“She’s burning up and she’s got spots” — a mother with her two-year-old

Candidates: do not open until you have consulted.

How to run this station

• The role player is Isla’s mother and holds a doll or a rolled blanket on her lap as Isla. Isla herself does not speak. Everything the doctor would see or measure is read out from the findings at the end of this script, only when the doctor asks for it.
• If the doctor asks you to do something practical — hold Isla, undress her, fetch your partner — do it and say so. If the doctor asks the receptionist or supervising GP for help, say “She’s on her way” or “They’re calling now” and continue.
• Drugs and oxygen are ‘given’ when the doctor states the drug, dose and route aloud (or the oxygen flow); hold the doll still for an injection if asked. Time: if the doctor has not called 999 two minutes (station time) after the first observations were given, the examiner announces “ten minutes have passed” and gives the deterioration findings when asked. If 999 was called, the examiner announces “the ambulance crew has arrived” four minutes after the call, or at 7:00 if sooner. With no examiner, you say these announcements aloud, out of character, and then return to the role.

Persona and manner

• Rachel Dunne, 31, a hairdresser. You live with your partner Tom and Isla. Your mum lives two streets away.
• Frightened and trying to hold it together. You speak quickly, keep looking down at Isla, and stroke her hair. You are not angry — you just want someone to tell you what to do.

Opening line — say this verbatim

• “She’s burning up, doctor, and now she’s got spots — look. She’s just not herself. I didn’t know whether to come here or go to A&E.”

Volunteer freely if given the space

• She was fine at nursery yesterday. Last night she was hot and clingy and would not eat her tea; you gave paracetamol at about seven and again at two in the morning. She slept badly and was “moaning” in her sleep.
• This morning she was sick once and has been floppy and quiet — “she normally never stops”. You noticed the spots on her tummy when you changed her about an hour ago; there seem to be more on her legs now.
• You rang the surgery and reception fitted you in. You walked here — ten minutes.

Only if asked

• The rash: tiny red-purple dots, some bigger ones on her shins that look like little bruises. If asked whether you have pressed a glass on them, or whether they fade when pressed: “I tried it with a tumbler — they didn’t go away. That’s why I panicked.” If not asked, do not mention the glass.
• She has had one wet nappy since last night, less than usual. She has taken a few sips of juice. She was sick once this morning, no diarrhoea.
• No cough, no runny nose, no pulling at her ears. No fits. She has not hit her head.
• Her hands and feet felt cold to you this morning even though she was hot. She cried when you lifted her and “didn’t want her head moved” when you tried to put her coat on.
• She was born at term; no problems. All her jabs are up to date — the nurse said so at her two-year check. No allergies. No regular medicines. Nobody else at home or at nursery has been unwell, as far as you know. No travel.
• What you gave: paracetamol 120 mg (5 mL of the 120 mg in 5 mL suspension) at 7 pm and 2 am — nothing else. No ibuprofen. No antibiotics.
• How she is right now, if asked to describe her rather than examine her: “She’s just lying on me. She looked at you when you came in but she hasn’t smiled. She’s hot but her feet are freezing.”

Impact on daily life — home and work (only if asked)

• You were due at the salon at ten and have already rung in; your boss is “not happy”. Tom is a delivery driver and is out on his round — you have not been able to reach him.
• You have no car here. Your mum could get to you in ten minutes if someone rang her.
• You have not eaten or slept; you have been up with her since two.

Ideas, concerns and expectations

• Idea: “I thought it was chickenpox — the girl next door had it last month. But chickenpox spots are blisters, aren’t they?”
• Concern: the word you cannot say out loud is meningitis — a girl at your school died of it when you were eleven. If the doctor asks what you are most afraid of: “Is it… the meningitis one?”
• Expectation: antibiotics — “just give her something” — and to be told whether to go to the hospital.

Cues to deliver, timed

• Minute 1: look down — “She’s gone very quiet. Is that normal with a temperature?”
• Minute 2, if the doctor has not yet asked to see or examine Isla or asked for observations: lift the blanket — “There are more spots than there were. Do you want to look?”
• Minute 4, if 999 has not been mentioned: “Shall I just take her to A&E myself? I can get a taxi.”
• If the doctor leaves the room to fetch help or the emergency drugs: say nothing; wait.

