PLAB 2 Febrile Child Station: How to Approach, Mark Scheme & Free Practice

Hold these differentials in your head

Bracket the deadly causes first. If you fail to consider any of these in your reasoning out loud, the clinical-management domain will suffer.

• Viral upper respiratory tract infection
  The commonest cause of fever in a young child - runny nose, cough, mild fever, feeding preserved. A safe diagnosis only after you have actively excluded the serious causes, never a shortcut to reassurance.
• Acute otitis media
  Ear-tugging or ear pain, irritability and fever, with a red bulging eardrum when you request the ENT examination. A classic fever source in toddlers and the underlying cause in the standard febrile-convulsion version of this station.
• Tonsillitis
  Sore throat, refusal to eat or drink, fever and cervical lymphadenopathy. Ask about drooling and stridor - a child who cannot swallow their own saliva needs urgent assessment for a deeper neck infection.
• Urinary tract infection
  Easily missed in nappies because there is no localising complaint - ask about smelly or dark urine, more or fewer wet nappies, vomiting and poor feeding. Fever with no obvious source in a young child needs a urine sample.
• Pneumonia
  Fever with fast or laboured breathing, chest recession, grunting or reduced feeding. Ask the parent directly about breathing and request the respiratory rate and oxygen saturations from the examiner.
• Meningitis or meningococcal sepsis
  The diagnosis this station is really testing you against. Ask specifically about a non-blanching rash, neck stiffness or crying on neck movement, dislike of light, unusual drowsiness or irritability, and a bulging fontanelle in babies. Screen before you reassure.
• Febrile convulsion (simple vs complex)
  A fit triggered by fever in a child aged six months to five years. Simple means single, generalised, under 15 minutes, with full recovery. Focal features, duration over 15 minutes, recurrence within 24 hours or incomplete recovery make it complex and change the disposition.
• Kawasaki disease
  Think of it in any fever lasting more than five days, especially with red eyes, cracked lips, a rash, swollen hands or feet, or a swollen neck gland. Mentioning the five-day threshold in your safety-netting shows the examiner you know it exists.

Step-by-step approach

This is the structure that scores. You do not need to follow it verbatim, but every numbered block below maps to a cluster of marks in the rubric.

1. 1. Open and acknowledge the parent's fear

   The simulated patient here is the parent, and they are usually visibly frightened. Address the emotion before the clinical questions.

   • Introduce yourself with name and grade, confirm who the parent is and the child's name and age.
   • Acknowledge early and specifically: "Watching your child have a fit is terrifying - you did the right thing bringing her in."
   • Reassure them the child is being looked after and you want to understand exactly what happened.
   • Signpost: history first, then examination findings, then a clear plan.

2. 2. Characterise the fever

   Duration, height and trend frame everything that follows.

   • How long has the child been hot, and how was the temperature measured?
   • How high has it been, and is it climbing, stable or settling?
   • Have antipyretics been given - what, how much, and did they help?
   • Any pattern - constant or coming in spikes?

3. 3. If there was a fit, dissect it completely

   The description of the episode is what separates a simple febrile convulsion from a red flag. Every feature is a mark.

   • What was the child doing when it started, and were there warning signs (pallor, clamminess)?
   • How long did the shaking last? Under five minutes is reassuring; over 15 makes it complex.
   • Was it whole-body or confined to one limb or one side? Focal features change everything.
   • Was the child responsive during it? Eye-rolling, incontinence, tongue-biting?
   • How were they afterwards - brief drowsiness with full recovery, or still not themselves?
   • Any injury or head knock during the episode, and has it ever happened before?

4. 4. Systems screen for the fever source and the red flags

   This is the traffic-light thinking in plain-English questions. Cover every system that could be the source, and screen meningitis explicitly.

   • Ears - tugging or rubbing, discharge, which side?
   • Throat and chest - cough, runny nose, noisy or fast breathing, working hard to breathe.
   • Urine - smelly or dark wee, more or fewer wet nappies than usual (also your dehydration check).
   • Tummy - vomiting, diarrhoea, refusing feeds or drinks.
   • Meningitis screen - any rash (and does it fade when pressed?), crying when the neck is moved, bothered by light, unusually drowsy, irritable or difficult to console.
   • Overall behaviour - alert and playful between fevers, or floppy and withdrawn?

5. 5. Complete the paediatric history

   The paediatric extras are marks candidates from adult-medicine backgrounds routinely forget.

