Clinical Signs and Diagnosis of Subacute Bacterial Endocarditis

Subacute bacterial endocarditis (SBE) is a condition caused by Streptococcus viridans, an oral commensal, and presents with malaise, weakness, and low-grade fever. Diagnosis is often delayed due to non-specific presentation, but it should be suspected in any febrile or unwell patient with a new or changing murmur. The three classic clinical signs of SBE are finger clubbing, Roth spots, and Osler’s nodes, along with Janeway lesions, which are subcentimeter, non-tender, raised papules on the palms and soles of the feet. Confirmation of SBE usually requires three separate sets of blood cultures taken in a 24-hour period, ideally during times the patient is febrile.

While Janeway lesions may be found in systemic lupus erythaematosus (SLE), the combination of the three described findings is unique to SBE. Tuberculosis does not present with the above constellation of findings but would be expected to present with chronic cough, haemoptysis, fever, and night sweats. Subacute meningococcal septicaemia typically gives a non-blanching petechial rash in the context of fulminating sepsis and does not present subacutely as described here. Rheumatoid arthritis (RA) patients may have subcutaneous rheumatoid nodules on the extensor surfaces of the limbs, but RA does not give the findings described.

Type II diabetes is commonly diagnosed in patients over 40 years old, with many patients showing no symptoms. However, when symptoms do occur, they often include increased thirst (polydipsia), frequent urination (polyuria), excessive hunger (polyphagia), blurred vision, yeast infections (balanitis in men), peripheral neuropathy, and bed-wetting (nocturnal enuresis) in younger patients with type I diabetes. While patients with type II diabetes are often overweight, they typically present with recent weight loss rather than weight gain. Markedly elevated ketones are not a common presentation of type II diabetes, but may occur in advanced stages of the disease. Oliguria, or decreased urine output, is not typically seen in patients with type II diabetes, as they tend to experience excessive thirst and increased urine output.

If a child is experiencing hip pain or a limp and also has a fever, it is important to refer them for same-day assessment, even if the suspected diagnosis is transient synovitis.

Based on the child’s age, overall health (aside from the fever), recent cold, and examination findings (limited movement but a normal-looking joint without significant restriction), transient synovitis is the most likely cause of the hip pain. While this condition can be managed with pain relief and typically resolves on its own, any child with hip pain and a fever should be assessed immediately to rule out septic arthritis.

In secondary care, the Kocher criteria are used to determine the likelihood of a septic joint based on a combination of signs and symptoms (fever and non-weight bearing) and blood tests (ESR and white cell count).

A routine hip ultrasound is not necessary in this case, as it is typically used to screen for developmental dysplasia of the hip in newborns or those with risk factors. Bilateral hip x-rays are also not required, as they are used to investigate suspected Perthes’ disease, which presents differently and is more common in slightly older children.

Conservative management is appropriate for transient synovitis, but it is important to have a low threshold for referral to secondary care given the potential for septic arthritis. A routine referral to paediatric orthopaedics is not necessary for either transient synovitis or septic arthritis.

Transient synovitis, also known as irritable hip, is a common cause of hip pain in children aged 3-8 years. It typically occurs following a recent viral infection and presents with symptoms such as groin or hip pain, limping or refusal to weight bear, and occasionally a low-grade fever. However, a high fever may indicate other serious conditions such as septic arthritis, which requires urgent specialist assessment. To exclude such diagnoses, NICE Clinical Knowledge Summaries recommend monitoring children in primary care with a presumptive diagnosis of transient synovitis, provided they are aged 3-9 years, well, afebrile, mobile but limping, and have had symptoms for less than 72 hours. Treatment for transient synovitis involves rest and analgesia, as the condition is self-limiting.

Distinguishing Irritable Bowel Syndrome from Other Gastrointestinal Disorders

Irritable bowel syndrome (IBS) is a common gastrointestinal disorder that affects more women than men and is often associated with affective disorders. Symptoms of IBS may vary throughout the menstrual cycle, but it is important to rule out other possible diagnoses such as endometriosis. Physical exams and tests are typically normal in IBS, but any unintentional weight loss, rectal bleeding, nocturnal diarrhea, fecal incontinence, or onset of persistent GI symptoms after age 40 requires further assessment. Management of IBS may include dietary changes and medication such as antispasmodics, anti-diarrheals, laxatives, and even Antidepressants. Other gastrointestinal disorders such as chronic pancreatitis, diverticulitis, peptic ulcer disease, and ulcerative colitis have distinct clinical features that can help differentiate them from IBS.

