I practice in a small hospital in a rural town. Early in my career I was making rounds on a 3-year-old patient who had been admitted for fever and leukocytosis two days earlier. I had not seen her previously.
When I arrived the patient’s mom was awake, but the girl was still sleeping. I began to approach the patient to examine her with the lights off, so as not to wake her, but I had an instinct to turn the lights on. When I did, the patient awoke, and I noticed she had blood shot eyes and conjunctiva without discharge. I also noticed her face was redder than what it should be, and asked if it had looked like that all along.
After obtaining more history, I found that the patient’s fever had actually been going on for more than a week before she came to our office. Upon examination, I noted the patient had a strawberry looking tongue and bright red lips. She also had a red, slightly papular rash on the palms of her hands and a cardiac murmur that no one else had noted previously.
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I knew that all 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-like name” but 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 half way through I saw it — Kawasaki disease. I turned to the pages, and everything I read was consistent with my patient.
My biggest concern was the patient’s new heart murmur. I knew we needed to get her to a higher level facility, so treatment could be instituted as soon as possible. I phoned my back-up physician and began to explain everything to him. When I told him my diagnosis, I actually heard him chuckle over the phone. He said he would be in to see the patient shortly, and I again heard doubt in his voice.
Once the physician 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 over 15 years at that time, and said he had only seen one other case of Kawasaki disease. He was very impressed and has never again questioned or chuckled at my thoughts or calls.
The patient was transferred to a children’s hospital about 70 miles away. They confirmed the diagnosis and immediately began treatment with aspirin and intravenous gamma globulin. An echo cardiogram revealed coronary artery dilation. Had her symptoms been missed, it may have been too late to prevent coronary artery abnormalities from worsening and causing permanent cardiac damage.
This patient is now 13 years old, and I have seen only one other case of Kawasaki disease in my career. The girl is doing well and her mom never fails to introduce me to family as the one who “saved her daughter’s life.” I always respond that it 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 rare illnesses, I do remember the cues and know where to look to investigate further.
I will never forget this patient, and what she taught me — to always be astute when examining a patient. Now I always turn the lights on when I perform rounds on a patient. Had I left the lights off that morning, I may not have noticed the changes in my patient’s eyes, lips and tongue that indicated Kawasaki disease.
No matter what another provider may think, go with your intuition and the facts you have and know. This story has become one of my favorites to tell new students that I am precepting. I always tell them that you don’t have to remember it all, just enough to know you need to find out the rest.
Rennie Rhodes, is an APRN-BC, DNP-candidate from Barnwell, South Carolina.
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