The following scenarios are fictitious but similar to those experienced by real patients and are designed to help you reflect on what you have learnt after reading the article. They could also be used for group discussion in an education or practice meeting. There are no right or wrong answers but some pitfalls to avoid.
Icon used to indicate Guidelines in Practice test and reflect content
The following case studies written by Dr Nazia Hussain relate to her expert article, Key learning points: NICE fever in under 5s. In this article, Dr Hussain identifies five key learning points for primary care from the updated NICE guideline on fever in under 5s (NICE Guideline 143).

Thomas, aged 2 years

‘I do not think it is anything, but I wanted him checked over as he got sent home from nursery today.
‘He had a runny nose 4 days ago and just seems to be getting everything. His eyes were pink yesterday but not sticky. His temperature can go up to 38.5°C. He has this rash that looks blotchy, but the glass test was ok.
‘He is drinking less than he usually does and is off his food.
‘His nappies seem ok, maybe a little drier than normal.’

Context

Thomas is otherwise a well child. He has been seen twice this year and diagnosed with viral upper respiratory tract infections. He is not on any regular medications.
On examination, Thomas is alert but clingy and shy. He walked into the consulting room normally. His temperature is 38.3°C, his respiratory rate (RR) is 32 breaths per minute, his pulse rate (PR) is 142 beats per minute (bpm), and he has a capillary refill time (CRT) of <2 seconds.
His throat is red, and there is no pus. The heart sounds normal, his chest is clear, and his abdomen is normal. He has mild dry lips.
There is a non-specific blanching macular rash on his trunk, with no vesicles seen.

Questions for reflection

  1. What is your differential diagnosis?
  2. What is the child’s risk of serious illness?
  3. What would your management plan be?

Reveal how to manage this patient

1. The differential diagnosis would include a viral upper respiratory tract infection. The chest does not currently show signs of a pneumonia. It would be worth considering a urine dip test to rule out a urinary tract infection (UTI).
2. Using the traffic light system:
  • Green: His activity seemed normal on entering the room
  • Amber: Tachycardia >140 bpm, dry lips, reduced urine output
  • Red: None.
As Thomas has an amber feature, he has an intermediate risk of serious illness.
3. Depending on clinical judgement and parental concerns, there are the options of giving a ‘safety net’ or referring to specialist paediatric care for further assessment. It is important to provide safety-netting advice and encourage the parent to seek advice at any time of the day or night if there are any concerns. The child is just on the borderline for having a fever for 5 days, so it may be worth considering a review the next day to assess his progress. Given that he has a history of non-exudative conjunctivitis and a rash, the fever continuing for 5 days or more would warrant a paediatric assessment for Kawasaki disease.

Daniel, aged 4 years

‘For the last few days he keeps getting a temperature—I have not measured it but he feels boiling.
‘It did not start as a cough or cold. He seems off his food a bit but does drink enough. He is passing urine ok and there are no rashes. He has not had a bad stomach. He had a blotchy rash but that seems to have settled. There are some lumps in his neck.
‘No one else is unwell. We returned from India for a family visit 3 weeks ago.’

Context

Daniel is a child with a history of well controlled asthma. He was born early at 36 weeks via a forceps delivery and spent 1 week on a special care baby unit being treated for sepsis. He uses salbutamol p.r.n and is prescribed beclometasone.
On examination, Daniel is alert and exploring the room. His temperature is 37.3°C, he has a RR of 30 breaths per minute and a PR of 130 bpm, with a CRT of <2 seconds.
His ear, nose, and throat are normal. There are several small reactive cervical lymph nodes. His heart sounds normal, his chest is clear, and his abdomen is normal.
There are no visible rashes and he is properly hydrated.

Questions for reflection

  1. What is your differential diagnosis?
  2. What is the child’s risk of serious illness?
  3. What would be your management plan?

Reveal how to manage this patient

1. The differential diagnosis is difficult as there does not seem to be an obvious focus of infection. This could be a non-specific simple viral illness, but it is more important to rule out serious causes of infection, like a UTI. Given the recent travel history, it would be worth exploring vaccination history and exposure to tropical diseases, like malaria. It would be important to clarify the duration of fever, as Kawasaki could be a potential differential.
2. Using the traffic light system:
  • Green: His activity seems normal as he explores the room. His observations are normal and he is not dehydrated.
  • Amber: None definite
  • Red: None.
In the absence of any amber or red features, Daniel is at a low risk of serious illness. However, you would need to clarify the duration of the fever as, if it is 5 days or more, this would be an amber (intermediate) risk symptom.
3. This child would warrant urgent assessment by a paediatrician. The travel history is very significant, and he would need investigations to rule out malaria, even though according to the traffic light system, he seems to fall into the ‘green’ low-risk category. In the absence of a relevant travel history, it would be important to rule out a UTI. 

