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Case 1

This case write up is for an 11-year-old female who presented with 5 days of fever and sore throat followed by 1 day of bilateral leg swelling and pain. On examination, she had tonsillitis, swollen and tender knees and ankles with reduced movement, and a grade 2 systolic murmur. Investigations showed elevated inflammatory markers and a positive IgM for dengue. She was diagnosed with acute rheumatic fever based on the Jones criteria and a possible underlying rheumatic heart disease. She was admitted, treated with antibiotics and aspirin, and her symptoms improved. At discharge, she was started on long-term aspirin prophylaxis and scheduled for an echocardiogram

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Tony Chan
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18 views4 pages

Case 1

This case write up is for an 11-year-old female who presented with 5 days of fever and sore throat followed by 1 day of bilateral leg swelling and pain. On examination, she had tonsillitis, swollen and tender knees and ankles with reduced movement, and a grade 2 systolic murmur. Investigations showed elevated inflammatory markers and a positive IgM for dengue. She was diagnosed with acute rheumatic fever based on the Jones criteria and a possible underlying rheumatic heart disease. She was admitted, treated with antibiotics and aspirin, and her symptoms improved. At discharge, she was started on long-term aspirin prophylaxis and scheduled for an echocardiogram

Uploaded by

Tony Chan
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Case Write Up – 1

Patient Details
Name: Navisha Prasad
NHN: 990026656
DOB: 1/6/2012
Race: FID
Sex: Female
Date: 26/1/24

Admitting this 11yrs old, FID, F with nil comorbidities


c/o - fever x5/7
- sore throat x5/7
- bilateral leg swelling + pain x1/7

History of Presenting Illness


According to child’s grandmother, child had fever and sore throat for 5 days prior to having leg pain +
swelling for 1 day. The child was given paracetamol but the fever did not subside. Pt. however was
active and developed pain in the right ankle, which spread to the left knee before both ankles and
knees were paining. Pt. presented to Samabula HC yesterday and X-Ray was done and stat Benza IMI
was given.

ROS: (+) fever, (+) sore throat, (+) polyarthritis, (+) headache, (+) loss of appetite, (-) vomiting, (-)
loose bowel motion, (-) palpitations, (-) nausea, (-) chorea, (-) trauma, (-) chest pain, (-) fits, (+) PU
and BO

Past Medical History


(-) admissions
(-) allergies
(-) surgeries
(-) drugs

Pediatric History
 Mother was well, nil complication during pregnancy
 born through caesarean section secondary to abnormal presentation
 birth weight – 3.5kg
 nil complications at birth
 immunization was UpToDate according to grandmother
 developmental milestones achieved
 MCH card was not sighted
 no issues in school

Social History
 lives in Jittu Estate, Samabula
 6 people at home, with parents
 Proper hygiene at home

Family History
 Nil sick family members

On examination – patient lying supine, no obvious distress, alert to TPP, GCS-15/15


Vitals – P-83, RR-34, SpO2-99% RA, T-37.5, CBG-6, Weight-40.11kg
Physical Examination
HEENT ABDO
soft
(+) mild pallor
non-tender
(+) tonsilitis
(-) jaundice EXT
(+) moist oral mucosa (+) swollen bilateral knees + ankles
(-) Distended JVP (+) tenderness on affected joints
(-) adenopathy (-) redness
(-) warm to touch
CHEST
(+) mild loss of movements
Clear Lung Fields B/L
(+) neurovascular intact
CVS – (+) systolic murmur grade 2, radiating to
(-) rashes
mitral region
(-) nodules
(-) chorea
(+) good volume pulse
(+) cr<2 seconds

Investigations
Electrocardiogram

PR Interval – Normal
Normal Sinus Rhythm at 100 bps

Bloods

FBC RF - 9 LFT
WCC-16.5K ALP-258
Blood Culture – No Growth
HB-10.1 AST-42
for 48hrs
PCV/MCV-21/69 TP-78
PLT-434K RFT ALB-44
Na-137 LDH-727
ESR-135
K-4.5
Dengue – (+) IgG
CRP-355 Urea-3.7
Cr-44
ASOT-370
Cl-97

+ IgM Antibody detected

Assessment
1. Acute Rheumatic Fever (Jones Criteria Fulfilled (1 Major + 2 Minor)
2. R/O Rheumatic Heart Disease
3. Dengue (+) IgM

Plan
1. Admit to Children’s Ward
2. Bloods – FBC/ESR/CRP/RFT/LFT/LDH/RF/Serology/Blood Culture/ASOT
3. Stat Benza Penicillin 1.2mu IMI ON 25TH January, 2024
4. Meds
a. Cloxacillin 2g IV q6h
b. Gentamicin 240mg IV OD
c. Paracetamol 500mg PO q6h
d. Aspirin (60mg/kg) 600mg PO q6h
5. For Chest X-Ray
6. Monitor Vitals
7. Refer PRN

Pt.’s physical exam and vitals maintained the same through the admission with betterment of joint
pain and able to mobilize. On the 29th January, 2024.

Plan
1. Continue current dose of aspirin for x2/52 and review in outpatient with ESR on arrival for
possible weaning of dose in x2/52
2. RHD registration to be filled
3. Home today
4. Book for echo this week
5. Mother and child counselled on
a. ARF Pathophysiology
b. RHD Prophylaxis (monthly Benza 0.6mu IMI)
c. Need for review regularly
d. Aware on recurrence signs (joint pain + acute illness)
6. Home on Aspirin 600mg PO q6h and Omeprazole 20mg PO OD x2/52

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