X.

DIAGNOSTICS
There is no specific diagnostic test in diagnosing Kawasaki disease, however the
physician will perform physical examination and order some actual diagnostic test to
help in diagnosing the disease (Mayo Clinic, 2022).
A. Actual Diagnostic Tests
Actual diagnostic tests for acute respiratory distress leading to Kawasaki disease are
tools that are helpful for the following reasons: (1) to help diagnose Kawasaki disease,
(2) to know what the bacteria is causing the infection (3) monitor the progression of the
disease process along the course of ongoing treatment. To confirm the diagnosis of
ARDS leading to Kawasaki disease, actual diagnostic tests and procedures include
Warm CREAM and FEBRILE Mnemonics for KD Criteria, Berlin Diagnostic Criteria for
Respiratory Distress, Arterial blood gas (ABG), Complete Blood Count (CBC), Sputum
test, Chest Radiograph (X-ray), Erythrocyte Sedimentation Rate (ESR), C- Reactive
Protein (CRP).
Warm CREAM and FEBRILE Mnemonics for KD Criteria
Warm CREAM and FEBRILE Mnemonics for KD Criteria is a tool used to
diagnose Kawasaki disease. It is a series of symptoms present in the patient's body.
The symptoms include fever which is the most consistent presentation seen in patients
with Kawasaki disease. Also found in the criteria are conjunctival injection with
photophobia, which is also correlated with uveitis present in about 65% of the patients.
When these symptoms are present sequentially, it will indicate the diagnosis of KD.
Furthermore, a diagnosis of KD should be made in the acute phase of the disease
(Modesti & Plewa, 2021). The table summarizes the result of Patient J.D.'s Warm
CREAM and FEBRILE criteria, which can be found in the respiratory care plan.
Table 9-1
Warm CREAM and FEBRILE ,03/18/2022, Inspection at 07:45 a.m.
Warm = Fever for > 5 days 
C = Conjunctivitis without exudate 

R = Rash

E = Edema or erythema of hands or feet, followed by desquamation and

 nail changes

A = Adenopathy, often unilateral, cervical node > 1.5 cm


M = Mucosal erythema, fissures or crusting of lips or strawberry tongue


F = Fever for > 5 days


E = Enanthem of mucosal membranes

B = Bulbar conjunctivitis


R = Rash, erythematous, polymorphous

I = Internal organ involvement: coronary, abdominal, pneumonitis,

hepatitis, orchitis

E = Extremity changes, initial edema, and erythema, desquamation, nail

changes
Impression: The patient is experiencing high fever for more than five days, a
presence of rash, mucosal erythema, fissures or crusting of lips or strawberry tongue,
enanthem of mucosal membranes and erythematous polymorphous rash.
Implication: The patient is positive for Kawasaki disease (presence of at least five
days of high fever and presence of six other criteria).

Berlin Diagnostic Criteria for Acute Respiratory Distress Syndrome

The ARDS diagnosis is based on the acute onset and bilateral lung infiltrates of
non-cardiac origin on chest- ray and moderate to severe impairment of oxygenation
(Haskwel,2020). To know the severity of ARDS berlins test is used as a diagnostic
criterion (Des Jardins & Burton, 2016). This criterion is classified as mild, moderate, and
severe ARDS. Patients with a PaO 2/FiO2 ratio of 200-300 are considered mild ARDS,
those with PaO2/FiO2 100-199 are deemed moderate ARDS, and those with <100 are
considered to have severe ARDS. Patient J.D is hooked in mechanical ventilator with an
FiO2 of 100 % and PaCo2 of 78 mmHg which shows a PaO 2/FiO2 ratio of 76 mmHg
leading to Patient J.D to have a severe acute respiratory distress syndrome.
Sputum Culture
A sputum culture, also called a sputum test, is a painless test to study what
bacteria or fungi might be growing in the lungs and causing sputum production. This test
lets the patient cough up profoundly and spits any phlegm from the patient's lungs into
the container provided. After that, it will be delivered to the laboratory, which is also
placed in a special dish for culture. After that, it will be cultured for 2-3 days (Gill, 2018).
The result of a sputum test is primarily reported as normal(negative) or abnormal
(positive). A normal or negative result indicates that there are no harmful germs in the
sputum of the patients. On the other hand, a positive result indicates the presence of
bacteria or fungi in the patient's sputum (Testing.com, 2020). The table shows the
sputum analysis of Patient J.D found in the respiratory therapy care plan.
Table 9-2
Sputum Culture Result for Pathogen Identification, 03/18/2022, 8:00 a.m.
Sample Collection Date: 03/14/2022
Sputum Color/Consistency: Yellow, Pathogen: Streptococcus pneumoniae
Purulent

