A young girl with Kawasaki disease: Diagnosing a rare disorder
A girl presented to a small town hospital symptoms including fever, bloodshot eyes, red lips, and rash on the palms of her hands.
Early in my career, I was making rounds regarding a 3-year-old girl who had been admitted for fever and leukocytosis 2 days earlier. I had not seen her previously. I practice in a small rural town and hospital.
When I arrived, her mom was awake, but the girl was still sleeping. I started to go over and examine her with the lights off, so as not to wake her. However, something told me to turn on the lights. When I did, she awoke and I noticed that she had bloodshot eyes and conjunctiva without discharge.
I began to also notice that her face was redder than what it should be, and I asked if it had looked like that all along. After obtaining more history, I found that the fever had actually been going on for more than a week before she came to our office.
During the examination, I noted that she had a strawberry-looking tongue and bright red lips. She also had a red, slightly papular rash on the palms of her hands. In addition, she had a cardiac murmur that no one else had noted previously.
I knew that all of these symptoms were diagnostic of a rare illness, but I could not remember the name of it. I kept thinking that it had a “motorcycle name,” but I couldn't remember what it was called!
I went to the nurses' station and pulled out a general pediatrics book and began to scan the index. About halfway through, I saw it—Kawasaki disease. I turned to the pages, and everything I read was consistent with my patient. My biggest concern was her new murmur, and I knew that we needed to get her to a higher-level facility so that treatment could be instituted as soon as possible.
I phoned my backup physician and began to explain everything to him. I actually heard him chuckle over the phone at my diagnosis. He said he would be in to see her shortly, and I again heard in his voice doubt in my clinical skills and intuition.
Once he arrived and began to examine my patient, his doubt changed to surprise, and he said he agreed 100% with my diagnosis. He had been a pediatrician for more than 15 years at that time, and he said that he had only seen one other case of Kawasaki disease.
He was very impressed with my diagnosis and never has questioned or chuckled at my thoughts or calls again. The patient was transferred to a children's hospital about 70 miles away. The hospital confirmed the diagnosis and immediately began treatment with aspirin and intravenous gamma globulin. An echocardiogram revealed coronary artery dilation. Had the symptoms been missed, it may have been too late to prevent coronary artery abnormalities from worsening and her having permanent cardiac damage.
This patient is now 13 years old, and I have seen only one other case in my career. She is doing well, and her mom never fails to introduce me to her family as the one who “saved her life.” I always say, “no, that was God working through me.” I had been well trained, and although I did not and sometimes still do not always remember the names of rarely seen illnesses, I do remember the cues and know where to look to find what I need to know.
I will never forget this patient, and what she taught me—to be astute when examining a patient. I always turn the lights on when I go to examine a patient now, because if I had not done so that morning, I may not have noticed the changes in her eyes, lips, or tongue.
Also, no matter what another provider may think, go with your intuition and the facts that you have and know. This story has become one of my favorites to tell to new students whom I am precepting. I always tell them that you don't have to remember it all, but you need to remember enough to know you need to find out the rest.—Rennie Rhodes, APRN-BC, DNP, Barnwell, S.C.
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