Pediatric Chest Pain  CC: year old MFtransgendercustom with no pertinent PMH/PSH presents with  Focused HPI  Cardiac hx:no custom hx of sudden cardiac death in family, no custom hx of syncope,  Pulmonary: no custom hx of cough, no custom recent fevers, LPno custom reactive airway disease, not custom of URI or infectious respiratory symptoms,not custom on OCPs or with other high risk factors for PE GI: no custom hx of abd pathology, no custom not worse with eating, no custom abd pain,  no recent trauma affecting chest,  HPI: Characteristics obtain from interview with patient: Pertinent positives:  Pertinent negatives:  REVIEW OF SYSTEMS: Much of this set of ROS can be generally obtained by asking: Are you sick now or recently sick? Any pain anywhere in your body other than what we spoke about? Any vomiting or changes in your bowel habits? Any bleeding from anywhere?  Constitutional:  ENT:  Eye:  Cardiac:  Pulmonary:  GI:  GU:  Nuero:  MSK:  Pysch: ID:  Endo:  EXAM:  VITALS: (overall impression of vital signs with repeat vitals in EMR as RNs re-access patient): HR: normal HR.tachycardic BP: normotensive.hypertensive (attempted to inform pt to advise to f/u with PMD).hypotensive. O2 sat: no hypoxiahypoxic RR: normal RRtachypnic  PHYSICAL EXAM:  General: well nourishedno distressmild distressmoderate distresssevere distress  HEENT: vision grossly intact. hearing grossly intact.  Cardiovascular: \ no r/m/g \ no LE swelling  Pulmonary: Lungs CBTA, No respiratory distress, Speaking comfortably in full sentences.I/E wheezing,rales,rhonchi,respiratory distress.  GI: \ abd soft, \ abd non-tender in all 4 quadrants,TTP diffuselyTTP in RUQTTP in RLQ  Neuro: \ Normal LOC. \ No grossly focal neurological deficits.Somnolent though protecting airway  MSK: no deformities, moving all extremitiesNon-ambulatory.  Pysch: Normal speech. Demonstrates linear thinking.No SI/HI.Endorses SIEndorses HIExam consistent with gravely disabled.No AH/VH.Agitated.Confused. Focus Exam (based upon chief complaint)  Cardio-Pulmonary Exam:cfm: CoreCodeMDM  ED COURSE and MDM:Diagnostically:  cfm: DxEKG  cfm: DxCXRtrop ,upreg ,cbc (to eval for luekocytosis or significant anemia)bmp (to eval for electrolyte derangements)LFT"s, lipase (to eval for labratorial evidence of hepato-biliary pathology)Therapeutically:analgesiaASA Additional Diagnostics/Therapeutics  Diagnostically: Point of Care Testing: Pregnancy Testnegative POC glucwnl POC Hgwnl iStatpotassium wnlhyperkalemiano base deficit lactatewnl EKG (as interpreted by prelim ED): Non-remarkable EKG. No evidence of ischemia. NSR, regular rate, normal intervals, no abnormal TWI, no ST elevation/depression.Rate normal,bradycardic,tachycardic, ST-segment morphology: TWaves: No abnormal TWI,Abnormal TWI,Non-specific repolarization abnormalities,No ST depression, ST depression,No ST elevation, ST elevation but does not meet STEMI criteria, meets STEMI criteria and cath lab activated,  Comparison to prior: Unchanged when compared to prior,Attempted but no old EKG available for comparison, ,  Summary to pt's clinical condition:Normal EKG - not suggestive any pathology elucidated on EKG, Non-specific repolarization abnormalities - no definitive evidence of active ischemia on EKG, Evidence on EKG concerning for active ischemia. Rhythm:Regularly regular:NSR,Sinus tachycardia,Sinus bradycardia,Irregularly irregular:Atrial fibrillation with normal ventricular rate,Atrial fibrillation with RVR,Regularly irregular:tachycardic,Atrial flutter with RVR,bradycardic,Heart block,Type: , Intervals:Narrow QRS,supraventricular:irregular:AVRT (considering pre-excitation, considering WPW, etc),Tx: Procainamide (20-50mg/min until arrhythmia suppressed, hypotension, QRS duration >50%, or max 17mg/kg. Maintenance 1-mg/min.Tx: Synchronized cardioversion.Per ACLS 120-200J.regular:AVNRT (considering supraventricular tachycardia),Tx: Adenosine 6mg IV push,Refractory, therefore second dose 12mg IV pushSynchronized cardioverson.100 Jper ACLS for narrow regular 50-100JWide QRS,bradycardic:low junctional escape/ventricular origin,tachycardic:regular:stable,Amiodarone 