January to May 1995 Kawasaki's notes

January 18, 1995
S: In November and again in early January he had a routine hearing tests in the Oregon City School District which showed decreased hearing and a stiffness reported apparently on tympanometry. The audiogram report is submitted. He doesn’t have problems, but his mother thinks intermittently he doesn’t hear very well. O: Ears and TMs entirely normal. Very translucent. A: History of decreased hearing, perhaps now resolved. P: Repeat tympanometry and audiometry. T: Michael Norris, M.D.
March 30, 1995
S: Seen in consultation with Kathy Hobbs. Has a 2-day history of fever, now with a fine macular rash. Has some significant stiffness of his neck on Brudzinki’s sign, Kernig’s sign is negative. He is a little listless, but not terribly. No photophobia. Throat is not particularly hyperemic. Moderate lymphadenopathy. He was taken to the Emergency Room for a spinal tap which produced clear fluid. They were to wait in the Emergency Room until the results of the cell count come back which showed no white cells, discharged home for close monitoring and follow-up. ADDENDUM: The family was seen in the Emergency Room and he was examined, still has some thickness in his neck but I don’t really feel a lot of adenopathy. Throat is not red. Rash is possibly Strep related, but his throat doesn’t look like that at the present time. Wouldn’t be surprised to see him develop increased adenopathy or pharyngitis overnight, if so would place him on Erythromycin. The family was so notified. T: Michael Norris, M.D.
March 31, 1995
Talked with patient’s mom. Michael is worse today. He is having trouble moving his neck and when he does so it is very painful. Per Dr. Hickman send him back to ER to be evaluated by Dr. Brown. Dr. Norris
April 3, 1995
Mom called 3rd day still has 100-101 fever, rash still itchy, Dr Norris wants to see appt. 4/4/95.
April 4, 1995
S: 7-year-old boy now in his 8th day of rash and 7th day of fever. Had a lot of stiffness, had a normal lumbar puncture performed four das ago, but the fever has continued. His appetite has been pretty good. He has developed a little desquamation of the hands. O: Not particularly ill appearing boy, somewhat sleepy. He has bilateral conjunctivitis. He has a diffuse dry macular eruption, mostly on the trunk. No palmar or plantar erythema, but a markedly red strawberry tongue. Pharynx is fairly normal. There is a strikning 3-4+ cervical adenopathy and a Grade II/VI systolic murmur, largely ejection. A: Suspect Kawasaki’s syndrome. P: Referred to Doctor Paisley at Emanuel. T: Michael Norris, M.D.
April 6, 1995
Dear Dr. Norris This is a Brief letter about Michael Epperson. I think he does have Kawasaki’s disease. The stiff neck is not too common with this but aseptic meningitis certainly occurs. He has a high ESR and WBC with a left shift, slightly elevated platelets, a normal EKG and echocardiogram, a normal chest x-ray. We treated him with 2 grams per kg of IVIG and aspirin, 400 mg four times a day chewables. The usual routine for this is to give high doses for about 4-5 days until they are doing well with no more fever, a resolving rash and no other significant problems. Then the dose for the next 8 weeks or so until the final cardiac exam is normal. Dr. Doug King was the cardiologist and gave them his cad. He usually re studies them at 3 weeks, the peak time for aneurisms to be seen, then again at 2 months. Activity is limited (no competitive or very active sports) until he sees Dr. King again. There is about a 1% chance of someone else in the family developing KS in the next few months; it is not otherwise considered contagious. We may be able to send him home today and will have him see you next week for a recheck. I don’t think you have to draw lab tests or do other studies at that time. Dr. King will probably recheck the platelet count and ESR when he sees him. They remain high for several weeks, usually, after adequate treatment. Many of the children are fatigued for a couple of weeks after the illness. There should not be other longer sequelae. Let me know if you have other questions. I enjoyed meeting him and his family. John Paisley, M.D., Ped Inf Dis
April 10, 1995
PROBLEM: Kawasaki’s disease – he has decreased his aspirin from five-baby aspirin q.i.d. yesterday to one a day this morning. Has increasing problems with back pain and a little lethargy and some other diffuse joint pain. His rash is mostly gone. The lymphadenopathy is decreased, but still quite significant. He still has quite a bit of redness of his lips and tongue, the redness was less. He has a lot of peeling of his hands and feet. A: Improved Kawasaki’s disease after IV Gamma globulin and high-dose aspirin. P: Keep him on the high-dose aspirin through the rest of the week before cutting down and recheck again in a week. He has an appointment to see Doctor King in cardiac follow-up in a couple of weeks. Heart exam today is normal. T: Michael Norris, M.D.
