# Teenager with chest pain



## Seaglass (Feb 11, 2010)

I've been wondering about this one, so I figured I'd post it here. 

I had a 19 y/o F call in with chest pain. Normal resps, no fever. Slow cap refill and low pulse ox (don't remember number) but pt said that was normal because of Raynaud's hx. Pulse 80 and strong, except for a few seconds where it got thready and sped up. That didn't last long enough for me to get a count. She said she also had a headache and joint stiffness, with particular pain in her neck and back along the spine. Said she'd also been getting stabbing pains in her chest and wrist, along with her heartrate feeling weird. When asked to describe her chest pain, she said it was 4/10, with occasional spikes to 8/10. As for the heartrate, said it had been racing and slowing down intermittently for the past few hours, and that at one point she "stood up and almost fainted, then it felt like something kicked me in the chest and I didn't faint." She seemed a little scared, but denied any unusual emotional stress. No real medical hx, and she hadn't had a physical in a few years. I questioned her more about heart problems, and got "my parents say I had a murmur when I was a baby." No exercise within the past day, and moderate exercise within the previous days as per her routine.

So, I transferred care to ALS and immediately got dispatched to another call. I don't see that crew often, so I don't know what they found. In the meantime, I'm curious. I can think of a couple suspects, but nothing that fits the joint stiffness with lack of fever, and cardiac stuff. Opinions?


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## lightsandsirens5 (Feb 11, 2010)

Endocarditis?

Had a 16 yof with pretty much the same symptoms and that is what she had. I would have thought there would be a high fever with that, but the Doc said that Endocarditis will sometimes not display a fever and if it does it is usually very lo-grade.

Symptoms may include:

Possible chills and lo-grade fever
Fatigue
Stabbing chest pain
Night sweats
Joint pain and stiffness
Shortness of breath
Weight loss (long term)
Slight bleeding under fingernails
Occasional arrythmias (From what the Doc was saying, this is rare)
Possible vague flu-like symptoms


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## Veneficus (Feb 11, 2010)

There is not nearly enough findings presented to narrow this one down. 
Endocarditis
Rheumatic fever
Cardiomyopathy
Various valvular stenoses
Congenital abnormalities (long QT, etc)
Pregnancy
Drug use
Pericarditis

To name a few.

Could be secondary to another disorder; pulmonary, vascular, endocrine, the list could go on.  

Most people have a murmur for the first few weeks of life.


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## WolfmanHarris (Feb 11, 2010)

I had a 19 y/o present with similar S&S ~ 2 weeks ago only stated pain 1/10 intermittent w/ absolutely no meds, Hx, drug use, recent illness etc.

12 lead showed global ST elevation and early repolarization with the machine interpretation screaming "Acute MI Suspected." (That part's not important, just show's why we don't follow machine interpretation; casts too wide a net.) My working diagnosis was pericarditis. Of course by working diagnosis I mean shot in the frigging dark since nothing else seemed to fit and the back of my mind was whispering pericarditis. By the time I completed my ACR and brought it in from the reporting room the diagnosis was confirmed by the Attending MD.

Without some lab work or at least a diagnostic quality ECG you've got a whole lot of nothing to go on.


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## mikie (Feb 11, 2010)

*Had chest pain in my adolescense...*

Lacking any physiological findings...Costochondritis?


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## MrBrown (Feb 11, 2010)

I have been having chest pain for three years and I am in my early 20s, is that bad?


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## Seaglass (Feb 11, 2010)

Thanks, everyone! There were possibilities in there I hadn't thought of, and it's interesting to see other people getting chest pain in teenagers too. This was the first time I'd gotten one that wasn't having a panic attack, and it's one of those subjects that never seems to be mentioned in training. 

I'll update if I ever find out what the eventual findings were. I would've liked to at least see what the 12-lead picked up. 



MrBrown said:


> I have been having chest pain for three years and I am in my early 20s, is that bad?



Me too, actually, though for a bit longer. Never really worried about it. I figure I'll go see a doctor if it continues for a few more years, get more commons, or worsens. 

I brought it up once at a physical, and the doctor told me it was likely growing pains and not to worry. (He was later proven to be less than competent, though, so I have no idea what that's worth.)


