Approach to rash in infants and children — OSCE

Candidate brief (read outside)

You are the paediatric registrar. A 14-month-old is brought in by a parent with a 12-hour history of fever, irritability and a rash on the limbs; the parent has noticed that some spots do not fade when pressed with a glass. The child looks drowsy. You have 8 minutes to assess the child, communicate with the parent, and agree an immediate plan. A nurse can help. [7]

Encounter and clinical reasoning

• Acknowledge the parent, confirm the child's identity, and start with the sick-or-well assessment: the child is drowsy, so this is an emergency regardless of the rash.
• Examine with the parent present: fully undress the child, look at the whole skin including mucosae, palms and soles, and test blanching with a glass slide - the non-blanching purpura in a febrile, unwell child is presumed meningococcaemia until proven otherwise.
• Run the immediate bundle: oxygen, IV or IO access, blood cultures and a parenteral third-generation cephalosporin per local paediatric sepsis protocol, fluids for shock; involve senior staff and retrieval. [7]

Communication domains

• Use clear, non-technical language; explain that the rash is a sign the body is seriously unwell and that you are starting treatment immediately.
• Share the reasoning briefly: the spots that do not fade with the glass tell you blood is leaking into the skin, which in a feverish, drowsy child means you treat for a serious infection now.
• Gain consent for the emergency bundle; explain you will not wait for tests.
• Reassure that the team is being mobilised, give the parent a role (staying with the child), and commit to updating them. [1]

Marking domains

• Clinical reasoning: sick-or-well first; non-blanching purpura in an unwell febrile child equals presumed sepsis; immediate bundle.
• Communication: plain language, shares reasoning, gains consent, supports the parent.
• Patient safety: no delay for tests; escalates and retrieves; safety-net.
• Organisation: calm, structured, time-managed. [7]