Case History
10 month old boy. Taken to GP with h/o sudden onset of fever, vomiting and lethargy for 4 hours. Mother very anxious about child. GP referred child to walk-in clinic at hospital.
History on admission: Feverish and drowsy – sudden onset. 2 episodes of vomiting, 1 soft stool, no rash.
Assessment on admission:
Drowsy and pale, dark rings around eyes.
Temp 37.7
CVS: P 181, BP 120/52. CRT ( capillary refill time) 4 secs. Child peripherally shutdown.
RS: RR 32 breathing laboured and child cyanosed.
SaO2 100% in oxygen.
NS: GCS10 then 9, no neck stiffness. Fine blanching rash on abdo/chest. 1 petechial spot on abdo.

Questions
What might sudden onset of illness in an otherwise well child suggest?
What do you think of this assessment?
What do these signs tell you? How would you interpret the normal blood pressure in the context of other observations?
When conscious level is depressed and/or falling, is severity of disease likely to be worse when signs of meningitis are present, or when they are absent?
Is the very scanty rash a reassuring sign?