A child with bruising and a low platelet count — long case

Candidate instructions (10-minute long-case discussion)

You are the paediatric registrar in the emergency department. A previously well four-year-old boy presents with three days of increasing bruising over the limbs, a petechial rash over the ankles, and two episodes of epistaxis. He is afebrile, active and cheerful, with no hepatosplenomegaly or lymphadenopathy. His full blood count shows a haemoglobin of 124 g per litre, a white-cell count of 7.2 × 10⁹ per litre, a neutrophil count of 3.1 × 10⁹ per litre, and a platelet count of 10 × 10⁹ per litre, with a normal film showing no blasts. The examiner asks you to discuss the triage, the diagnosis and the exclusion of leukaemia, the management, the safety-netting, and the safeguarding assessment of his bruising. ^[3]

Your tasks are: ^[3]

1. Outline the triage of this child and how the sick-versus-well split directs your pathway. ^[2]
2. State the diagnosis and explain how you confirm it and exclude leukaemia. ^[3]
3. Outline the management, including when you would treat and with what, and the safety-netting for serious bleeding. ^[1]
4. Discuss how you would apply the safeguarding assessment to a bruising presentation, and what would change the picture to IgA vasculitis. ^[12]

You are not expected to manage refractory or chronic ITP independently — haematology is involved — but you should explain the first-line approach and the indications for referral. ^[2]