April 17, 1995
PROBLEM: Kawasaki’s disease – still quite tired, eating better but spends a lot of time sleeping and laying around. Hasn’t gone back to school as yet. O: Lips are still red, with some peeling. He still has peeling but no redness or inflammation of the palms and soles. Cervical adenopathy is almost entirely gone. Throat is normal. HEART – Grade I/VI holosystlolic murmur, rate is about 100-110. He cut his aspirin down to one baby aspirin a day three days ago. Seems like he has more aching in his back since he’s done that. A: Improving Kawasaki’s disease. P: Resume 3 baby aspirin q.i.d. which is an in between dosage. Recheck in a week. Begin half-day school now. He has a follow up appointment in two weeks with the pediatric cardiologist. T: Michael Norris, M.D.
April 24, 1995
PROBLEM: Kawasaki’s disease. He has been more active, is only able to go to school half days before becoming very tired. He still has conjunctivitis, although not bothering him but is certainly injected. His hands are drying up, but there is still some evidence of peeling. HEART – no evidence of murmur at this time. Good regular rhythm. Blood pressure is normal. He seems to function better when he takes his q.i.d. He will see Doctor King, the pediatric cardiologist, later this week. We will then see him in a week. T: Michael Norris M.D.
April 26, 1995
Dear Dr. Norris As you know, I saw Michael back in follow-up today. You will recall that Michael is the seven year old who was recently admitted to Emanuel Hospital for presumed Kawasaki Disease. He was treated as you know with gamma globulin and was discharged from Emanuel approximately 48 hours after admission. An echocardiogram was performed at that time. A small pericardial effusion was noted but no evidence of any coronary artery involvement was noted. Since discharge from the hospital, Michael has continued to be somewhat listless. Apparently he has continued to have a low grade fever ranging between 99.8 to 100, which is especially noted when his aspirin dosage is decreased. He is currently receiving 12 baby aspirins per day in divided dosages. When the dosage has been decreased, his temperature has recurred. As expected for Kawasaki Disease, Michael did develop desquamation of his hands and feet. He has had no further rash; however, he has had some mild residual conjunctivitis. He has had no overt arthritis; however, he has had some mild arthralgias involving the wrists, ankles and shoulder. Overall, Michael’s energy level is low but appears to be improving slowly. On physical exam, Michael is a slightly listless, pale appearing seven-year-old male in no acute distress. The vital signs reveal a heart rate of 90, a blood pressure of 90/60, and a weight of 53 pounds. Exam of the chest reveals good breath sounds bilaterally. Exam of the heart reveals a quiet precordium. The first heart sound is normal; the second heart sound is split. There is a Grade I to II/IV low frequency vibratory murmur noted along the left sternal border which does not significantly radiate. There is no diastolic murmur noted. The pulses are 2+ and symmetrical in all four extremities. Abdominal exam reveals no hepatosplenomegaly. Exam of the extremities reveals no cyanosis or clubbing. There is some residual desquamation noted on the palms. Laboratory data today included an echocardiogram, which now reveals evidence of coronary artery dilation involving the left main, proximal, circumflex and left anterior descending coronary arteries. The average diameter of the left anterior