Febrile Child OSCE - Kawasaki Disease | Free OSCE Practice

Case Overview

Age/Sex: 11-year-old male
Occupation: Primary school student
Setting: Emergency department, brought by parent
Chief complaint: "My child has had a fever for days and looks different"

Patient Script

Who I Am

I'm his mother and I've brought my 11-year-old son from home — he goes to Year 6 at the local primary school.

What Brings Me In

He has had a high fever for several days and today his hands and lips look swollen and red, so I got worried and brought him in.

My Story

He first got a fever 6 days ago. It started suddenly and was mostly around 38.5–39.5°C, and hasn't gone away even with paracetamol and ibuprofen. For the first two days he had a bit of a runny nose and was a bit coughy, so we thought it was a cold. Around day 3 his right ear ached so our GP gave him a short course of amoxicillin for possible ear infection. Over the next couple of days the fever continued, he became more irritable, his eyes looked quite red without pus, and his lips got very dry and cracked. Yesterday I noticed a rash on his trunk and his hands felt swollen; today the fingertips look a bit flaky. He did vomit once on day 4 but has had no significant diarrhoea. He hasn't eaten much for a few days. He hasn’t been able to play much and complains his neck is sore on the right side when I touch it.

My Medical Background

Past medical history: generally well, no chronic illnesses
Medications: paracetamol and ibuprofen at home; completed 3 days of amoxicillin started by GP
Allergies: none known
Vaccinations: up to date
Social: lives with parents and a younger sibling who had strep throat 2 weeks ago
Family history: father has high cholesterol; no known childhood inflammatory disease

What I Think & Worry About

I worry it might be something serious like meningitis or sepsis because the fever won't go away.
I wonder if the antibiotics missed something or if he caught something from his sibling.
I worry about his heart because I heard fevers like this can cause problems (I don’t know much about it).

If You Ask Me About Other Symptoms...

Cough: "Only a mild cough at the start — not bad now."
Runny nose/sore throat: "A little runny nose early on; throat looks a bit red but there's no white stuff in it."
Eyes: "Both eyes are red and a bit watery, but he says they don't hurt and there's no sticky discharge."
Mouth: "His lips are cracked and very red; he complains they sting when he drinks. No big ulcers as far as I can see."
Skin: "There was a red rash on his chest and tummy yesterday; it’s patchy and looks a bit raised. His fingertips look like they are peeling a little today."
Neck: "I can feel a lump on the right side of his neck; he says it hurts when I press it."
Urine: "He’s been a bit less than usual but still peeing; I didn’t notice blood."
Activity: "He’s been grumpy and not his usual self, but he’s not floppy or hard to wake."
Recent exposures/illness: "Younger sibling had strep throat 2 weeks ago; he was in the same class as a child with chickenpox about a month ago."

Clinical Summary

Examination

General: alert but irritable 11-year-old, appears unwell, not toxic
Temperature: 39.2°C
Heart rate: 128 bpm (sinus tachycardia for age)
Blood pressure: 104/64 mmHg
Respiratory rate: 22/min
SpO2: 98% on air
HEENT: bilateral conjunctival injection without purulent discharge; lips red, cracked; oropharynx mildly erythematous, no exudate
Neck: tender right anterior cervical lymph node ~2.0–2.5 cm
Skin: polymorphous maculopapular rash on trunk and groin; mild periungual desquamation of fingertips
Extremities: erythema and mild swelling of hands; no obvious joint effusion
Cardiorespiratory: heart sounds normal, no audible murmur; lungs clear
Abdomen: soft, non-peritonitic, mild right upper quadrant tenderness

Investigations

CBC: WBC 15.2 x10^9/L (neutrophils 78%) (leukocytosis with neutrophilia)
Hemoglobin: 12.1 g/dL
Platelets: 420 x10^9/L (mild thrombocytosis, note timing day 6)
CRP: 120 mg/L (markedly elevated)
ESR: 62 mm/hr (elevated)
Electrolytes/renal function: Na 137 mmol/L, K 4.1 mmol/L, creatinine normal
LFTs: ALT 58 U/L (mildly elevated)
Urinalysis: sterile pyuria (WBCs 10–20/hpf, no bacteria on microscopy)
Blood cultures: pending / no growth (initially)
Throat swab: pending; rapid strep test negative
SARS-CoV-2 PCR: negative
Chest X-ray: normal
ECG: sinus tachycardia, otherwise unremarkable
Echocardiogram (urgent): mild dilation of the proximal right coronary artery, Z-score ~2.8 (borderline dilation)

Diagnosis

Primary: Incomplete (atypical) Kawasaki disease

Evidence: persistent fever for 6 days, bilateral non-exudative conjunctival injection, mucocutaneous changes (red cracked lips, erythema and swelling of hands, periungual desquamation), tender cervical lymphadenopathy (~2–2.5 cm), markedly raised inflammatory markers (CRP, ESR), sterile pyuria, mild thrombocytosis, and borderline coronary artery dilatation on echocardiogram.

Differential diagnoses and reasoning:

Scarlet fever (group A strep): possible given sibling history and rash — but rapid strep negative, no tonsillar exudate, and the conjunctivitis, sterile pyuria, and coronary changes point away from scarlet fever.
Viral infection/adenovirus: could explain fever, conjunctivitis and pharyngitis early on, but persistent high inflammatory markers, desquamation, thrombocytosis and coronary changes favor Kawasaki.
MIS-C (post-COVID inflammatory syndrome): clinically similar; less likely here with negative SARS-CoV-2 testing and no prominent GI shock features, but should be considered in the appropriate epidemiological context.
Bacterial sepsis/toxic shock: child is not toxic-appearing, blood cultures negative so far, and focal bacterial source is not evident.
Stevens-Johnson syndrome: mucosal involvement present but skin lesions are not targetoid/necrotic and distribution is more consistent with Kawasaki.

Management

Admit to paediatric ward with paediatric cardiology involvement.
Start intravenous immunoglobulin (IVIG) 2 g/kg as a single infusion as soon as possible.
Start high-dose aspirin (e.g., 80–100 mg/kg/day divided) during the acute febrile/inflammatory phase, then transition to low-dose aspirin (3–5 mg/kg/day) for antiplatelet therapy once afebrile, per local protocol.
Cardiology: arrange urgent baseline and follow-up echocardiography (repeat at 1–2 weeks and 4–6 weeks) to monitor coronary arteries.
Monitor fluids, input/output, and for signs of heart failure or shock; consider IV fluids cautiously if needed.
Baseline and repeat blood tests: CBC, CRP/ESR, LFTs, electrolytes; monitor platelets for rising thrombocytosis.
If persistent fever or IVIG-resistance: discuss second IVIG dose or adjunctive therapy (e.g., corticosteroids) with paediatric rheumatology/cardiology per local guidelines.
Provide antipyretics and symptomatic care; avoid live vaccines for ~11 months after IVIG.
Educate family about follow-up and signs to seek immediate care (worsening fever, chest pain, lethargy, decreased urine output).

Key Learning Points

Consider Kawasaki disease in any child with fever ≥5 days plus mucocutaneous features even if the presentation is incomplete or atypical; early recognition is essential to prevent coronary complications.
Supportive lab clues include markedly elevated CRP/ESR, sterile pyuria, and rising platelet count; echocardiography is mandatory to assess coronary involvement and guide urgency of treatment.
Treatment with IVIG (2 g/kg) and aspirin should be initiated promptly when Kawasaki disease is suspected; involve paediatric cardiology early for follow-up and management of potential coronary artery abnormalities.