Lily, aged 13 months

‘Doctor, could you have a look at this rash for me?
‘She went off her food a few days ago—I thought it was her tonsils as she had antibiotics for this a few months back. She seems paler than normal, and she is getting temperatures as well the last 2 days.
‘She has been pushing food away and has been sick a few times.’

Context

Lily is a child without a significant medical history. She was treated for tonsillitis 4 months previously and prescribed 10 days of antibiotics. Her immunisations are up to date.
She is sleeping in a pram when she is brought into the consultation room, but cries when examined. Her temperature is 37.5°C with an RR of 36 breaths per minute and a pulse rate of 156 bpm. Her heart sounds normal, her chest is clear, and her abdomen is normal.
Her throat is red, with pus spots. She does not have a strawberry tongue, but has a non-blanching spots on her cheeks only, dry cracked lips, and reactive cervical lymphadenopathy. [EQ: is this what the author means?]

Questions for reflection

  1. What is your differential diagnosis?
  2. What is the child’s risk of serious illness?
  3. What would be your management plan?

Reveal how to manage this patient

1. The differential diagnosis would include bacterial tonsillitis, viral gastroenteritis, and meningococcal septicaemia. The petechiae are of concern but may be explained by increased pressure from vomiting in the superior vena caval distribution. A UTI may be considered as well if things do not settle as expected.
2. Using the traffic light system:
  • Green: None
  • Amber: Parent reports pallor. Dry mucous membranes are noted. She is documented as having tachycardia—but is this significant if the child is crying?
  • Red: Non-blanching rash. 
As Lilly has a red feature, she has a high risk of serious illness.
3. This child would warrant urgent assessment by a paediatrician. The presence of a non-blanching rash raises concern. It may be worth discussing with the on-call team whether or not you should give the child early antibiotic treatment for suspected meningococcal disease before her admission to hospital, as the rash is solely in the superior vena caval distribution but there is a history of vomiting.

Julia, aged 3.5 years

‘Doctor, could you have a look at this rash for me?
‘There is scarlet fever going around at the school. I wonder if she has the same.
‘She went off her food and drink for a few days, but is picking back up.’

Context

Julia is a well child with a history of a temperature for the last 5 days. Her mum noted she had dry cracked lips, but this has settled as her fluid intake has improved. On further questioning she noted her hands looked quite red but there has been no peeling. The rash is patchy and red but fades on pressure. There is no history of conjunctivitis.
Julia is alert, sitting quietly with mum, and responding normally. On examination, her temperature is 37.8°C with an RR of 30 breaths per minute, a PR of 130 bpm, and a CRT of <2 seconds.
There is no peeling on her hands and feet, and they are of normal colour. Her throat is normal with no pus, she is hydrated, her heart sounds normal, her chest is clear and her abdomen appears normal.
She has a blanching macular rash on her trunk and upper limbs that is not rough. She has a strawberry tongue.

Questions for reflection

  1. What is your differential diagnosis?
  2. What is the child’s risk of serious illness?
  3. What would be your management plan?

Reveal how to manage this patient

1. The differential diagnosis would include scarlet fever, a viral upper respiratory tract illness, rubella, and Kawasaki disease. Despite her mum giving a history of scarlet fever contact, it would be prudent to refer the child to secondary care for assessment of possible Kawasaki disease owing to the duration of the fever.
2. Using the traffic light system:
  • Green: Responding normally, not dehydrated
  • Amber: Fever for 5 days or more
  • Red: None.
As Julia has an amber feature, she has an intermediate risk of serious illness.
3. Though the child has no red features, it would be prudent to have the child assessed by a paediatrician for possible Kawasaki disease because of the significant risks in potentially missing this diagnosis. If the child had presented with a fever of less than 5 days’ duration, she would most likely have been treated as having scarlet fever and advice about what to do if she worsened issued as a safety net.