Author: Caitlyn Rerucha, MD
Co Author #1: Collin Hu, DO, FAAFP
Co Author #2: Julie Creech, DO
Co Author #3: Sean Wise, DO, CAQSM, FAAFP
Senior Editor: Warren Bodine, DO, FAMSSM
Editor: Rock Vomer, DO, DPT

Patient Presentation:
A 17 year-old African American male with a past medical history of Risk-Level 1 Kawasaki's Disease, diagnosed at age four years old, presented after he woke up in the morning with diffuse intermittent substernal chest pain which he described as " 4/10 pressure he has never felt before". The pain was, non-radiating, and non-exertional, and was not previously provoked during his routine weightlifting and football practices. Prior to presentation the patient tried an over-the-counter antacid without relief. A thorough review of systems is unremarkable including no recent illnesses, palpitations, dyspnea, or unexplained syncope.

History:
He is a lifelong multi-sport athlete excelling in football, baseball, tennis, basketball, soccer, and swimming. He is currently weight training at home four days per week with infrequent aerobic exercise during the COVID-19 pandemic. He is a junior at a competitive high school that recently transferred in on scholarship to play football linebacker.
Medical History, Risk Level 1 Kawasaki’s Disease diagnosed at age four
Surgical History, none
Medications or supplements, no chronic medications, took one antacid this morning
Drug Allergies, none
Family History, he reports healthy immediate family members without heart disease and a maternal grandmother with heart failure that died suddenly at age 58 presumably from a heart
attack without autopsy.

Physical Exam:
Height 6 feet 3 inches, 274lbs, BMI 35, blood pressure 117/65 normal for pediatric age and
height, 96 oxygen saturation on room air
General – well-appearing with a muscular body habitus, comfortable and non-toxic appearing, in
no acute distress
HEENT – unremarkable with normal jugular venous pulse (5cm) and no carotid bruits
Pulmonary – lung sounds clear bilaterally
Cardiac – S1 and S2 sounds present with normal intensity without fixed split. Normally placed
apical impulse. There is a new 2/6 systolic ejection murmur at the left lower sternal boarder that
increases from squat to stand and with Valsalva. No S3, S4, or rub appreciated. Radiofemoral
pulses are equal without delay.
Chest Wall/Abdomen – non-tender to palpation
Skin – unremarkable
Peripheral extremities – unremarkable

Click here to continue. Challenge yourself by writing down a broad differential diagnosis before moving to the next slide.