Cardiovascular Case
CC: “Chest pain”
HPI: This is a 14yo male, no PMH, who presents to the PCP for evaluation of right-sided chest pain, which began 1 day ago after he sustained an injury playing football. He states he was playing tackle football with his friends when he received an injury to the right side of the chest from am players elbow. He immediately fell to the ground in pain. He laid still for 1-2 minutes, expecting the pain to subside, but it did not. He attempted to continue playing but experienced difficulty taking a deep breath and the pain was more noticeable when running and twisting. He took 600mg ibuprofen the night before, but the medication did not relieve his pain. After a restless night, his mother has brought him in for evaluation.
ROS:
ROS positive for SOB, CP, pain with movement
Negative for fever, chills, cough, palpitations, edema, N/V/D, numbness, tingling
PMH: unremarkable; Immunizations UTD
PSHX: none
Medications: None; took 600mg IBU x 1
FHX: Lives with mother and father, 10 yo sister
SHX: Denies ETOH, tobacco, illicit drugs
Allergies: NKDA
Physical Exam:
VS: T37.7C (99.8F), HR 102, RR24, BP124/76, SPO2 98% WT 61KG, HT162CM BMI 23
General: No acute distress
Psych: Mildy anxious
Skin, Hair, Nails: no rash, skin warm and dry. No abnl findings with hair or nails
Chest: Ecchymosis and tenderness to palpation of the right lateral chest wall located in mid-axillary line at approximately the 4th-5th ICS. No pain with lateral rotation of torso. Pain elicited with forward flexion and extension of torso. Symmetrical movement of chest wall with inspiration and expiration.
Lungs: Clear to auscultation bilaterally with diminished breath sounds in RLL. Percussion to posterior chest wall on right demonstrates hyperresonance.
Heart: RRR, no murmurs, rubs or gallops
Abd: SNTTP, +BSX4
- What are your differential diagnoses?
- What is the most likely Diagnosis, why?
- What would you like to order on patient? Labs? Imaging? Why?
- Next appropriate steps for this patient?
- Patient education?
Cardiovascular Case. If not managed appropriately, what are the medical/legal concerns that may arise? APA format, and references, scholarly resource cited in APA format from 2018-2023 only. (Within the last 5 years)