Lecture Paediatric Rheumatology

Question 1

You are the doctor take a history from this five year old boy who has a swelling on his right knee. Discussion based flash card

Answer 1

So starting from the beginning confirm name age date of birth presenting complaint is already established
extra to know within the presenting complaint is how long the problem has been going on for
in the history of the presenting complaint you want to ask about the details of the knee swelling which comes in the form of an open question after receiving information from the open question identify how many problems there are. Then ask more about timing going retrospective and asking how the patient felt before noticing this problem were there any warning signs which covers onset and then ask about how the problem has progressed then you want to identify any other sites get a good description find out if there’s anything that he’s tried that makes it better but anything that makes it worse find out if there are any other problems associated with the knee swelling. In fact the most important part of this history of presenting complaint are the associated symptoms with kidney swelling because the Red Flag differential to rule out in this case is septic arthritis which you would expect that the child would have a red hot swollen knee you may also expect to see other signs of infection where
if it was something like reactive arthritis you may expect the child to have had an infection prior to the presenting complaint today

Question 2

hi Dr I just want to make sure that I have covered everything before I go and take this history from a 4 year old child who has come in with his mother
What are the extra points in a paediatric history that you must ask that are different from an adult history.

Answer 2

In the history of presenting complaint you must ask about feeding drinking pooing weeing and sleeping and any problems in school.

In the past medical history in must ask about the pregnancy of the particular child. Specifically you must ask about any problems during pregnancy any problems with labour how the baby was delivered how much the baby weighed weather there was any time spent in the neonatal intensive care unit. In the drugs history you must ask about immunisations. In the social history you must ask about developmental milestones and School.

Question 3

Hi Dr I am a fourth year medical students practicing my end blurb after completing a paediatric examination what should I say to show completeness of my examination

Answer 3

Summary of findings example I have examined such and Such who is a 3 year old child with no significant medical background. Overall the findings are abnormal. On inspection the child looks on palpation this area was tender on auscultation such and such.
To complete my examination I would like to take a height weight and head circumference of this child to plot on a growth chart

Question 4

You are a 4th year medical student who has finished doing a history and examination of a young patient who has come in with joint pain after doing some investigations you discover that he has a streptococcus infection alongside the joint pain which differentials should this point you towards

Answer 4

Rheumatic fever septic arthritis osteomyelitis as these are associated with infection

Question 5

Hi Dr I want to make sure I take the throne history of this 13 year old boy who has come in complaining of left knee pain what are the essential Questions to ask for a joint pain history within the history of presenting complaint discuss

Answer 5

If the patient doesn’t volunteer information regarding how many joints are affected this is a key thing to ask. Remember all the questions are based towards a differential so asking about which joints are affected and whether the joints are affected symmetrically is guiding you more towards a rheumatology diagnosis as opposed to an infective cause

Question 6

Hi Dr I have just seen a 13 year old boy with left knee pain who has stiffness swelling but no heat coming from the joint it has prevented him from playing football and this is now been going on for a week. Discuss the other questions you would like to ask him

Answer 6

So still on the topic of associated symptoms you would like to ask him whether he has any fevers rashes weight loss and how he was feeling before the knee pain

Question 7

Hi Dr in any child under the age of 16 presenting with a type of joint pain when I’m asking about the timing of the problem what is the Essential question that I must ask

Answer 7

You must ask whether or not the pain or swelling is worse in the morning if there’s only stiffness in the morning and if there is how long it takes to dissipate and ask if the symptoms relieved after exercise

Question 8

PGals

Answer 8

Pgals

Question 9

Pgals

Answer 9

Pgals

Question 10

Pgals

Answer 10

Pgals

Question 11

Pgals

Answer 11

Pgals

Question 12

Pgals

Answer 12

Pgals

Question 13

Hi Dr I have just seen a 15 year old girl who presented with a swollen wrist she has denied any trauma to the area and I have completed examination and found no other abnormalities I’m about to order some investigations to rule out and will in some differentials are there any special investigations that might help me will in rheumatological conditions

Answer 13

Yes if you make sure to do an antinuclear antibody test this will help you rule in conditions such as rheumatoid arthritis scleroderma or lupus

Question 14

Hi Dr I have just seen a 13 year old boy who has a swollen elbow and is complaining of pain from his elbow I have taken history and done an examination and then regards investigations I know that there is another type of inflammatory marker that we can check for but I can’t remember what either of them are called can you tell me

Answer 14

The inflammatory markers are ESR and plasma viscosity

Question 15

Hi Dr one of the fourth year medical students has recently taken a history and done an examination of a 18 year old guy who presented with bilateral knee pain. Based on her findings she believes that the patient may have a diagnosis of juvenile idiopathic arthritis. Why is this an unlikely diagnosis for this particular patient. Just think solely based on the initial information you were given even before the presenting complaint was told

Answer 15

Juvenile in juvenile idiopathic arthritis refers to an age of 16 and under this patient is 18 and therefore it is unlikely that you will have this diagnosis

Question 16

Hi Dr I have just seen a 15 year old boy who has come in today with his mum is Mum has been saying that over the last two months her son has been complaining of left sided knee pain which is currently being investigated but the results have been delayed. What are other presenting features that this boy may have in his history

Answer 16

Alongside joint pain never forget to ask about any problems with vision or the eyes in general also don’t forget about jaw pain.