Complete Blood Count

A complete blood count is a test used to measures several components and
features of the blood. This is to evaluate for any range of disorders, including anemia,
infection, and leukemia (Mayo Clinic, 2020). A CBC is done by drawing a blood from a
vein (Sullivan,2018).
In patient with Kawasaki disease there is leukocytosis which often marked with
increase in immature cells, mild normocytic anemia, thrombocytosis (≥ 450,000/mcL [≥
450,000 × 109/L]) in the 2nd or 3rd week of illness (Raab,2021).
Table 9-3
Complete Blood Count (CBC) Result for Infection Evaluation, 03/18/2022
CBC Result Received at 9:30 a.m. Reference Range
Hemoglobin : ↑9.98 g/dL 10.2-15.2
Hematocrit : 30% 36-46
RBC : ↑5.03 X 1012/L 4.00-5.20
MCH : N 24 pg 23-31
MCHC : N 35 g/dL 32-36
MCV : N 90 fL 78-94
9
WBC : ↑20.2 X 10 /L 5.0-17.0
Neutrophil : ↑11.4 X 109/L 1.5-11.0
Basophil : ↑0.4 X 103/L 0.0-0.3
Eosinophils : ↑ 0.8 X 10 /L 3
0.0-0.7
Lymphocytes : ↑1.2 X 109/L 1.5-11.1
Monocytes :↑2.0 X 109/L 0.1-1.9
Monocytes :↑2.0 X 109/L 0.1-1.9
Platelet : 145 X 109/L 150-450
Impression: All WBC components are increased indicative of presence of infection.
Implication: CBC reveals presence of infection.
Complete Blood Count Result for Infection Evaluation, 03/20/2022
CBC Result Received at 10:00 a.m Reference Value
Hemoglobin : N 10.5 g/dL 10.2-15.2
Hematocrit : 34 % 36-46
RBC :↑5.15 X 1012/L 4.00-5.20
MCH : N 26.3pg 23-31
MCHC : N 35.10 g/dL 32-36
MCV : N 91 fL 78-94
WBC : ↑21.0X 109/L 5.0-17.0
Neutrophil : ↑11.3 X 109/L 1.5-11.0
Basophil : ↑1 X 103/L 0.0-0.3
Eosinophils : ↑ 0. X 10 /L
3
0.0-0.7
Lymphocytes : ↑11.2 X 109/L 1.5-11.1
Monocytes : ↑6 X 109/L 0.1-1.9
Platelet : N 147 X 109/L 150-450

Impression: All WBC components were elevated.

Implication: Infection were present.
Complete Blood Count Result for Infection Evaluation, 03/22/2022
CBC Result Received at 10:00 a.m Reference Value
 Hemoglobin : N 12.8 g/dL 10.2-15.2
Hematocrit : N 42% 36-46
RBC : N 4.50 x106/uL 4.00-5.20
MCH : N 25 pg 23-31
MCHC : N 33% 32-36
MCV : N 81 fl 78-94 fL
WBC : ↑ 18.5 x 103/uL 5.0-17.0
Neutrophil : ↑ 13 x 103/uL 1.5-11.0
Basophil : ↑ 0.5 103/uL 0.0-0.3
Eosinophil : ↑ 0.9 x103/uL 0..-0.7
Monocytes : ↑ 1.2 103/uL 0.1-1.9
Lymphocytes : ↑ 12 103/uL 1.5-11.1
Platelet : N 200 X 109/L 150-450
Impression: WBC components were elevated.
Implication: Increased WBC indicates that there is a presence of infection.

