History Taking · Intermediate · Infectious Diseases

Fever and Rash in an Unvaccinated 7-Year-Old Child

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

Clinical scenario

You are an FY2 doctor in a GP practice. You are seeing Mrs Rosemary Reynolds with her 7-year-old daughter, Sophie, who has had a fever and a spreading rash for the past four days. Sophie has not been vaccinated against measles. The child has characteristic symptoms including coryza and cough. Please take a focused history, examine the rash, and discuss management and notification requirements.

Background notes: PMH: Nil significant

What this station tests

  • Measles clinical sequence: prodrome (fever, cough, coryza, conjunctivitis) followed by rash spreading from face downward
  • Koplik spots as pathognomonic but transient: may have resolved before the rash appears
  • Complication screening: otitis media, pneumonia, encephalitis (most feared)
  • Notifiable disease: legal obligation to inform public health team
  • Non-judgmental approach to unvaccinated child: focus on current illness and sibling protection

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

Fever with rash in an unvaccinated child is measles until proven otherwise. The candidate must identify the clinical features, recognise the public health implications, and sensitively address the vaccination decision. Sophie is 7, unvaccinated, with 4 days of fever and spreading rash. Open with: 'Mrs Reynolds, tell me about Sophie's illness and when the rash appeared.' Focus on the clinical sequence: prodrome then rash.

Core approach

Identify the measles pattern. Prodrome: high fever, cough, coryza, conjunctivitis (the 3 Cs plus fever) for 3 to 5 days before the rash. Koplik spots (white spots with red halo on buccal mucosa) are pathognomonic but may have resolved by the time the rash appears. Rash: starts behind ears and on face, spreads downward to trunk and limbs over 3 to 4 days. Maculopapular, initially discrete then confluent. The child appears unwell.

Confirm vaccination status. Sophie is unvaccinated by parental choice. The mother may be defensive about this. Do not lecture or blame. Focus on managing the current illness and protecting contacts.

Screen for complications. Otitis media (commonest complication). Pneumonia (cough worsening, breathlessness). Encephalitis (headache, drowsiness, seizures, the most feared acute complication). Febrile convulsions. Check: is Sophie alert, interactive, drinking fluids? Any neck stiffness? Any respiratory distress?

Public health: measles is a notifiable disease. The local health protection team must be informed. Ask about contacts: school, siblings (brother Jack, age 4, also unvaccinated), vulnerable contacts (pregnant women, immunocompromised).

Closing and safety netting

Management: supportive (paracetamol for fever, fluids, rest). No antiviral treatment. Vitamin A supplementation may be considered (WHO recommendation, reduces complications). Isolation: Sophie should stay away from school for 4 days after rash onset (infectious from 4 days before to 4 days after rash).

Address the vaccination gap. 'I am not here to judge the decision about vaccination. But now that Sophie has had measles, it would be worth discussing MMR vaccination for Jack to protect him.' Offer to discuss vaccine concerns in a separate, dedicated appointment.

Notify public health (legal obligation). Safety net: 'If Sophie becomes very drowsy, develops neck stiffness, has a seizure, or her breathing becomes difficult, call 999 immediately.' Follow-up in 48 hours.

How examiners mark this station

Examiners will focus on the thoroughness and structure of your history taking for measles. 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: Clinical sequence identified (prodrome, Koplik spots, rash). Vaccination status confirmed. Complications screened. Contacts assessed (sibling, school). Notifiable disease recognised.

Costs marks: Not identifying the clinical pattern. Not screening for complications. Not asking about contacts.

Domain 2: Clinical Management Skills (Primary focus)

Scores well: Supportive management. School exclusion (4 days from rash onset). Public health notification. Sibling vaccination discussed. Complication safety netting. Follow-up arranged.

Costs marks: Not notifying public health. No school exclusion. No complication safety netting.

Domain 3: Interpersonal Skills (Primary focus)

Scores well: Non-judgmental about vaccination decision. Addressing sibling protection gently. Managing the mother's guilt or defensiveness. Clear safety netting for the frightened parent.

Costs marks: Lecturing about vaccination. Being judgmental. Not addressing sibling. Dismissive of parental concern.

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. Lecturing the mother about vaccination. She made a choice and her child is now ill. Blame is unproductive and damages the therapeutic relationship. The appropriate approach is non-judgmental management of the current illness with a gentle offer to discuss vaccination for the sibling.
  2. Not notifying public health. Measles is a notifiable disease. Candidates who manage the case without mentioning notification miss a legal obligation.
  3. Not screening for complications. Measles complications (particularly encephalitis) can be life-threatening. Candidates who diagnose measles without checking for drowsiness, neck stiffness, and respiratory distress miss the severity assessment.

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 do I approach the consultation in this measles station?

Fever with rash in an unvaccinated child is measles until proven otherwise. The candidate must identify the clinical features, recognise the public health implications, and sensitively address the vaccination decision. Sophie is 7, unvaccinated, with 4 days of fever and spreading rash.

What does a strong performance look like to the examiner in this station?

Strong performances show: Clinical sequence identified (prodrome, Koplik spots, rash). Vaccination status confirmed. Complications screened. Contacts assessed (sibling, school). Notifiable disease recognised. Weak performances: Not identifying the clinical pattern. Not screening for complications. Not asking about contacts.

What is the biggest pitfall in this measles station?

Lecturing the mother about vaccination. She made a choice and her child is now ill. Blame is unproductive and damages the therapeutic relationship.

How should I prepare for measles if I have never seen it in practice?

Structure beats experience here. Focus on koplik spots as pathognomonic but transient: may have resolved before the rash appears. The written guidance on this page covers the full approach, and practising the consultation aloud builds the fluency the examiner is listening for.

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