Problem Rounds

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Problem Rounds 6/15/06
11 year old with chest pain
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CC Chest Pain HPI Patient began to complain
of substernal 8/10 chest pain at approximately
9pm the night prior to presentation to ER. The
pain was constant and made it difficult for him
to sleep. He denied diaphoresis, shortness of
breath, radiation or palpitations. Patient was
unable to describe the quality of the pain. Dad
said that he slept with the patient and noted him
to be restless, only sleeping intermittently.
When he would fall asleep he would groan. Mom
noted that his abdomen was moving up and down
quickly while he slept, but didnt notice
anything different about his breathing pattern or
chest rise.
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HPI Continued Beginning the first week of May
the patient began to complain once a week that
the posterior aspect of his left knee hurt, but
there was no swelling, redness or warmth. The
pain would occasionally wake him from sleep
during his afternoon nap after school. He was
able to walk and perform his activities of daily
living. Two weeks prior to admission he
developed green/blue discoloration like a
bruise to the plantar surface of his left foot
without redness swelling or warmth.
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HPI Continued Several days later he noted
swelling, without warmth or redness, of his left
ankle. It was too painful to walk. He went to
his PMD at an outside hospital where X-Rays were
taken, no blood was drawn. Family was told that
X-Rays were normal. PMD gave the patient
crutches and a note to be excused from PE for 10
days. Swelling of ankle and discoloration of
foot resolved in 2-3 days. Patient with lumbar
back pain and intermittent bilateral knee pain
throughout the week prior to admission, but no
redness, swelling or warmth. 1-2 days PTA began
to have left wrist swelling and pain. Denied
trauma to any of the joints.
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HPI Continued Patient with rash intermittently
since he was an infant, ocurring 1-3 times per
year. Rash consists of red, non-pruritic, flat
0.5cm to 2cm round patches. Since early May
patient has experienced this same rash 3 times,
the last being 1 week prior to admission.
Initially mom said that the rash was like the
other rashes the patient had gotten throughout
his life, but later reported that it seemed to
move more than previous rashes, with changes in
the rash notable within hours. She reported that
sometimes it looked like the center of the rash
was lighter than the outer portions. Rash
occurred of flexor surfaces of arms, medial
aspects of thighs, chest and back.
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HPI Continued Patient also with dry cough for
three weeks prior to presentation that parents
thought was getting stronger. Cough increased at
night. No rhinorrhea, fever, headache, vomiting,
diarrhea. No sick contacts. 3 days prior to
admission he felt dizzy much of the day, worse
when he rose from sitting, but did not actively
stumble, fall, or have unusual movements. Mom
noted that he looked pale and weak with decreased
energy for the week prior to admission. History
of possible mild sore throat for 1 day 2-3 weeks
prior to admission which was associated with no
other symptoms and resolved on its own with no
medical care. No change in urine color, or
output. No hematuria.
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Take a moment to consider your differential
diagnosis
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Allergies 1. PCN-rash, no respiratory distress
2. Pork PMD Outside facility Imm last PPD
negative 2000, otherwise UTD per card Meds
Tylenol 500mg, last use morning of
admission Birth Hx Former 7 month premie born
by NSVD-2 days in normal nursery at Outside
Hospital-mom had prenatal care PMH none, never
told that he has a heart murmur PSH none
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Fam Hx mom 30, dad 35, 3 sibs-8yo sis, 6yo bro,
3 yo bro Paternal GM-DM, pat GF-heart
problem for which he takes a blood
thinner, mat great GF-arthritis his whole
life Soc Hx Lives in East LA in a 2
bedroom duplex with his parents and sibs. No
pets. Social alcohol drinking by dad. No
tobacco. No drugs. Gets along with his family.
In 6th grade, getting As and gets awards almost
every month for being a good student. End of May
began playing basketball because his doctor told
him that he needed to lose weight. He stopped
when he began to have joint pain. Prior, was not
physically active. Denied drug use, alcohol,
sex, SI, HI.
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Take a moment to consider your differential
diagnosis
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PE T 99.8, BP 107/50, HR 118, RR 14, SaO2
100 RA, Pain 2/10 General awake, alert,
sitting up on gurney, able to speak in full
sentences, non-toxic Neuro alert and oriented x
3, CN II-XII intact, 2 DTR bilateral, strength
5/5 x 4 extremities, normal rapid alternating
movements, normal heel-to-shin, normal gait,
normal heel/toe/tandem walk, negative Romberg, no
focal deficits HEENT NCAT, PERRLA B,
conjunctival pallor, no conjunctival injection,
nares clear without rhinorrhea, MMM, o/p clear,
2 tonsils without exudates or erythema, TM clear
B, neck supple, no JVD, no meningismus CV
tachycardic, RR 2-3/6 harsh, blowing, nearly
pan-systolic murmur best heard at LLSB associated
with a 2/6 mid-diastolic murmur, closely split
S2, widened P2, no gallop, CRlt2 seconds, pulses
2 equal, not bounding Resp faint crackles at R
lung base, otherwise clear with good air movement
throughout Abdomen soft, obese, normo-active
bowel sounds, non-tender, non-distended, no HSM,
no fluid shift or wave GU normal tanner III
male, testes down bilaterally without mass Ext 1
pretibial edema, no clubbing/cyanosis, left
wrist mildly swollen with slight decreased range
of motion secondary to pain but without
erythema/warmth/effusion/crepitus, otherwise
unremarkable extremity exam
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Skin no Oslers nodes or Janeway lesions, no
splinter hemorrhages, several nonblanching 1-2 cm
nonpruritic erythematous patches with central
clearing and distinct out rim border on upper
aspect of back, no other rash, acanthosis
nigricans of posterior neck extending to
sternocleidomastoid, no subcutaneous
nodules Lymph no cervical/axillary/inguinal
adenopathy
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Lab Highligts Na 134, K 4.5, Cl 100, CO2 23,
BUN 15, Cr 0.6, Glu 100, Ca 9.2, Mg 2.1,
Phos 4, Alk Phos 110, T prot 7.2, Alb 3.5,
AST 23, ALT 15, T bili 0.8, B bili 0.2, CK
317, LDH 303 WBC 8.8, Hgb 9.1, Hct 27.2,
Plt 267, N 63, L 29, M 7.4, E 0.1, B 0.4,
Bands lt 10, PT 17.8, INR 1.46, APTT 42.8,
Fibrinogen 736, D-dimer 1893 U/A 6.5/1.016
negative ESR 96, CRP 10.6, ASO 1300 Blood
culture negative x 3, Throat Culture negative
EBV/CMV/Mycplasma titers negative for acute
infection
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In our ER T 100.6, BP 108/50, HR 120, RR
20, SaO2 100 RA, Pain 3/10 Noted to be alert
and responsive,but tired appearing. Pale hands
and face. 2/6 systolic blowing murmur with
bounding pulses. Vancomycin given. Labs drawn.
Chest X-Ray and Echocardiogram done.
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Take a moment to consider your differential
diagnosis
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Studies CXR hazy interstitial areas RgtL, c/w
mycoplasma vs interstitial edema, generous heart,
no mediastinal adenopathy
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EKG prolong PR for age 0.174, left atrial
enlargement
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Echocardiogram mitral valve regurgitation, left
atrial and ventricular enlargement, EF 69
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Take a moment to consider your differential
diagnosis
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Diagnosis Acute Rheumatic Fever
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• Special Thanks to Moni Stevens for this
  outstanding writeup.