Date: November 25
Time: 1302
Location: Resident Alley
You return from grabbing your lunch and finish submitting the last of your daily progress notes for the day. As you breathe a sigh of relief that your work is essentially complete, you feel a buzz at your hip: the admission pager has gone off. You look at the patient counts on each team, only to discover that your team has six (6) patients on them while the other teams are stuck at twelve (12) each. The page reads “57275” indicating that a patient is being admitted from the Pediatric Emergency Room. While opening FirstNet, you return the call. The Fellow answers, greets you warmly while apologizing for the admission, and begins to provide you a report on the patient:
Name: Bethel “Kristen” McAlister
Age: 17 years
Room: ED-7
Information: 17 year old female with anxiety and depression who presented with ten episodes of severe chest pain over the past week. The chest pain is located over the left anterior chest and is described as sharp, stabbing pain. When she presented she was stable and not complaining of any pain. However, during their evaluation Kristen had an episode of chest pain. During this time, Kristen’s pain was rated as a 10 out of 10, and she complained of numbness and tingling down her left arm. She was notably tachypneic and had some dizziness and unsteadiness when attempting to stand. She was given a dose of intravenous Morphine which caused her pain to subside and her to fall asleep. Given the severe presentation of her symptoms, they ordered an EKG and troponins. They are admitting her for pain control and a Cardiology evaluation.
Let’s pause…
- What are your differential diagnoses?
After discussing the case with your Attending, you promptly work your way down to the Emergency Room to speak with the patient. As you enter the room, you find a well-appearing female with a nasal cannula in place. Her parents sit to her right and appear very anxious. You introduce yourself as a member of the inpatient team who will help coordinate their admission to the hospital.
Kristen reports that she has had eleven (11) episodes of severe chest pain over the past week, including the episode that recently occurred in the Emergency Room. The chest pain occurs suddenly without prompting or activity, and almost exclusively happens while she is sitting still on the couch or in bed. The pain is localized to the left anterior chest overlying the heart. It is described as sharp, stabbing, and severe. The pain is exacerbated by deep breathing and causes her to take fast, shallow breaths. These episodes last roughly one (1) to two (2) minutes before resolving. She has associated dizziness and numbness down her left arm during these pain events. Outside of the Morphine that she received, the pain generally self-resolves. Kristen does note that she sometimes can take a deep breath causing a “pop” in her chest to help alleviate the pain.
The parents express a significant concern that this may be related to undiagnosed heart disease. One of Kristen’s classmates recently died while playing basketball from an “englarged heart that he never knew about.” There is a strong family history of dyslipidemia and congestive heart failure in both maternal and paternal grandparents and great-grandparents (now deceased). There is no immediate family history of sudden death at a young age or cardiac disease.
Kristen has a prolonged history of anxiety and depression, for which she is on Fluoxetine 40mg once daily. Both she and her family deny any history of psychiatric hospitalizations for suicidal ideations. You ask that the family step out so that you may explore some questions with her in privacy, and they comply. While alone with Kristen, she reports that she has been sexually active with two (2) partners in the past year. She inconsistently used contraceptives. Her last episode of intercourse was four (4) months ago. She denies actively using tobacco, drugs, or alcohol, though admits to “having a beer” once at a friend’s party last year.
After speaking in private, you inform the family that they may return into the room so that you may begin your focused physical examination:
Temp: 36.3°C
HR: 61
RR: 10
Sat: 99% on room air
Gen: Awake. Alert. Appears mildly anxious, though in no acute distress.
HEENT: Atraumatic. Moist mucous membranes. Nasal cannula in place without nasal discharge. TMs clear bilaterally. Neck is supple without lymphadenopathy.
Resp: Clear to auscultation bilaterally. No ronchi or wheeze. No increased work of breathing.
CV: RRR. No murmurs auscultated. No dizziness with standing. Capillary refill is less than 2 seconds.
Abd: Flat. Belly button ring in place. Soft, non-distended, non-tender.
MSK: No palpable musculoskeletal tenderness over the chest wall or upper extremities. Spine straight without tenderness.
Neuro: Awake and alert. Upper and lower extremity strength is 5/5 bilaterally. Normal gait. Normal heel-to-shin. Normal finger-to-nose.
Anxiously, the family wants to know what the next steps you will take will be. You tell them …
Let’s pause…
- What are you looking for on the EKG?
