A previously healthy 9-year-old boy who recently emigrated from Polynesia presents to the ED with joint pain and swelling. According to his parents, he has been sick for 4 days with intermittent fever and began experiencing trouble breathing over the past day. Initially, he had a painful and swollen left knee, but this seems to be better today. Upon arrival in triage, he has an axillary temperature of 39°C (102.2°F). His vital signs are as follows: heart rate, 160 beats/min; respiratory rate, 30 breaths/min; and oxygen saturation, 93% on room air. On examination, he appears tired and complains of trouble breathing when lying down. His right knee is swollen, warm, and very tender to the touch. His left ankle is also swollen and he is unable to walk because of the pain and swelling. On examination of his chest, his lung sounds are clear, but you hear a holosystolic murmur at the apex. His abdomen is soft, but you feel a liver edge 5 cm below the costal margin. The boy is alert and oriented throughout your examination. What are your first steps toward treating this child? How will you establish your diagnosis? Can this child be safely discharged from the ED? What are the potential long-term sequelae?
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