Explaining a negative malaria film and the plan to repeat it — OSCE

Candidate instructions (8-minute station)

You are the paediatric registrar in the emergency department. An eight-year-old girl has been assessed for two days of fever and headache, one week after returning from visiting family in Papua New Guinea. She did not take malaria prophylaxis. Her first malaria blood film has come back negative. She is currently well-looking, febrile but alert, with no signs of severe disease, and the plan is to observe and repeat the film. [6]

Your tasks are: [11]

1. Explain to her parents what a negative film means and why one negative film does not rule out malaria, in plain language that neither alarms them nor underplays the need to repeat the test. [6]
2. Set out the safety-net plan clearly — when the film will be repeated, and what warning signs must bring them straight back. [11]
3. Acknowledge the family's anxiety and hold their trust, while being honest that the possibility of malaria has not yet been excluded. [2]

You are not expected to give a detailed pre-travel counselling session, to discuss antimalarial drug dosing, or to manage severe disease. [11]

Examiner prompt to the actor (parent)

"The doctor just said the malaria test is negative. Does that mean she's in the clear? Can we take her home? Her grandmother is so worried — she said to ask whether she needs the strong medicine anyway, just to be safe. And if the test was negative, why do you want to keep checking her?" [6]

Marking domains

• Accuracy and honesty (3): explains correctly that a single negative film does not exclude malaria, because the parasites can be present at low or fluctuating levels and a single sample can miss them; does not falsely reassure, and does not over-state the risk or cause panic. [6]
• Safety-net plan (4): states clearly that the film will be repeated (typically at twelve to twenty-four hours, and sooner if she deteriorates) until malaria is excluded or another diagnosis is found; names the warning signs that must bring the family straight back — increasing drowsiness, repeated vomiting, fast or difficult breathing, dark urine, bleeding or bruising, a rash, or simply that the parents are worried; confirms a clear return pathway. [11]
• Communication (3): uses plain language, acknowledges the grandmother's and parents' worry, holds a calm and trustworthy tone, checks understanding, and does not lecture or use jargon. [2]

Model answer — the explanatory script

"Thank you for bringing her in, and I understand how worrying this is, especially after the trip to see family in Papua New Guinea. I want to be straight with you about what the malaria test shows and what we're going to do next." [11]

"The first piece of news is that her first blood film came back negative — we didn't see malaria parasites on that sample. That's reassuring, but I have to be honest with you: it does not rule malaria out. The reason is that the parasites move in and out of the bloodstream in waves, and a single sample can miss them even when they're there. So one negative test is not the same as 'she definitely doesn't have malaria.' That's why we don't stop at one." [6]

"Here's the plan. We'll repeat the film — usually within the next twelve to twenty-four hours, and straight away if anything changes. We keep repeating it until either we find the parasites and treat them, or we're confident something else is causing the fever and she's clearly on the mend. She's well-looking at the moment, so we're watching her carefully rather than giving the strong treatment 'just in case' — because those medicines have side effects, and we give them when we have a reason to, not as a guess." [11]

"What I need you to watch for, and what should bring you straight back at any time of day or night, is this: if she becomes drowsy or hard to wake, if she's sick repeatedly and can't keep fluids down, if her breathing gets fast or she seems to be working hard to breathe, if her urine goes dark or there's any bleeding or bruising, if a rash appears, or — honestly — if you just feel something isn't right. You know her best, and we would always rather see her again than have you wait." [11]

"I know her grandmother is worried. I'd like to reassure her that we're taking this seriously — the fact that we're repeating the test is exactly us doing that — and that the best thing for your daughter right now is close watching, fluids, and repeating the film, not starting strong treatment without a reason. I'll come back and review her in a few hours, and I'll let you know as soon as the next film result is ready. Is there anything you'd like me to go over again?" [2]