   • Past medical history, previous admissions, regular medicines, recent antibiotics, allergies.
   • Birth history - delivery, complications, prematurity.
   • Immunisations - up to date, and anything given in the last two weeks? A recent MMR is a recognised trigger for fever and febrile convulsions.
   • Family history of febrile fits or epilepsy - it raises recurrence risk and it is what the parent is silently worrying about.
   • Who looks after the child at home, and is anyone else in the house unwell?

6. 6. Ideas, concerns and expectations

   In this station ICE is not a formality - the parent's real fears are epilepsy, brain damage and meningitis, and addressing them is heavily weighted.

   • "What is worrying you most right now?"
   • Common answers: "Is it epilepsy?", "Is her brain damaged?", "Will it happen again?", "Is it meningitis?"
   • Acknowledge each fear as reasonable before you answer it. Never wave one away.

7. 7. Request examination findings and observations

   Ask the examiner out loud for each component - nothing is volunteered.

   • Vital signs - temperature, heart rate, respiratory rate, oxygen saturations, capillary refill.
   • General examination - alertness and consolability, any rash and whether it blanches, hydration status, any injury.
   • Neurological assessment - neck stiffness, Kernig's sign, photophobia, moving all four limbs, focal signs.
   • ENT examination - the eardrums and throat are where the source usually hides.
   • Respiratory examination - air entry, added sounds, recession.

8. 8. Explain the diagnosis honestly and in plain English

   Name what happened, name the cause, and answer the epilepsy fear directly.

   • "This was a febrile convulsion - a fit triggered by a high temperature in a young child. They are common, and frightening to watch, but they do not usually cause any lasting harm."
   • Identify the source: "The fever is coming from an ear infection, which we can treat."
   • If the features fit, say so: single, short, whole-body, full recovery - a simple febrile convulsion.
   • Address epilepsy explicitly: "This is not epilepsy. The risk of developing epilepsy later is only slightly higher than for any other child."
   • Be honest about recurrence: roughly one child in three will have another with a future fever, and children grow out of them by around age five or six.

9. 9. Management, fever advice and first aid for a future fit

   Practical, specific advice the parent can act on at home - and honesty about what antipyretics cannot do.

   • Treat the underlying source - antibiotics only if indicated for the specific infection, and say so if they are not: most childhood fevers are viral and antibiotics will not help.
   • Fever comfort measures - light clothing, plenty of fluids, paracetamol or ibuprofen if the child is distressed by the temperature, not to chase a number.
   • No tepid sponging or aggressive cooling - and be honest that antipyretics do not reliably prevent further fits.
   • First aid for a future fit: stay calm, lie the child on their side, clear the area, do not restrain them, put nothing in the mouth, time the episode.
   • Call 999 if a fit lasts longer than five minutes, repeats, or the child does not recover normally afterwards.

10. 10. Safety-net explicitly and close

    Spell the worsening advice out as if you were writing it down, and offer to actually write it down.

    • Return immediately if: a rash appears that does not fade when a glass is pressed on it, the child becomes floppy, unusually drowsy or hard to wake, cries inconsolably or seems in pain when the neck is moved, has fewer wet nappies or shows signs of dehydration, breathing becomes fast or laboured, or the fever lasts more than five days.
    • Offer a written leaflet on febrile convulsions and fever in children.
    • Arrange follow-up or a review plan, summarise, invite final questions, thank the parent.

Common pitfalls

• Reassuring the parent before you have screened for meningitis and found the source of the fever - premature reassurance is the classic safety-critical fail in this station.
• Forgetting to ask about wet nappies - it is simultaneously your UTI screen and your dehydration check, and it is almost always in the mark scheme.
• Skipping the paediatric extras: birth history, immunisations (including anything in the last two weeks) and who cares for the child at home.
• Not asking whether the fit was generalised or focal, or how long it lasted - the two features that decide simple versus complex.
• Dodging the epilepsy question with vague comfort instead of a direct, honest answer about the small increase in risk.
• Promising that paracetamol will prevent another fit - it will not, and the mark scheme rewards saying so.
• Giving safety-netting as a vague "come back if you're worried" instead of naming the specific red flags and the five-minute 999 rule.
• Dismissing or talking over the parent's instinct that something is wrong - parental concern is itself an amber feature and the interpersonal domain punishes it hard.

Frequently asked questions