History Taking · Intermediate · Paediatrics

Ear Pain and Fever in Young Child

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

Clinical scenario

You are an FY2 doctor in a general practice surgery. Miss Amelia Hopkins is attending with her four-year-old son, Marcus, who has developed ear pain and fever over the past 24 hours. Please take a focused history from Amelia, examine Marcus, explain the likely diagnosis of acute otitis media, and discuss management including when antibiotics are indicated and when watchful waiting is appropriate.

Background notes: PMH: Nil significant

What this station tests

  • NICE delayed prescribing strategy: prescription given but used only if not improving after 3 days
  • Indications for immediate antibiotics: systemically unwell, under 2 with bilateral AOM, ear discharge, immunocompromised
  • Mastoiditis safety netting: swelling behind the ear is a serious complication requiring urgent assessment
  • Managing parental expectation for antibiotics: acknowledging concern while explaining the evidence
  • Symptomatic management: alternating paracetamol and ibuprofen, warm compress, fluids

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

Acute otitis media in a child tests the candidate's ability to distinguish viral from bacterial aetiology, apply the NICE watchful waiting guidance, and address parental expectations for antibiotics. Marcus is 4, with 24 hours of ear pain and fever. His mother Amelia is worried. Open with: 'Tell me about Marcus's ear pain and how he has been.'

Core approach

Clinical assessment. He had coryza for 2 to 3 days (viral URTI) before the ear pain started. Now has unilateral ear pain (tugging at right ear), fever (38.5C), irritable, sleep disrupted, but drinking adequately. No ear discharge. No signs of systemic toxicity. This is classic AOM following viral URTI.

NICE guidance for AOM in children: most episodes are self-limiting (viral or bacterial) and resolve within 3 days without antibiotics. Immediate antibiotics are indicated only if: systemically unwell, high-risk (under 2 with bilateral AOM, ear discharge), or immunocompromised. Marcus does not meet these criteria.

Delayed prescribing strategy. 'I would like to give you a prescription for antibiotics (amoxicillin) but ask you to wait 3 days before using it. If Marcus is not improving or gets worse after 3 days, start the antibiotics. If he is getting better, you do not need to use them.' This approach reduces unnecessary antibiotic use while providing a safety net.

Address the mother's concern. She is a single parent, worried about managing a sick child while working. She wants antibiotics now. Acknowledge the difficulty without capitulating.

Closing and safety netting

Symptomatic management: regular paracetamol and ibuprofen (alternating if needed) for pain and fever. Warm cloth against the ear for comfort. Adequate fluids. No evidence for decongestants or antihistamines in AOM. Delayed prescription: amoxicillin 40mg/kg/day in 3 divided doses for 5 days if needed after 3 days.

Safety net: 'Bring Marcus back or call if: he develops ear discharge (suggests perforation), he becomes very drowsy or difficult to rouse, the fever does not respond to paracetamol and ibuprofen, he develops swelling behind the ear (mastoiditis), or you are worried about him at any point.' Follow-up in 3 days if not improving.

How examiners mark this station

Examiners will focus on the thoroughness and structure of your history taking for acute otitis media. 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: AOM diagnosis confirmed. Severity assessed (no systemic toxicity, no discharge). Immediate antibiotic criteria checked. Preceding URTI noted. Hearing and development asked.

Costs marks: Not assessing severity. Not checking immediate antibiotic criteria.

Domain 2: Clinical Management Skills (Primary focus)

Scores well: Delayed prescribing strategy. Correct antibiotic choice and dose. Symptomatic management (paracetamol, ibuprofen). Mastoiditis safety netting. Follow-up plan.

Costs marks: Immediate antibiotics without indication. No delayed prescription option. No mastoiditis warning.

Domain 3: Interpersonal Skills (Primary focus)

Scores well: Acknowledging the mother's difficulty as a single parent. Explaining delayed prescribing rationale. Empowering her with the prescription while explaining when to use it. Not dismissing her request.

Costs marks: Dismissing antibiotic request. Not acknowledging her situation. Being condescending about antibiotic stewardship.

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 immediate antibiotics without indication. Marcus is 4, has unilateral AOM without discharge, and is not systemically unwell. Immediate antibiotics are not indicated per NICE. Candidates who prescribe immediately demonstrate antibiotic overuse.
  2. Not offering a delayed prescription. Simply saying 'no antibiotics' leaves the parent without a safety net. The delayed prescription empowers the parent to act if needed without requiring another appointment.
  3. Not safety netting for mastoiditis. Swelling behind the ear is mastoiditis until proven otherwise and needs urgent hospital assessment. Candidates who do not mention this miss the most serious complication.

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

What is the best way to take an acute otitis media history in PLAB 2?

Acute otitis media in a child tests the candidate's ability to distinguish viral from bacterial aetiology, apply the NICE watchful waiting guidance, and address parental expectations for antibiotics. Marcus is 4, with 24 hours of ear pain and fever. His mother Amelia is worried.

Where are marks won and lost in this acute otitis media station?

Examiners reward: AOM diagnosis confirmed. Severity assessed (no systemic toxicity, no discharge). Immediate antibiotic criteria checked. Preceding URTI noted. Hearing and development asked. Candidates are penalised for: Not assessing severity. Not checking immediate antibiotic criteria.

Where do candidates most often go wrong in this station?

Prescribing immediate antibiotics without indication. Marcus is 4, has unilateral AOM without discharge, and is not systemically unwell. Immediate antibiotics are not indicated per NICE.

Can I do well in this station without real-world experience of acute otitis media?

This station rewards process over personal experience. The skill being assessed: Indications for immediate antibiotics: systemically unwell, under 2 with bilateral AOM, ear discharge, immunocompromised. Work through the consultation approach above, then rehearse it aloud under the 8-minute time pressure so the structure holds up in the exam.

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