History Taking · Foundation · Dermatology

Oozing Lesions on Face and Hands in Young Child

Practise this PLAB 2 history taking station on Impetigo. 8-minute voice AI simulation with feedback on all 3 marking domains.

Clinical scenario

You are an FY2 doctor in a GP surgery. Mrs Salma Khalaf has brought her four-year-old son, Joshua, to see you. He has developed yellow-crusted lesions on his face and hands that are weeping and spreading. The lesions appeared suddenly about a week ago. Please take a focused history from the mother and examine the child, then discuss your assessment and management plan with the parent.

Background notes: PMH: Good health, normal development, up-to-date vaccinations, no chronic conditions

What this station tests

  • Classic impetigo features: honey-coloured crusts on erythematous base, perioral and on hands, rapidly spreading
  • Topical versus oral antibiotic decision based on extent: localised = topical, moderate/widespread = oral
  • Playgroup/school exclusion: 48 hours after starting antibiotics or until lesions are no longer weeping
  • Infection control advice: no sharing towels, handwashing, hot wash bedding, watch siblings
  • Reassuring parents: impetigo is not a sign of poor hygiene and responds well to treatment

How to use your 8 minutes

  • 0-1 min — Introduction: Introduce yourself, confirm identity, open question. 'What's brought you in today?'
  • 1-4 min — Systematic History: Presenting complaint detail (SOCRATES for pain, timeline, severity). Systems review. PMH, medications, allergies.
  • 4-6 min — Context and ICE: Social history (smoking, alcohol, occupation, living situation). Family history. Ideas, Concerns, Expectations.
  • 6-7 min — Summary and Plan: Summarise findings back to patient. Share differential/working diagnosis. Outline investigation and management plan.
  • 7-8 min — Closing: Safety netting with specific red flags. Arrange follow-up. Check for questions.

Consultation approach

The opening

Paediatric impetigo stations test the candidate's ability to diagnose a common childhood infection, provide appropriate treatment, and advise on infection control (particularly school/nursery exclusion). Mrs Khalaf has brought her 4-year-old son Joshua with yellow-crusted, weeping lesions on his face and hands. Open with: 'Mrs Khalaf, tell me about Joshua's skin and when you first noticed the spots.'

Core approach

Classic non-bullous impetigo. Yellow honey-coloured crusts on an erythematous base, around the mouth and nose (typical location), spreading to hands (autoinoculation from touching face). Started about a week ago as small spots, rapidly developed the characteristic crusting. Spreading to new areas. He is otherwise well: no fever, eating and drinking normally, normal energy. His playgroup has reported cases of skin infections.

Distinguish from other conditions. Eczema herpeticum: vesicles, punched-out erosions, child may be systemically unwell (absent). Chickenpox: widespread vesicular rash in different stages (absent). Herpes simplex: grouped vesicles, usually perioral (different morphology). Fungal infection: annular, scaly (different). The honey-coloured crusting on the face with rapid spread is diagnostic of impetigo.

Assess extent. Localised (fewer than 3 lesions, one area) versus widespread (multiple areas, many lesions). Joshua has lesions on face and hands: moderate extent. Check for bullous form: any large blisters? (No.) Check ears and scalp (common extension sites).

Closing and safety netting

Treatment depends on extent. Localised (fewer than 3 lesions): topical fusidic acid or mupirocin. Moderate or spreading (as in Joshua's case): oral antibiotics (flucloxacillin first-line for 5 to 7 days; if penicillin allergic: clarithromycin). Clean crusts gently with warm soapy water before applying topical treatment (improves penetration). Keep nails short to reduce autoinoculation from scratching.

Infection control: 'Joshua needs to stay away from playgroup until 48 hours after starting antibiotics or until the lesions have crusted over and are no longer weeping.' Do not share towels, flannels, or bedding. Wash hands frequently. Wash bedding and towels on hot cycle. Other family members should watch for similar lesions.

Reassure: 'Impetigo is a very common childhood infection. It is not a sign of poor hygiene and it responds well to antibiotics. He should be noticeably better within a few days.' Safety net: 'If it spreads despite treatment, he develops a fever, or the skin becomes very red and swollen, come back.' Follow-up if not improving in 5 to 7 days.