Differential Diagnosis: Addisonian Crisis and Other Conditions

Addisonian crisis is a condition caused by adrenal insufficiency, with autoimmune disease being the most common cause in the UK. Symptoms are vague and present insidiously, including depression, anorexia, and GI upset. Diagnosis is made through a short ACTH stimulation test. Emergency treatment involves IV hydrocortisone and fluids, while long-term treatment is based on oral cortisol and mineralocorticoid. Any stressful activity should lead to an increase in steroid dose.

Other conditions, such as insulin overdose, salicylate overdose, meningococcal septicaemia, and paracetamol overdose, have different clinical features and are not compatible with the symptoms described for Addisonian crisis. It is important to consider these differential diagnoses when evaluating a patient with similar symptoms.

If a child under 3 months old is suspected to have a UTI, it is important to refer them to specialist paediatrics services. In the case of a baby with a persistent fever and no clear source of infection, a urine sample should be collected to check for a UTI. It is important to note that a raised temperature alone is considered a red sign according to NICE guidance for assessing fever in children, and the child should be referred for urgent paediatric assessment. It would be inappropriate to reassure the mother that this is just a virus and can be managed at home, and using paracetamol to manage the fever would not be acceptable in this case. While antibiotics may treat the infection, waiting a week for a review could be dangerous for an unwell child who may deteriorate rapidly. Referring the child for a routine review with paediatrics would also not be appropriate, as urgent attention is required. While a health visitor may be helpful for feeding issues, the short history of poor feeding and fever suggests that the baby is struggling to feed due to illness, and this would not address the current presentation.

Urinary tract infections (UTI) are more common in boys until 3 months of age, after which the incidence is substantially higher in girls. Presentation in childhood depends on age, with infants showing poor feeding, vomiting, and irritability, younger children showing abdominal pain, fever, and dysuria, and older children showing dysuria, frequency, and haematuria. NICE guidelines recommend checking urine samples in children with symptoms or signs suggestive of a UTI, unexplained fever of 38°C or higher, or an alternative site of infection but who remain unwell. Urine collection should be done through clean catch or urine collection pads, and invasive methods should only be used if non-invasive methods are not possible. Management includes referral to a paediatrician for infants less than 3 months old, admission to hospital for children aged more than 3 months old with an upper UTI, and oral antibiotics for 3-10 days for children aged more than 3 months old with a lower UTI. Antibiotic prophylaxis is not given after the first UTI but should be considered with recurrent UTIs.

Gross Motor Developmental Milestones

Gross motor skills refer to the ability to use large muscles in the body for activities such as crawling, walking, running, and jumping. These skills are essential for a child’s physical development and are achieved through a series of developmental milestones. The table below summarizes the major gross motor developmental milestones from 3 months to 4 years of age.

At 3 months, a baby should have little or no head lag when pulled to sit and should have good head control when lying on their abdomen. By 6 months, they should be able to lift and grasp their feet when lying on their back, pull themselves to a sitting position, and roll from front to back. At 9 months, they should be able to pull themselves to a standing position and crawl. By 12 months, they should be able to cruise and walk with one hand held. At 18 months, they should be able to walk unsupported and squat to pick up a toy. By 2 years, they should be able to run and walk up and down stairs holding onto a rail. At 3 years, they should be able to ride a tricycle using pedals and walk up stairs without holding onto a rail. By 4 years, they should be able to hop on one leg.

It is important to note that while the majority of children crawl on all fours before walking, some children may bottom-shuffle, which is a normal variant that runs in families. These milestones serve as a guide for parents and healthcare professionals to monitor a child’s physical development and identify any potential delays or concerns.