descending coronary artery is between 5 and 6 mm. In addition, the proximal and middle third of the right coronary artery measuring 6 mm in diameter. There is a trace amount of mitral valve insufficiency noted. There is no evidence of any aortic valve insufficiency. The overall left ventricular function is normal. A 12 lead EKG today reveals no evidence of any ST-T wave changes. My evaluation today reveals that Michael now has echocardiographic findings of coronary artery disease related to his Kawasaki Disease. There is diffuse dilation of all the major branches of the coronary artery system, which is a new finding compared to his echocardiogram performed three weeks ago. I did have Dr. Paisley re-examine Michael today and he has recommended re-treatment with gamma globulin. Apparently Dr. Paisley has discussed Michael’s case with some infectious disease colleagues in Denver, who have recommended re-treatment to prevent any further progression of the coronary artery disease. Consequently Michael was admitted this afternoon to Emanuel Hospital. I will most likely repeat the echocardiogram on Michael in another three weeks. We have decreased Michael’s aspirin dosage to two baby aspirins per day. He will be started on ibuprofen in an effort to control his suspected ongoing inflammation. Please do not hesitate to contact me if you have further questions. Sincerely, Douglas H. King, M.D.
April 27, 1995
Dear Dr. Norris, This is a letter regarding Michael Epperson. As you know, he seemed to still be ill when Dr. King saw him yesterday. I was concerned that he was unable to come off of high dose ASA. When Dr. King saw aneurysms, we felt it would be prudent to retreat him. I have not seen a case smoulder along like this, but I spoke to an expert in Denver who had. His ESR was 90, consistent with persistent inflammation. We gave him another 2 grams per kg of IVIG and he seemed to respond to it again. He was sent home on 160 mg per day of ASA for an antiplatelet effect and 200 mg ibuprofen up to every 6 hours for an anti-inflammatory to use for the next few days. Since he has been an odd case I cannot guarantee that he will finally respond to this. I would like to see him next week to see how he is and probably to redraw his ESR. Hopefully by then he will be able to be off the ibuprofen and just remain on the low dose ASA which he may need for months or life. He should not be in gym until further cardiology studies have been done. Dr. King planned to redo these in about a month. Hopefully his aneurysms will resolve also, although the intimal hypertrophy may persist. As you know, there is a small chance there will be thromboses of the coronaries even now with infarction or death. I reviewed all of this with his mother and father; I did not go into specifics of the rare infarction possibility. Sincerely, John Paisley, M.D.
May 5, 1995
Dear Dr. Norris, It appears Michael Epperson is finally recovering from his acute Kawasaki’s disease. His mother said he is back in school and yesterday seemed essentially back to normal. He still complains the light is bright in the morning. He has had no more fever or other specific symptoms the past few days and is eating well. I suggested they discontinue the ibuprofen entirely to see how he does off of it. He continues on his aspirin daily. Some children have second episodes of Kawasaki’s months to years later. Hopefully this will not be the case. I will stay in touch with them early next week to see if he has any suggestion of relapse. Sincerely, John Paisley, M.D.
