By Erin Madison MSN APRN NP-C
and Dr. Alicia V. Tezel MD FAAP FCUCM
Chief Medical Officer Little Spurs Pediatric Urgent Care
Chief Complaint
5y male with one day history of cold symptoms
History
5 y/o boy presented with mother with a one-day history of nasal congestion, runny nose, sore throat, cough. In addition, he developed a fever to 104.5 degrees on the day he presented. He had not had body aches, fatigue, ear symptoms, chest tightness, shortness of breath, diarrhea, vomiting, headache, or loss of taste and/or smell. Patient had an ongoing exposure from sibling with COVID-19. He also had a h/o previous COVID-19 infection > 90 days ago. Medications already tried included Acetaminophen and last given 5 hours prior. He was taking fluids well and having good UOP. Pertinent medical history is unremarkable. Negative cardiac history. A home covid test was negative on the day of the visit.
Physical with vital signs
- Wt: 25.6 kg (94.98%) T: 102.2 F; BP: 103/70 mm Hg (left arm, sitting); P: 123 bpm (finger clip, sitting); R: 26 bpmO2 Sat: 96 % (room air)
- GENERAL: well developed, well nourished, well groomed, no apparent distress, appeared well hydrated
- NECK: supple and full range of motion
- EYES: normal with no redness, swelling or edema. Conjunctiva: bilateral conjunctiva clear. Pupils/Iris: pupils and irises were normal
- E/N/T: Ears: both TMs were normal and bilateral EACs are normal. Nasal Septum/Mucosa: was partially obscured by clear drainage and erythematous mucosa. Oropharynx: normal mucosa, moist mucus membranes, normal palate, no posterior pharyngeal exudate, and uvula midline & mobile, no trismus
- RESPIRATORY: Normal respiratory rate and pattern with no distress. CTAB, Good air exchange, Normal breath sounds with no rales, rhonchi, wheezes, or rubs
- CARDIOVASCULAR: Auscultation: Rate: was normal, Rhythm: is regular, and Heart sounds: included no murmurs and an S3 gallop was noted, no change in heart tones with vagal maneuver
- LYMPHATIC: There is no enlargement or tenderness of the supraclavicular, suboccipital, periauricular or other lymph nodes
- MUSCULOSKELETAL: Gait is Normal.
- SKIN: Cap refill < 2 seconds. No rashes, lesions, or ulcerations
Urgent Care workup
Tylenol PO given per MA protocol during triage. Chest XRAY: Normal, no acute cardiopulmonary process. In house rapid covid test negative. Gallop heart tones remained one-hour after antipyretic administration, so patient was transferred to local children’s ER for further evaluation and management (no EKG or immediate labs available in our urgent care setting).
Ultimate Diagnosis
Influenza, mitral valve prolapse (MVP), and supraventricular tachycardia (SVT)
In the ER, Cardiac ECHO showed mitral valve prolapse (MVP) without evidence of myocarditis. Cardiac markers were normal, other labs non-contributory. TheEKG showed Bundle Branch Block (BBB) in all leads. The EKG was repeated at least 3 times in the ER, all with same BBB, as they initially felt that the leads may have been misplaced by the tech. While in the ER, patient changed from BBB to SVT, with a heart rate in the 270s. The SVT resolved on its own without intervention, and he was admitted to the PICU. Cardiology concluded that the fever illness exacerbated the MVP causing the gallop heart tone changes. He was not started on any chronic meds.
Learning Pearls
- Among children with congenital heart disease, the prevalence of SVT is approximately 7 percent. However, most patients presenting with SVT have structurally normal hearts.
- Supraventricular tachycardia in the mitral valve prolapse patients occurs through atrioventricular bypass tracts that may be related to the mitral valve abnormality since they are always left-sided.
- Gallop heart tones in children: S3 can be normal, S4 is always pathologic.
