mis-diagnosis

abrafnp · Sep 21, 2006

Hi,

I hope your daughter is doing well. Personally I would appreciate the feedback to get both information on the patient's outcome and a possible learning opportunity. Diagnosing is challenging especially in the urgent care setting.

cgfnp · Sep 21, 2006

Hi NP's,
My daughter was seen in an urgent care clinic over the weekend by two NP's. She was diagnosed with a virus, when I took her to her pediatrician for follow up on monday she was diagnosed with something else (which seemed to make more sense given her symptoms). I was just wondering if you would want to know about the other diagnosis to add to your base of knowledge or if you would feel insulted being told that your diagnosis may be incorrect.

I would definitely want to talk about it. First, just because a pediatrician comes up with a different Dx doesn't necessarily make the NPs wrong or the Dr right. I know some docs that will rename the same diagnosis just so it's different (the equivalent of a bull stomping the ground). Now they very well could've been seriously wrong as well. Either way, I'd want to know to be able to learn or explain why I'm still right.

ERNP · Sep 21, 2006

I would be interested in more details of this "mis-diagnosis" so I could make an informed comment here.

Jilaweez, BSN, MSN, RN · Sep 21, 2006

Thanks everyone for the feedback. My daughter is doing a little better, thank you. I am pretty sure the Dr's dx was the right one after doing some research, but I did say the diagnosis may be incorrect, not that it was. I just pondered calling the urgent care to tell the NP's what the Dr. suggested was the diagnosis because if it were me, I'd want to know for future reference. Then I decided against it because I thought they might feel insulted and I would'nt want to make them feel that way...that's why I thought I'd ask for your feedback.

I would be interested in more details of this "mis-diagnosis" so I could make an informed comment here.

My daughter was scratched by a cat on Fri. evening. On saturday morning she was complaining that her legs were sore. Later in the afternoon she started to develop a rash all over her lower extremity. It started on the leg where she was scratched but spread to the other leg fairly quickly. As the day progressed she was having trouble walking, her knees and ankles began to swell. She had also complained of abdominal pain on Thur. and Fri. No noticable swelling in her lymph nodes. The NP diagnosed her with cat scratch fever and gave her an IV antibiotic and sent us home with zithromax. I followed up with ped on Monday and she diagnosed her with HSP..symptoms, rash on lower extremeties, swelling of joints, especially knees and ankles, usually preceeded by abdominal pain. It made more sense, although being scratched by a cat was pretty coincidental. I have read that cat scratch doesn't usually show up for 3-10days and symptoms are headache, fever and swollen lymph nodes, not rash on legs.

It's not really a big deal....just wondered if you'd want to know.

Thanks again for your feedback, I really appreciate it.

ERNP · Sep 22, 2006

Ok, based on that information it doesn't sound like anyone was incorrect. HSP does present in the way you described. Quoting from AFP website, "HSP is caused when a person's immune system doesn't fight an infection like it's supposed to." The website goes on to say that there is increased incidence in spring associated with URI and the like. Of course I would never personally end a sentence in a preposition... lol

The reason I might have sounded suspicious is due to my work environment. It is frequent that I encounter people who have developed fever in the last hour of 99.7 with no other symptoms and I am supposed to define a definitive diagnosis. Of course this is impossible most of the time and usually it is a self limited viral type infection.

As far as follow up, I would love to have follow up. In ER there is very little. You do the workup and go with what looks like the best answer at the time, all the while explaining that things can change and develop and suggesting return for decline in condition or follow up with PCP if just not getting better for further investigation. Sometimes diagnosis is like a good stew, it needs to simmer before a definitive answer is possible.

cgfnp · Sep 22, 2006

Thanks everyone for the feedback. My daughter is doing a little better, thank you. I am pretty sure the Dr's dx was the right one after doing some research, but I did say the diagnosis may be incorrect, not that it was. I just pondered calling the urgent care to tell the NP's what the Dr. suggested was the diagnosis because if it were me, I'd want to know for future reference. Then I decided against it because I thought they might feel insulted and I would'nt want to make them feel that way...that's why I thought I'd ask for your feedback.
My daughter was scratched by a cat on Fri. evening. On saturday morning she was complaining that her legs were sore. Later in the afternoon she started to develop a rash all over her lower extremity. It started on the leg where she was scratched but spread to the other leg fairly quickly. As the day progressed she was having trouble walking, her knees and ankles began to swell. She had also complained of abdominal pain on Thur. and Fri. No noticable swelling in her lymph nodes. The NP diagnosed her with cat scratch fever and gave her an IV antibiotic and sent us home with zithromax. I followed up with ped on Monday and she diagnosed her with HSP..symptoms, rash on lower extremeties, swelling of joints, especially knees and ankles, usually preceeded by abdominal pain. It made more sense, although being scratched by a cat was pretty coincidental. I have read that cat scratch doesn't usually show up for 3-10days and symptoms are headache, fever and swollen lymph nodes, not rash on legs.
It's not really a big deal....just wondered if you'd want to know.
Thanks again for your feedback, I really appreciate it.

Also keep in mind that any rash can happen in any person at any time for any reason. The NPs did the right thing covering for the bacterial infections because who gives a rats ass if its HSP, or any other viral self limited disease that gets better on its own. If you're wrong and its viral, fine... it will get better. But let's say you see a similar situation and the kid doesn't remember if the cat actually bit them and you diagnose a virus and then Pasturella Multicida takes over and causes rapid sepsis and death. Most patients don't understand a virus anyway no matter how much you try to educate them and are pissed off if you don't give an antibiotic, as most parents are smarter than the doctors/practitioners and already know what's wrong and what medicine they need.

I agree with ERNP too in that it's easy to diagnose from hind-sight after someone has seen the patient early in the case and given a med that didn't work because most often they will dx the most common disease at that point of the presentation and by the time you get a second opinion, the problem is in full bloom and you have the advantage of seeing that the first thing didn't work.

Jilaweez, BSN, MSN, RN · Sep 22, 2006

Thank you for taking the time to post such well thought responses. I appreciate your feedback.

JEKA · Oct 1, 2006

I am an NP student. I hope I don't sound too dumb, but what is HSP? Thanks

Home Health Columnist / Guide · Oct 1, 2006

henoch-schonlein purpura (hsp or anaphylactoid purpura) is a form of blood vessel inflammation, seen often in spring after throat infections or reaction to medication.

considered minor illness .

http://www.medicinenet.com/henoch-schonlein_purpura/article.htm

Editorial Team / Admin · Oct 1, 2006

HSP=Henoch-Schonlein Purpura (HSP) Vasculitis

http://www.emedicine.com/EMERG/topic845.htm

JEKA · Oct 1, 2006

Wow, Thanks guys for such a quick response.