To maintain a patent ductus arteriosus in cyanotic congenital heart diseases, prostaglandin E1 should be administered. It is helpful to recall the 5 T’s for cyanotic CHD, which include Tetralogy of Fallot, Transposition of Great Vessels (TGA), Tricuspid Atresia, Total Anomalous Pulmonary Venous Return, and Truncus Arteriosus. Based on the timing of onset and heart murmur, the patient in this case likely has TGA with a concurrent VSD. TGA typically presents shortly after birth. Prostaglandin E1 is given in ductal dependent cyanotic heart diseases to prevent closure of the patent ductus arteriosus until surgical correction can be performed. This allows for mixing of oxygenated and deoxygenated blood to ensure adequate systemic circulation. Antibiotics should also be administered as prophylaxis for bacterial endocarditis. It is important to note that nonsteroidal anti-inflammatory drugs (NSAIDs) such as indomethacin and ibuprofen will actually close the ductus arteriosus and should not be used in this situation.

Cyanosis, a bluish discoloration of the skin, is a common occurrence in newborns. Peripheral cyanosis, which affects the hands and feet, is often seen in the first 24 hours of life and can be caused by crying or illness. Central cyanosis, on the other hand, is a more serious condition that occurs when the concentration of reduced hemoglobin in the blood exceeds 5g/dl. To differentiate between cardiac and non-cardiac causes of central cyanosis, doctors may use the nitrogen washout test, which involves giving the infant 100% oxygen for ten minutes and then measuring arterial blood gases. A pO2 of less than 15 kPa indicates cyanotic congenital heart disease, which can be caused by conditions such as tetralogy of Fallot, transposition of the great arteries, and tricuspid atresia.

If cyanotic congenital heart disease is suspected, initial management involves supportive care and the use of prostaglandin E1, such as alprostadil, to maintain a patent ductus arteriosus in ductal-dependent congenital heart defects. This can serve as a temporary measure until a definitive diagnosis is made and surgical correction is performed.

Acrocyanosis, a type of peripheral cyanosis, is a benign condition that is often seen in healthy newborns. It is characterized by bluish discoloration around the mouth and extremities, such as the hands and feet, and is caused by vasomotor changes that result in peripheral vasoconstriction and increased tissue oxygen extraction. Unlike other causes of peripheral cyanosis that may indicate significant pathology, such as septic shock, acrocyanosis occurs immediately after birth in healthy infants and typically resolves within 24 to 48 hours.

For patients with menorrhagia who have completed their family and do not have any underlying pathology, pharmaceutical therapy is recommended. The first-line management for these patients, according to NICE CKS, is the Mirena coil, provided that long-term contraception with an intrauterine device is acceptable.

Managing Heavy Menstrual Bleeding

Heavy menstrual bleeding, also known as menorrhagia, is a condition where a woman experiences excessive blood loss during her menstrual cycle. While it was previously defined as total blood loss of over 80 ml per cycle, the management of menorrhagia now depends on the woman’s perception of what is excessive. In the past, hysterectomy was a common treatment for heavy periods, but the approach has changed significantly since the 1990s.

To manage menorrhagia, a full blood count should be performed in all women. If symptoms suggest a structural or histological abnormality, a routine transvaginal ultrasound scan should be arranged. For women who do not require contraception, mefenamic acid or tranexamic acid can be used. If there is no improvement, other drugs can be tried while awaiting referral.

For women who require contraception, options include the intrauterine system (Mirena), combined oral contraceptive pill, and long-acting progestogens. Norethisterone can also be used as a short-term option to rapidly stop heavy menstrual bleeding. The flowchart below shows the management of menorrhagia.

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Management of Acutely Hot and Swollen Knee Joint: Aspiration, Antibiotics, and Arthroscopy

Any patient presenting with an acutely hot and swollen joint should be treated as septic arthritis until proven otherwise. To diagnose and treat this condition early, the knee joint should be aspirated and the aspirate should be analyzed for white cells and microorganisms. IV antibiotics are necessary after the knee joint has been aspirated to increase the yield of the knee aspiration. Blood cultures have already been taken and further cultures are not required at this stage. An ultrasound scan of the knee may reveal increased joint fluid and swelling suggestive of infection or inflammation, but it will not confirm any infection. After the knee aspiration, if there was any pus, an arthroscopy and washout of the joint should be done to clear the joint of the infective fluid and protect the articular junction.