In the second of our series to help you avoid missing a diagnosis, Dr Des Spence offers advice on how to treat children – and parents 'Have you got any kids, doctor?' she spat. 'No,' I replied. 'Thought not!' came the response as the door slammed. So much for my textbooks, I thought – the real world is different. Our job is about reassurance and, it seems, having your own kids changes your perspective. Here are a few things I've learned about treating children.
•Parents must be given easy access to the surgery and this should be same day. Be wary of telephone advice.
•Explore the parental agenda – address concerns and expectations – then explain your thinking and management. Sharing uncertainty is a key theme.
•Children aren't great fakers and observation is king. Learn some kiddy culture, such as Barney (a nauseating purple singing dinosaur), and use distraction during observation. A bright, interactive, freely mobile kid is likely to be well. Examine children on the parent's knee and don't restrain to examine.
•'It's just a virus!' you think – but this is a diagnosis of exclusion. Consider the significant bacterial causes of fever – meningitis, urinary tract infection, pneumonia.
•Meningitis is rare. A typical septicemia presentation is acute with the classical haemorrhagic rash. Recently it was suggested that (a) severe leg pain that prevents standing, (b) cold hands or feet with a high temperature and (c) pallor and blue or dusky lips are early warning signs. A meningitis-type presentation displays neck stiffness, headache and straight leg raising. Hopping, as ever, is a useful screen.
•Breathlessness is always significant. Be aware of stridor, indrawing and signs of exhaustion. Consider croup, bronchiolitis, pneumonia and asthma – monitor and have a low threshold to refer.
•Always consider appendicitis. The child may present with a limp. They may have the classic signs and the hop test again is a useful screen.
•Consider UTI fever with no localising symptoms – urine specimens are difficult to obtain. Treat while you await urine culture results.
•Parents are neurotic. Give Supernanny-style parenting advice. Are the new psychological diagnosis in children – such as attention deficit hyperactivity disorder – valid? Referrals only feed this medical monster so be judicious in the use of psychology services.
•Finally, remember if you are worried about a patient but not sure whether admission is required, don't be afraid to phone the hospital and ask the specialist registrar to give an opinion. Remember the 'three strikes and you're out' GP rule – if a patient consults three times in quick succession with same symptoms, get a second opinion or admit to hospital.
Dr Des Spence is a GP trainer in Glasgow