Dueling Diagnoses

Dr. Lucius Keinde was not the sort to suffer fools. As was his manner, he went down to the Georgia Hospital pediatric floor at 10:30 A.M. precisely. As head of his department he had the singular privilege of instilling fear among his staff. He did so with Machiavellian glee. His position had its perks, of course. Today was no different: he simply could never bring himself to tolerate any gaffe. Nurses, attendings, and residents alike all respected him for his expertise in the finer points of pediatric care. Of course he was up to date in the current standard of care. He always was. He did not become chairman because of something as delicate as bedside manner. A kind word only goes so far. No, he made decisions based on efficacy. Any contradiction to his decisions would be an invitation to the severest form of vituperation thought possible. Reap the whirlwind, he liked to put it. It had been a while since he extended this honor to just anyone. Perhaps today he would get lucky.

He turned the corner to the elevator with one hand held steadfast along one suspender and the other clicking on a gold ballpoint pen. The pen was a present for his 25 years as department head. Residents tended to cringe at the sound of this clicking pen coming down the hall, much as sheep tended to scatter when the wolf appears. But it kept the flock in line. He pushed the down button, then stepped onto the elevator. Down two floors, the doors again slid aside and a student rushed in.

"Dang," he said.

"What's the matter?" asked Dr. Keinde.

"I didn't have time to round on all my patients this morning and I hear that old man Keinde is a stickler for promptness."

"Who?" asked Dr. Keinde innocuously.

"Dr. Keinde... who I hear is anything but... He's the head of peds. He's supposed to be one tough S.O.B. And this is my first week on my peds rotation."

"Is that a fact? Doesn't sound like a very nice guy," the good doctor responded.

"Nope," the student replied. "I was on call last night and wrote up one of his patients. Keinde will eat me for breakfast if my notes aren't done right. Well, here's my floor. Gotta go... see ya."

"See you later," the good doctor replied with a twinkle in his eye.

The student ran around the corner out of sight. Perhaps today would be a good day after all, thought Dr. Keinde. Yes, sir, a good day indeed.

As he rounded on the floor, he came to room 2330E. That's where the girl lay with a fever of 105. He picked up the door chart. As it happened, the third year student was still there, finishing up his physical exam. A nurse walked in to take her hourly vitals.

"Still here?" asked the nurse. "I thought y'all would be in class by now."

"I was, but I left to finish my rounds."

"Well, it's a bit late. Let the girl have some rest. She's been poked and prodded

enough as it is." "I know, I know. I just want to be thorough," the student said with an apologetic look to both the nurse and his patient. "Oh, hello Dr. Keinde!" the nurse greeted the chairman as he walked through the door. "Why hello there, Phyllis," the good doctor greeted her in return. "How are you

doin', this fine day?" "Right as rain," she replied. The student turned to the door. "Oh hell." "Why hello there yourself, young man. What do you think you are doin' this fine

morning?" "I'm rounding on my patient, sir," said the student, flustered. The good doctor looked at his pocket watch then back at the student. "A bit late now, are we?" "Yeah... sorry, I got held up," the student said, his gaze dropping to the good

doctor's shoes. "Well then, what have you found?" "She's sick." "Holy Mother of all that is good! Boy, any milkmaid dairy queen social worker could

tell me that. Are you trying to upset me, boy?" Dr. Keinde growled. "No, sir." "What is your name?"

"John Lane"

"Well, Johnny, I'm guessing you didn't know this but I'm rounding too and I happen to know a little something about this patient. You better be able to tell me more than just 'she's sick.'"

"Uh, I didn't have enough time to enter my progress note," the student's heart raced.

"Not enough time? Why it's been a good half-hour since I had the pleasure of making your acquaintance. And you wrote an H&P up yesterday. Surely you must have some idea of what's going on with her by now."

"Yes sir, I do," he managed, not exactly with courage.

"Then speak up, boy."

"I can present if you give me a second to collect my thoughts."

"Collect your thoughts? Is that your hobby, Johnny, collecting thoughts? Because if it is, I can give you one. I'll make a bet with you."

"A bet? That's not necessary, sir."

"Oh, but it is! If you want to amount to anything in our profession, you have to have some gumption, boy. You do have gumption, don't you?"

"Yes sir."

"Then let's step outside and you can tell me all I need to know about this patient."

He really did it now, the student thought as he followed the good doctor out the door, he was screwed.

"Well... Johnny, this young girl, Angela is her name by the way..., was admitted late last night. She's been here before. I know this for a fact because I've treated her in the past. I'm willing to wager you my..." the doctor looked down at his hand, "my gold pen that you have no idea what is going on here. Why don't you tell me what you know about her case."

"I haven't had time to review all the labs... I would like a little time to think about her case. To organize my thoughts."

"First you collect thoughts, now you organize them. Who are you, boy, Martha Stewart's son? Are you going to bunch them up and put them into a flower arrangement? How much time do you need, Johnny? An hour? A day? A week? Do you think that little girl or her parents can afford to wait for you to make up your mind? Do you think she'll get better on her own?"

"No sir."

"No, you don't think you can make up your mind or no, you don't think she'll get better?"

"No, I don't think she'll get better on her own."

"Well, nine times out of ten, most fevers do resolve on their own. What we must be mindful of is the one out of ten that don't. Is she in this one out of ten group? She was admitted after all..."

"Yes, she was."

"It seems you are a font of all knowledge, my boy. Tell me what you do know," the good doctor asked, "so that I may be illuminated by your brilliance."

"Patient is a 12 year old caucasian female who presents to Georgia Hospital E.R. with a temperature of 105 degrees...."