Electrocardiogram
An electrocardiogram is a non-invasive procedure used to detect the heart's
rhythm. This is done by placing electrodes at certain spots on the chest, arms, and legs.
Then the electrodes are connected to an ECG machine by lead wires. Then the
electrical of the heart is measured, interpreted, and printed out (John Hopkins, 2020).
An electrocardiogram is a test done for patients with Kawasaki disease to rule
out different heart problems such as ventricular dysfunction and arrhythmias due to
myocarditis. Furthermore, in the acute phase of Kawasaki disease, prolonged PR
interval and nonspecific ST changes, t-wave changes, and increased q/r changes
(Gibson,2018). The table shows the electrocardiogram of Patient J.D that can be found
in respiratory therapy care plan.

Table 9-4

ECG Result, 03/18/2022

ECG Result Received at 8:00 a.m.

Impression: Increase heart rate of 125bpm and fast R-R interval

Implication: Sinus Tachycardia

ECG Result, 03/20/2022

ECG Result Received at 9:45 a.m.

Impression: Persisting T wave inversion in V2

Implication: Rate has slowed, axis is normal, and QRS width has begun to normalize

ECG Result, 03/22/2022

ECG Result Received at 8:06 a.m.

Impression: Rate: 100 bpm P waves: Upright and Regular QRS: 0.04 sec
Rhythm: Regular P-R interval: 0.16 sec
Implication: Sinus Tachycardia
Chest X-Ray
A chest X-ray is an imaging test that uses X-rays to look at the structures and
organs in your chest. It can help the healthcare provider see how well the lungs and
heart of the patient are working. Certain heart problems can cause changes in the
lungs. Certain diseases can cause changes in the structure of the heart or lungs.
(Hopkins medicine, 2019)
Table 9-5
Chest Radiograph (AP Views) Baseline Results

Impression: Taken on 03/18,2022, The Impression: Increased Opacity due to

AP view shows that there is an increase in bilateral alveolar infiltrates
radiodensity. Lungs become whiter
(increased opacity), enlarged heart,
diaphragm is flattened, and retrosternal air
is increased.
Implication: Bilateral infiltrates
Implication: Increased Opacity due to consistent with acute respiratory distress
bilateral alveolar infiltrates due acute syndrome
respiratory distress syndrome
 Impression: Chest radiograph shows confluent airspace opacity in the right and
upper lobe of the right lung and patchy infiltrates with air bronchogram indicating
consolidation or accumulation of secretions in the lung parenchyma.

Arterial Blood Gas

An arterial blood gas analysis (ABG) measures the balance of oxygen and
carbon dioxide in your blood to see how well your lungs are working. It also measures
the acid-base balance in the blood (URMC, 2019) An arterial blood gas (ABG) test
measures the oxygen and carbon dioxide levels in your blood as well your blood's pH
balance. The sample is taken from an artery, not a vein, and healthcare providers
typically order it in certain emergency situations. This test is used to determine the acid-
base balance of the patient. Furthermore, this test will also help in ruling in the
diagnosis.

Table 9-5

STAT ABG on Initial MV Set-Up at 100 FiO2

ABG Taken at 8:45 a.m

PARAMETERS Result Reference Value

pH 7.30 7.35-7.45

PaCO2 ↑55 mmHg 35-45 mmHg

PaO2 ↑75 mmHg 80-100 mmHg

HCO3 N 22 mEq/L 22-26 mEq/L

SaO2 94% 90-95%

Impression: A low pH level shows acidemia with an increase in pCO2 is called

respiratory acidosis. The slight reduction of HCO3 is the effect of the hydration
reaction. Oxygen desaturation occurs when the body is experiencing low blood
oxygen concentration.

Implication: Uncompensated Respiratory Acidosis with uncorrected Hypoxemia

Post-Hooking ABG from the Current MV Set-up at 100 % FiO 2, 03/18/2022

ABG Taken 9:15 a.m.

PARAMETERS Result Reference Value

pH 7.30 7.35-7.45

PaCO2 ↑55 mmHg 35-45 mmHg

PaO2 78 mmHg 80-100 mmHg

HCO3 N 22 mEq/L 22-26 mEq/L

SaO2 N 95 % 95-100%

Impression: The pH, HCO3, and PaCO2 are elevated. The PaO2 is also below the
normal range.
Implication: Partially Compensated Respiratory Acidosis.

