Station 2 · Feverish child

Candidates: do not open until you have consulted.

Persona and manner

• Chloe Barnes, 27, Oscar's mother; young, tired, trying to sound calm; a baby can be heard now and then. You are sensible but frightened by the last admission and you do not want to waste anyone's time.
• You answer accurately when asked precise questions and reassure yourself between them.

Opening line (verbatim)

• “Hi, it's about Oscar, my two-year-old — he's had a temperature since yesterday afternoon and he's really not himself today. I've given him Calpol. I just wanted to check what I should be doing.”

The story

• “His temperature was 39.2 on the ear thermometer an hour ago, before the Calpol. It was 38.8 last night.”
• “He's off his food. He's drinking a bit, maybe half what he usually would. Two wet nappies today by lunchtime; he usually has five or six.”
• “He's clingy and whingy, he wanted to sleep on me all morning, he's not interested in the telly, which is not like him.”
• If asked: a cough since yesterday, not barking; his breathing seems fast when he sleeps; no noise; if asked to look at his chest, “maybe a little bit of sucking in at the bottom of his ribs”.
• If asked to count his breathing for 30 seconds: 24 in 30 seconds.
• Colour: “pale, but he's always pale”; lips a normal colour; no mottling; hands and feet cool.
• No rash. No stiff neck: he turned his head to look at the baby. No vomiting; one loose stool. Not pulling at his ears. No pain passing urine that you can tell.
• He woke and smiled once at his sister this afternoon; “it took a bit to get him to smile”.
• Calpol at 08:00 and 14:00; no ibuprofen, you were once told not to. No asthma.
• The baby, Freya, is six weeks old and well; you are breastfeeding.

Ideas, concerns and expectations

• Idea: “A virus. It's going round nursery.”
• Concern: Meningitis (“you hear things”) and the memory of the bronchiolitis admission; also being told you are overreacting.
• Expectation: Advice. You have not considered that he might need to be seen today.

Impact

• Transport: no car; your husband has it and is in Scotland until Thursday. Your mum is in Kent. A neighbour might help. A taxi would be £15 you do not have until Friday. The nearest walk-in centre is a 40-minute bus ride with two children.
• The last admission was “terrifying”; you do not want to go to hospital “unless I really have to”.
• You are alone with a six-week-old and a sick toddler; you have not eaten since breakfast.

Red flags

• Present: Amber features for the candidate to find: reduced wet nappies, breathing rate 48 a minute, reduced activity and not responding normally, possible lower chest recession, pallor reported by the parent.
• Absent: No red features: he can be roused and has smiled; no grunting; lips a normal colour; no mottling; no non-blanching rash; no bulging fontanelle (closed); no fit; temperature below 40.
• Absent: No stiff neck; no vomiting; no ear pulling; no breath-holding or wheeze.

Hidden facts and their triggers

• There is no one who can bring you in and no money for a taxi until Friday — released only if the doctor asks how you would get to the practice or the hospital; before that you are vague (“I'll see if someone can bring us”)
• The lower chest recession — released only if the doctor asks you to lift his top and look at his chest while he breathes
• The breathing rate — released only if the doctor asks you to count for 30 seconds; you do not know it otherwise
• The meningitis fear — released only if the doctor asks what worries you most
• How frightened you were by the last admission — released only if the doctor asks about it, or about how you are coping

Behaviour

• Minute 1: “I don't want to waste your time.”
• Minute 3: the baby cries in the background; apologise — “Sorry, I've got the baby too.”
• Minute 6, if the doctor suggests coming in: “I haven't got the car… I'll see if someone can bring us.” Stay vague unless asked directly how you would get there.
• If the doctor works through the features calmly, decides Oscar needs to be seen today, explains why, then solves the transport (an appointment today with transport arranged or paid for by the practice, a home visit, or an ambulance if any red feature) and gives clear red-flag advice: relieved to be told what to do. Ask, “What do I do about the baby?”
• If the doctor gives telephone advice only (fluids, Calpol, ring back if worse): accept it quietly — “OK, thank you.”
• If the doctor says to take him to A&E now without acknowledging the transport problem: “I can't… I've no car and I've got the baby.” Then silence.
• If the doctor talks over the baby crying: sound more flustered and lose the thread.

Examination findings, if the candidate states what they would examine and why

• None: audio-only telephone consultation. There are no examination findings to give.
• The mother can report what she sees if asked precisely: the breathing count (24 in 30 seconds), the chest (a little sucking in at the bottom of the ribs), the colour (pale, lips normal), the rash (none; a glass pressed on his skin shows nothing), the neck (he turns his head freely), the nappies (two by lunchtime).

