History Taking · Intermediate · Paediatrics

Fever and Dysuria in Four-Year-Old

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

Clinical scenario

You are an FY2 doctor in primary care. Mrs Tolu Bello has brought her four-year-old daughter Amy to the surgery with fever and painful urination. The symptoms started two days ago. Please take a focused history from the parent and discuss investigation and treatment options.

Background notes: PMH: Healthy, no previous UTI, fully vaccinated, meets developmental milestones

What this station tests

  • Urine culture is MANDATORY in children before starting antibiotics: unlike adult uncomplicated UTI
  • Clean catch urine as preferred collection method for toilet-trained children
  • Distinguishing lower from upper tract infection: fever >38C with loin pain/systemic toxicity suggests pyelonephritis
  • NICE imaging criteria: USS for under 6 months with any UTI, or atypical/recurrent UTI in older children
  • Constipation as a predisposing factor for paediatric UTI: commonly overlooked

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

UTI in a child requires urine culture (mandatory, unlike in adult women), age-appropriate antibiotic choice, and consideration of imaging to exclude underlying structural abnormality. Amy is 4, with 2 days of fever and dysuria. Open with: 'Mrs Bello, tell me about Amy's symptoms and what you have noticed.'

Core approach

Confirm UTI symptoms. Dysuria (pain on urination, makes her cry), frequency (lots of small wees), urgency, suprapubic discomfort. Fever (started suddenly, high). She is less active than usual. No vaginal discharge (distinguish from vulvovaginitis). No constipation (which can predispose to UTI in children). Urine appearance: cloudy, strong smell (mother has noticed).

In children, urine culture is MANDATORY before starting antibiotics (unlike adult women where culture is not needed for uncomplicated UTI). Clean catch urine is the preferred method for a toilet-trained 4-year-old. Dipstick for initial guidance, but culture confirms and provides sensitivities.

Assess for upper tract infection (pyelonephritis). Temperature above 38C (yes, 38.8C). Any loin pain (difficult to assess in a 4-year-old but no back tenderness). Systemically unwell? She is off her food but drinking. If upper tract is suspected: hospital referral for IV antibiotics.

First UTI in a girl: NICE recommends imaging (USS) for children under 6 months with any UTI, or for children with atypical or recurrent UTI. A first uncomplicated lower UTI in a child over 6 months does not routinely require imaging, but recurrence would.

Closing and safety netting

If lower UTI (no systemic toxicity, no loin pain): oral antibiotics (trimethoprim or nitrofurantoin, age-appropriate dose, 3 to 7 days depending on local guidance). Send urine culture before starting. Adequate fluid intake. Paracetamol for pain and fever.

Practical advice: encourage regular toileting, adequate fluids, wipe front to back. Address constipation if present (predisposes to UTI). Reassure: 'UTIs in young children are common and respond well to antibiotics.'

Safety net: 'If Amy becomes more unwell, develops high fever not responding to paracetamol, vomits and cannot keep fluids down, or develops back pain, bring her in urgently or go to A&E.' Follow-up: check culture result, and if recurrent UTI occurs, imaging (USS) will be needed. Follow-up in 48 hours.

How examiners mark this station

Examiners will focus on the thoroughness and structure of your history taking for urinary tract infection. 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: UTI symptoms confirmed. Upper vs lower tract assessed. Urine culture sent (mandatory). Constipation checked. Vulvovaginitis excluded. Previous UTIs checked.

Costs marks: No culture. Not assessing upper tract. Not checking constipation.

Domain 2: Clinical Management Skills (Primary focus)

Scores well: Appropriate antibiotic with culture before treatment. Antipyretic for fever. Imaging criteria known. Constipation addressed. Follow-up at 48 hours with culture result.

Costs marks: No culture before antibiotics. Not knowing imaging criteria. No follow-up.

Domain 3: Interpersonal Skills (Throughout)

Scores well: Child-friendly communication. Reassuring mother. Practical hygiene advice. Clear safety netting for pyelonephritis.

Costs marks: Not addressing the child. Not reassuring. Vague safety netting.

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. Not sending urine culture. In children, culture is mandatory before antibiotics. This is different from adult women where culture is not needed for uncomplicated UTI. Candidates who treat without culture cannot confirm the diagnosis or check sensitivities.
  2. Not assessing for upper tract infection. A febrile child with UTI symptoms may have pyelonephritis, which requires different management (IV antibiotics, hospital). Candidates who treat all paediatric UTIs the same miss severity stratification.
  3. Not asking about constipation. Constipation is a common and modifiable risk factor for UTI in children. Candidates who treat the UTI without addressing constipation miss prevention of recurrence.

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 urinary tract infection station?

UTI in a child requires urine culture (mandatory, unlike in adult women), age-appropriate antibiotic choice, and consideration of imaging to exclude underlying structural abnormality. Amy is 4, with 2 days of fever and dysuria.

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

Strong performances show: UTI symptoms confirmed. Upper vs lower tract assessed. Urine culture sent (mandatory). Constipation checked. Vulvovaginitis excluded. Previous UTIs checked. Weak performances: No culture. Not assessing upper tract. Not checking constipation.

What is the biggest pitfall in this urinary tract infection station?

Not sending urine culture. In children, culture is mandatory before antibiotics. This is different from adult women where culture is not needed for uncomplicated UTI.

How should I prepare for urinary tract infection if I have never seen it in practice?

Structure beats experience here. Focus on clean catch urine as preferred collection method for toilet-trained children. 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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