Assessment

HISTORY. Usually, the patient has a sore throat and a fever of at least 100.4°F a few days to several weeks before the onset. The patient either may have been treated with antibiotics or may not have completed a full course of treatment. Determine if the patient has experienced migratory joint tenderness (polyarthritis), chest pain, fever, and fatigue. Some patients describe unexplained nosebleeds as well. Patients with pericarditis may describe sharp pain over the shoulder that radiates to the neck, back, and arms. The pain may increase with inspiration and decrease when the patient leans forward from a sitting position. Patients with heart failure may describe shortness of breath, cough, and right upper quadrant abdominal pain. In addition, the patient may describe fatigue or activity intolerance, along with periorbital, abdominal, or pedal edema.

PHYSICAL EXAMINATION. The patient may have a distinctive red rash, referred to as erythema marginatum. This nonpruritic rash appears primarily on the trunk of the body, the buttocks, and the extremities; it appears on the face in only rare instances. In addition, subcutaneous nodules of less than 1 cm in diameter form on the skin. Painless and movable, they usually appear over bony prominences: the hands, wrists, elbows, knuckles, feet, and vertebrae. If the patient has heart failure, there may be peripheral edema.

The patient may also demonstrate chorea (previously referred to as St. Vitus' dance). Mild chorea produces hyperirritability, problems concentrating, and illegible handwriting. Severe chorea causes purposeless, uncontrollable, jerky movements and muscle spasms, speech disturbances,

820 Rheumatic Fever, Acute muscle fatigue, and incoordination. Transient chorea may not appear until several months after the initial streptococcal infection.

When the joints are palpated, the patient may have migratory polyarticular arthritis (more than four joints are progressively involved). The most frequently involved joints include the knees, elbows, hips, shoulders, and wrists. These joints are extremely warm and tender to the touch, and even a light palpation can cause pain. The pain usually subsides after the patient becomes afebrile.

Heart murmurs serve as an indicator that carditis has occurred. The aortic and mitral valves are particularly involved as a result of the Aschoff bodies (small nodules of cells and leukocytes) that form on the tissues of the heart. You are more likely to hear the murmurs at the third intercostal space right of the sternum for the aortic valve and at the apex of the heart if the mitral valve is involved. When you palpate peripheral pulses, you may note a rapid heart rate.

PSYCHOSOCIAL. The disease is likely to occur at an age when children are active and industrious. Those that require extended bedrest may have trouble coping with the limitations placed on them.

Diagnostic Highlights

Modified Jones Criteria (American Heart Association major and minor criteria). To

make the diagnosis, there needs to be evidence of a previous streptococcal infection

and two major Jones criteria or one major plus two minor Jones criteria.

Criteria

Description

Explanation

Major manifestations

Carditis

Cardlomegaly, new murmur, congestive heart

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