Fever in the returned traveller — branching viva

Opening question

Examiner: The registrar asks what the single most important action is. What is it, and why? ^[2]

Candidate: The single most important action is to recognise that this child has possible severe falciparum malaria and to send a same-day thick and thin malaria blood film in the first blood draw. The frame is that a febrile child who has been in a malaria-endemic area has falciparum malaria until a competent film proves otherwise — and this child is drowsy, acidotic and splenomegalic, so he is not just possibly infected, he is possibly severe. The film is part of the resuscitation, not a downstream test. ^[11]

Examiner: What else will you do in the first hour? ^[6]

Candidate: A structured ABC assessment with a paediatric early-warning score, high-flow oxygen for the respiratory distress, and intravenous access. In the same first draw I send a full blood count and film, venous gas and lactate, glucose, urea and electrolytes, liver function tests, C-reactive protein, blood cultures and a urinalysis. I give empiric ceftriaxone because bacterial sepsis cannot be excluded and dual pathology occurs, and I hold IV artesunate ready, because if the film confirms malaria and he is severe, he receives it immediately. ^{[11] [6]}