WA Health, Government of Western Australia



WA RHEUMATIC HEART DISEASE REGISTER AND CONTROL PROGRAMAcute rheumatic fever (ARF) and rheumatic heart disease (RHD) are notifiable conditions in WA. Report all confirmed and suspected cases by faxing or emailing this form and supporting documentation to:-WA RHD Register & Control ProgramEMAIL RHDRegister@health..au or FAX 08 6553 0899PHONE 1300 622 745 PATIENT DETAILSSurname:Given name/s:UMRN:Date of birth:Full address:Phone/Mobile:Ethnicity: FORMCHECKBOX Aboriginal FORMCHECKBOX Aboriginal & Torres Strait Islander FORMCHECKBOX Torres Strait Islander Other (specify):Sex: FORMCHECKBOX M FORMCHECKBOX F FORMCHECKBOX TransgenderIs the patient pregnant?: FORMCHECKBOX No FORMCHECKBOX Yes (please refer to RHD guidelines) FORMCHECKBOX EDD: Is the patient a transfer? FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX Interstate FORMCHECKBOX International Transferred from: If patient is under 18 years of age, please provide parent/guardian detailsSurname:Given Name/s:Full Address:Phone/Mobile:Relationship to patient:NOTIFIER DETAILSDate of Notification:Full Name: Telephone:Hospital/Clinic Name:Full Address:PATIENT’S USUAL HEALTH CARE PROVIDERFull Name: Telephone:Hospital/Clinic Name:Full Address:Comments:MANIFESTATIONS (tick all that are applicable) APPLYING THE AUSTRALIAN MODIFIED JONES CRITERIAHIGH-RISK GROUPSLOW-RISK GROUPSMAJORMAJOR FORMCHECKBOX Clinical carditis FORMCHECKBOX Subclinical carditis (lesions on echo) FORMCHECKBOX Clinical carditis FORMCHECKBOX Subclinical carditis (lesions on echo) FORMCHECKBOX Polyarthritis FORMCHECKBOX Aseptic monoarthritis FORMCHECKBOX Polyarthralgia FORMCHECKBOX Polyarthritis FORMCHECKBOX Sydenham chorea FORMCHECKBOX Sydenham chorea FORMCHECKBOX Erythema marginatum FORMCHECKBOX Erythema marginatum FORMCHECKBOX Subcutaneous nodules FORMCHECKBOX Subcutaneous nodulesMANIFESTATIONS Cont.HIGH-RISK GROUPSLOW-RISK GROUPSMINORMINOR FORMCHECKBOX Fever ≥38°C FORMCHECKBOX Fever ≥38.5°C FORMCHECKBOX Monoarthralgia FORMCHECKBOX Polyarthralgia FORMCHECKBOX Aseptic monoarthritis FORMCHECKBOX ESR ≥30 mm/hr or CRP ≥30 mg/L FORMCHECKBOX ESR ≥60 mm/hr or CRP ≥30 mg/L FORMCHECKBOX Prolonged P-R interval on ECG FORMCHECKBOX Prolonged P-R interval on ECGSUPPORTING LABORATORY EVIDENCEPositive culture (Streptococcus) Site:Date:Anti-DNase B titre (U/ml)Result:Date:ASOT (U/ml)Result:Date:Highest CRP (mg/L)Result:Date:Highest ESR (mm/hr)Result:Date:CURRENT EPISODE DIAGNOSIS (refer to Australian modified Jones criteria for diagnosing ARF) FORMCHECKBOX Definite FORMCHECKBOX Probable FORMCHECKBOX Possible FORMCHECKBOX Recurrence FORMCHECKBOX UnknownDate of onset: Date of diagnosis:Date of 1st episode:CURRENT EPISODE MANAGEMENT PROVIDED BY HEALTH CARE PROVIDER (HCP)Benzathine benzylpenicillin G or 10 days of oral prophylaxis given? FORMCHECKBOX No FORMCHECKBOX Yes HCP: DateLaboratory bloods done? FORMCHECKBOX No FORMCHECKBOX Yes HCP: DateECHO Performed? FORMCHECKBOX No FORMCHECKBOX Yes HCP: DateWas the patient hospitalised due to the current episode of ARF? FORMCHECKBOX No FORMCHECKBOX Yes Hospital: DateCOMMENTS:RHEUMATIC HEART DISEASE (RHD)RHD Status FORMCHECKBOX RHD presentDate diagnosed: FORMCHECKBOX RHD absent FORMCHECKBOX Echo not performedSeverity of RHD (if known) FORMCHECKBOX Priority 1 (severe) FORMCHECKBOX Priority 2 (moderate) FORMCHECKBOX Priority 3 (mild) FORMCHECKBOX Priority 4COMMENTS:CLINICAL DECLARATIONName of person notifying the Register:Position:Signature:Date:LINKS FOR CLINICAL RESOURCESThe Australian RHD Guideline resource book, online education modules promotional resources: .auThe statutory notification information and ARF /RHD notification form: PATIENT RESOURCESPatient education on ARF/RHD: healthywa..auAUSTRALIAN MODIFIED JONES CRITERIA FOR DIAGNOSING ARFDefinite initial episode of ARF = 2 major manifestations plus evidence of preceding Group A Streptococcus OR1 major and 2 minor manifestations plus evidence of preceding Group A Streptococcus Definite recurrent episode of ARF (in a patient with a documented history of ARF or RHD) = 2 major manifestations plus evidence of preceding Group A Streptococcus OR1 major and 2 minor manifestations plus evidence of preceding Group A Streptococcus OR 3 minor manifestations plus evidence of preceding Group A Streptococcus Probable or possible ARF (initial or recurrent) = A clinical presentation in which ARF is considered a likely diagnosis but falls short in meeting the criteria by either:one major or one minor manifestation ORno evidence of preceding Group A Streptococcus (streptococcal titres within normal limits or titres not measured)Probable- ARF is still considered the most likely diagnosisPossible- ARF is considered uncertain but cannot be ruled out UPPER LIMITS OF NORMAL FOR P-R INTERVAL ON ECGAge Group (Years)Seconds3-110.1612-160.1817+0.20UPPER LIMITS OF NORMAL (ULN) FOR SERUM STREPTOCOCCAL ANTIBODY TITRES IN CHILDREN AND ADULTSAge GroupULN (U/mL)(Years)ASO titreAnti-DNase B titre1-41703665-1427649915-2423847325-34177390≥35127265 ................
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