According to NICE, 3 or more loose or liquid stools in a day (or more frequently than is normal for the individual) counts as diarrhoea.
Persisting for more than 14 days makes it chronic.
Acute typically gastroenteritis. Presence of blood and/or mucus suggests more invasive inflammation, viz colitis.
In kids, can occur with pretty much any illness!
Vomiting with diarrhoea makes a primary gut cause more likely, but still not specific.
Acute bloody diarrhoea usually infective –
Usually worse abdominal pain than usually seen in gastroenteritis, can also be high fever. If severe, shigella/campylobacter can be treated with antibiotics.
If chronic, consider
Some serious causes:
An added sound heard when listening with a stethoscope, distinct from heart sounds or other clicks or snaps.
Can indicate a structural abnormality. But can be heard in normal hearts too, esp kids.
Or “innocent” murmur. Characteristic vibratory, low pitched, crescendo-decrescendo sound – “like an Aeolian harp” – loudest along left sternal border. Never louder than grade 3. Typically gets quieter when child sits or stands up (reduced venous return?) – you would not expect a murmur caused by a structural abnormality to change much.
Present at any age. Usually goes away by adolescence.
Another innocent one, a rumble heard in the upper chest, disappears when lying down, or when neck turned or neck veins occluded gently.
Pulmonary valve closest to anterior chest wall, which might explain why you sometimes hear this. Might be confused with pulmonary stenosis or subaortic membrane.
Or erythema subitum, or Sixth disease. Dramatic viral rash. Caused by Herpesvirus 6 and 7.
Classically high fever, URTI symptoms or no focus, potentially febrile convulsion! Then rash appears as fever subsides, day 2-4.
Rash is widespread fine maculopapular, can be pale haloes around spots, mostly on trunk. Can be in mouth! Not itchy.
A viral rash, sometimes dramatic, can last for months! Typically young adults. Some characteristic features:
Yes if under 28 days and febrile.
Older infants who otherwise appear well and have a positive urine dipstick or microscopy to suggest UTI, do not routinely require a lumbar puncture to exclude bacterial meningitis – PECARN study of 697 febrile infants aged 28-60 days with suspected UTI found no cases of bacterial meningitis.
In bronchiolitis, wide variation in practice – NICE bronchiolitis guidelines do not comment, and NICE suspected sepsis guidelines do not say that bronchiolitis exempts you from “suspected sepsis”.
Increasing RBC counts were statistically associated with increasing WBC counts (P < .001). But in febrile babies under 90 days,where RBC < 10 000/mm3 no real impact and reference range for WBC in uninfected infants with traumatic lumbar punctures was still 0 to 16/mm3.
CSF protein increased linearly with increasing CSF RBCs (up 1.1 mg/dL for every 1000 RBC).
Correct 500:1? Sounds good in theory, but not in practice. Predicted leukocytes matched observed leukocytes poorly for 682 CSF specimens. Adjusted blood counts in CSF have no advantage over uncorrected counts for predicting bacterial meningitis. [PIDJ ;25(1):8-11DOI: 10.1097/01.inf.0000195624.34981.36 · ]
Rare in developed world now, still common in underdeveloped world, or at least in underdeveloped communities eg Aboriginal Australians. Prob also genetic susceptibility.
Autoimmune, multisystem disease triggered by Group A streptococcus infection. Important cause of acquired heart valve disease.
Can recur.
Probably cross reactivity between specific Group A strep M proteins and human tissues.
Jones criteria:
Note that initial infection may be subclinical eg pharyngitis, erysipelas. Symptoms of rheumatic fever develop 10 days to several weeks later. Chorea can appear months later. Low threshold for echo as carditis can also be subclinical.
Established criteria for rheumatic valvulitis – Gewitz 2015
Antibiotics – Treat with penicillin, this does not however affect clinical course but hopefully prevents further spread of that particular bug. Traditionally single dose intramuscular Penicillin G Benzathine.
NSAIDs for joint pain. Usually dramatic response, if not then reconsider diagnosis!
Valproate for chorea, possibly steroids – see Sydenham’s.
Aspirin and/or Steroids for carditis, but not much evidence. Diuretics, ACE inhibitors for cardiac failure.
Recurrence with progression of valve damage is the main concern, and well recognized. Subclinical carditis improves in about 50% but definite risk of progression (mild definite and borderline RHD showed 26% and 9.8% echocardiographic progression respectively).
Regular intramuscular penicillin (benzathine pencillin G) every 2-3 weeks has the lowest recurrence rates but oral penicillin V more acceptable. Erythromycin or cephalexin if allergic.
WHO recommendations:
American and Australian heart association guidelines vary slightly:
Seizures, fits, funny turns, convulsions, attacks… None of these really has a medical meaning. Convulsion suggests rhythmic motor activity, but that’s about it. The implication of most of these is that there is excessive abnormal, involuntary muscle contraction, usually bilateral. But more broadly, some involuntary, usually sudden and self terminating episode of abnormal (or at least non-purposeful) activity and/or impaired awareness. Can be sustained or interrupted.
Nottingham RCPCH approved guideline distinguishes:
Most commonly Febrile convulsions ie age related, benign. Beware complex (multiple seizures in same illness, focal features, prolonged >15 mins) and any abnormal findings eg neck stiffness, bulging fontanelle, prolonged illness, abnormal cognition before/after.
Important differentials are:
May represent first evidence of epilepsy.
Horner’s syndrome = small pupil, ipsilateral ptosis +/- reduced sweating. Compare Holmes Adie pupil.
Anhidrosis localizes lesion to preganglionic branch.
Turn down the lights to make it more obvious! Look for associated Klumpke’s.
In babies usually congenital or related to birth trauma, rarely it can be due to:
Other cranial nerve involvement clearly points to brainstem problem.
[British Journal of Ophthalmology 1998;82:51-54. ]
The foreskin cannot, and should not, be retracted in newborn babies. It should gradually begin to separate in the first few years of life. Sometimes it takes until puberty.
Retraction should lead to a pouting appearance of the foreskin. Technically this is not phimosis, which implies an abnormality. Some ballooning with micturition is seen, and is not an indication for surgery.
Can try application of topical steroid cream to speed up separation eg 0.025% betamethasone (1 in 4, or RD) cream twice daily for 2 to 4 weeks. Gently retract foreskin without causing any discomfort and apply a thick layer of cream to the tightest part of the foreskin. Steroid creams of higher potency may be tried if this fails.
Inflammation of the foreskin (posthitis), glans (balanitis) responds usually just to hygiene measures – bathing, cleaning, drying. Antibiotics might be needed if spreads on to shaft. Topical steroids can help.
Circumcision if significant phimosis and steroid creams fail.
Retained smegma can accumulate into substantial but painless lumps down the shaft of the penis. Can be ignored.
A form of lichen sclerosus affecting the tip of the penis. No pouting of foreskin seen on retraction. Can be white, crinkly thickening. Can be bleeding, discomfort. No good evidence for topical steroids, usually surgical treatment.