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## mycrofft (Feb 11, 2010)

*Get a piece of paper.*

Three lists:
SUBJECTIVE C/O...SUBJECTIVE HX...OBJECTIVE S/S and directed hx/interview.

Then overlay this with what's most likely.

You observed an arrythmia, the pt c/o not dissimilar s/s, and VS did not rule out, so ALS was good call.

While waiting for the parameds to arrive, see if the pains can be alterd or triggered by movement of the head/neck/shoulders, or stiff paplpation of thye sternum ribs or spine. (See a map of the human dermatome, plenty online and in books).
Costrochondritis, infection, tox, are all candidates, possibly with a little overglaze of Mycrofft's Munchausen (a family designates a member s sick, keeps telling them they are sick and have been sick, so they are sick).


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## Aidey (Feb 11, 2010)

Not to pull out the Zebra here, but it also could have been more than one thing, like meningitis with a sinus arrhythmia, or runs of SVT.


The reason I mention it is because a lot of young women have a sinus arrhythmia that is totally benign, but if they don't know they have it you may think it is abnormal. I have it, and my resting pulse ranges between 48bpm and 76bpm, and I always have to warn people before they take it.

I may even be guilty of scaring an EMT student by holding my breath when the poor kid practiced checking my pulse...:blush:


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## TransportJockey (Feb 11, 2010)

Aidey said:


> I may even be guilty of scaring an EMT student by holding my breath when the poor kid practiced checking my pulse...:blush:



That's a little bit mean  But I freaked out a partner by having a LITTLE too much caffeine when she was just starting to learn cardiology in medic school. That was a fun EKG, so I can't really say too much.


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## DrParasite (Feb 11, 2010)

any person less than 35 with chest pain, no difficulty breathing, no drug use, no cold sweats/clammy skin, who is alert and without any cardiac history (no, murmurs don't county), gets coded in my system as a low priority BLS dispatch.

we go by the National Academy of EMD's Medical Priority Dispatch System, which is developed by people smarter and more educated than me.  figured I would throw that out


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## Seaglass (Feb 12, 2010)

Aidey said:
			
		

> Not to pull out the Zebra here, but it also could have been more than one thing, like meningitis with a sinus arrhythmia, or runs of SVT.



I worried about meningitis with the stiff neck and back. But there was no fever and she didn't have the degree of pain I'd expect for meningitis when asked to move her head. 

More than one thing occurred to me as well, but didn't help me narrow things down. At a certain point, I figured that I was out of my depth. 



			
				Veneficus said:
			
		

> Pregnancy
> Drug use



Those two seemed fairly unlikely. She was on BCP for irregular menstruation, but claimed to have not had any sexual contact in well over a year, or to have ever tried drugs. I believe she was telling the truth.

Everything else could easily be the case.



DrParasite said:


> any person less than 35 with chest pain, no difficulty breathing, no drug use, no cold sweats/clammy skin, who is alert and without any cardiac history (no, murmurs don't county), gets coded in my system as a low priority BLS dispatch.
> 
> we go by the National Academy of EMD's Medical Priority Dispatch System, which is developed by people smarter and more educated than me.  figured I would throw that out



To clarify, the murmur just told me that she was trying pretty hard to remember if she'd ever had any relevant history. If that's all she can come up with, I'm not too worried.

My county protocols say anything cardiac=ALS. Even if they didn't, I'd prefer to have ALS support for a long transport. Not that I expected her to code, but I'd have trouble justifying that feeling as a basic, since there's not much I can see without a monitor. CYA.


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## Veneficus (Feb 12, 2010)

Seaglass said:


> Those two seemed fairly unlikely. She was on BCP for irregular menstruation, but claimed to have not had any sexual contact in well over a year, or to have ever tried drugs. I believe she was telling the truth.



That puts her at risk for a PE, as well if she has irregular menstruation there has to be a reason why. Some of the suspect pathologies could cause cardiac issues.


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## mycrofft (Feb 12, 2010)

*Without seeing her, I'd weigh in on anything not objective...*

...being false.
Don't you watch House MD?

(Yeah, I thought about meningitis too. Meningiococcal meningitis, right age group. Mask up, lady!).

WE need a ZEBRA emoticon, don't we?


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## RescueYou (Feb 14, 2010)

Cardiomyopathy or Endocarditis would be my best guesses.


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