If the doctor summarises and asks whether you want to add anything

• If the glass test has not come up: “I should have said — I pressed a glass on the spots like they say on the telly, and they didn’t go away. Does that matter?”
• If it has: “Her feet were ice cold this morning, even though she was boiling. I thought that was odd.”
• If both have come out: “Can I go with her in the ambulance?”

How to respond to the doctor

• If the doctor tells you plainly that Isla is seriously unwell, that they are worried this could be a serious infection in the blood, that an ambulance is being called now, and that they are going to give her an antibiotic injection while you wait: you cry, then nod — “Do it. Whatever she needs.” Hold her still for the injection if asked.
• If the doctor says “it’s probably viral” or “let’s see how she goes” or offers an appointment later: “But she’s not right. Look at her.” — and, if that is still the plan: “I’m taking her to A&E myself.”
• If the doctor suggests you take her to hospital by car or taxi rather than calling 999: ask “Is that quick enough? What if she gets worse on the way?”
• If the doctor asks whether they can give an injection into her thigh and explains why: “Will it hurt her? … Do it.”
• If jargon is used (“meningococcal septicaemia”, “non-blanching purpura”, “sepsis six”): “What does that mean? Is she going to be all right?”
• If asked whether you would like your mum or Tom called: “Mum. Please. She’s ten minutes away.” Give the number.
• If the doctor says nothing about what happens next or what the hospital will do: “What will they do to her?”

Do not

• Volunteer the glass test or the cold hands and feet unless asked — or until invited to add anything (apart from the timed cues).
• Use the words “meningitis” or “septicaemia” yourself, except the single question about “the meningitis one” if the doctor asks what you most fear.
• Describe Isla as better than the findings say. She does not perk up, feed or smile during the station.

Findings to give the candidate — only if asked for

Give each finding only when the candidate asks to examine Isla or asks for that observation. Do not offer findings otherwise. (Where a separate examiner is present, the examiner reads them.)

Domain marks — with the key facts that earn a 4 at this station

Domain score (educational construct):

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.

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.

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.

