Station Title & Timing
- Title: Pediatric Rash and Abdominal Pain
- Duration: 10 minutes (2 minutes reading time + 8 minutes performance)
Learning Objectives
- Clinical Recognition: Identify the classic triad of Henoch-Schönlein Purpura (HSP).
- Examination Skills: Perform a focused systemic/hematological examination, including joints and abdominal palpation.
- Safety: Rule out life-threatening differentials (Meningococcemia).
- Communication: Explain a complex vasculitis to a parent using effective lay analogies.
Patient Profile
- Name: Leo (5-year-old child, represented by a mannequin)
- Relative: Sarah (Leo’s Mother)
- Ethnicity: Any
- Social History: Attends preschool; lives with both parents and a younger sister.
Presenting Complaint
Leo has a “scary-looking” purple rash on his legs and buttocks that appeared yesterday. He has also been complaining of intermittent tummy pain and “sore legs.”
Contextual Information
- HPC: Leo had a “bad flu” with a high fever and sore throat about 14 days ago, which resolved. Yesterday, Sarah noticed small red spots that turned into purple bumps. Today, Leo is limping and crying when his belly is touched.
- PMH: Generally healthy. No previous hospitalizations.
- Medications: Children’s Panadol (Paracetamol) given this morning.
- Urine Result (Provided in Stem): Dipstick: Blood 4+, Protein 1+.
Exam Instructions
Candidate Instructions
You are a GP seeing 5-year-old Leo and his mother, Sarah.
- Take a focused history from Sarah regarding the rash and associated symptoms.
- Perform a focused physical examination on the mannequin.
- Explain the diagnosis, the urine findings, and the management plan to Sarah.
- Note: You must verbalize your safety checks to the examiner.
Standardised Patient (SP) Instructions (The Mother)
- Affect: Anxious and protective. You are worried the rash is “meningitis” because you saw it on the news.
- Response to Explanation: If the candidate uses medical jargon like “IgA Vasculitis” or “palpable purpura” without explaining them, look confused and ask: “Is it a blood cancer? Is it contagious?”
- Key Concern: “Why is there blood in his urine? Are his kidneys failing?”
Examiner Checklist Items
- Asks about a preceding viral infection (the “trigger”).
- Inspects the rash and confirms it is non-blanching/palpable.
- Safety Check: Checks for neck stiffness/Brudzinski’s sign (verbalizes ruling out meningitis).
- Systemic Check: Palpates the abdomen for tenderness/masses.
- Joint Check: Examines the ankles and knees for swelling or limited range of motion.
- Analogies: Uses the “Inflamed Blood Tubes” analogy to explain HSP.
- Management: Identifies the need for blood pressure monitoring and pediatric referral due to renal involvement (Nephritis).
Key Clinical Findings
- Vital Signs: HR: 105 bpm, Temp: 37.2°C, BP: 105/70 mmHg (Normal for age).
- Skin: Palpable purpura (raised purple spots) concentrated on the buttocks and extensor surfaces of the legs.
- Abdomen: Soft but generalized mild tenderness. No “sausage-shaped” mass (rules out intussusception).
- Joints: Mild swelling and tenderness of the right ankle; decreased weight-bearing.
- Neurological: No neck stiffness; Photophobia negative.
Communication Triggers (Murtagh-Aligned)
- Open-ended questions: “Sarah, I can see you’re worried. Can you tell me exactly how Leo has been acting since these spots appeared?”
- Summarising: “So, Leo had a cold two weeks ago, and now he has this rash, a sore tummy, and a bit of a limp. Is that correct?”
- Handling Emotions: “It’s very common for parents to worry about meningitis when they see a rash like this. I’ve checked his neck and his temperature, and I can tell you this is a different condition called HSP.”
- Lay Language: “Think of his blood vessels as tiny ‘blood tubes’ that have become a bit irritated and leaky.”
Assessment & Marking Guide
| Domain | Key Performance Indicators |
| History | Identified the viral prodrome and screened for gut/joint symptoms. |
| Safety | Explicitly ruled out Meningococcemia (Neck stiffness check). |
| Examination | Performed a systemic check (Abdomen, Joints) rather than just a skin check. |
| Explanation | Used the “Inflamed Blood Tubes” analogy; explained renal findings. |
| Management | Recognized significant hematuria (4+) requires Pediatrician follow-up. |
Sample Answers / Model Performance
Suggested History Questions:
- “Did Leo have any fevers, sore throats, or coughs in the last few weeks?” (Probing for viral trigger).
- “Has the tummy pain been constant, or does it come and go in waves?” (Probing for colicky pain).
- “Has he been able to walk normally, or have you noticed any swelling in his joints?”
Explaining the Diagnosis:
“Sarah, based on Leo’s rash, his tummy pain, and the sore ankle, I believe he has a condition called Henoch-Schönlein Purpura, or HSP.
I know it sounds like a mouthful, but the best way to think about it is that the tiny ‘blood tubes’ or vessels in his body have become inflamed or irritated. This usually happens as a delayed reaction to a virus, like the flu he had two weeks ago.
- The Rash: Is caused by those tiny tubes in the skin leaking a little bit of blood, which creates those purple bumps.
- The Tummy & Joints: The same thing is happening in his bowels and his ankle, which is why they are sore.
- The Urine: We found blood in Leo’s urine because the blood tubes in his kidneys are also a bit inflamed.”
The Management Plan:
“The good news is that for most children, this settles down on its own with rest and some Panadol for the pain. However, because we found quite a bit of blood in his urine, we need to be very careful with his kidneys.
I would like to refer Leo to a Pediatrician (a child specialist) to monitor his kidney function and blood pressure over the next few weeks. If his tummy pain becomes very severe or if he starts vomiting, you must bring him straight back to the hospital.”