ROYAL 

AUSTRALIAN COLLEGE OF GENERAL PRACTITIONERS RACGP
Access Provided by:

Clinical Cases for General Practice Exams, 4e

Case 1: Kasey Kox

INSTRUCTIONS FOR THE DOCTOR

This is a long case.

Please take a history from Kasey. When you are ready, request examination findings and the results of surgery tests from the examiner and outline
your differential diagnosis. Outline your immediate investigations and negotiate a management plan with Kasey. Please answer the examiner’s
questions.

Scenario

Kasey is a 17-year-old Aboriginal girl who has not been seen at your Melbourne practice before.

The following is on her summary sheet:

Past medical history

Grommets as a child

Medications

Etonorgestrel contraceptive implant (Implanon)

Allergies

Nil known

Immunisations

As per schedule

Family history

Nil recorded

Social history

From Balgo in WA

Moved to Melbourne last year for boarding school.

INSTRUCTIONS FOR THE PATIENT, KASEY KOX

You are a 17-year-old Aboriginal girl from Balgo in WA who has a scholarship to complete year 12 in Melbourne. Over the past few days you have been
unwell with aches and pains. Five days ago, your left wrist was sore and warm. Then both wrists were affected, but they have improved.

Now your right knee has become really painful. It is difficult to walk or bend your knee so you couldn’t go to school today. You have a headache and
feel thirsty.
Downloaded 2021­2­8 8:6 A  Your IP is 14.201.138.207
Case 1: Kasey Kox, Page 1 / 6
You feel cold even though it’s warm outside. You have had no skin sores, no diarrhoea or vomiting, no abdominal pain, and no urinary symptoms.
©2021 McGraw Hill. All Rights Reserved.   Terms of Use • Privacy Policy • Notice • Accessibility

You like boarding school but you do get homesick. You spend a lot of time on social media connecting with your family back home.
You are a 17-year-old Aboriginal girl from Balgo in WA who has a scholarship to complete year 12 in Melbourne. Over the past few days you have been
unwell with aches and pains. Five days ago, your left wrist was sore and warm. Then both wrists were affected, but they have improved.
ROYAL AUSTRALIAN COLLEGE OF GENERAL PRACTITIONERS RACGP
Now your right knee has become really painful. It is difficult to walk or bend your knee so you couldn’t go to school today. You have a headache and
Access Provided by:

feel thirsty.

You feel cold even though it’s warm outside. You have had no skin sores, no diarrhoea or vomiting, no abdominal pain, and no urinary symptoms.

You like boarding school but you do get homesick. You spend a lot of time on social media connecting with your family back home.

You’ve recently been at home for the holidays and, if asked, you did have a sore throat a few weeks ago. As usual your three-bedroom house was
packed; there are often 12 people living there, depending on who is in the community.

Sexual health

You were sexually active with a boyfriend last year (aged 16) and would accept an STI check if offered.

You had the cervical cancer vaccines at school and haven’t had any screening tests yet.

Your periods are regular and very light since the contraceptive implant went in.

Social (home and education)

You are one of five children. Your older sister is studying medicine in Melbourne and you hope to be a teacher. You are fit and a keen Aussie rules
footballer.

Drugs and alcohol

You don’t smoke.

You’ve tried marijuana and alcohol at parties but take nothing regularly.

Family history

Your dad has diabetes and kidney problems.

Your mum had a heart operation in her 30s for her valves. If asked for more detail say, ‘rheumatic heart’ and that she takes blood thinners.

Your sister also has heart problems; if asked specifically, say she gets a monthly injection to prevent it getting worse.

The following is on your summary sheet:

Past medical history

Grommets as a child

Medications

Etonorgestrel contraceptive implant (Implanon)

Allergies

Nil known

Immunisations

As per schedule

Family history

Nil recorded

Social history
Downloaded 2021­2­8 8:6 A  Your IP is 14.201.138.207
Case 1: Kasey Kox, Page 2 / 6
From Balgo in WA
©2021 McGraw Hill. All Rights Reserved.   Terms of Use • Privacy Policy • Notice • Accessibility

Moved to Melbourne last year for boarding school.

 As per schedule

Family history
ROYAL AUSTRALIAN COLLEGE OF GENERAL PRACTITIONERS RACGP
Nil recorded
Access Provided by:

Social history

From Balgo in WA

Moved to Melbourne last year for boarding school.

Questions for the doctor

Will I need to go to hospital?

INFORMATION FOR THE FACILITATOR

Vital signs

Temperature 38.3°C

Pulse 80 bpm

BP 100/60

Sp02 99% room air

RR 20/min

BMI 22

ENT throat NAD

No cervical lymphadenopathy

Ears—bilateral scarred tympanic membranes

Chest clear

Heart sounds—systolic murmur

JVP normal

Abdomen soft and non-tender

Right knee warm to touch, obvious effusion, mild limitation in range of motion in all directions

Antalgic gait, significant limp but can weight bear

Left wrist—warm, mild tenderness to palpation

Skin NAD

U/A normal

BSL 4.5 mmol

ECG—see page 6.