150mg IV / 10 minRefractory, repeated PRN recurrence of VT.Maintenance 1mg/min x 6 hrs.Procainamide (20-50mg/min until arrhythmia suppressed, hypotension, QRS duration >50%, or max 17mg/kg. Maintenance 1-mg/min.synchronized cardioversion100 J (per ACLS)unstable:with pulse. Therefore Unstable Ventricular Tachycardia with Pulse.Synchronized cardioversion (per ACLS 100J).pulseless. Therefore pulseless ventricular tachycardia. ACLS initiated: (CPR. Defibrillation 200 J Biphasic. Epi 1mg. Continuation of ACLS.) Labs: Ordered, pending at this time, including: CBC,BMP,LFTs/lipase,UA,Urine CxlactateBlood Cx x2CK,EtOH level,Ingestion labs (acetaminophen, ASA),Troponin,Delta troponin,BNP,HIV,Influenza,Urine toxicological screen,CRP,ESR, Reviewed and interpreted/correlated to clinical scenario to inform diagnosis and plan by me.No significant labratory abnormalities contributory to patient's presentation.Non-emergent abnormalities which I informed the patient about and advised for prompt outpatient follow up for outpatient care.  Specifically:  CBC: No significant unexpected anemia, No significant leukocytosis, No thrombocytopenia.Hganemia,transfusion indicated givensymptomatic< 7 Hg (6-8 range from restrictive transfusion strategy)active significant bleedingtransfusion not indicated (considered)peri-baseline,significantly lower than baselineunknown baseline,suspected iron deficiency contributory, will advise/rx Ferrous sulfate 325mg daily w/ vit C.wbc'sluekocytosissuspect demarginalization given lack of infectious findings on hx/exam,suggestive of infectious process,concerning for malignancy, advised to for follow upleukopenicneutropenic((ANC < 500))platelets:thrombocytopenic((platelets < 150k))transfusion not indicatedgiven suspected consumptive process((ITP, TTP, HIT))transfusion indicated given<10 k (regardless that pt is asymptomatic)<20k and and planned CVP or pt febrile<50k and planned LP or neurosurgical procedurepancytopeniaclikely 2/2 chemolikely 2/2 HIVlikely 2/2 hep Cunclear etiology, will initiate eval w/ completion of eval and monitoring/treatment to be continef as outpatientafter ED  BMP:No significant pathologic electrolyte derangements.AKI, 50% increase from baseline BUN/Cr >20 suggestive of prerenal process,will administer IVFand recheckCKD,grossly unchanged from prior,Hyperkalemia,Anion gap((> 12))acidotic suggested by low bicarb, LFTs/lipase: No laboratory evidence of hepato-biliary pathology.Transaminitis without elevated bilirubin, suggestive of hepatic pathologyElevated direct bilirubin suggestive of biliary pathologyElevated indirect bilirubin suggestive of increased rbc breakdown UA: Not consistent with urinary tract infection.Urine Cx sent with follow mechanism in placeEquivocal for infectionEmpirically treated.UCx sent with f/u mechanism in place Cardiac Labs:  Troponin:undetectable <99th percentile>99th percentile but under cut off for positivepositive  Delta troponinpending, pt under care of other service at time of delta troponin,undetectable,<99th percentile,>99th percentile but under cut off for positive,positive,  BNP: please note that greater than 500 suggests CHF, under suggests not CHF not suggestive of CHF exacerbationsuggestive of CHF exacerbationnon-diagnostic HIV:negative,positive, I discussed this finding with patient in sensitive private manner, educated on treatment options, offered resources, answered all questions, advised to have partner evaluated and advised to refrain from any of the common modes of transmission.Prior to test sent, pt was informed that we advise for testing for HIV. Pt did not opt out. Influenzanegative CK:significantly elevated, requires trending, usually for >500-1000k mildly elevated, not anticipated to rise given negated precipitant,not high enough to suggest concern for pathology, Ingestion labs: acetaminophen non-detectable, ASA: non-detectable, etoh non-detectable,positive  Urine toxicological screen: negativepostive for  Markers of inflammationCRP suggestive of more acute inflammation wnlelevatedESR suggestive of more chronic inflammation wnlelevated Radiographically:  