Fever and "worst pain ever" in the chest: In one ED, out the other

DR. LAYTON is a pediatric hospitalist at Peninsula Regional Primary Care, Peninsula Regional Medical Center, Salisbury, Md.

DR. SIBERRY is an assistant professor of pediatrics in the divisions of general pediatric and adolescent medicine and pediatric infectious diseases at Johns Hopkins Hospital, Baltimore.The authors and section editor have nothing to disclose in regard to affiliations with, or financial interests in, any organization that may have an interest in any part of this article.

You are the pediatric hospitalist at a community hospital, and the particular chart in your hands this morning belongs to a 6-year-old African-American boy admitted to your service the evening before by the pediatrician on call. The saga of this patient, who has no previous medical history, began four days earlier when he was brought to the emergency department by his family, complaining of fever and chest pain.

Next day, fever and chest pain returned and he was brought back to the ED. Temperature was now 39.7°C; heart rate, 108/min; and respirations, 22/min. Oxygen saturation had fallen to 96% on room air, and he now rated his pain as "7." The chart indicates an unremarkable physical exam and a normal chest radiograph. No other studies were performed. A diagnosis of pleurisy was made in the ED and the patient was discharged with instructions for ibuprofen.

The pattern repeated itself the following day: The boy's temperature rose to 40.1°C and the chest pain returned and persisted. This time, however, his mother brought him to the ED of a tertiary care hospital. There, another chest radiograph was taken and a diagnosis of "air under the diaphragm"--you presume that means colonic air--was made. He was again discharged, and his mother was instructed to give him Fleet enemas and continue the ibuprofen. Neither blood tests nor an electrocardiogram were obtained at the tertiary care hospital, according to the mother.

He must be enduring déjà vu, too

Yesterday, the boy was brought back to the ED at your hospital because of persistent fever and chest pain. The chart notes that the chest pain was localized on the left side; he described it as "the worst pain ever"--sharp, stabbing, lasting 40 to 60 minutes, and returning approximately every three hours. Pain radiated to the back, became worse on deep inspiration, and was relieved somewhat with ibuprofen. There was no associated shortness of breath or diaphoresis.

And so it goes in the chart. The history is negative for trauma or GI symptoms. The boy denies cough, symptoms of a respiratory tract infection, genitourinary symptoms, vomiting, diarrhea, joint pain, and rash. A complete review of systems is negative.

The medical history is insignificant. The boy does not take medication. Immunizations are up to date. He lives with his mother, father, and two siblings. He is in the first grade. The mother has a history of hypothyroidism, hypertension, and gallstones; the father carries the sickle cell trait. There is a family history of kidney stones and unspecified heart disease.

In the ED yesterday, the boy's vital signs were as follows: temperature, 37.8°C; heart rate, 120/min; respirations, 24/min; and blood pressure 100/84 mm Hg. Oxygen saturation was 99% on room air. He rated the pain "10" again.

The physical exam was unremarkable. He was described as moaning in the triage room but not doubled over, and was able to answer questions appropriately. Pulmonary, cardiac, and abdominal examinations were normal. The chest wall was not tender to palpation. He was given morphine for pain.