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Recognising meningococcal disease in primary care: qualitative study of how general practitioners process clinical
1Department of General Practice and Primary Care, King's College School of Medicine and Dentistry, London.
Objectives:
To describe the presentation of meningococcal disease in primary care; to explore how general practitioners process clinical and contextual information in children with meningococcal disease; and to describe how this information affects management.
Design:
Qualitative analysis of semistructured interviews.
Setting:
General practices in South Glamorgan.
Subjects:
26 general practitioners who between January 1994 and December 1996 admitted 31 children (under 16 years of age) in whom meningococcal disease was diagnosed.
Main Outcome Measures:
Categories of clinical rules and techniques used by general practitioners in processing each case.
Results:
22 children had rashes; in 16 of them the rashes were non-blanching. When present, a haemorrhagic rash was the most important factor in the doctor's decision to admit a child. 22 children had clinical features not normally expected in children with acute self limiting illnesses--for example, lethargy, poor eye contact, altered mental states, pallor with a high temperature, and an abnormal cry. Contextual information, such as knowledge of parents' consultation patterns and their normal degree of anxiety, played an important part in the management decisions in 15 cases. Use of penicillin was associated with the certainty of diagnosis and the presence and type of haemorrhagic rash.
Conclusion:
The key clinical feature of meningococcal disease--a haemorrhagic rash--was present in only half of the study children. The general practitioners specifically hunted for the rash in some ill children, but doctors should not be deterred from diagnosing meningococcal disease and starting antibiotic treatment if the child is otherwise well, if the rash has an unusual or scanty distribution, or if the rash is non-haemorrhagic.