- How does the history and examination augment your differential?
- What laboratory studies are you looking to add?
- What question do you have for Cardiology?
You excuse yourself from the room to review the medical record in more detail:
Pediatric EKG: Link to EKG
Troponin (0425): 0.08
Troponin (0731): 0.06
Na: 141
K: 4.2
Cl: 103
CO2: 21
BUN: 18
Cr: 0.44
Gluc: 89
While looking over the records, your Attending walks into the Emergency Room to evaluate Kristen. They notice your presence, and walk over to you to discuss the case since your evaluation and review of the medical record.
During your conversation, a portable chest x-ray machine rolls into the Emergency Room and into Kristen’s. The Emergency Room Attending apologizes for forgetting to sign out this order out to you. The machine enters the room, takes the ordered films, and begins to leave. You wait a few minutes for it to be uploaded into iSite (PACs) before logging in and viewing the images directly:
Let’s pause…
- What is your interpretation of the EKG?
- What is your interpretation of the image?
- What laboratory or imaging studies would help solidify the diagnosis?
- What medication(s) would you use to treat her pain?
After completing the admission process — including placing orders, completing the Admission Medication Reconciliation, and creating the Cache — you head back to the floor. A short while later you receive a page on the admit pager reading “20348,” indicating that someone from the Pediatric Specialty Care Unit has a question for the admission pager. When you return the page, the nurse asks you to pass along to the team caring for Kristen McAlister that they would like an update on this patient’s situation.
When you arrive at Kristen’s bedside, you repeat a focused examination:
Temp: 36.9°C
HR: 58
RR: 11
Sat: 98% on room air
Gen: Awake. Alert. Interactive. No acute distress.
Resp: Clear to auscultation bilaterally. No ronchi or wheeze. No increased work of breathing.
CV: RRR. No murmurs auscultated. No dizziness with standing. Capillary refill is less than 2 seconds.
The family anxiously looks to you for advice and insight. The nurse encourages you to explain, to the best of your ability, what is worrisome and what is reassuring…
Let’s pause…
- How do you explain unknown diagnoses to families?
- How would you characterize this patient’s acuity during sign out?
- What situational awareness items around this patient would you provide during sign out?
Cardiology Questions
While on a Cardiology rotation, a second-year resident meets with an adolescent female with a history of recurring, relapsing left-sided severe chest pain. The patient reports to the resident that her chest pain lasts roughly a minute, and is worsened with deep breathing. She reports that she sometimes develops numbness going down into her left arm and has some dizziness. A comprehensive physical examination and portable electrocardiogram are normal. The Cardiologist states that she believes the diagnosis is “Texidor’s Twinge.” Which of the following is the most likely diagnosis?
A.) Costochondritis
B.) Pleuritis
C.) Myocardial Cushion Defect
D.) Precordial Catch Syndrome
E.) Conversion Disorder
_____________________________________________________________
An 8 year old male presents to the Emergency Department with increased work of breathing and chest discomfort. His examination reveals a mid-diastolic murmur heard most pronounced at the apex of the heart. In review of his medical history, his family reports that approximately one month ago he had a sore throat with a fever, but they used Turmeric as an anti-inflammatory as opposed to going to the doctor. Which of the following is another major manifestation of the most likely diagnosis?
A.) Joint pain in the right great toe
B.) Fever for five days
C.) Abnormal movements of the hands while asleep
D.) Firm, painless nodules over extensor surfaces
E.) An ESR of 110 and a CRP of 17
_____________________________________________________________
A 17 year old female with chronic abdominal pain is admitted for acute on chronic feeding intolerance. During family-centered rounds, the team discusses the case with both Gastroenterology, Chronic Pain, and the Pediatrics services present. The mother asks about Methadone as a potential option for chronic pain, as she has seen it used successfully in her nephew for his cancer-related pain. Gastroenterology comments that Methadone is likely to cause problems in this patient given that it, along with her other maintenance medications, can prolong an individual’s QTc-interval. Above which of the following QTc-intervals would the value be considered prolonged for a post-pubertal female?
A.) 400 ms
B.) 450 ms
C.) 470 ms
D.) 480 ms
E.) 500 ms
Chest Pain in Children and Adolescents
Pediatrics in Review (January 2010)
American Family Physician (February 2010)
Long QT Syndrome – GeneReviews
National Institutes of Health (February 2003)
Answers:
- D
- D
- D