Hot Seat Case #135 Denouement: 12 yo M with chest pain

Posted on: August 22, 2019, by :

The Case:  a 12 yo healthy boy presenting with exertional chest pain associated with SOB/incr WOB with exam notable for tachypnea, clear lungs, EKG NSR, and normal CXR. 

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Discussion

A challenging case given the nonspecific history, exam, and work up. For initial steps, the majority would obtain an EKG and CXR and trial symptomatic management of common etiologies of chest pain in this demographic (ibuprofen for MSK/costochondritis, asthma for albuterol, bolus if dehydrated). 

Following the initial work up and attempt at management, comes the interesting discussion of which more rare diagnoses you would target. While some of these tests are low cost/low risk (such as a UA or POC blood glucose to evaluate for DKA), others, (such as a Chest CT) carry higher risk. While fellows were split on whether or not to order a chest CT, majority of attending would defer. While some people in the group argued that this patient has no risk factors for a PE (immobilization, coagulopathy or family history of such, malignancy), he does have tachycardia and tachypnea without another diagnosis more likely. Other steps in work up suggested included bedside Echo, urine drug screen.

Ultimately, with most responders and audience members stumped by the presentation and nonspecific work up, a cardiology consult is warranted. Pending their recommendations, many would admit for observation given unclear etiology of this patient’s symptoms.

Denouement

The patient continued to have mild intermittent tachypnea but was discharged home with cardiology follow-up after repeated MD re-evaluations with stability. He was seen by cardiology a few days later and noted that all her symptoms had resolved and she did not have further episodes of palpitations. He was discharged from cardiology follow-up.

The information in these cases has been changed to protect patient identity and confidentiality. The images are only provided for educational purposes and members agree not to download them, share them, or otherwise use them for any other purpose.

Mary Beth Howard
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