ABG from Adjusted MV Set-up at 80 % FiO2, 03/20/2022

PARAMETERS Result Reference Value

pH ↑7.50 7.35-7.45

PaCO2 ↑50 mmHg 35-45 mmHg

PaO2 79 mmHg 80-100 mmHg

HCO3 N 27 mEq/L 22-26 mEq/L

SaO2 N 95 % 90-95%

Impression: The patient’s pH, PaCO2 and HCO3 is above normal and Sao2 is 95 %.
 Implication: Partially Compensated Respiratory Acidosis with uncorrected hypoxemia

ABG from C-PAP, 03/22/2022, Taken at 8:05 a.m.

PARAMETERS Result Reference Value

pH ↓7.26 7.35-7.45

PaCO2 ↑ 65 mmHg 35-45 mmHg

PaO2 ↓60 mmHg 80-100 mmHg

HCO3 N 23 mEq/L 22-26 mEq/L

SaO2 N 96 % 90-95%

Impression: Uncompensated Respiratory Acidosis with Uncorrected Hypoxemia

Implication: Patient’s acidosis is uncompensated, and the primary problem is in the
ventilation side.

Erythrocyte Sedimentation Rate

Erythrocyte Sedimentation Rate or also called as sedimentation rate test or sed
rate test, it does not diagnose any condition but help medical professionals to determine
inflammation and what further may be needed. An ESR test measures the rate at which
your red blood cells (RBCs) fall to the bottom of a test tube. The blood sample for this
test is measured over the course of hour. Furthermore, if a patient has an acute
infection or chronic inflammation it can increase the RBCs which causes the blood to
settle quicker (Goodwin, 2021).
In Kawasaki disease the patient typically shows >40 mm/hr. When patient
receives IVIG therapy and ESR are elevated it indicates positive for Kawasaki disease
(The Royal’s Children Hospital Melbourne, 2021). Table shows Patient J.D ESR test
after 1 hour of IVIG which can be found in the respiratory therapy care plan.
Table 9-6
ESR TEST, 03/18/2022, taken at 10:00 a.m.
ESR : 60 mm/hr
Impression: The RBCs settle quicker in the bottom of the test tube and ESR test is
greater than 40 mm/hr.
 Implication: Patient has inflammation caused by Kawasaki disease.

C-reactive
A c-reactive protein test measures the level of c-reactive protein (CRP) in your
blood. CRP is a protein made by your liver. It's sent into your bloodstream in response
to inflammation. Inflammation is your body's way of protecting your tissues if you've
been injured or have an infection. It can cause pain, redness, and swelling in the injured
or affected area. Some autoimmune disorders and chronic diseases can also cause
inflammation. A health care professional will take a blood sample from a vein in your
arm, using a small needle. After the needle is inserted, a small amount of blood will be
collected into a test tube or vial. (Medline plus, 2021)
In general, high serum CRP levels are expected in KD. Therefore, in patients
presenting with incomplete KD that does not fulfill the diagnostic criteria, a CRP serum
level > 3 mg/dL is used as a criterion to confirm KD.

Table 9-7

C-Reactive Protein Test

Date of Submission: 03/18/2022 Date of Release: 03/18/2022

Result : 5 mg/L

Impression: The C-reactive protein is elevated.

Implication: A presence of infection leading to acute inflammation.

C-reactive Protein Test

Date of Submission: 03/202022 Date of Release: 03/20/2022

Result : 10 mg/L

C-reactive Protein Test

Date of Submission: 03/22/2022 Date of Release: 03/22/2022

Result : 5 mg/L

Impression: The c-reactive protein is elevated.

 Implication: Increased C-reactive protein indicates there is a presence of
inflammation.

B. Possible Diagnostic Tests

Renal function Test

Kidney function tests are urine or blood tests that evaluate how well your kidneys
are working. Most of these tests measure glomerular filtration rate (GFR). GFR
assesses how efficiently your kidneys clear waste from your system. (Cleveland Clinic,
2021)
This test is a measure of how well the kidneys are removing wastes and excess
fluid from the blood. It is calculated from the serum creatinine level using age and
gender. The normal value for GFR is 90 or above. A GFR below 60 is a sign that the
kidneys are not working properly. Once the GFR decreases below 15, one is at high risk
for needing treatment for kidney failure, such as dialysis or a kidney transplant. (Kidney
Org, 2021)
Kawasaki disease (KD) is a systemic vasculitis and can develop multiple organ
injuries including kidney and urinary tract involvement. Because KD is a systemic
vasculitis, multiple organ involvement can develop, including coronary artery lesions
(CALs), carditis, arthritis, hepatitis, central nervous system (CNS) disease, KD shock
syndrome (KDSS), muscle involvement, hyponatremia and kidney and urinary tract
involvement.

