Feeling Frustrated

Don’t you hate it when you have unsatisfying visits? Like when there is no clear diagnosis or you just feel inadequate as a health care provider?

I had two of those yesterday.

The first was a toddler presenting with 4 days of fever, 2 days of red eyes, and 2 days of maculopapular rash on the trunk, palms, and soles. He was febrile in the clinic and had one sided lymphadenopathy. When I saw him I initially was thinking roseola, but that usually presents after the fever ends, and does not affect the hands and feet. My next thought was Kawasaki. I had him seen by a pediatrician who had Incomplete Kawasaki and Adenovirus on his differential. In order for a diagnosis of Kawasaki you need*:

The diagnosis of Kawasaki disease requires the presence of fever lasting at least five days without any other explanation combined with at least four of the five following criteria:
Bilateral bulbar conjunctival injection
Oral mucous membrane changes, including injected or fissured lips, injected pharynx, or strawberry tongue
Peripheral extremity changes, including erythema of palms or soles, edema of hands or feet (acute phase), and periungual desquamation (convalescent phase)
Polymorphous rash
Cervical lymphadenopathy (at least one lymph node >1.5 cm in diameter)


This patient had only 4 days of fever, but 4 of the 5 above criteria. For us, that was sufficient concern to send to the ER for further evaluation (lab work, echo, adenovirus swab). Unfortunately the ER rarely does what we would want them to do. They evaluated the patient, did a strep test and adenovirus test (not processed due to incorrect specimen container), and sent him home. They want to wait for one more day of fever before evaluated for Kawasaki. What a waste. So if he still has fever today he has to return to the ER AGAIN. Poor family.

The second patient I saw at the end of the day when there were no more provider appointments available.

She is a preteen female that presented with one day of bilious emesis and pelvic pain. The pain started suddenly and was accompanied by nausea. She had 4-5 episodes of green emesis without blood that ceased around 4 in the morning. By the time I saw her that evening, she was pain free and had not vomited in over 12 hours. I know bilious emesis is bad, because we always ask about it, but now that I had a patient with it, I didn’t know what to do. I consulted with the provider still in the clinic and she wanted me to rule out appendicitis. I guess a ruptured appendicitis can lead to bilious emesis, as well as bowel obstruction. My patient could jump up and down with no pain and her only tenderness was suprapubic. Her urine was concentrated and had a small amount of urobilinogen and protein. What does that mean? Could she have hepatitis? Her vital signs were normal, she had no fever, no recent travel, no recent undercooked foods. She is premenarchal, so she wasn’t pregnant. Maybe she was getting her menses, but that doesn’t cause bilious emesis! I palpated her abdomen and didn’t feel an enlarged liver or any masses, but then again, I’m not that confident in my exam. It was an unsettling visit.

So I sent her home with strict precautions to go to the ER for any return of abdominal pain or vomiting and made her an appointment with her PCP in the morning. She did not go to the ER and presented today with continued abdominal pain, but no fever, emesis, or other symptoms. Her urine was concentrated and had trace bilirubin and trace protein. The physical exam was completely normal so the PCP sent her home with precautions. How unsatisfying! What did she have!?

*Kawasaki Diagnostic Criteria taken from Uptodate



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