Hot Seat Case #135: 12 yo with chest pain and SOB
Posted on: August 15, 2019, by : Sarah Isbey
Sarah Isbey, MD, Children’s National Medical Center with Rosemary Thomas-Mohtat, MD, Children’s National Medical Center
CC: Chest pain and SOB
HPI: A 12 year old male with a history of eczema and past diagnosis of bronchitis presents to ED with intermittent SOB last night. Symptoms started last night and did not resolve with albuterol (old prescription at home). Mother listened with a stethoscope at home and did not hear anything so went to bed, but this morning he had continued pain and clutched his chest this morning. Pain and dyspnea is worse with exertion. Mom listened to patient again after climbing stairs at home and felt like patient had “dropped beats.” No recent weight loss, night sweats or hx of fevers. No reported palpitations. No personal or family cardiac history. No syncope.
ROS: Positive as described in HPI
Negative for: headaches, seizure, cough, diarrhea, vomiting, constipation. No history of immobilization
PMHx: eczema, “bronchitis” with prescription for albuterol
PSHx: none
Fam Hx: no family cardiac history
Social: In middle school, no issues in school. No recent travel, no long trips
Physical Exam
T37.2 RR26 HR112 BP 128/79 Sat 98% on RA
General: Alert. Appropriate for age, cooperative.
Skin: Warm. No rash. Normal for ethnicity.
Head: Normocephalic. Atraumatic.
Neck: Trachea midline
Eye: Pupils are equal, round and reactive to light. Extraocular movements are intact. Normal conjunctiva.
Ears, nose, mouth and throat: Oral mucosa moist. No pharyngeal erythema or exudate.
Cardiovascular: Mild tachycardia and regular rhythm. No murmur. No gallop. Normal peripheral perfusion. Extremity pulses equal.
Respiratory: Lungs are clear to auscultation. Tachypneic to mid 20s with intermittent suprasternal retractions and nasal flaring, no wheezing, no crackles.
Chest wall: tenderness to palpation of upper third of sternum
Musculoskeletal: No tenderness. No swelling. No deformity. Moves all extremities.
Gastrointestinal: Soft. Nontender. Non-distended. Normal bowel sounds. No organomegaly.
Neurological: Alert. No focal neurological deficit observed. Normal coordination observed.
The patient was given Motrin for chest wall pain and a single albuterol nebulizer treatment without change. EKG was ordered with normal sinus rhythm and CXR was non-focal. He continues to have intermittent tachypnea and nasal flaring with O2 sats 94-97% on RA, worse with exertion (ie walking to radiology for CXR), with normal rhythm on monitor and no focal findings on lung exam. He does not appear to be anxious.
Please comment below on additional lab or imaging studies that you would want based on this new information.
Reassessment: CBC shows no signs of anemia, leukocytosis, or thrombocytopenia. You are able to get patient HR to 160s on monitor with exercise without changes in rhythm. BMP normal and UA normal without signs of hyperglycemia. VBG without acidosis or hypercapnia, EtCO2 placed and 25-35.
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Yet another non specific history and case!
The way I would think about this case is ABC’s! So first to decipher is this child purely tachpyenic or tachypneic with hyperventilation as well. Your VBG is normal but keeping this child on ETCO2 while you hammer out your differential is extremely helpful so that you can keep an eye out for any impending deterioration prior to hypoxemia.
The tachycardia is also concerning especially without a fever but this is sort of like chicken and the egg…which came first? Is his tachycardia a result of the respiratory distress?
POC tests in my mind are helpful to get me down a path. Things like H/H on the VBG to assess for anemia. Fingerstick glucose to make sure this isnt DKA. EKG to help with potential arrhythmias (although very well could be normal in that point of time). And then CXR to make sure were not missing a pnuemothorax, effusion, or heart failure.
Clearly you tried the asthma and costochondritis treatments without any help so i think you would be hard pressed not to pursue a CT Chest to rule out PE in someone who is tachypneic, tachycardic, and increased work of breathing without a source. Anxiety/Panic attacks shouldn’t make you retract!
Everyone had great thoughts. With all the press recently about e cigarettes, I suppose one should ask whether or not he “vaped” something. Perhaps pneumonitis with a delayed radiographic presentation?
I agree with Haroon’s above comment. While there is no mention of fever on the history or recent viral illness, I think it is also important to think about possible early myocarditis. Given his persistent tachycardia I think it is prudent to get the HR into a more reasonable range prior to discharge. Granted, he has received albuterol both at home and here in the ED, which could be resulting in tachycardia but if you observe him for over 4 hours the effects of that should wear off. I would also like to know what his response to fluids is, could this be tachycardia secondary to dehydration? Unfortunately, dehydration does not explain the chest pain. If fluids do not improve his HR and he remains tachycardia despite a 3-4 hour ED observation period I think he should be admitted to see if his symptoms are going to progress or improve.
Interesting case. This 12 yr old essentially healthy male presents with acute onset (<24hrs) of dyspnea, and SOB with exertion, with sternal pain to palpation- with findings of tachycardia, slight tachypnea, nasal flaring, retractions and slight hypoxia with exertion. I wonder if mom is some medical field with a stethoscope and reporting “dropped beats” even though now everyone has pulse ox ordered from Amazon.
I agree with what Haroon and Christina have said.
Taking a step back to think about chest pain, it’s likely from one of these elements affecting the thorax:
1. Lungs (parenchyma/ventilation or perfusion problem): asthma, infection like pneumonia, pneumothorax, PE and pulmonary infarct (though unlikely in a totally well kid)
2. Cardiac (intrinsic- myocarditis, arrythmia vs. extrinsic- pericardial effusion, pericarditis) or precordial catch
3. GI- GERD, esophagitis, FB in the esophagus
4. MSK- costochondritis, trauma (rib fracture), pulled muscle
5. Tox- Inhalational, Salicylate related metabolic acidosis resulting in compensatory resp alkalosis, caffeine, sympathomimetics (cocaine, ecstasy, amphetamines).
6. Psych- anxiety, stress
7. Metabolic- DKA, or response for other etiology of metabolic acidosis.
Something is going on- it’s hard for a 12yr old male to generate nasal flaring, retractions though not impossible, and lower oxygen sats. You’ve already tried some asthma and costochondritis management and you have a normal basic labs. I’d enquire more about toxic exposures. I’d do a bedside ECHO to evaluate for function and pericardial effusion. And continue to observe for few hours, if symptoms don’t resolve, I’d consult cardiology.