Liver enzymes Test

This test is used to measure the level of alkaline phosphatase (an enzyme) in the
blood. Alkaline phosphatase is found in many tissues, with the highest concentrations in
the liver, biliary tract, and bone. This test may be performed to assess liver functioning
and to find liver lesions that may cause biliary obstruction, such as tumors or
abscesses. (Hopkins, 2020)
The blood sample for liver function tests is usually taken from a vein in your arm. The
main risk associated with blood tests is soreness or bruising at the site of the blood
draw. Most people don't have serious reactions to having blood drawn (Mayo Clinic,
2021)

Elevated liver enzymes in children are often found during a routine blood test. Elevated
liver enzymes are a warning sign of possible liver damage, irritation or inflammation.
Elevated liver enzymes are usually due to common conditions that are easily treated or
resolve on their own.

Albumin Test
Albumin is a protein made by the liver. A serum albumin test measures the
amount of this protein in the clear liquid portion of the blood. Albumin can also be
measured in the urine. Blood is drawn from a vein (venipuncture), usually from the
inside of the elbow or the back of the hand. Serum albumin levels are a useful predictor
of IVIG resistance in patients with KD.
Hypoalbuminemia may be present and correlates with a more severe and
prolonged disease course. Hyperbilirubinemia and elevated liver enzymes can be
caused by hepatic congestion, which in turn can lead to obstructive jaundice as well as
gallbladder hydrops.

Reference:
 Haskel, R. (2020). Calculating Acute Respiratory Distress Syndrome Severity.
Nursing Center. https://www.nursingcenter.com/ncblog/march-2020/calculating-severity-
of-ards

John Hopkins (2022). Electrocardiogram. John Hopkins.

https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/
electrocardiogram

Gibson, M. (2018). Kawasaki disease electrocardiogram. Wikidoc.Org.

https://www.wikidoc.org/index.php/Kawasaki_disease_electrocardiogram#:~:text=Electr
ocardiogram%20in%20Kawasaki%20disease%20may,occasionally%20arrhythmia
%20due%20to%20myocarditis.

Gill, K. (2018). Routine Sputum Culture. Healthline.

https://www.healthline.com/health/routine-sputum-culture

Goodwin, M. (2021). Erythrocyte Sedimentation Rate Test (ESR Test).

Healthline. https://www.healthline.com/health/esr#overview

MedlinePlus (2020). C-Reactive Protein Test. Medline Plus.

https://medlineplus.gov/lab-tests/c-reactive-protein-crp-test/#:~:text=A%20c%2Dreactive
%20protein%20test,injured%20or%20have%20an%20infection.

Modesti, A. & Plewa, M. (2021). Kawasaki Disease. NCBI.

https://www.ncbi.nlm.nih.gov/books/NBK537163/?
msclkid=7c350792aca711ecbf58f0a4cc37a0be&fbclid=IwAR2yQzVnHne29wFqE_GWa
OvMG7DAcR9Bgf_iTmERhvdhBHjAuqWuIU0Y6mo

Raab, C. (2021). Kawasaki Disease. MSD Manual.

https://www.msdmanuals.com/professional/pediatrics/miscellaneous-disorders-in-
infants-and-children/kawasaki-disease

Sullivan, D (2018). Complete Blood Count. Healthline.

https://www.healthline.com/health/cbc

Testing.Com (2020). Sputum Culture, Bacteria. Testing.com.

https://www.testing.com/tests/sputum-culture-bacterial/
 The Royal Childrens Hospital Melbourne (2021). Kawasaki Disease. The Royal
Children’s Hospital Melbourne.
https://www.rch.org.au/clinicalguide/guideline_index/Kawasaki_disease/