With three minutes to go, or when the candidate finishes speaking, ask the following:

1. What are your differential diagnoses? Tell me your favoured diagnosis.

2. What blood tests are you going to do?

Downloaded 2021­2­8 8:6 A  Your IP is 14.201.138.207
Case 1: Kasey Kox, Page 3 / 6
3. What immediate management will you provide?
©2021 McGraw Hill. All Rights Reserved.   Terms of Use • Privacy Policy • Notice • Accessibility

4. What are the criteria for diagnosing acute rheumatic fever?

ECG—see page 6.

With three minutes to go, or when the candidate finishes speaking, ask the following:

ROYAL AUSTRALIAN COLLEGE OF GENERAL PRACTITIONERS RACGP
1. What are your differential diagnoses? Tell me your favoured diagnosis.
Access Provided by:

2. What blood tests are you going to do?

3. What immediate management will you provide?

4. What are the criteria for diagnosing acute rheumatic fever?

SUGGESTED APPROACH TO THE CASE

History

History of presenting complaint and risk factors for acute rheumatic fever need to be solicited.

A HEADDSSS (Home situation; Employment, Education, Economic situation; Activities, Affect, Ambition, Anxieties; Drugs, Depression; Sexuality;
Suicide, Self-esteem, Stress) approach is also valuable for this young woman who finds herself far from home and is unknown to the practice. Offering
a chaperone or an Aboriginal health worker if available would be helpful.

Examination

Vital signs

Joint examination—including other joints

Skin examination looking for skin sores (alternative source of Group A Strep) and erythema marginatum or subcutaneous nodules (both rare)

Cardiovascular, particularly auscultation of the heart and looking for signs of heart failure.

Investigations

FBC, UEC, CRP/ESR

Blood culture

Throat swab and swab any infected skin sores

Anti-DNase B

Anti-streptolysin O titre

Echocardiogram

STI screen

Surgery tests

ECG

Urinalysis.

Downloaded 2021­2­8 8:6 A  Your IP is 14.201.138.207
Case 1: Kasey Kox, Page 4 / 6
©2021 McGraw Hill. All Rights Reserved.   Terms of Use • Privacy Policy • Notice • Accessibility
Surgery tests

ECG
ROYAL AUSTRALIAN COLLEGE OF GENERAL PRACTITIONERS RACGP
Urinalysis.
Access Provided by:

Major criteria (need two major or one major and two minor for diagnosis plus evidence of preceding Group A streptococcal infection)

— Carditis, including subclinical evidence of rheumatic vasculitis on echocardiogram

— Polyarthritis or aseptic monoarthitis or polyarthralgia

— Erythema marginatum

— Subcutaneous nodules

— Chorea (Sydenham’s chorea does not need evidence of preceding Group A streptococcal infection, providing other causes of chorea are
excluded).

Minor criteria
Downloaded 2021­2­8 8:6 A  Your IP is 14.201.138.207
Case 1: Kasey Kox, Page 5 / 6
— Monoarthralgia
©2021 McGraw Hill. All Rights Reserved.   Terms of Use • Privacy Policy • Notice • Accessibility

— Fever (>38°C)
 — Subcutaneous nodules

— Chorea (Sydenham’s chorea does not need evidence of preceding Group A streptococcal infection, providing other causes of chorea are
ROYAL AUSTRALIAN COLLEGE OF GENERAL PRACTITIONERS RACGP
excluded).
Access Provided by:

Minor criteria

— Monoarthralgia

— Fever (>38°C)

— ESR > 30 or CRP >30

— Prolonged PR interval on ECG.

Management

Given the differentials in this case, hospital referral for further workup is appropriate. If septic arthritis can be excluded, benzathine penicillin would be
given for acute rheumatic fever and aspirin or NSAIDs would be first-line treatment for pain.

Ongoing management would include four-weekly benzathine penicillin as secondary prophylaxis of recurrent episodes of acute rheumatic fever with
the aim of preventing rheumatic heart disease.

COMMON PITFALLS

Doctors working outside areas with a high prevalence of acute rheumatic fever may not have this diagnosis at the forefront of their minds. Untreated
acute rheumatic fever leads to rheumatic heart disease, which causes significant morbidity and mortality, so it is an important disease not to miss.

ONLINE RESOURCES
ARF/RHD Guideline app

www.rhdaustralia.org.au

http://kamsc.org.au/wp-content/uploads/2016/11/Acute-Rheumatic-Fever-October-2016.pdf.

REFERENCES

Bossingham, D 2015, ‘Case study: Atypical arthritis: a young woman presents with fever and joint pains.’ How to Treat—Australian Doctor , Available at:
https://www.howtotreat.com.au/case-report/case-study-atypical-arthritis, accessed 18 March 2019.

Karthikeyan, G, Guilherme, L 2018, ‘Acute rheumatic fever’, Lancet , vol. 392 (10142), pp. 161–74. [PubMed: 30025809]

Downloaded 2021­2­8 8:6 A  Your IP is 14.201.138.207
Case 1: Kasey Kox, Page 6 / 6
©2021 McGraw Hill. All Rights Reserved.   Terms of Use • Privacy Policy • Notice • Accessibility