Domain grades — with the key facts that earn a clear pass at this station

Global rating (recorded, not added to the total): ☐ Fail ☐ Bare Fail ☐ Bare Pass ☐ Pass

The domain grades (RCGP descriptors): CP clear pass — above the standard of a newly qualified, independent GP · P pass — sufficiently demonstrated at the standard · F fail — insufficiently demonstrated at the standard · CF clear fail — clearly demonstrated below the standard.

The RCGP grades each domain CF, F, P or CP and weights clinical management and medical complexity against the other two domains; the examination's maximum is 126 over twelve cases, which is 10.5 per case. The RCGP does not publish the mark each grade carries. MD Acumen's training sheet uses CF 0 · F 1 · P 2 · CP 3, with clinical management weighted ×1.5 (0 · 1.5 · 3 · 4.5), so that a case is marked out of 10.5 and a twelve-case circuit out of 126. A P in all three domains is 7.0; MD Acumen treats that line as the training standard for a case. The examination's pass mark is set by borderline regression for each diet and is published in the RCGP's diet summary reports; it is not a fixed fraction of 126.

Weighting rationale, in the RCGP's words: “To reflect the capability coverage within the clinical management and medical complexity domain this is weighted in comparison to the other two domains.”

Written to the standard of a newly qualified independent GP; the clear-pass row describes practice above that standard. It is a debriefing aid, not a checklist: the grade is a judgement that the essentials, the italic key facts on the mark sheet, were done well, at the patient's pace and in plain language. MD Acumen training standard; the RCGP does not publish case mark sheets.

Where candidates lose this station

• Accepting “he's really not himself today” as the whole assessment and never asking the mother to count his breathing or look at his chest (statement D1)
• Deciding he must be seen and then telling her to go to A&E without asking how she would get there, so that he is not seen at all (statement C8)
• Talking through the baby crying and the fear from the last admission, so that she stops contributing and agrees to anything (statement R1)

What the examiner is listening for in the last four minutes

By 8:00 the amber features should have been named and the decision to see him today stated. The examiner is listening for: the route (an appointment today with the transport solved, a home visit, or 999 if a red feature appears), the antipyretic and fluids advice, a safety-net that names the 999 triggers (hard or noisy breathing, blue lips, floppy or unrousable, a rash that does not fade under a glass, a fit), the plan for the baby, the telephone check this evening, and the mother repeating back what she will watch for.

The ten statements below are postulated: the feedback an examiner would most likely attach at this station, chosen from the RCGP's standardised list of 26 feedback statements that applies to every SCA case and spans the three marking domains (Data Gathering and Diagnosis; Clinical Management and Medical Complexity; Relating to Others). They are a prediction from the case content, its complexity and the marks that matter, not an examiner's record: any statement on the full list can be attached to any case, and feedback plays no part in the mark. Record the statements that applied in the practice log.

The full list of 26 statements, with the generic meaning of each, is on the exam and the mark scheme.

Points of fact the examiner should have to hand

Each statement is drawn from the named guideline, in its current version, with the date it was checked. The examiner marks against these facts; the candidate is not expected to quote them.