Question 17

You are the foundation year 2 Doctor when a 14 year old girl comes into the ward because of a left sided knee pain which has been going on for the last 2 months which tests are this girl likely to have had before coming in today

Answer 17

She is likely to have had UBEX. Specifically bloods and an X-ray. ESR/plasma viscosity CRP and the standard Bloods. She is likely to have had an MRI if the x-ray was inconclusive she may have also had a CT none of her chest and she may also have had a bone scan.
She is also likely to have had a special antinuclear antibody tests to rule in rheumatological conditions

Question 18

Hi Dr I am one of the medical students and I wanted to make sure that I had the done and appropriate systems review for a patient who I believe may have juvenile idiopathic arthritis due to her age being under 16 and her presenting complaint of joint pain that has been going on for a minimum of 6 weeks. What other parts of the body may be affected by juvenile idiopathic arthritis apart from the main presenting complaint joint

Answer 18

Always ask about the eyes and the jaw as anterior uveitis and temporomandibular joint arthritis may be associated with JIA

Question 19

Hi Dr we have diagnosed this 15 year old boy with JIA due to his six week plus history of joint pain positive antinuclear antibody and positive rheumatoid Factor investigations. I am about to go and speak to his mum about the treatment. But I can’t remember what it was can you help me

Answer 19

Yep no problem so as with a lot of conditions from rheumatology associated with joint pain anti-inflammatory is are they tend to be the first line because the underlying pathophysiology behind these kinds of problems is inflammation
Ibuprofen and naproxen

Question 20

Hi Dr I have just diagnosed a 15 year old boy with the diagnosis of JIA. One of the medical students has asked me about the specific medications we give to relieve the pain associated with this type of arthritis what should I tell her

Answer 20

Ibuprofen 30 to 40 mg per kg per day or naproxen 20 mg per kg per day

Question 21

Hi Dr I have just been speaking to the father of a 15 year old boy recently diagnosed with JIA. His son is getting a lot of pain from his right knee which is primarily affected. He asks is it better for him to give paracetamol or non-steroidal anti-inflammatories such as ibuprofen or naproxen.

Answer 21

NSAIDs are first line ibuprofen 30 to 40 mg per kilogram per day
Naproxen 20 mg per kg per day

He can give paracetamol as well if the NSAIDs alone aren’t enough

Question 22

Hi Dr
I am the GP and I would like to refer this 15 year old boy who has a diagnosis of JIA. His current medication 30 mg per kg per day of ibuprofen + paracetamol is not managing his pain. The parents would like to see a specialist to discuss further treatments. What is the rheumatologist likely to discuss in regards to treatment

Answer 22

If non-steroidal anti-inflammatory drugs and paracetamol aren’t adequate pain relief then the next line is to use joint injections
DMARDS such as methotrexate
And or oral steroids

Question 23

You are the rheumatologist
Ok so I have heard that unfortunately the ibuprofen and the paracetamol are not managing the pain you’re getting from your condition (JIA) we can try giving you a medication (DMARD) called methotrexate (10 - 15mg / metre squared / kg / week). There are two key things I need to tell you first. You must not….
Apart from taking folic acid with methotrexate, in regards to the social history what must an adolescent abstain from drinking whilst on methotrexate

Answer 23

Alcohol

Question 24

You are the rheumatologist
A 15 year old boy has come in to see you with his parents and you have decided that the best thing for his JIA is to start methotrexate. You have remembered to prescribe folic acid as well. The parents ask you if there are any side effects to this medication. What would you tell them

Answer 24

It can cause abdominal upset and some people describe feeling almost hungover

Question 25

The consultant is testing you the newly qualified rheumatologist on some of your basics. Hi Dr you have just started a child on Methotrexate and you recognise that you need to monitor them regularly what do you specifically need to monitor every month?