Radiographs ordered pending at this time Radiographs reviewed interpreted by me Radiographs reviewed by me agree with radiology interpretation Radiology interpretation reviewedcustom CXR: Normal study: no tracheal deviation, non-widened mediastenum, normal cardiac boarder, no pleural effusion, no air under diaphragm, no focal consolidation, no PTX, no gross bony abnormalities.Pulmonary edema,Cardiomegaly,lobar opacity,diffuse radio-opacitiespneumothoraxon righton leftmediastenium midline(This is an ED prelim radiographic interpretation in order to increase chance of finding obvious emergent pathology which can be intervened upon and to minimize delay in care secondary to delay of radiology to be able to provide formal reads. Given these studies require board certified radiologists to review and formal reads are beyond the scope of Emergency Medicine, institutional protocol in place which will alert current care team/patient for over-reads/changes/critical reads). PXR (Pelvic XR):no evidence of pelvic fractureno evidence of hip fractureappreciate limited sensitivity of PXR and therefore correlated clinically XR of extremity Advanced Imaging:CT head: negative for acute intra-cranial pathologyCT c-spine negative for acute cervical neck pathologyCT chestPE protocolnegative for PEangionegative for aortic dissectionCT a/pw/ contrast,non-con,negative for acute intra-cranial pathologyCT of extremity:with venous contrast:with arterial contrast:non-con: Consultations:Discussed case with of the service who kindly recommended Discussed case with who kindly agrees to come evaluation patient and provide recommendations. Obtained the collateral information to assist in ED care for patient advises Time of consultation:  Therapeutically: Empirically: Anti-platelet agent: ASAEmpirically administered given ddx includes ACS and potential benefit outweighs potential harm162mg PO chewed325mg PO chewed IVF30 cc/kg,250cc,500cc,1 L,2 L, Analgesia:acetaminophen,ibuprofen,hydrocodone/acetaminophen (pt informed not to drive/drink/take fall precautions/not make significant decisions for remainder of day)morphine,ketorolac,hydromorphonehaloperidol (haldol)indication:sx refractory to other analgesia,side effect profile of opioids likely to exacerbate symptoms,3mgIVIM5 mgIMIV10mgIM Anti-emeticsondansetron (zofran),IV,ODT oral dissolving tablet metoclopramide (reglan),5 mg,10mg,PO,IV,IM,lorazepam,indication:prolonged QTC make risk of other similar medications that would prolong QTC prudent to avoid,sx refractory to other anti-emetics,haloperidol (haldol)indication:sx refractory to other anti-emetics,pain refractory to other analgesia,suspected to have quality of component of pain that may benefit from analgesic effects,3mgIVIM5 mgIMIV10mgIM Anxiolyticlorazepam0.5 mg1 mg2mgPOIVIM Anti-biotics:Timing: administered as promptly as source identified with sufficient likelihood to inform appropriate antibiotics (goal directed)administered when source identifiedadministered within 1 hrs from triageadministered within 3 hrs from triageRegimen:ceftriaxone 1 g IVceftriaxone 1g IV / azithromycin 500mg IVvancomycin IV / cefepime 1 g IV / azithromycin 500mg IVceftriaxone 1g IV / metronidazole 500mg IVUnasynvancomycin / zosyncefazoline (ancef) 1 g IV  Assessment/Plan: year old with PMH/PSH of presented with  evaluation is most consistent with Chest pain of non emergent cardio-pulmonary etiology.   Concurrent evaluation for secondary problem is consistent with  DDx includes but in not limited to (pt does not meet reasonable likelihood/consistency with the dx to warrant additional pursuit of these entities (risks outweigh benefits of non-indicating testing) Chest pain of non emergent cardio-pulmonary etiology.  Plan:   Re-evaluation:Unchanged on re-evaluation.Improved on re-evaluation.On re-evaluation, remains intoxicated. Hemodynamically stable. Will continue observation. Supplemental Documentation: OBSERVATION NOTE: CRITICAL CARE PROCEDURE NOTE:  COUNSELING: SUPERVISION:  Of note, follow up over-read mechanism in place for over-reads and follow up of pending diagnostics.