A 4-Year-Old Girl Is Brought to the Emergency Department for Evaluation

A 4-year-old girl is brought to the emergency department for evaluation of a rash.  This morning, the family noticed "lots of little spots on her arms and legs" that have now spread to her chest and trunk.  Her mother also noticed several bruises over the lower extremities and says, "She had a nosebleed this morning but it stopped after a few minutes."  The patient and her family do not recall any preceding trauma.  She has no fever, vomiting, diarrhea, or decrease in appetite, but did have a "cough and runny nose a few weeks ago."  The patient has mild, intermittent asthma for which she takes albuterol as needed.  Immunizations are up to date.  Temperature is 36.7 C (98 F), blood pressure is 100/60 mm Hg, pulse is 100/min, and respirations are 20/min.  Physical examination shows a well-appearing, smiling girl.  Scattered petechiae and ecchymoses are noted over the upper and lower extremities, chest, and trunk.  There are 3 small hematomas on the buccal mucosa, and there is dry, crusted blood in the left nostril.  Cardiac, abdominal, and lymphatic examinations are normal.  Laboratory results are as follows: Which of the following is the most appropriate management for this patient?

A)Bone marrow biopsy
B)Emergency splenectomy
C)Intravenous immune globulin
D)Observation with repeat platelet count in 8 hours
E)Transfusion of packed red blood cells

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