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P Org 6III 2
P Org 6III 2
Chapter 6
Mere is an 11 year old girl brought to hospital after 4 days of fever. She has pain in her right knee that is preventing her from walking.
2.
3. 4. 5. 6. 7.
Differential diagnoses
Main diagnosis
Triage
Emergency signs (Ref. p. 2, 6) Obstructed breathing Severe respiratory distress Central cyanosis Signs of shock Coma Convulsions Severe dehydration Priority signs (Ref. p. 6) Tiny baby Temperature Trauma Pallor Poisoning Pain (severe) Respiratory distress Restless, irritable Referral Malnutrition Oedema of both feet Burns
Oxygen?
Intravenous fluids?
Immediate investigations?
History
Mere was apparently well until 4 days ago when she developed a fever. She also had a painful left ankle for 2 days. Yesterday, she developed right knee pain with swelling and is now unable to walk. 2 weeks prior she had a sore throat that was treated by her aunty with a Fijian herbal remedy. She has had no rashes, no neck stiffness, no abdominal pain. She is not eating, but drinking OK. Past history: Mere had a similar episode of sore joints 1 year ago. Family history / social history: lives in a rural village with her large extended family.
Examination
Assess signs of systemic illness Temp: 38.9C Pulse: 110/min RR: 20/min BP 115/65 mmHg Assess chest and heart Chest clear, systolic murmur loudest at the apex and radiating to the axilla. No thrill. Apex beat normally placed. Assess abdomen Soft to palpation, normal bowel sounds, no organomegaly Assess neurological state AVPU = A (alert), no neck stiffness, pupils equal and reactive Assess skin No rashes Assess nutritional state Height: 135 cm Weight: 30 kg Assess MSK Hot and swollen right knee that is very tender to touch (Ref. p.150, p.154)
1. Fever with no localising signs (no rash) 2. Fever with localising signs (no rash) 3. Fever with rash 4. (Fever lasting longer than 7 days)
Differential diagnoses
List possible causes of the illness
Main diagnosis
Secondary diagnoses (Tables 16, 17, 19 may be helpful) Differential diagnoses:
Septic arthritis
Rheumatic fever Dengue
Joint aspiration?
Arthritis unaccompanied by other major manifestations of rheumatic fever deserves differential diagnosis from many clinical entities .
Investigations
Full blood examination:
Haemoglobin: Platelets: WCC: Neutrophils: Lymphocytes: Monocytes: 110g/l (115-140) 450x109/l (150 400) 16.2x109/l (5.5 15.5) 7.9x109/l (1.5 8.5) 4.0x109/l 1.2x109/l (2.0 8.0) (0.1 1.0)
Investigations (continued)
Blood culture: sent, awaiting cultures ESR: sent, awaiting result
ECG: normal
CXR: normal ASOT: sent, awaiting result
Diagnosis
Summary of findings: History: 11 yo girl with PHx of joint pains presents with polyarthritis Exam: febrile but non-toxic with right knee arthritis and a cardiac murmur
Diagnosis
Likely acute rheumatic fever
2.
3. 4. 5. 6. 7.
Differential diagnoses
Main diagnosis
Treatment
Suspected acute rheumatic fever
(Ref p. 367)
Supportive Care
Fever control Pain control Bed rest Nutrition
Monitoring
Nurses should monitor the child's state using a monitoring chart (Ref. p. 320, 413) Assess response to treatment (Ref .Chart 1 p.xxii; p. 319) Expected response to treatment Is there an alternate diagnosis Consider the complications of the disease Consider the complications of the treatment Follow-up results ASOT 1600 BC ve ESR 88mm/h
Discharge plan
Mere responds quickly to the aspirin and her joint pain reduces significantly within 2 days; her fever also reduces She is able to walk adequately She is eating well after 2 days
Follow-up
Regular benzathine penicillin G every 28 days Register the patient on the National RHD Register Echocardiogram and paediatric review Reinforce education Advise the mother when to bring the child back if unwell
Major manifestations Polyarthritis Carditis Chorea Erythema marginatum Subcutaneous nodules Minor manifestations Polyarthralgia Fever, Elevated inflammatory markers Prolonged PR interval on ECG Evidence of antecedent Group A Streptococcus infection in the last 45 days Elevated or rising streptococcal antibody titre (ASOT) Positive throat swab
Primary episode of acute rheumatic fever Two major OR one major and two minor Evidence of Group A Streptococcal antecedent No History of RHD Other forms exist Recurrent episode with and without RHD Rheumatic chorea (chorea only) Insidious onset rheumatic carditis (carditis only) Chronic valve lesions of RHD
Summary
Careful history taking, examination and the investigations pointed towards a diagnosis of acute rheumatic fever However, more serious causes of fever and joint pain should be excluded AND/OR treated presumptively, e.g. Septic arthritis
In regions of where rheumatic heart disease is prevalent: Acute rheumatic fever should be considered whenever a child presents with a history of joint pain. Acute rheumatic fever confers a risk of progression to rheumatic heart disease and therefore long term secondary prevention is essential.