The heart has its reasons, which the reason knows not. —Pascal
It has been a particularly trying week. Cracks appear at the edges of my well-ordered world: too many patients, not enough time to devote to difficult cases, staffing issues at the office. Moreover, I feel a cold coming on, a growing discomfort in my chest.
Now here before me sits a 14-year-old boy, my last patient of this busy Friday afternoon.
His mother called the office an hour ago. Her son had come home from school complaining of chest and back pain. The back pain had gotten so bad that he went to the nurse. The nurse called the mother and suggested that she bring the boy in.
I know this mother well. She has three children, all teenagers now. Her older boy suffered postconcussion syndrome last year. Her daughter is a star athlete and a good student. I have performed her younger son's annual physical exam for the past several years. He's a tall, lanky boy, usually in excellent health. Until now, that is.
On closer questioning, I learn that the boy has had intermittent chest pain for the past month. It started during the Christmas holiday vacation. He got sick with a cough and cold but recovered fine—except for the chest discomfort, which never went away entirely.
He tells me that the pain is in the center of his chest, "in the heart." Today it got worse at school, much worse. Today it radiated to his back, right between the shoulder blades.
Curiously, he feels better when he lies down. The pain gets more intense when he sits up or when he stands.
"I thought he might have broken a rib," his mother says. "He's a soccer player. He took a blow to the chest during a game last August."
"Five months ago," I muse. "I doubt that that has much to do with what he's experiencing now. Any history of inhaled medication use?"
"No, none of my kids have asthma."
The boy is quiet; he doesn't seem to be in any distress. I examine him from the head down: eyes, ears, nose, throat, neck. I squeeze his torso, but can't reproduce the pain. I place my stethoscope on his chest and listen. With each heart beat I hear a distinct clicking sound, as though an invisible musician were snapping fingers in time to the cardiac rhythm. Kentucky, Kentucky, Kentucky, his heart whispers in my ears.
The lungs sound clear. I ask him to lie down. I listen intently but am unable to discern the click when he's supine. "Let's have you sit up one more time," I say. I listen again: the click has returned.
I review the vital signs in the chart. The boy's blood pressure is 86/64. Perhaps he's normally hypotensive. I recheck the pressure: 88/62. I ask him to take a deep breath and hold it while I check the pressure again: 78/60. The 10-point systolic drop defines pulsus paradoxus.
His mother reads the concern on my face. "What are you thinking?" she asks.
"He's got some abnormal findings on exam," I tell her. "I'm worried about a pericarditis—inflammation in the sack that houses the heart."
"How would he have gotten that?"
"It could have come up after that respiratory infection he had during the holidays," I explain. "Sometimes we don't know what brings it on."
"What should we do?"
"He needs a chest x-ray and a cardiogram. It's after 5 o'clock; all our local facilities are closed. Let's have you take him down to the emergency room at Children's Hospital. They'll be able to attend to him there."
"You'll let them know?"
I nod my head. "I'll give you a copy of my note and call to tell them you're coming."
After they depart, I pull on my stocking cap and gloves and step out the side door of the office into sharp evening cold. My car stands sentinel watch in the parking lot. A full moon hangs on the eastern horizon.
As I fly down the interstate, the January wolf moon races ahead. Like a flashlight bobbing rhythmically from an unseen hand along a trail at night, it serves to offer reassurance, to calm my anxiety.
Later that evening the call comes through. The boy
has been admitted to surgical service. His chest x-ray
documented a 20% right-sided pneumothorax. No one knows what to make of the click in his heart: faced with a normal echocardiogram, even the cardiologists are stumped.
As the pneumothorax recedes, the click disappears. Perhaps it was an accentuated P2, brought about by increased pressure in the pulmonary circuit from the partially collapsed lung. In any case, the click was the clinical finding that led to the proper diagnosis and timely intervention.
As I ponder this thought at the end of this harrowing week, my own chest discomfort begins to subside; and suddenly, I feel an inexplicable redemption. JAAPA
Brian T. Maurer, PA-C, practices pediatrics at Enfield Pediatric Associates, Enfield, Connecticut. He is the author of Patients Are a Virtue and a member of the JAAPA editorial board. Visit the author at http://briantmaurer.wordpress.com/.