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You are the FY1 on paediatric admissions at the local hospital. You have had a young boy, Levi Dopa, come to the ward with his mum, Carol. Levi is 6 years old and has presented with bruising on his legs. This is the first time he has been brought to hospital.

Take a history from Carol, and elicit her concerns. Perform an appropriate examination on Levi, and answer the examiner’s questions.

HPC: You are Carol Dopa, a 36 year old lady who has come to the unit with your son, Levi. Levi is normally an active and playful boy, but you are increasingly worried about his behaviour recently. He just hasn’t been himself. You originally went to the GP because of this bruising, but he didn’t have a clue what it was! He seemed like a useless GP: you’ve been meaning to change practices for a while now. However, this has made you very frustrated and worried that Levi might have something dangerous. You first noticed the bruising on Levi’s legs yesterday morning. They were purple and blotchy, and there were lots of little spots around them. The spots are new, and are what brought you to the GP. They don’t seem to be itchy or painful. He doesn’t have the rash anywhere else, and he’s never had anything like this before.

He hasn’t changed his diet recently, though he has been eating less. He didn’t even want his fish fingers for tea last night – he loves his fish fingers! He was slow to grow when he was a baby, but caught up in the end. Due to this, you keep a close eye on his weight: it hasn’t changed recently. He had all his injections, even though Levi’s dad wasn’t keen on him getting the MMR, as he thought it might have some funny chemicals in it. You told him that that was silly! He has been going to the toilet as normal, in every way. He had a bit of a cough a few weeks ago, but not anymore. He hasn’t had any fevers or headache.

Levi was a natural birth, which was uncomplicated. You even managed to have the birth at home! He hit all his developmental milestones, and has just joined a new school after you and your partner moved to the local area one month ago. Levi became unwell 3 weeks ago, when he came down with a cold. You went to that bothersome GP at the time, but he fobbed you off and said antibiotics wouldn’t work. Levi did get better, but you don’t think he’s been quite himself since.

ICE: You had originally been quite concerned because of the bruising. You were worried that he was possibly having a hard time at school, or maybe falling when at school. You called his teacher yesterday, but she didn’t know anything about it. However, when the spots first appeared, you went into a panic. You had been reading about the ebola virus recently, and have a fear that the infection Levi had a few weeks ago has turned into something horrible. You went on a family holiday to Dubai a few months ago – could that be the cause? You expect to be given an answer now, since the GP was so clueless earlier.

PMH: Levi has always been well and doesn’t take any regular tablets. He isn’t allergic to anything that you know of.

SH: Levi lives in a house with you and your partner, Matt. Your mum lives close by and is very close to Levi. No one at home smokes, and no one has been unwell.

FH: Everyone in the family is very well.

The student should elicit Carol’s concerns thoroughly and take a structured history of the rash. Excellent candidates would include a brief risk assessment for abuse. A dermatological examination would be appropriate.

The student’s differential diagnosis should sound something like:

My differential diagnosis would include a haematological cause. Specifically, this would include Idiopathic Thrombocytopaenic Purpura, or potentially Henoch-Scholein Purpura. I would, however, wish to rule out an infective cause, namely meningitis septicaemia. Finally it would be important to rule out abuse in a case of a child with bruising. Example for discussion may include:

  • How would you investigate this patient in the acute setting?
  • How would you manage this patient acutely?
  • Why do you think that this is not a case of meningitis?
  • What is the difference between ITP and HSP?
  • Do you know any ‘classic’ signs of abuse in a child?
  • What kinds of abuse are there?
  • What is the long term prognosis of this patient’s ITP?