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Premier Health Care Services Physician Melissa Knarr, DO, wins CERP Award

February 13, 2009

Melissa Knarr, DO Image After months of weakness and pain, Kelly Makowski came to the Emergency Department at Marion General Hospital on April 30, 2008, looking for help. This 33-year-old female had undergone a hysterectomy on March 5th, 2008, for cervical cancer. About a week after the surgery, she began developing a progressive, generalized weakness and a generalized rash. At first, the patient and her husband attributed these symptoms to just being post operative with the rash possibly a reaction to some medication given at the time of her surgery. However, the symptoms progressed over the next six weeks to the point where it would take her two hours to get ready in the morning and she could not even do her hair due to extreme weakness. The patient had gone to her Obstetrician, who was not able to make a diagnosis, and then to her Family Physician, who ordered some lab work and noted a positive ANA level (antinuclear antibody), a test that points to autoimmune disease. This result led to a referral to a Rheumatologist who was going to refer Mrs. Makowski to a Dermatologist. At this point, the patient could no longer tolerate these symptoms and came to Marion General Hospital Emergency Department for help.

Mrs. Makowski was seen in the Emergency Department by Dr. Missy Knarr. Dr. Knarr felt there was more going on and ordered blood work, including a CPK level that came back elevated at 750 (CPK is a blood test that measures creatine phosphokinase [CPK], an enzyme found mainly in the heart, brain, and skeletal muscle. Normal CPK levels are in the range of 250 or less). Dr. Knarr was suspicious for Dermatomyositis, which is one of a group of muscle diseases known as the inflammatory myopathies, characterized by chronic muscle inflammation accompanied by muscle weakness. Dermatomyositis’ cardinal symptom is a skin rash that precedes or accompanies progressive muscle weakness. Dr. Knarr had the patient transferred to Riverside Methodist Hospital in Columbus where the diagnosis of Dermatomyositis was confirmed (secondary to her cervical cancer). She was immediately started on steroids, which resolved all her symptoms. Several months later, she is maintained on steroids, doing well, and back to work. The patient and her husband were very grateful for Dr. Knarr’s exemplary diagnosis and management and for giving Mrs. Makowski her life back.

Not the First Time Dr. Knarr has Made a Rare Diagnosis
Dermatomyositis is certainly a rare emergency medicine case, and this pickup was remarkable. This instance is not the first time Dr. Knarr has made a rare diagnosis. About a year and a half ago, she picked up a case of TTP in one of Marion General’s medics presenting with flu like symptoms. Thrombotic Thrombocytopenic Purpura (TTP or Moschcowitz disease) is a rare disorder of the blood-coagulation system, causing extensive microscopic blood clots to form in the small blood vessels throughout the body. TTP can be fatal or cause lasting damage, such as brain damage or stroke, if it’s not treated promptly. This life-threatening disorder is considered a true medical emergency. More recently, Dr. Knarr diagnosed an ovarian torsion in a patient with non-specific abdominal pain. Based on all of these fantastic cases, I would like to nominate Melissa Knarr for a CERP award.

CERP Logo Image CERP – the Clinical Excellence Recognition Program – highlights Premier Health Care Services health care professionals (Physicians, Physician Assistants, Nurse Practitioners) who have been recognized as having provided excellent clinical care in a specific Emergency Department encounter. Award winners are recognized in the Premier Perspective Newsletter, and a letter acknowledging the award is sent to the CEO, Chief of the Medical Staff, ED Medical Director, and ED Nurse Manager of the facility in which the award winner works the most ED shifts. Nominations for this award may be submitted by anyone, and the forms can be found on the Premier Intranet and submitted to your Premier ED Medical Director. Nominations are taken year-round, and winners are selected by a committee composed of the Chief Development Officer, Chief Executive Officer, and the Chair of the Clinical Services Committee. As a reward, each CERP winner receives a $100 gas card, and an annual winner will be chosen from the winners for a grand prize of $1000.00 travel voucher. In addition, the picture of the practitioner will be posted on a Premier Health Care Services Clinical Excellence Wall of Fame in the Premier corporate offices.

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