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Fever, Fits & Foresight: Febrile Seizure Station in PLAB 2


In this engaging mock PLAB 2 consultation, a junior doctor addresses a paediatric emergency where a mother brings in her 2-year-old daughter following a sudden fit at home. The doctor assesses a 2-year-old with a seizure, identifies a febrile seizure, and receives expert feedback on PLAB 2 exam skills and structure.

This case involves a child presenting with a seizure likely caused by fever—termed a febrile seizure. The focus of this PLAB 2 case is to differentiate between potential causes of the seizure (such as meningitis, epilepsy, and otitis media), effectively communicate with a worried parent, and deliver a clear, structured management plan that ensures safety and reassurance.

Key Points:

Data Gathering – Pediatric Neurology & Infectious Disease

  • Initial Presentation: Child experienced a fit during fever.

  • Differential Diagnosis: Febrile seizure, meningitis, epilepsy, otitis media.

  • Focused History:

    • Event description (before, during, after seizure)

    • Fever characteristics (onset, duration, measured?)

    • Infection signs: cough, nasal discharge, urinary issues, diarrhea, ear pulling/discharge

    • Rule out red flags: neck stiffness, photophobia, altered consciousness, rash

    • Duration of seizure (<5 minutes is non-emergency)

  • Past Medical & Family History:

    • Past seizures, developmental milestones

    • Family history of seizures (important for febrile seizure risk)

  • Pediatric-Specific Framework:

    • Use P-BINDS (Pregnancy, Birth, Immunizations, Nutrition, Development, Social)

Clinical Reasoning:

  • Correct diagnosis: Febrile seizure secondary to otitis media.

  • Missed opportunity: Ear discharge not specifically asked.

  • Critical Thinking Tip: Always rule out the most dangerous diagnosis first (e.g., meningitis).

Important Considerations:

  • Allocate time effectively: 4 minutes for history, 4 minutes for management.

  • Use open-ended questions initially, followed by closed questions for specifics.

  • Pick up and follow simulator clues (e.g., ear pulling = possible otitis).

  • Always address parental concerns (e.g., fear of meningitis).

Diagnostic Approach:

  1. Presenting Complaint: Ask for full description using open-ended prompt.

  2. Seizure Details: Onset, duration, nature, recovery.

  3. Fever Source Identification:

    • Respiratory, ENT, urinary, GI, systemic.

    • Specific signs of otitis media (e.g., ear pain, discharge).

  4. Rule Out Red Flags:

    • Meningitis: photophobia, neck stiffness.

    • Sepsis: lethargy, dehydration, high fever.

  5. Past & Family History

  6. P-BINDS assessment (children-specific history)

Management:

Diagnosis Communication:

  • Use both medical and layman terms: "Febrile seizure" due to ear infection (otitis media) causing high fever.

  • Explain pathophysiology briefly.

Treatment Plan:

  • Fever control:

    • Paracetamol (dosage/frequency)

    • Tepid sponging, hydration

  • Infection treatment:

    • First-line: Amoxicillin (if no allergy)

    • If allergic: Refer to BNF or state you’d consult a senior / BNF for macrolides like azithromycin

  • Seizure safety advice:

    • If seizure lasts >5 minutes → Call ambulance/ED

    • Do not restrain child or put anything in mouth

    • Place in recovery position

Safety Netting:

  • Warn signs to watch for (red flags)

  • Reinforce when to seek urgent care

Follow-Up:

  • Arrange GP follow-up

  • Refer to First Fit Clinic (UK practice for any new-onset seizure)

Patient Education:

  • Provide NHS leaflet/pamphlet on febrile seizures

  • Encourage questions and address parental concerns

Communication Skills:

  • Demonstrated strong empathy and rapport

  • Excellent acknowledgment of parental anxiety

  • Encourage open dialogue

  • Use signposting before sensitive topics

Ethical Considerations:

  • Ensure parental understanding and consent for treatment.

  • Address safeguarding if concerns arise (e.g., frequent admissions or unusual injuries).

  • Be transparent about limitations and when consulting seniors.

Additional Resources:

  • GMC Good Medical Practice – Domains 1 & 2: Competent care, clear communication, safety​

  • BNF for Children – Antimicrobial guidelines

  • NHS Leaflets – Febrile seizures, otitis media

  • PLAB 2 Consultation Guides – Time management, communication tips​




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