18 y/o male patient that comes to ED due to chest pain of 2 weeks of evolution, worst when laying upright, pressure sharp, with subjective fever and shortness of breath.
Pt states that was seen in the ED one week prior,due to flu like symptoms (fever, cough and nasal congestion) followed by chest pain. Currently, pt states being afebrile, with chest pain 7/10 with shortness of breath, worst in supine position and with improvement when leaning forward.
PE: Temp 98.1 F, HR 92 RR 20 BP 109/60 Sat 100%
GEN: Mild to moderate distress.
HEENT: Dry oral mucosa, No JVD
CHEST: Regular rhythm, no murmurs, no gallops, clear to auscultation bilateral
ABD: Bowel sounds present, no tenderness
Ext: No edema or cyanosis
Neuro: No gross deficits.