May 30, 1995
Dear Dr. Norris, I saw Michael back in follow up today. As you know, Michael is now approximately six weeks status post his febrile illness which was secondary to Kawasaki disease. You will recall that Michael initially received a dose of gamma globulin and was then retreated because of persistent signs of inflammation. He has not been out of the hospital for approximately one month. The mother feels that Michael’s energy level is now back almost to normal. He still does exhibit some fatigue with heavy activity. He has had no complaints of chest pain or dizziness and his appetite has returned to normal. He has had no recent fever or rash and is currently on two baby aspirins per day which is approximately 6.5 mg/kilo/day. Michael now returns for follow up of the coronary artery aneurysms which were noted on his previous echocardiogram. On physical exam, Michael is a well developed, well nourished, 7 year old male in no acute distress. The vital signs reveal a heart rate of 80, blood pressure is 110/70 and the weight is 54.5 pounds. Exam of the chest reveals the lungs to be clear to auscultation. Exam of the heart reveals a quiet precordium. First heart sound is normal; second heart sound is split. There is a grade I to II/VI low frequency vibratory murmur noted along the left sternal border which does not significantly radiate. Pulses are 2+ and symmetrical in all four extremities. Abdominal exam reveals no hepatosplenomegaly. Exam of the extremities reveals no cyanosis or clubbing. Laboratory data today include a follow up echocardiogram. This continues to show coronary artery enlargement involving the left main and left anterior descending coronary arteries. The proximal circumflex coronary artery appears to be slightly dilated as well. The right coronary artery is dilated approximately 5 to 6 mm in diameter and extends around the right AV groove. The posterior descending coronary appears normal in caliber. There is no pericardial effusion. The left ventricular size and function is normal. Michael appears to be clinically stable with regards to his Kawasaki’s disease. His echocardiogram does continue to show diffuse coronary artery involvement involving the left anterior descending proximal circumflex and right coronary artery. The left ventricular function remains normal and there is not segmental wall motion abnormalities noted. At this point in time, it appears that we will need to continue Michael on aspirin for the foreseeable future. I may consider starting him on Persantine as well sometime in the next few months. I anticipate performing a cardiac catheterization and angiography sometime between 6 months to a year post-illness. This will help us determine whether there is any coronary artery stenosis as a result of the aneurismal dilatation. I have asked the mother to curtail contact sports and I would keep him from roller blading at least for another 1 to 2 months. I will plan on re-evaluating him 2 months time or certainly sooner if there is any change in status. If he develops any chest pain or dizziness I will need to see him much sooner. Sincerely, Douglas H. King, M.D.

First time shadowing.

Today I was able to shadow Doctor Stefanelli a pediatric cardiologist.
I went up to the NorthWest Children's Heart Care clinic and they were expecting me since I previously scheduled this day to shadow Dr. Stefanelli. I got there about an hour before the first patient arrived, so Dr. Stefanelli showed me around the clinic and it was significantly bigger from that last time I was there because they had expanded. Then they put me on what they called a murmur machine that was used to train your ears to the different types of murmurs an unhealthy heart can make so that I could be able to recognize it when we started seeing patients. It was pretty cool to listen to how different the heart can sound with each of the problems that cardiologist face.
But before long we were in seeing patients. Dr. Stefanelli would give me a brief about what problem the child had so that I could have a good idea what they were talking about. We saw a lot of infants and whenever they had a murmur the doctor would give me the stethoscope so that I could listen and hear the murmur in a real patient. It was pretty neat to see how much you can actually diagnose from just listening to someones heart.
While we were not seeing patients I went in with the lab techs and watched them give echocardiograms. Something that over the years I seen a lot of but this time the lab techs explained what they were doing and what we were looking at. After watching a few I was able to see the different parts of the heart and was able see what didn't look right. After the echocardiograms we would go back to the tech room and sit down with the doctors and review the echo and see what was wrong if there was anything or any improvements they were making. We also looked at some chest x-rays to see if there were any improvements.
I was able to see a pretty wide range of heart problems that Dr. Stefanelli sees everyday from an infant that just completed his 4th surgery to rebuild his heart. To a 12 year old that was just trying to see if they have a heart problem. It was great learning experience that just reaffirmed my desire to become a doctor and my fascination with the human heart.
Great day.

First Post

I just finished up my freshman year at Brigham Young University-Idaho. I was able to come out of my first science prerequisite course (Chem 105) with an A grade and a job of tutoring chemistry for my teacher this fall. I now have a cumulative GPA of 3.49. So things are looking good. I am in Washington living with my brother for the break while i find some odd jobs and do some job shadowing with some friends that are doctors here. My first job shadow will be this Thursday with Dr. Stefinelli, a pediatric cardiologist.