I suspect that the purpuric rash in a child with NOTHING else is innocent,
especially in the common situation, of a parent having noticed it the night
before and ambled down to the surgery for an opinion. The purpura of
septicaemia means that DIC is occurring and that really is happening to an
ill child. I've seen this in many kids in the days when I worked at a
regional ID unit, some had no fever, but all looked sick. Of the two in GP (
only two, thank God) both were sicker than the objective findings would have
you believe.
Now, what we need to do is persuade the powers that be that A GP's eye, and
opinion on clinical diagnosis, are valuable.
-----Original Message-----
From: GP-UK [mailto:[log in to unmask]] On Behalf Of Declan Fox
Sent: 23 April 2007 17:50
To: [log in to unmask]
Subject: Re: Kids with fine purpuric/petechial rashes.
I have had this while working part time as a staff grade in a paeds day
unit in a small general hospital--proper paeds unit 27 miles away over
poor roads. Never really got a good ruling from the consultants other
than clinical impression. ie fever, prob UTI, couple of wee dark spots,
already started on oral antibiotic, send along for overnight stay. Well
kid with cough and a few tiny spots which may have been there for ever,
keep an hour or two, let home if ok, return asap if any changes.
Kid with malaise and fever for day and few jagged bad looking dark spots
on one arm (tho pretty small)--the works. That particular kid, as I
recall, was negative on all tests but got the full treatment anyway.
Which raises question of what is the gold standard, diagnostically?
Consultant on the last kid was positive it was meningococcal and pointed
out that the tests can be negative in a few cases.
Personally I have some reservations about the Pen G shot--it pretty much
condemns the kid to a few days of IV antibiotics in hospital. PCR
testing takes about a week, round here.
I think this illustrates the conflict--and it may not be possible to
reconcile the two extremes--between protocols (which work v well for
life threatening illness, eg ATLS, ACLS, PALS etc) and clinical judgment
which is probably safer for the bulk of community work.
A parallel is patients admitted with chest pain. How suspicious of IHD
do you have to be to put them on monitor, give low molec wt heparin,
ASA, beta blocker and 40mg statin? In other words, at what point does
the protocol cut in?
Declan
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