1. Amber (intermediate-risk) features in a child under 5 with fever include pallor reported by the parent, not responding normally to social cues, no smile, decreased activity, nasal flaring, a respiratory rate above 40 breaths a minute at 12 months or older, oxygen saturation 95% or less, crackles, poor feeding, reduced urine output, and rigors. NICE — NG143 Fever in under 5s: assessment and initial management, section 1.2, the traffic light system, 2019, last updated November 2021, checked 10 Oct 2026
2. Red (high-risk) features include pale, mottled, ashen or blue skin, no response to social cues, appearing ill, not waking or not staying awake, a weak high-pitched or continuous cry, grunting, a respiratory rate above 60, moderate or severe chest indrawing, reduced skin turgor, a bulging fontanelle, a non-blanching rash, neck stiffness, status epilepticus, focal neurological signs or focal seizures, and a temperature of 38 or more under 3 months. NICE — NG143 Fever in under 5s: assessment and initial management, section 1.2, the traffic light system, 2019, last updated November 2021, checked 10 Oct 2026
3. Remote assessment: a child with any red feature but no life-threatening illness should be seen face to face within two hours; a child with any amber feature should be seen face to face by a healthcare professional, with the urgency set by clinical judgement; a child with only green features can be managed at home with advice. NICE — NG143 Fever in under 5s: assessment and initial management, section 1.3, management by remote assessment, 2019, last updated November 2021, checked 10 Oct 2026
4. Antipyretics: consider paracetamol or ibuprofen for a child who is distressed by fever; do not use them with the sole aim of reducing the temperature; do not give both at the same time, and consider alternating only if distress persists or recurs before the next dose is due. NICE — NG143 Fever in under 5s: assessment and initial management, section 1.6, antipyretic interventions, 2019, last updated November 2021, checked 10 Oct 2026
5. Advice for home care: offer regular fluids (breast milk if breastfeeding), look for signs of dehydration (sunken fontanelle, dry mouth, sunken eyes, no tears, poor overall appearance), check the child during the night, keep the child away from nursery while the fever persists, and seek help if a non-blanching rash appears, a fit occurs, the child seems less well, the parent is more worried, or the fever lasts more than five days. NICE — NG143 Fever in under 5s: assessment and initial management, section 1.7, advice for home care, 2019, last updated November 2021, checked 10 Oct 2026
6. A urine sample should be tested in any child with an unexplained fever of 38 or higher, and in a child with symptoms and signs suggestive of urinary tract infection, within 24 hours; the source of fever in a child with no localising signs is not assumed. NICE — NG224 Urinary tract infection in under 16s: diagnosis and management, section 1.1, diagnosis, July 2022, checked 10 Oct 2026
7. Children with symptoms and signs of pneumonia (fever, tachypnoea, chest recession, crackles) and a feverish illness need face-to-face assessment; antibiotics are not started by telephone for an unexamined child. NICE CKS — Feverish children: risk assessment and management, management: remote assessment, current online version, checked 10 Oct 2026
8. Measure temperature in a child aged 4 weeks to 5 years with an electronic or chemical dot thermometer in the axilla, or an infra-red tympanic thermometer; do not use the oral or rectal route routinely, and do not use forehead chemical thermometers. Green features are normal colour, a normal response to social cues, being content or smiling, staying awake or waking quickly, a strong normal cry, and moist mucous membranes. NICE — NG143 Fever in under 5s: assessment and initial management, section 1.1, thermometers and the detection of fever; section 1.2, green features, 2019, last updated November 2021, checked 10 Oct 2026
9. Consider pneumonia in a feverish child with tachypnoea (a respiratory rate over 60 a minute at 0 to 5 months, over 50 at 6 to 12 months, or over 40 a minute from 12 months), crackles in the chest, nasal flaring, chest indrawing, cyanosis, or an oxygen saturation of 95% or less in air. Oral antibiotics are not prescribed for a feverish child in whom no source of infection is apparent. NICE — NG143 Fever in under 5s: assessment and initial management, section 1.2, symptoms and signs of specific illnesses: pneumonia; section 1.4, management by the non-paediatric practitioner, 2019, last updated November 2021, checked 10 Oct 2026
10. Consider meningococcal disease in a feverish child with a non-blanching rash, especially if the child looks ill, the lesions are larger than 2 mm, capillary refill is 3 seconds or more, or there is neck stiffness. Consider bacterial meningitis with neck stiffness, a bulging fontanelle, decreased consciousness or convulsive status epilepticus. Consider urinary tract infection in any feverish child under 3 months, and in an older child with fever and vomiting, poor feeding, lethargy, irritability, abdominal pain, urinary frequency or dysuria. NICE — NG143 Fever in under 5s: assessment and initial management, section 1.2, symptoms and signs of specific illnesses: meningococcal disease, meningitis, urinary tract infection, 2019, last updated November 2021, checked 10 Oct 2026
11. A child with symptoms or signs of an immediately life-threatening illness is referred for emergency care by the most appropriate route, usually a 999 ambulance. When a child is to be cared for at home, the safety net is one or more of: verbal or written information on the warning symptoms and how to get help, a follow-up appointment at a set time and place, and liaison with other healthcare professionals, including out-of-hours providers. NICE — NG143 Fever in under 5s: assessment and initial management, sections 1.3 and 1.4, management by remote assessment and by the non-paediatric practitioner: the safety net, 2019, last updated November 2021, checked 10 Oct 2026
12. When pneumonia is diagnosed in a child, amoxicillin is the first-choice antibiotic, with clarithromycin or erythromycin if there is penicillin allergy; the course is five days, extended if the child is not improving as expected. A child with severe symptoms or signs, or who cannot take or absorb oral treatment, is referred to hospital. NICE — NG138 Pneumonia (community-acquired): antimicrobial prescribing, section 1.1, managing community-acquired pneumonia: choice of antibiotic for children, September 2019, checked 10 Oct 2026
13. The Topic Guide 'Children and young people' expects the GP to assess an acutely unwell child, by telephone as well as face to face, using a structured approach such as the NICE traffic-light system; to recognise the seriously ill child and arrange care at the right urgency; to communicate with and support parents; and to consider the child's safety and the family's circumstances in every plan. RCGP — GP curriculum: Children and young people, the acutely unwell child; working with parents and carers, Being a GP, 2025 curriculum, checked 10 Oct 2026

Working references for this station

13 statements, 792 words. Every statement is signed by the Course Director before it is published; a station whose facts have changed since signature carries no signature line until it is signed again.

Record your three domain grades, your case total out of 10.5, your global rating, the RCGP feedback statements that applied, 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 SCA-02