Monica Prieto MD, Children’s National Medical Center
With Michael Quinn MD, Children’s National Medical Center

The Case:

A 16 yo old otherwise healthy male presented with 2d of chest pain and fever. It is qualified as 5/10, localized to his mid-sternum and left chest, exacerbated by deep inspiration, and improved by taking shallow breaths.  It was not associated with SOB or palpitations. The fever had been daily for the previous 2 days, with a maximum reported temperature of 105 degrees F. He denied URI symptoms or cough, but did report one episode of headache the day prior that self-resolved and one episode of non-bilious, non-bloody emesis at around the same time.

ROS notable for fatigue, but no weight loss or weight gain, night sweats, rashes or joint pain or swelling. No dizziness, lightheadedness or syncope. He did report groin pain for 4 days in the setting of playing football.

PMHx/PSHx: None

FHx: No family history of sudden cardiac death or congenital heart disease.

Immunizations: UTD

Medications: None

Vital Signs: Wt: 74.6kg, T 37.6, HR 107, RR 24, SBP 133/77, SpO2 100% on room air.
General:  Alert adolescent sitting in a chair, in no apparent distress.
Cardiovascular:  Regular rate and rhythm.  No murmur or gallop.  Normal peripheral perfusion.  Dorsalis pedis pulses 2+ and equal bilaterally.
Respiratory:  Lungs clear to auscultation bilaterally without wheezes, crackles or rhonchi. Symmetric expansion, but deep inspiration limited by pain.
Chest wall:  Pain reported lateral to mid-clavicular line at the level of ~T6. Not reproducible on palpation. No sternum or other chest wall tenderness.
Gastrointestinal:  Soft.  Non-tender.  Non-distended.
MSK: Moves all extremities. Able to ambulate.
Neuro: Alert and oriented with normal gait and speech.

Question:

You perform an infectious lab screen with blood culture. The patient’s CBC shows WBC count 10.33, 76% PMNs, and an ESR/CRP of 50 and 21.69, respectively . There is no evidence of atypical lymphocytes, bands, or blasts on the differential for the CBC. You also obtain the following chest X-ray :

You re-evaluate the patient and he is still complaining of chest pain and groin pain. He is now febrile to 38.2, HR 85, RR 20, BP 119/84. You perform an EKG and administer ibuprofen for the patient’s fever and pain. The EKG is notable for a biphasic T-wave in V3, and flipped T-waves in V4, V5.

The radiologist calls after reviewing the film and reports nodular opacities in the RUL and LUL.

More Questions:

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