Febrile Child OSCE - Viral Upper Respiratory Infection

Case Overview

• Age/Sex: 5-year-old male
• Occupation: Preschooler
• Setting: Walk-in paediatric clinic; parent as historian
• Chief complaint: "My child has a fever."

Patient Script

Who I Am

I'm his mother; he is a 5-year-old boy who attends preschool.

What Brings Me In

He's had a fever and a runny nose for the last couple of days and I'm worried because he seems a bit quieter than usual.

My Story

He started with a runny nose and sneezing 2 days ago, then developed a low-grade fever last night (I measured it at home). He has a mild cough and his voice sounds a bit hoarse, but he is still eating small amounts and will play quietly. His fever has been between 38.0–38.5°C despite me giving paracetamol overnight. There was a moment yesterday when he tugged at his ear once, so I checked and he seemed fine after. His older sister had a cold at preschool last week and he was around her. He has no breathing difficulty, no persistent vomiting, and hasn't had any convulsions. We did go to our local urgent care 6 months ago for an ear infection, but that was then and resolved. We visited my parents' farm 2 weeks ago (just a short visit) — nothing unusual there.

My Medical Background

• Past medical history: uncomplicated; no hospital admissions; one resolved acute otitis media at age 4
• Medications given at home: paracetamol (15 mg/kg) once last night; small dose of ibuprofen this morning (per dosing chart)
• Allergies: none known
• Social: attends preschool; vaccinated per schedule; non-smoker household
• Family: older sister recently had upper respiratory symptoms; no chronic illnesses in family

What I Think & Worry About

• I think he has a bad cold and caught it from his sister.
• I'm worried the fever might get worse or he might have a febrile seizure.
• I expect to get some advice or medicine to help him feel better; I don't want him to miss too much preschool.

If You Ask Me About Other Symptoms...

• Appetite: He’s eating less than usual but will take small meals and drinks.
• Urine: Wet diapers/pee normally; no decrease in urine output.
• Breathing: No noisy breathing, no fast breathing, no wheeze that I noticed.
• Ear pain: He only tugged his ear once yesterday; he hasn’t complained since.
• Rash: None today; he had a tiny itchy spot after strawberries once when he was 2 but nothing now.
• Recent antibiotics: None currently (we do not have any leftover antibiotics at home).

---

Clinical Summary

Examination

• General: alert, cooperative, playing quietly with parent at side
• Temperature: 38.3 °C (tympanic)
• Heart rate: 110 beats/min (within expected range for age)
• Respiratory rate: 22 breaths/min (comfortable, no distress)
• Oxygen saturation: 98% on room air
• Weight: ~18 kg (parent report)
• ENT: nasal mucosa congested with clear discharge; pharynx mildly erythematous without exudate
• Ears: tympanic membranes clear, mobile on pneumatic otoscopy, no bulging
• Neck: small, mobile anterior cervical lymph nodes (≈ <1 cm)
• Chest: chest clear to auscultation bilaterally, no crackles or wheeze
• Hydration: moist mucous membranes, capillary refill 2 seconds
• Skin: no rash or petechiae

Investigations

• Rapid strep test (performed if sore throat severe): negative (makes GAS pharyngitis unlikely)
• Influenza/RSV point-of-care test: negative (reduces likelihood of influenza/RSV in clinic)
• CBC: WBC 9.2 x10^9/L (neutrophils 55%, lymphocytes 35%) (no leukocytosis)
• CRP: 5 mg/L (low) (supports non-bacterial inflammation)
• CXR: not indicated / not performed (no focal signs of pneumonia)

Diagnosis

• Primary: Viral upper respiratory infection (common cold)

  • Evidence: 2-day history of nasal congestion, sneezing, low-grade fever, mild cough, normal respiratory exam, clear tympanic membranes, low inflammatory markers, and recent household exposure to another child with similar symptoms.

• Differentials:

  • Acute bacterial otitis media — less likely: no TM bulging, normal pneumatic otoscopy, only a single episode of ear tugging.
  • Group A streptococcal pharyngitis — less likely: age 5 can get strep but absence of tonsillar exudate, low-grade fever, negative rapid strep test, and presence of cough point away from strep.
  • Influenza or RSV — less likely given negative rapid tests and mild symptoms, but consider if illness progresses or seasonal context suggests it.
  • Early community-acquired pneumonia — unlikely: normal respiratory rate, oxygenation, clear chest auscultation, and low CRP.

Management

• Symptomatic care:
  • Antipyretics as needed for fever/comfort: paracetamol 15 mg/kg per dose, can alternate with ibuprofen (10 mg/kg) if needed for comfort; follow dosing intervals and total daily limits.
  • Ensure adequate fluids and rest.
  • Saline nasal drops and gentle suctioning for nasal congestion before feeds/sleep.
• Antibiotics: not indicated now; avoid prescribing antibiotics for viral URI.
• Safety-netting / return precautions (advise parent to return or seek urgent care if):
  • Child becomes more lethargic, difficult to wake, or inconsolable.
  • Respiratory distress: persistent tachypnea, accessory muscle use, audible wheeze, or oxygen saturation <94%.
  • Inability to drink or decreased urine output (fewer wet diapers or <4-6 wet pants/day for this age).
  • Persistent high fever >39.5°C, febrile fits, or fever lasting >48–72 hours without improvement.
  • New focal ear pain or evidence of middle ear infection.
• Additional steps:
  • No immediate investigations required beyond point-of-care tests already done.
  • Provide advice on exclusion from preschool: keep home while febrile and until fever-free for 24 hours without antipyretics.
  • Arrange follow-up if symptoms worsen or fail to improve in 48–72 hours.

Key Learning Points

• Most preschool children with acute nasal congestion, mild cough, and low-grade fever have a viral upper respiratory infection — treat with supportive care and avoid antibiotics.

• Use focused examination and simple tests (rapid strep, pulse oximetry, targeted CRP/CBC when uncertain) to exclude bacterial causes or serious lower respiratory involvement.

• Safety-net clearly: recognize red flags (respiratory distress, poor intake, signs of dehydration, altered consciousness, persistent high fever) that require urgent reassessment.