April 2026)
- NCEPOD — Twist and Shout: care of children and young people with testicular torsion (2024)
- BAUS — patient leaflet: scrotal exploration for suspected torsion of the testis (check for a newer version)
- GMC — 0–18 years: guidance for all doctors (capacity to consent; confidentiality)
- Family Law Reform Act 1969, section 8 — consent by persons over 16 to surgical, medical and dental treatment
6 · MLA content map tags for this case
| MLA content map | This station |
|---|---|
| Domain 1 · Areas of clinical practice | Renal and urology · Surgery |
| Domain 3 · Clinical and professional capabilities | History, examination and differential diagnosis · Emergency and acute management plans · Capacity, consent and confidentiality · Pain management · Communication with patients, relatives and carers |
| Domain 5 · Patient presentations | Scrotal/ testicular pain and/ or lump/ swelling |
| Domain 6 · Conditions | Testicular torsion · Prostatitis, epididymitis and orchitis |
| Station family | History, diagnosis and management — History, diagnosis and management |
7 · My marks and reflection — practice log form
Record your three domain marks, your station total, the GMC feedback statements that applied (where underperformance was identified), and what you will keep and change. The form is already labelled with this case and its web address; a copy of your entry is emailed to you, so your practice log builds up in your inbox and can be downloaded.
Record my marks and reflection for P2-27
Revision link for this case: mdacumen.com/plab-2-osce/case-27-sudden-groin-pain-teenager
Independence & scope. Independent, formative training material from MD Acumen Ltd. Not affiliated with, endorsed by, or delivered on behalf of the General Medical Council. The GMC does not publish its station mark sheets: every mark scheme and descriptor on these pages is an Acumen training tool calibrated to the GMC's published marking domains, feedback statements and the MLA content map. Practice scores are not a prediction of examination performance. Clinical content reflects UK guidance at the date of editorial review — always check the current guideline. All patients are fictional. This course never provides, and will never ask you to share, real GMC exam content — full regulatory statement: Legal & Regulatory.
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