History Taking · Intermediate · Paediatrics

Head Injury After Fall - Paediatric Assessment

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

Clinical scenario

You are an FY2 doctor in the Emergency Department. You see a two-year-old girl, Pooja, who fell from the sofa at home approximately forty minutes ago and hit her head. Her mother, Rebecca, is with her and very anxious. Please take a focused history of the incident, assess Pooja's current status, and discuss observation and safety netting.

Background notes: PMH: Delivered at term, normal development, varicella at 18 months

What this station tests

  • NICE head injury criteria: identifying which children need CT versus home observation
  • Red flag assessment: LOC, vomiting pattern, GCS, focal neurology, skull fracture signs, mechanism severity
  • Non-accidental injury screening: is the mechanism consistent with the injury and the child's developmental stage?
  • Written head injury advice: wake every 2 hours, watch for repeated vomiting, drowsiness, seizures, clear fluid
  • Addressing parental guilt: normalising childhood falls without being dismissive of the concern

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 head injury assessment requires NICE head injury guideline application, specifically identifying which children need CT imaging versus observation. Pooja is 2 years old, fell from the sofa 40 minutes ago and hit her head. Her mother Rebecca is anxious and self-blaming. Open with: 'Rebecca, tell me exactly what happened and how Pooja has been since the fall.'

Core approach

Assess mechanism. Fall from a sofa (low height, approximately 50cm). Onto carpeted floor. No sharp edges. This is a low-energy mechanism. NICE criteria for CT: fall from height greater than 3 metres in a child, high-speed RTA, or significant mechanism. A sofa fall does not meet the CT threshold unless other red flags are present.

Assess for red flags requiring CT. Loss of consciousness: was she knocked out? (Brief cry then normal, no LOC.) Vomiting: any vomiting since the fall? (One episode immediately after, common and not concerning if isolated.) GCS: is she alert, interactive, responding normally? (Yes, GCS 15.) Focal neurology: any abnormal movements, weakness, unequal pupils? (None.) Bruise or swelling: where exactly? (Small bump on forehead, not temporal or occipital.) Skull fracture signs: palpable step, Battle's sign, racoon eyes, CSF from ears or nose? (None.) Non-accidental injury: is the mechanism consistent with the injury? (Yes, witnessed by mother, consistent.)

If no red flags: observation at home is appropriate with clear head injury advice.

Closing and safety netting

Reassure the mother. 'From my assessment, Pooja appears well. The mechanism was a low fall and she has no concerning signs. She does not need a CT scan. But I want to give you clear instructions about what to watch for at home.'

Head injury advice (written and verbal). Wake her every 2 hours overnight to check she rouses normally. Watch for: repeated vomiting (more than 3 times), increasing drowsiness or difficulty waking, seizures, clear fluid from ears or nose, unequal pupils, unusual behaviour, weakness of arms or legs. If any: bring her to A&E immediately.

Address the mother's guilt: 'Toddlers fall. This is a normal childhood accident and you did exactly the right thing bringing her in.' Paracetamol for the bump if painful. Safety net: 'If anything concerns you over the next 48 hours, come back. Trust your instinct as her mum.'

How examiners mark this station

Examiners will focus on the thoroughness and structure of your history taking for paediatric head injury. 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: Mechanism assessed. NICE criteria applied. Red flags screened (LOC, vomiting, GCS, neurology, skull fracture signs). NAI briefly considered. Developmental stage considered.

Costs marks: Not applying NICE criteria. Not screening red flags. Not considering NAI.

Domain 2: Clinical Management Skills (Primary focus)

Scores well: Correct decision not to CT. Written head injury advice provided. 2-hourly waking overnight. Clear return criteria. Paracetamol for bump. Follow-up plan.

Costs marks: Unnecessary CT. No written advice. Inadequate safety netting. Sending home without instructions.

Domain 3: Interpersonal Skills (Primary focus)

Scores well: Addressing maternal guilt. Normalising childhood falls. Empowering her with clear instructions. 'Trust your instinct as her mum.' Calm, reassuring manner.

Costs marks: Reinforcing guilt. Being dismissive. Not providing reassurance. Cold, procedural manner.

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. Ordering CT for a low-energy mechanism without red flags. A 2-year-old falling from a sofa (50cm) with GCS 15, no LOC, and no focal neurology does not meet NICE criteria for CT. Candidates who scan unnecessarily expose the child to radiation.
  2. Not providing written head injury advice. Verbal instructions alone are insufficient. The parent needs a written list of what to watch for and when to return. Candidates who advise verbally only provide inadequate safety netting.
  3. Not considering NAI. Every paediatric injury should trigger a brief NAI consideration: is the mechanism consistent with the injury? Is the history consistent between caregivers? Are there other injuries? Candidates who do not mention this miss a safeguarding step.

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 paediatric head injury history in this PLAB 2 station?

Paediatric head injury assessment requires NICE head injury guideline application, specifically identifying which children need CT imaging versus observation. Pooja is 2 years old, fell from the sofa 40 minutes ago and hit her head. Her mother Rebecca is anxious and self-blaming.

What are examiners marking in this paediatric head injury station?

Marks are won for: Mechanism assessed. NICE criteria applied. Red flags screened (LOC, vomiting, GCS, neurology, skull fracture signs). NAI briefly considered. Marks are lost for: Not applying NICE criteria. Not screening red flags. Not considering NAI.

What is the most common mistake candidates make in this paediatric head injury station?

Ordering CT for a low-energy mechanism without red flags. A 2-year-old falling from a sofa (50cm) with GCS 15, no LOC, and no focal neurology does not meet NICE criteria for CT. Candidates who scan unnecessarily expose the child to radiation.

How do I prepare for this station if I have not managed paediatric head injury in clinical practice?

This station rewards process over personal experience. The skill being assessed: Red flag assessment: LOC, vomiting pattern, GCS, focal neurology, skull fracture signs, mechanism severity. 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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