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Bleeding gums


“So how long have you had the headache?” I ask. I am at one of our most remote clinics. Two hours drive from the hospital, the last 30 mins bumping along dirt road.

“Just today,” she replies. The patient is a teacher in her thirties with excellent English.

“Any other problems?” She shakes her head, and then stops, looking thoughtful.

“I did cough up a little blood this morning.” She opens her mouth wide, and sure enough there is a little fresh blood on her tongue. There is no torch so I angle her head towards the window through which the still hot winter sunlight is streaming in. I pull up her lip and see a small area of the gum is bleeding. And there, on her palate at the back of her mouth are numerous small red spots, petechiae. The rest of her examination is completely normal.

Guiltily I move from “coasting” to “thinking” mode. It is a terrible thing to confess but we see so many people with non-specific “aches and pains” that it is all to easy to adopt the “take paracetamol and come back in 2 weeks if it doesn’t get better” approach. What we as hospital physicians, safely insulated from the public frontline. used to self-righteously joke about as the “GP-way”.

“Have you any rashes on your skin?” She shakes her head. “Any bruising? Fever?” No. “And you have been completely well over the last few months?” Yes. “Have you ever had an HIV test?” Last year and it was negative. I scratch my head. If I had seen this lady at the hospital I would have been able to do various tests there and then. Out here I am a bit stuck.

“Do you have a cellphone?” Yes, she does. I turn to Sister. “Could you take a blood count?” She nods. “Ok – so take the blood count, and I will take it to the hospital tonight. Then I will phone you to let you know the result and what we must do.”

There are a few classic causes of a rash like that in an individual who otherwise looks well – and none of them are great news.

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