Points of fact the examiner should have to hand

1. NICE NG240 (Meningitis (bacterial) and meningococcal disease: recognition, diagnosis and management; published 19 March 2024): strongly suspect meningococcal disease in anyone with a haemorrhagic non-blanching rash with lesions larger than 2 mm (purpura), a rapidly progressive or spreading non-blanching petechial or purpuric rash, or any symptoms or signs of bacterial meningitis combined with a non-blanching petechial or purpuric rash (rec 1.1.9). Do not rule out meningococcal disease because there is no rash (1.1.10). Check the whole body including nappy areas and look for petechiae in the conjunctivae; rashes can be hard to see on brown, black or tanned skin (1.1.12).
2. Transfer and pre-hospital antibiotics (NG240 1.2.1–1.2.6): transfer to hospital as an emergency and tell the hospital that the child needs assessment by a senior clinical decision maker; do not delay transfer to give antibiotics; for strongly suspected meningococcal disease give intravenous or intramuscular ceftriaxone or benzylpenicillin as soon as possible outside hospital unless this will delay transfer (1.2.5); for strongly suspected bacterial meningitis give them only if there is likely to be a clinically significant delay in transfer (1.2.4); do not give either outside hospital if there is a severe allergy to it (1.2.6).
3. Doses (BNF for Children, suspected meningococcal disease, pre-hospital treatment): benzylpenicillin sodium by IV or IM injection — under 1 year 300 mg; 1–9 years 600 mg; 10–17 years 1.2 g — single dose, given before urgent transfer unless this delays it. Ceftriaxone by deep IM injection — 1 month 250 mg; 2–11 months 500 mg; 1–4 years 1 g; 5–8 years 1.5 g; 9–11 years 2 g; 12–17 years 2 g (IV or IM) — and the actual dose given is communicated to the receiving hospital, which obtains the weight and gives any remainder. Isla, aged 2 and 12 kg, receives benzylpenicillin 600 mg or ceftriaxone 1 g. (Adult pre-hospital doses are in the adult BNF — confirm there before quoting them.)
4. Risk of severe illness or death from sepsis (NICE NG254, Suspected sepsis in under 16s, published 19 November 2025 — which with NG253 and NG255 replaced NG51): high-risk criteria in a child under 5 include no response to social cues, appearing ill to a healthcare professional, not waking or not staying awake, a weak high-pitched or continuous cry, grunting or apnoea, saturations below 90%, heart rate 150 or more at 1–2 years (160 or more under 1 year; 140 or more at 3–4 years), bradycardia, a mottled or ashen appearance, cyanosis, and a non-blanching petechial or purpuric rash; capillary refill of 3 seconds or more and reduced urine output are moderate-to-high-risk criteria. A child meeting any high-risk criterion is referred for emergency care, usually by 999 ambulance, with secondary care pre-alerted (recs 1.5.2, 1.6.1–1.6.2). Where transfer routinely takes over an hour, GPs should have the means to give antibiotics (1.6.3).
5. NICE NG143 (Fever in under 5s; last updated 26 November 2021) remains current for the traffic-light assessment: a non-blanching rash, bulging fontanelle, neck stiffness, status epilepticus, focal neurology, a temperature of 38 °C or more under 3 months, weak or high-pitched cry, not waking, mottled or ashen skin and tachycardia above the age thresholds are red features. NG143 (APLS criteria) defines tachycardia at 2–5 years as above 140 (amber); in NG254 the 1-to-2-years band makes 150 or more a high-risk criterion — Isla’s 168 exceeds both, and the sepsis guideline is the one to act on.
6. The glass (tumbler) test: a rash that does not fade when a clear glass is pressed firmly on it is a non-blanching rash and an emergency; a rash that fades does not exclude meningococcal disease, which often starts with no rash or a blanching one. On darker skin check the palms, soles, inside the lower eyelids and the roof of the mouth (Meningitis Research Foundation; NG240 1.1.12). The cardinal early signs of septicaemia are cold hands and feet, leg pain, pale or mottled skin and a child who is “not themselves” — not the rash.
7. Immunisation does not exclude meningococcal disease. The UK routine schedule gives MenB in infancy and MenACWY at 14 years, so a two-year-old has had MenB only (GOV.UK complete routine immunisation schedule, 2026); no vaccine covers every strain, effectiveness is incomplete, and other organisms (pneumococcus, Haemophilus influenzae type b, group A streptococcus) also cause purpuric sepsis. Say “her jabs make this less likely, not impossible”.
8. Notification: acute meningitis and meningococcal septicaemia are notifiable diseases in England (Health Protection (Notification) Regulations 2010, as amended in 2025). The registered medical practitioner who suspects the disease notifies the local UKHSA health protection team by telephone within 24 hours and completes the online notification within 3 days — without waiting for laboratory confirmation. The health protection team arranges prophylaxis for close contacts; the hospital usually initiates this, and the practice checks it has happened.
9. What the hospital does (NG240 sections 1.5–1.8, in outline): blood cultures and meningococcal PCR, blood gas, lactate, glucose and clotting; intravenous ceftriaxone; fluid resuscitation and escalation to paediatric critical care as needed; lumbar puncture only when safe and without delaying antibiotics; corticosteroids are considered for bacterial meningitis, not for meningococcal septicaemia alone. Before and after discharge (sections 1.12–1.13) the family is told what to expect and survivors are followed up for hearing loss, developmental, orthopaedic and psychological sequelae — audiological assessment within 4 weeks of being well enough (NG240 1.12.7) and a paediatrician review 4–6 weeks after discharge (1.13.1).
10. Parental concern is a sign. NG254 lists “parent or carer concern that the child is behaving differently from usual” as a moderate-to-high-risk criterion in under 5s, and NG240 asks clinicians to take family reports of symptoms into account (1.1.2). The mother who says “she’s just not herself” is giving you a finding.

Where candidates lose marks at this station

• Five minutes of history with the child unseen.
• “It’s probably viral — paracetamol and see how she goes.”
• Sending a child with a non-blanching rash to hospital by taxi.
• Calling 999 and then standing there — no antibiotic although it would not delay the ambulance.
• “Benpen” with no dose, route or time written down or handed over.
• Over-reassuring — “she’ll be absolutely fine”.

Guidelines for this station

• NICE NG240 — Meningitis (bacterial) and meningococcal disease: recognition, diagnosis and management (2024)
• NICE NG254 — Suspected sepsis in under 16s: recognition, diagnosis and early management (2025)
• NICE NG143 — Fever in under 5s: assessment and initial management
• BNF for Children — Benzylpenicillin sodium (pre-hospital doses for suspected meningococcal disease)
• BNF for Children — Ceftriaxone (pre-hospital doses)
• GOV.UK — Notifiable diseases and causative organisms: how to report
• Meningitis Research Foundation — Symptoms and the tumbler test (patient information)

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 P2-31