"Everyone has a temperature. I don't know, but where I come from, she could have what we might call a fever."

"Yes sir... A fever of 105."

"Celsius? We must be precise in our language, son, otherwise pandemonium results from lack of clarity. Do you want that?"

"Uh... Fahrenheit..."

"That's better. Continue."

"Her parents state that her fever has been present for the past 10 days and has not gone down despite having given ibuprofen and bed rest. She's had symptoms of nausea, vomiting, abdominal pain, shortness of breath, headaches, irritability, malaise... lack of appetite... On physical exam, she has..."

"Does she have a past medical history? We all have histories, Johnny, tell me her story."

"Past history of tonsillitis, one month ago she was admitted for a tonsillectomy. Her parents told me she has had a heart murmur since birth... She has been febrile on several occasions for which she missed school. No medications other than ibuprofen.... She's allergic to pollen, ragweed. No known drug allergies, no surgeries other than the tonsillectomy, no injuries. Immunizations are up to date with no recent travel. No siblings. No pets. Neither parent presently ill. No environmental irritants present in their home. Past family history is significant for cancer in her paternal grandmother, diabetes in her maternal grandfather.... Review of systems....."

"Stop. Before you go into all that, tell me what you found on physical exam."

"Patient appears to be her stated age, is erythematous, diaphoretic and irritable when I examined her..."

"I don't blame her, with your bedside repartee."

"... especially on her extremities. Alert and oriented times 2 (not to time). She follows commands. Vitals: Heart Rate 130, BP 130/94, Respirations: 24. Her pupils PERRL. Head is normocephalic... except for spotty red..., I mean injected conjunctiva. External ear canals are patent without any erythema or exudates. Mouth mucosa appears to be moist and erythematous with reddish petechiae.... Neck is soft with mild lymphadenopathy. No JVD or bruits heard. Significant are the presence of raised skin lesions on her extremities, especially her hands and feet and some on her torso. Papules, I think? She is warm on palpation and tender to touch everywhere, especially on her joints. She has limited range of motion...."

"Did you appreciate her heart?"

"Yes, she had regular rate and rhythm with a murmur present, I think diastolic."

"Do you think that's significant?"

"Yes sir, I do."

"Why?"

"Because it could be indicative of a congenital heart condition, or maybe rheumatic heart disease due to rheumatic fever or..."

"Rheumatic fever? Is that what you think this is? Rheumatic fever? Is that common nowadays in this great country of ours?"

"No, sir, it's not that common because antibiotics have taken care of most infections. It was common before penicillin was discovered..."

"How do we determine if it is rheumatic fever then?"

"The Jones criteria, I think... carditis, arthritis, erythema marginatum, nodules, fever...some kind of chorea ... suggests rheumatic fever. But I would order tests to confirm."

"And what tests would you order?"

"A chest x-ray or echo. A blood culture, blood count, sed rate, ASO antibodies... I'd look for strep. Maybe an EKG..."

"Were these ordered?"

"Yes. But the results aren't back yet."

"What would you expect?"

"I would expect a diastolic murmur due to valvular insufficiency, maybe mitral or aortic. I think there's some immunologic cross reaction between streptococcal proteins and heart valve tissue, causing the valvular insufficiency. There may be a friction rub because of the pancarditis. Echo might show effusions. EKG might show prolonged PR intervals. An increased sed rate because it's a generalized inflammatory reaction, rising ASO titers. The presence of streptococci in blood cultures."

"What would you do about this?"

"Bed rest. Antibiotic therapy should take care of the strep. Ibuprofen for her elevated temp. Maybe corticosteroids to decrease the inflammatory response if ibuprofen doesn't work."

"Sounds like you got it nabbed, doctor. Rheumatic fever? I should be singing your praises about now. Is that what you think?"

"No sir, I don't think she has rheumatic fever."

"Then what pray tell do you think, son? Do not tempt the fainted or intimate collusion with secrets. Silence is not always golden. Speak up, boy."

"I think that she may actually have infective endocarditis. Her history includes a tonsillectomy about a month ago, which may have introduced the infective agent. I would still order a blood culture to see what grows out of that. Staph would be more indicative of acute endocarditis and fungi, strep and other bugs would be more subacute. I also think she had a history of a murmur due to a congenital defect in the heart walls or to some prior valvular problem. This predisposes her to colonization of bacteria on her heart valves. Vegetations can form, then break off as emboli."

"She complains of pain in her hands and feet, with lesions on her fingers and toes, which could be Janeway lesions or Osler nodes, with petechiae in her mouth and conjuntiva. This suggests perhaps microemboli from vegetations from her heart. Non-specific abdominal pain and tenderness could also be due to emboli lodging in organs. So I think infective endocarditis is more likely in this case. But we won't know for sure until the tests come back."

"And how would you treat this, doctor?"

"Antibiotic treatment depends on the etiological agent, but I would first try penicillin G, as with rheumatic fever. The infective agent could be fungal as well, so treatment really depends on the cause. But here, the danger is the emboli which could cause infarction in the brain or other critical areas, so I guess, we should try broad-spectrum antibiotics? In the future, I would also watch out for future relapses with prophylactic antibiotic therapy."

"There may be hope for the future after all," Keinde admitted. "Just when I thought to give up all hope . Good job, Dr. Lane. Most in your position I consider to be penny wise but a pound foolish. You restore my hope in the fruits of our loins."

"Uh... thank you sir, I try my best. Sorry I have to go to class. If you'll excuse me, I'll finish my progress note and get back to you with the follow-up," the student extended his hand but the good doctor did not reciprocate. Instead he reached into his pocket pulled out the gold pen and extended it to the student.

"Doctor, you'll be needing this."

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