Physical Examination and Workup
Upon physical examination, the primary survey of his airway, breathing, and circulation is unremarkable. The patient has a blood pressure of 130/71 mm Hg and a heart rate of 106 beats/min, with a normal rhythm. His respirations are 28-30 breaths/min. The initial oxygen saturation is 83% while the patient is breathing room air, but it corrects to 98% with a non-rebreather mask. Soon after, his saturation improves to 99% with a 2-L nasal cannula.
His mentation is normal, and he is alert, with a Glasgow coma scale rating of 15. The skin examination reveals mild ecchymosis just anterior to his sternum. The lungs are clear to auscultation bilaterally, and the cardiac examination reveals a regular rate, with normal S1 and S2 heart sounds and no clicks, gallops, rubs, or murmurs. The abdominal and neurologic examinations are unremarkable. No hyperflexibility or marfanoid appearance is noted.
The patient is placed on a cardiac monitor upon arrival at the ED. A 12-lead electrocardiogram (ECG) reveals sinus tachycardia at a rate of 110 beats/min, with mild right-axis deviation. The QRS complex, QT interval, ST/T waves, and P waves are all normal (Figure 2). A portable, upright chest x-ray shows no signs of fractures, widening of the mediastinum, cardiomegaly, effusion, or pneumothorax (Figure 3).
A complete blood count is normal except for a mildly elevated white blood cell count of 13.6 ×103/µL (13.6 ×109/L). A metabolic panel is normal, including normal potassium and magnesium findings. The initial troponin I level is 0.04 ng/mL (0.04 µg/L; normal range, 0.02-0.04 ng/mL; indeterminate range, 0.05-0.30 ng/mL). A urine drug screen is negative. Computed tomography of the chest (Figure 4) is remarkable only for mild pulmonary and periportal edema.
The patient is admitted to the pediatric intensive care unit (PICU) for continuous cardiac monitoring and cardiology consultation. An echocardiogram ordered in the ED is to be done in the PICU.
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