Cases/Ear, Nose and Throat

Mother Phoning About Discharge From Her Child's Ear — Free SCA Practice Case

Mother phoning about discharge from her child's ear

Station Timer

12:00

Golden Minute

Initial Introduction

•Introduce yourself

•Ask an open question — "How can I help you today?"

•Listen — don't interrupt

•Catch early cues

Data Gathering

History, ICE & Diagnosis

Clinical Management

Diagnosis, Plan & Decisions

Safety Net

Follow-up & Close

12:00

Golden Minute

Materials for Candidate

Please review before starting the consultation

Patient Profile

Full Name

Rory Brennan

Age

4 years

Consultation Type

Telephone

Age

4 years 2 months

Mother's Name

Niamh Brennan (age 31)

Situation

Telephone Consultation. You are the duty GP. Rory's mother, Niamh, has booked a telephone appointment to discuss her son.

Reason for Encounter

"The health visitor saw Rory yesterday and told me to ring the GP. He's had ear pain, and now there's yellow discharge coming out of his ear and a temperature. She thought he might need antibiotics."

Medical Records (child)

●PMH: Born by normal vaginal delivery. Acute otitis media 9 months ago, treated with oral amoxicillin.
●Medications: None. Calpol (paracetamol) given at home.
●Allergies: NKDA.
●Recent notes: Immunisations not fully up to date — MMR second dose given 3 weeks ago; 4-in-1 preschool booster still outstanding. Did not attend a paediatric physiotherapy appointment for in-toeing 2 weeks ago; discharged back to GP with advice to re-refer if still needed.

Patient Script

For the friend playing the patient role

Character Overview: You are Niamh, Rory's mum. You are 31, a single parent, and you are calling from work on your break. You are stretched thin — juggling work, two children, and helping care for your own father who has dementia — and you feel a bit guilty and defensive about missed appointments, though your overriding concern right now is Rory's ear. You are cooperative and will follow sensible advice; you are not hostile, just under pressure.

Opening Sentence: "Hi Doctor, thanks for calling back. It's about my little boy, Rory — he's four. He's had a sore ear for a couple of days and now there's yellowy stuff coming out of it and he's warm. The health visitor saw him yesterday and said I should speak to a doctor about antibiotics."

History if Asked (Data Gathering Phase — gathered via the mother)

●The ear: "It's his right ear. He was tugging at it and crying two days ago, said it hurt. Then yesterday I noticed this yellowy discharge on his pillow and coming from that ear. Since the discharge came, he's actually seemed a bit more comfortable, oddly."
●Fever: "He's been warm — I've not taken a proper temperature but he feels hot and a bit flushed. I've been giving him Calpol."
●How he is in himself: "He's eating and drinking okay, running around a bit, wetting his nappies and going to the loo as normal. He's a bit grizzly but he's not floppy or drowsy or anything like that."
●The other ear / other symptoms: "Just the one ear. No rash, no being sick, no problems with his balance that I've seen."
●Recent cold: "He did have a snotty cold last week, runny nose, the usual."

ICE — Ideas, Concerns, Expectations

The mother does not volunteer this information unprompted. These responses surface only when the candidate directly explores her perspective.

●Ideas: Niamh thinks it is an ear infection and, because there is now discharge, that it must be bad enough to need antibiotics. "I'm sure it's an ear infection — and now it's leaking, so surely that means it needs antibiotics?"
●Concerns: She is worried it has not settled and that the health visitor flagged antibiotics; underneath is anxiety about being judged as a struggling parent. "I'm worried because it's not getting better and the health visitor seemed to think it was serious. And honestly, I feel like I'm being watched — I know we've missed some appointments."
●Expectations: She is hoping for an antibiotic prescription she can collect without having to leave work to bring him in. "I'm really hoping you can just send a prescription — it's so hard for me to get him up to the surgery today."

If Asked — Practical and Social Circumstances

The mother confirms these details only when directly asked.

●Who is with Rory: "He's with my mum and dad today. But they can't bring him in — they don't drive, and my mum's got her hands full with my dad, who has dementia."
●Work: "I'm at work — I've stepped out to call you. It's difficult for me to just leave."
●Other children: "I've got an eight-year-old too, she's at school, she's absolutely fine."
●Coping: "I'm managing, just about. It's a lot — work, the two kids, helping with my dad. Some weeks the appointments slip, I'll be honest."
●The missed appointments (if raised): "I know he's behind on a couple of jabs and there was a physio thing for his feet I missed. It's not that I don't care — it's just getting everything to line up is really hard on my own."

If Asked — Red-Flag Screen (via the mother)

The mother answers these only when directly asked.

●If asked whether pain is worse when the outer ear is pulled (tragus): "I don't think so — he didn't flinch when I cleaned around the outside."
●If asked about swelling or redness behind the ear: "No, I've not noticed anything behind his ear, no swelling."
●If asked about neck stiffness, unusual drowsiness, or a headache: "No, he's not stiff-necked or drowsy — he's his usual grizzly self, still pottering about."
●If asked about a rash (especially one that doesn't fade): "No rash anywhere."
●If asked about vomiting or refusing all fluids: "No, he's keeping his food and drink down fine."
●If asked about wet nappies / passing urine: "Yes, normal wet nappies, weeing as usual."
●If asked about swimming or water in the ear: "No swimming lately."
●If asked about previous ear infections: "He had one about nine months ago — had amoxicillin for it and it cleared up."

