A 16-year-old boy comes to the ED after awakening with waxing and waning central chest pain, aggravated by deep inspiration and described as a sensation of “pushing.” Two days ago, he experienced fever to 102.6°F (39.3°C), sore throat, mild fatigue, and several bouts of vomiting. He denies dyspnea, presyncope, syncope, palpitations, edema, coughing, and orthopnea. There is no family history of congenital heart disease, cardiomyopathies, or sudden cardiovascular death.

Examination reveals a healthy-appearing young man in no distress. His temperature is 98.6°F (37°C), heart rate is 71 beats/min, blood pressure is 105/69 mm Hg, and oxygen saturation is 99%. He has tenderness to palpation over the mid-to-lower sternum and at the mid-left and right sternal borders. His apical impulse is within the mid-clavicular line. There is a grade I–II/VI soft systolic pulmonary flow murmur audible at the upper left sternal border, with a physiologically split second heart sound of normal...

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