Answer 25

Any individual on Methotrexate must have their liver function monitored every month

Question 26

Hi Dr I am one of the fourth year medical students doing research into treatment for JIA If disease modifying antirheumatic drugs and corticosteroids injections fail to relieve joint pain in adolescents under the age of 16 with a diagnosis of JIA what else could you try

Answer 26

Biologics such as etanercept and infliximab

Question 27

You are the GP a 15 year old girl has come in today as she has sore eyes. When you read through her notes prior to the consultation. You see that she was diagnosed with JIA nearly eight years ago and is ANA+ve. Even before seeing this patient based on this information alone what differential do you need to make sure you rule out by referring her to an ophthalmologist for examination under a slit lamp and why is it so important you rule this out

Answer 27

You need to rule out a diagnosis of anterior uveitis which may present before alongside or after a diagnosis of arthritis because if this is left untreated the patient may potentially go blind

Question 28

You are the consultant doing a review of a controversial case. A 16 year old girl was originally diagnosed with JIA at age 14 which was managed initially with NSAIDs but after a flare up required (DMARDs) methotrexate and injection. She is ANA+ve last week she met with an ophthalmologist who diagnosed her with posterior synechiae (cataract/ glaucoma/ band keratopathy). What is an essential part of the long-term management for patients with JIA with any eye involvement

Answer 28

Regular eye appointments

Question 29

Hi Dr I am one of the third year medical students doing my GP placement I have just taken a history from the mother of a five year old boy who told me that her son has been waking up at night complaining of pain in both his legs but during the daytime there's absolutely no problem I was initially thinking possibly a rheumatological condition so I asked about any joint swelling and then he stiffness and any family history of autoimmune or rheumatic problems which all came back as negative. In terms of his past history there were no abnormalities in the pregnancy drug hx he is up to date with his immunisations social history he has reached all his expected milestones on time. No recent trauma or issues with feeding and fluid intake. What do you think I could explain this?

Answer 29

The key piece of information here is that the pain is only at night and is not present in the daytime and there is no the pathology such as delay in reaching gross motor milestones such as walking. In the absence of fever weight loss night sweats abdominal mass. This rules in a potential diagnosis of growing pains.

Question 30

You are a fourth year medical students doing a SIM session. The patient you are going to see have told you he has a very painful joint. Which differential needs to always be in your hand for an acute presentation of a red hot swollen joint

Answer 30

Septic arthritis

Question 31

You have to seem a child under the age of 5 years old who has come in pointing to his hip crying saying it hurts. Is Mum elaborate for him and says that he has been behaving like this for the past couple of days. She then tells you that he recently had a chest infection. What is the most likely differential based on the age of the child the sex of the child the recent past medical history

Answer 31

Transient synovitis

Question 32

You have just seen a a child between 5 to 10 years old. He has been crying and pointing and complaining of pain in his hip. His father goes on to elaborate that he has been like this for the past week what do you need to do for this child as the GP

Answer 32

The Crying suggest that this pain is really severe for the child so you want to carry out the basic investigations think UBEX an x-ray will help you determine if there is any serious abnormality such as avascular necrosis of the head of the femur which may occur in children of this age to have perthes disease

Question 33

You've just done an examination of a 14 year old obese Child Who report hip pain thigh pain knee pain and his mum notices that he has been limping around the house she is very concerned and so bring him in to see you the GP what do you need to tell her and what do you need to do for the child

Answer 33

The age of the child his BMI and pain all points to the most likely differential of slipped upper femoral epiphysis which needs an AP and frog lateral X-ray. Following on from that he will need an MRI to assess the degree of slip

Question 34

You are a medical student picking a case for your SSC presentation You find a case of a eight year old girl who has been getting pain ever since sports day which is worse in the evenings when she lies in bed however in the morning when she wakes up she doesn't have any stiffness and there isn't any joint swelling and there's no fever weight loss or night sweats. The keys doesn't mention her actual diagnosis but then used strike gold and see that she was given a beightons criteria score of 8. What is the most likely diagnosis.

Answer 34

The most likely diagnosis here can be gleaned from Beightons criteria which is only used for patients suspected to have hypermobility At the key findings include the pain starting after a big day but not accompanied by stiffness or swelling. You would also expect to see a family history of being bendy and examination findings of being bendy.

Question 35

Hi Dr I have just started here I wanted to check something with you I believe that one of my patients a girl age 8 may have hypermobility so I've started a Beightons modification of the Carter and Wilkinson questionnaire for hypermobility. I can't remember what score they need for a diagnosis

Answer 35

So the total score is 9 and they have to score greater than 6 so they have to score 7 8 or 9

Question 36

A mum comes in concerned because her daughter's joints are able to bend in an abnormal fashion. After doing a questionnaire Beightons you decide that the most likely diagnosis is hypermobility. What information do you need to tell the mother in regards to the management of this condition

Answer 36

The first this is not a pathological condition it is very common and can be advantageous the main thing is just to keep fit and healthy which can be done through physiotherapy strengthening exercises and swimming bike riding walking. Sometimes patients with hypermobility may get pain so in that case you can give her simple pain relief such as paracetamol or heat and ice packs