Welcome to this month’s What’s Your Diagnosis Challenge!
But before we begin, check to see if you got last Neonatal Hyperbilirubinemia: Recommendations for Diagnosis and Management in the Emergency Department right.
Case Presentation: Pediatric Chest Pain: Using Evidence to Reduce Diagnostic Testing in the Emergency Department
A 15-year-old boy presents with severe left-sided substernal chest pain that began while exercising 2 hours prior…
The boy says that the pain does not radiate to his arms, neck, or back. He tells you he had a similar episode of chest pain the evening prior, which resolved spontaneously after 1 hour. The patient had been ill with a mild URI and diarrhea 3 weeks prior, which resolved in a few days without requiring medical attention. He had also been doing many pushups over the last few months with some increase in intensity recently.
On physical examination, the patient appears uncomfortable, with slight diaphoresis. His vital signs are: temperature, 36.3°C; heart rate, 58 beats/min; respiratory rate, 24 breaths/min; blood pressure, 143/65 mm Hg; and oxygen saturation, 100% on room air. His chest examination is notable for the absence of chest tenderness or neck crepitus. Heart sounds are normal and without murmurs, rubs, or gallops. His chest pain does not worsen when supine. Breath sounds are clear and without respiratory distress. The abdominal examination does not show liver engorgement. Strong pulses are felt in all 4 extremities, and there is no lower-extremity edema. The neurologic examination is without deficit.
Are there red-flag signs or symptoms that identify this patient as being at high risk for cardiac chest pain? What diagnostic workup is indicated for this patient?
The patient was given aspirin 160 mg and oxycodone 5 mg orally, with resolution of pain within 20 minutes. A chest x-ray showed clear lungs, normal heart size, and pulmonary blood flow. An ECG revealed 3 mm of ST elevations in I, II, III, AVF, V4, V5, and V6. Troponin was markedly elevated at 4.58 ng/mL. A cardiology consult was obtained emergently. After an unrevealing echocardiogram, the patient was taken for cardiac catheterization. This revealed an aberrant coronary artery arising from the right sinus of Valsalva, coursing between the pulmonary artery and aorta and causing ischemia to the left ventricle. The patient was taken to the operating room for corrective open-heart surgery.
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Last Updated on January 26, 2023