Explain PFAPA and the management plan to parents — OSCE

Candidate instructions

Explain that PFAPA is a real, recognisable and ultimately self-resolving periodic fever syndrome — not a dangerous disease and not something the parents caused — outline why the inflammatory markers rise with attacks and fall between them, describe how a single dose of steroid aborts an attack, discuss when tonsillectomy might be considered and what the evidence shows, agree a fever diary and a safety-net of red-flag features that warrant urgent review, and check understanding. The examiner plays a parent. [1] [2] [3]

Candidate scenario

You are the paediatrician in clinic. Parents of a 3-year-old describe clockwork attacks every 5 weeks: high fever for 4 days with a sore throat, mouth ulcers and tender neck glands, then complete wellness between. A CRP during an attack was high and a repeat when well was normal. They are worried the fevers are dangerous, ask whether the tonsils should be removed, and want to know what to watch for. There are no red flags on review and growth is normal. [2] [3] [4]

Marking domains

• Empathy, structure and agenda-setting, including parental worry and guilt
• Accurate plain-language model: a real, recognisable periodic fever syndrome that resolves
• Clear explanation of why inflammatory markers rise then fall and what that means
• Practical attack-abort plan with a single dose of steroid, and the place of tonsillectomy
• Balanced discussion of tonsillectomy evidence and that the syndrome resolves regardless
• A clear, written safety-net of red-flag features and a review date

Model outline

Open. Name and normalise the problem without blame: "What your child has is a well-recognised pattern called PFAPA. It is real, it is not dangerous, and it is not something you caused. The good news is that it resolves on its own, usually by the early teenage years, and it does not damage the body." [2] [3]

The pattern. "PFAPA comes like clockwork — about every five weeks in your child — with high fever, a sore throat, mouth ulcers and swollen neck glands for a few days, then it vanishes and she is completely well until the next time. The clockwork pattern is actually what tells us it is PFAPA rather than ordinary repeated infections, which come at unpredictable times." [2] [4]

The blood tests. "You noticed the CRP was high during an attack and normal when she was well. That is actually a fingerprint of PFAPA — the body's alarm fires during an attack and switches fully off between them. If the numbers stayed high all the time we would worry about other things, but the rise-and-fall is reassuring and confirms the pattern." [3] [4]

Stopping attacks. "When an attack starts, a single dose of steroid — prednisolone, a short course — will usually switch the fever off within hours. It does not cure the syndrome, and sometimes it brings the next attack on a little sooner, but it gives you control. We keep a dose ready at home. For attacks that are very frequent, there is a medicine called cimetidine that helps some children." [3] [5]

Tonsillectomy. "Some families consider taking the tonsils out. Three good studies show it works to stop the attacks, so for a child whose attacks are very disruptive we can discuss it with an ear-nose-throat team. But because PFAPA resolves on its own anyway, we do not rush to surgery — it is an option, not a requirement, and we weigh it together if the attacks are hard to live with." [5]

Safety-net and close. "Most of the time PFAPA is the whole story. But come back urgently if you ever see fever with weight loss, drenching night sweats, unusual bruising or bleeding, a limp or swollen joint, a new rash that does not fit the attacks, or simply a fever that behaves differently from her usual pattern. Keep the diary going — write the start and end of each attack — and we will review together." Written plan: fever diary, a home steroid dose with clear instructions, a safety-net card, and a review date. [1] [3]