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Child with sore joints

Clinical Discipline(s)/Organ System(s)
Hauora Māori, Orthopaedics, Paediatrics, Rheumatology
Progress Test Topic(s)
Child health, Musculoskeletal
Description
A 5 year old Niuean girl is brought to the local Emergency Department as she has difficulty walking. On examination she has tenderness in her left ankle and her right knee is tender and swollen.
Applied Science for Medicine 
   - Anatomy of bone and joints including epiphyses
   - Pathophysiology of bone and joint disease
   - Common pathogens causing bone and joint infection
   - Microbiology of Streptococcus and streptococcal disease; both invasive and non suppurative sequelae
   - Features of autoimmune disease, including rheumatic fever
   - Pharmacology of benzylpenicillin
Clinical and Communication Skills 
   - Recognition and management of sepsis
   - Elicit a history from patient and parents/caregivers
   - Perform musculoskeletal examination in infants and children
   - 'Red flags' for rheumatic fever/serious sepsis; rash, fever, systemic signs
   - Differential diagnosis of the child with swollen joints and recognition of those requiring urgent investigation and management
   - Major and minor criteria for diagnosis of rheumatic fever (Jones criteria)
   - Role of radiology in diagnosis of bone/joint infection and other bone joint abnormalities
   - Knowledge of indications and procedures for joint aspiration
   - Interpret inflammatory markers, ECG, joint aspirate
   - Management of rheumatic fever: acute management (bedrest/mobilisation/discharge), long-term antibiotic prophylaxis, family education
   - Management of juvenile arthritis: principles of immobilisation, splinting, passive and active movement; roles of physiotherapist, ophthalmologist
   - Communicate with patient and family/whānau in a way that addresses health literacy needs of patient and family/whānau
Personal and Professional Skills 
   - Communicate empathetically with child and caregivers
   - Parental role and decision-making for children
   - Convey importance of urgency and continuity of treatment with a view to limiting long-term sequelae
   - Knowledge of when to get social worker involved; entitlements: e.g. Child Disability Allowance, 'Healthy Homes'
Hauora Māori 
   - Disproportionate impact of rheumatic fever and infectious disease on Māori compared with non-Māori in New Zealand
   - Understand inequities in access to health services and quality of medical care for Māori compared with non-Māori, and implication of this to clinical decision making and management
Population Health 
   - Epidemiology of rheumatic fever; New Zealand rates in international context; rheumatic fever register
   - Social determinants of rheumatic fever
   - Current screening initiatives for rheumatic fever and options for reducing rates in New Zealand context
   - Long-term care and public health implications of rheumatic fever and heart disease; potential for community, primary care and school-based prevention programmes
   - Management of sore throat
   - Paediatric specialist services in New Zealand (e.g. orthopaedics, rheumatology, cardiology)
   - Immunisation: vaccine-preventable causes of arthritis (rubella, hepatitis B)
Conditions to be considered relating to this scenario
Common
septic arthritis, reactive arthritis (post-infectious), osteomyelitis, rheumatic fever, trauma (accidental), 'growing pains'
Less common but 'important not to miss'
non-accidental injury
Uncommon
juvenile chronic arthritis, Crohn's disease, Henoch-Schonlein purpura, psoriatic arthritis, malignancy