Responses to Management (The Negotiation Phase)

●If the Doctor wants to see Rory face to face: "I really can't get him in today — my parents can't drive and I'm stuck at work. Is there any way round it?" (The tested point is balancing the need to examine an unwell child against genuine access barriers — arranging a workable alternative rather than either insisting rigidly or abandoning examination.)
●If the Doctor offers/agrees antibiotics: "Which one is it? Is it the same as last time? How long does he take it for?"
●If the Doctor offers a delayed (back-up) prescription instead: "So I only start it if he's not better? How will I know?"
●If the Doctor raises the missed vaccinations and physio: "I knew that would come up. Are you saying I'm not looking after him properly?" (The tested point is raising these supportively, not accusingly.)
●If the Doctor safety-nets: "What exactly should I be watching for that would mean I need to get him seen urgently?"

Mark Scheme

Domain 1: Data Gathering and Diagnosis

0 / 18 indicators checked+0−0

Positive (0/9)

Negative (0/9)

Domain 2: Clinical Management and Medical Complexity

0 / 18 indicators checked+0−0

Positive (0/9)

Negative (0/9)

Domain 3: Relating to Others

0 / 12 indicators checked+0−0

Positive (0/6)

Negative (0/6)

Clinical Learning Points

Acute Otitis Media in Children

●Acute otitis media (AOM) is a common childhood infection, frequently following a viral upper respiratory tract infection. It presents with ear pain, fever, and irritability; young children may tug at the ear.
●Perforation of the tympanic membrane produces otorrhoea (discharge) and characteristically relieves the pain, as in this case. Perforations from AOM usually heal spontaneously.

Distinguishing AOM from Otitis Externa

●Otitis externa causes pain on moving the pinna or pressing the tragus, with a discharging, inflamed ear canal.
●AOM causes deeper ear pain with systemic features and follows a URTI; discharge appears if the drum perforates. History (and, ideally, examination) helps separate them.

Antibiotic Decisions in AOM (NICE NG91)

●Many cases of AOM are self-limiting; NG91 supports no antibiotic, a back-up (delayed) prescription, or an immediate antibiotic depending on severity and the child.
●Immediate antibiotics are appropriate for children who are systemically unwell, at higher risk of complications, or who have symptoms lasting ≥3 days, otorrhoea (discharge), or bilateral infection in under-2s.
●Amoxicillin is first-line (5–7 days); use a macrolide (clarithromycin or erythromycin) if penicillin-allergic.
●Analgesia (paracetamol/ibuprofen) and fluids are the mainstay of symptom control regardless of the antibiotic decision.

Red Flags and Serious Complications

●Mastoiditis: swelling, redness, or tenderness behind the ear, with the pinna pushed forward — needs urgent assessment.
●Meningitis/intracranial spread: neck stiffness, photophobia, drowsiness, non-blanching rash — a medical emergency.
●Persistent high fever, a systemically unwell or dehydrated child, or failure to improve after 48–72 hours also warrants reassessment.

Assessing the Unwell (and Well) Child Remotely

●Remote assessment of a young child has real limits: the ear cannot be examined and subtle signs of serious illness can be missed. Arrange examination where a child is febrile with new signs, and where barriers exist, problem-solve rather than default to a phone prescription or an impossible instruction.
●Structured assessment of how the child is in themselves (feeding, hydration, alertness, activity, urine output) is central to safe remote triage.

Immunisation Catch-Up

●Children who are behind on the schedule should be offered catch-up. Missed doses (here, the 4-in-1 preschool booster) should be actively followed up and rebooked, with practical help for families who struggle to attend.

Proportionate Safeguarding and Missed Appointments

●Repeatedly missed health appointments ("was not brought") in a child can be a neglect indicator, but must be weighed proportionately against the family's circumstances.
●The first response is support — understanding barriers, offering practical help, involving health visitor and social prescribing. A pattern of missed essential care, or additional concerns, may warrant a safeguarding discussion or referral, framed around ensuring the child's needs are met.

Supporting Families Under Strain

●Recognise the pressures on a single working parent with caring responsibilities. Practical support — rebooking appointments, re-referring physiotherapy, social prescribing — both meets the child's needs and strengthens engagement.

Safety-Netting for a Febrile Child

●Give parents specific, actionable red flags: swelling/redness behind the ear, neck stiffness, drowsiness or being difficult to rouse, a rash that does not fade, not passing urine, refusing fluids, or becoming floppy — with clear advice on when to call 111/999 or seek same-day review.

Common Candidate Mistakes in This Case

●Prescribing blind over the phone: issuing antibiotics with no attempt to arrange examination of a febrile child with ear discharge.
●Rigidly insisting on attendance: ignoring genuine access barriers and offering no workable alternative.
●Missing the mastoiditis/meningitis screen: not asking about swelling behind the ear, neck stiffness, drowsiness, or rash.
●Mishandling the welfare thread: either ignoring the missed appointments, or raising them accusingly/leaping to heavy-handed safeguarding rather than a proportionate, supportive response.
●Weak safety-netting: vague advice to a parent instead of specific red flags and a review plan.

Free MRCGP SCA practice case for GP registrars covering Mother Phoning About Discharge From Her Child's Ear — Ear, Nose and Throat. Includes candidate brief, patient script, marking scheme mapped to the RCGP SCA marking domains, and learning points. Built directly from the RCGP curriculum topic stations listed under "How this might be tested in the MRCGP SCA," part of a free library of 79 SCA practice cases for simulated consultation assessment preparation.

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