A 9 Year Old Boy: Fever, Chest Pain, and USMLE

Introduction

In this article, we will explore a case study involving a 9-year-old boy who presents with fever and chest pain. The focus will be on understanding the potential causes and management options for his condition. This case is particularly relevant for medical students preparing for the United States Medical Licensing Examination (USMLE) as it emphasizes the importance of clinical reasoning and differential diagnosis. So, let’s dive into the details and analyze this intriguing case.

Case Presentation

A 9-year-old boy is brought to the emergency department by his parents due to complaints of fever and chest pain. The boy’s parents report that he has been experiencing high-grade fever for the past three days, accompanied by intermittent chest pain. They are concerned about his condition and are seeking medical attention.

History and Physical Examination

Upon further investigation, the medical team gathers additional information from the parents and conducts a thorough physical examination of the boy. Key findings include:

History

• Duration of fever: 3 days
• Chest pain: Intermittent
• Associated symptoms: Fatigue, decreased appetite, and mild cough
• No recent travel or exposure to sick contacts
• No significant medical history

Physical Examination

• Vital signs: Temperature 39.2°C (102.5°F), heart rate 100 bpm, blood pressure ¹¹⁰⁄₇₀ mmHg
• General appearance: Mildly ill, no distress
• Respiratory system: Clear breath sounds bilaterally, no wheezing or crackles
• Cardiovascular system: Regular rate and rhythm, no murmurs
• Abdomen: Soft, non-tender, no hepatosplenomegaly
• No lymphadenopathy

Differential Diagnosis

Based on the presenting symptoms and physical examination findings, several possible diagnoses should be considered. The following differential diagnosis can help guide further investigations and management:

1. Viral respiratory infection: Given the presence of cough, fatigue, and fever, a viral respiratory infection, such as influenza or adenovirus, should be considered as a potential cause.
2. Pneumonia: Chest pain and fever can also be indicative of a bacterial pneumonia. A thorough lung examination and imaging studies, such as a chest X-ray, may be necessary to confirm or rule out this diagnosis.
3. Pericarditis: Inflammation of the pericardium can cause chest pain and fever. A careful cardiac examination and an electrocardiogram (ECG) may be helpful in assessing for pericarditis.
4. Costochondritis: Inflammation of the cartilage connecting the ribs to the sternum can cause localized chest pain. Clinical examination findings and exclusion of other causes may aid in the diagnosis.
5. Musculoskeletal pain: Chest pain in children can sometimes be attributed to musculoskeletal causes, such as muscle strain or trauma. A detailed physical examination can help assess for any signs of injury or inflammation in the chest wall.
6. Rheumatic fever: Although less common, rheumatic fever can present with fever and chest pain. A thorough evaluation of the patient’s history and additional laboratory tests, such as antistreptolysin O (ASO) titers, may be required to investigate this possibility.

Investigations and Management

To arrive at a definitive diagnosis, further investigations and diagnostic tests will be necessary. The specific tests will depend on the suspected diagnosis and the patient’s clinical presentation. However, some commonly employed investigations may include:

1. Complete blood count (CBC): This test can provide insights into the patient’s white blood cell count, which may indicate an infectious cause.
2. Chest X-ray: A chest X-ray can help identify any signs of pneumonia, pleural effusion, or other abnormalities in the lungs.
3. Electrocardiogram (ECG): An ECG can help assess for any abnormalities in cardiac electrical activity, aiding in the diagnosis of pericarditis or other cardiac conditions.
4. Laboratory tests: Additional laboratory tests, such as C-reactive protein (CRP) levels, erythrocyte sedimentation rate (ESR), and specific viral or bacterial tests, may be ordered based on initial clinical suspicion.

Once a definitive diagnosis is made, appropriate management strategies can be implemented. Treatment options may include:

• Antipyretics: Fever can be managed with antipyretic medications, such as acetaminophen or ibuprofen, based on the patient’s age and weight.
• Antibiotics: If bacterial pneumonia is confirmed, antibiotic therapy targeting the causative organism will be initiated.
• Nonsteroidal anti-inflammatory drugs (NSAIDs): For conditions like pericarditis or costochondritis, NSAIDs can provide pain relief and reduce inflammation.
• Supportive care: Adequate hydration, rest, and symptomatic relief will form the basis of supportive care for viral respiratory infections or musculoskeletal causes.

Conclusion

In this case study, we explored the presentation of a 9-year-old boy with fever and chest pain. Through a systematic approach, we considered various differential diagnoses and discussed the importance of appropriate investigations to arrive at a definitive diagnosis. The management options highlighted the need for tailored treatment based on the specific diagnosis. This case emphasizes the significance of clinical reasoning and serves as a valuable learning opportunity for medical students preparing for the USMLE.

FAQ

1. What are the common symptoms experienced by the 9-year-old boy?

   • The common symptoms experienced by the 9-year-old boy include fever, chest pain, fatigue, decreased appetite, and mild cough.

2. What are the possible causes of the boy’s symptoms?

   • The possible causes of the boy’s symptoms include viral respiratory infection, pneumonia, and pericarditis.

3. How can viral respiratory infection be confirmed as a diagnosis?

   • Viral respiratory infection can be confirmed as a diagnosis through further investigations, such as laboratory tests or identification of specific viral pathogens.

4. What additional tests may be required to diagnose pneumonia?

   • Additional tests that may be required to diagnose pneumonia include a thorough lung examination and imaging studies, such as a chest X-ray.