A 16-year-old girl with a history of asthma, ulcerative colitis (UC), allergic rhinitis, multiple food and environmental allergies, migraines, and autoimmune hypothyroidism presents to the emergency department with 2 days of worsening chest pain. She describes the pain as a sharp sensation localized to her left upper chest, which is exacerbated by deep inhalation. Review of systems is notable for 3 days of intermittent low-grade fevers and a dry cough, which has not improved with inhaled albuterol or fluticasone use. On physical examination the patient is pale. Her respiratory rate is elevated to 22 breaths/min, with oxygen saturation greater than 95 on room air. Her temperature is IOI°F (38.3℃), heart rate is 130 beats/min, and blood pressure is 122/79 mm Hg. Her height is 64 in (162.8 cm) (51st percentile), weight is 114.6 lb (52 kg) (40th percentile), and BMI is 19.6. A thorough physical examination is performed, which is notable for marked nasal edema and copious clear discharge bilaterally. A systolic grade III/VI cardiac murmur is auscultated, and breath sounds are clear bilaterally without evidence of respiratory distress. On abdominal examination bowel sounds are hyperactive. There is diffuse abdominal tenderness to palpation without rebound tenderness or palpable masses. No rashes are identified.
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