Keeping with the pediatrics theme, here is the freshest installment of Case of the Month.
A 15 year-old boy with no significant past medical history presents to the Janus ED with chest pain and decreased oral intake over a two day period. He complains of nausea with two episodes of non-bloody, non-bilious emesis. He feels tired with minimal physical activity. His mom notes a cough that is worse at night. The patient denies any abdominal pain but does not feel hungry. There are no sick contacts at home, there is no rash, and his immunizations are all up to date. Of note, he was seen in his primary care doctor’s office a couple of weeks ago for an upper respiratory infection, when he presented with cough, fever, myalgias, and generalized malaise. Those symptoms have since resolved.
No OTC meds
SH: Denies toxic habits; good student in school per mom
VS: HR 105 RR 30 BP 100/55 SaO2 98% (RA) T 101.3 degrees F (temporal)
General: Young boy lying in stretcher in moderate respiratory distress
HEENT: No scleral icterus or conjunctival pallor; no oropharyngeal erythema or exudates, uvula midline, moist mucous membranes; bilateral clear TMs; nasal turbinates clear and not boggy
CV: Tachycardia, normal S1S2, S3 noted, 2/6 systolic murmur in the apex, no rubs or gallops
Pulm: Tachypnea, nasal flaring, suprasternal retractions, bibasilar crackles
Abd: Soft, non-distended, non-tender, dull to percussion, +normoactive BS; liver palpable 2 cm below costal margin, no splenomegaly
Ext: no C/C/E
Derm: No skin changes noted on trunk, abdomen, oral mucosa, palms, or soles
CMP: within normal limits
- What is your differential diagnosis? Which diagnosis is most likely, and which is less likely?
- What further tests would you do?
- What is your therapeutic plan?
- What is the ultimate disposition for this patient?