How examiners mark this station

Examiners will focus on the thoroughness and structure of your history taking for impetigo. Domain 1 (Data Gathering) carries the most weight: expect marks for systematic coverage of presenting complaint, red flags, PMH, medications, social and family history. Domain 2 (Clinical Management) requires a clear differential, appropriate investigations, and a safe management plan with safety netting. Domain 3 (Interpersonal Skills) is assessed throughout: genuine exploration of ICE, active listening, empathic responses, and clear communication without jargon.

Domain 1: Data Gathering, Technical and Assessment Skills (Primary focus)

Scores well: Classic features identified. Extent assessed (localised vs widespread). Differentials excluded. Systemic features checked (no fever). Contacts and playgroup cases noted.

Costs marks: Not assessing extent. Not excluding differentials. Not checking for systemic features.

Domain 2: Clinical Management Skills (Primary focus)

Scores well: Appropriate antibiotic choice based on extent (oral for moderate). Crust cleaning advice. School exclusion rule (48 hours). Infection control measures. Follow-up if not improving.

Costs marks: Topical for widespread. No school exclusion. No infection control. No follow-up.

Domain 3: Interpersonal Skills (Throughout)

Scores well: Reassuring parents about the condition (common, not hygiene-related). Practical advice about managing at home. Clear timeline for improvement. Addressing playgroup concern directly.

Costs marks: Implying poor hygiene. Not addressing school concern. Being vague about timeline.

Common examiner feedback (and how to fix it)

Did not gather sufficient information to make an adequate assessment of the patient's condition

Fix: Use a consistent framework for every history. After covering the presenting complaint, systematically move through PMH, drug history, social history, family history, and ICE. Keep a mental checklist.

Did not identify the patient's problems and/or did not develop a management plan adequately

Fix: Reserve the final 2 minutes to summarise your findings, share your working diagnosis with the patient, and outline your investigation and management plan including safety netting.

Common mistakes in this station

  1. Prescribing topical antibiotics for moderate or spreading impetigo. If lesions are in multiple areas or spreading, oral antibiotics are needed. Candidates who prescribe topical only for widespread disease provide inadequate treatment.
  2. Not advising school/nursery exclusion. Impetigo is contagious. The child must be excluded from playgroup until 48 hours after starting treatment or until lesions are dry. Candidates who do not mention this miss an infection control requirement.
  3. Making the parent feel it is a hygiene issue. Impetigo is caused by bacterial colonisation and is common in young children regardless of hygiene. Candidates who imply poor hygiene cause unnecessary guilt.

Resitting PLAB 2?

If you have previously struggled with history taking stations, focus on building a consistent systematic framework that you apply to every case. Practise structuring your history into clear phases (presenting complaint, systems review, PMH, social, ICE) so that even under pressure, you cover all domains. Many resitters lose marks not on knowledge but on organisation and time management.

Example opening

Good morning/afternoon, my name is Dr [Name], I'm one of the doctors here today. Could I confirm your name and date of birth please? Thank you. So, what's brought you in to see me today?

Frequently asked questions

How should I structure the impetigo history in this PLAB 2 station?

Paediatric impetigo stations test the candidate's ability to diagnose a common childhood infection, provide appropriate treatment, and advise on infection control (particularly school/nursery exclusion). Mrs Khalaf has brought her 4-year-old son Joshua with yellow-crusted, weeping lesions on his face and hands. Open with: 'Mrs Khalaf, tell me about Joshua's skin and when you first noticed the spots.'

What are examiners marking in this impetigo station?

Marks are won for: Classic features identified. Extent assessed (localised vs widespread). Differentials excluded. Systemic features checked (no fever). Contacts and playgroup cases noted. Marks are lost for: Not assessing extent. Not excluding differentials. Not checking for systemic features.

What is the most common mistake candidates make in this impetigo station?

Prescribing topical antibiotics for moderate or spreading impetigo. If lesions are in multiple areas or spreading, oral antibiotics are needed. Candidates who prescribe topical only for widespread disease provide inadequate treatment.

How do I prepare for this station if I have not managed impetigo in clinical practice?

This station rewards process over personal experience. The skill being assessed: Topical versus oral antibiotic decision based on extent: localised = topical, moderate/widespread = oral. The written guidance on this page covers the full approach, and practising the consultation aloud builds the fluency the examiner is listening for.

Related cases