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					                                                                    RIME – Chest Pain
                                                                               Andrew Hughey, MSIII
                                                                                    May 2011

History Intake
          Description of pain
               o Onset: acute vs. chronic
               o Quality: Sharp vs. dull, pain vs. “tightness/pressure”, “popping sensation”
               o Location: Diffuse vs. localized, radiation (e.g. to the shoulder, jaw, or between the scapulas)
          Precipitating factors: Body position or movement, swallowing or eating, pleuritic, exertion
          Associated symptoms: Fever, dyspnea, vomiting or regurgitation, lightheadedness, paresthesias, syncope,
          Past Medical Hx: Asthma, cardiac disease, Kawasaki disease, sickle cell disease
          Family Hx: Marfan syndrome, Turner syndrome, type IV Ehlers-Danlos syndrome, hypertrophic cardiomyopathy
          Social Hx: Cocaine and tobacco use, use of other vasoactive drugs

Physical Exam
          Chest wall: Assess for tenderness and anterior slippage (click) of lower costal margin
          Pulmonary: Assess for tachypnea and respiratory distress, wheezing, diminished breath sounds
          Cardiovascular: Assess for murmur, pericardial friction rub, or an abnormal pulse or blood pressure

Diagnostic Studies
          CXR (if suspect pulmonary/cardiac), ECG / Holter monitor / echocardiogram / (if suspect cardiac), EGD /
           manometry / 42 hr pH testing (if suspect GI)

Differential Diagnosis
                Musculoskeletal              Psychological                     Respiratory                          Cardiac *               Miscellaneous
                  (15-31%)                     (0-30%)                          (2-11%)                              (2-8%)
Causes         Costochondritis,         Anxiety, conversion         Asthma, severe cough,         CAD (ischemia/infarction, - IDIOPATHIC (21-45%)
               trauma / contusion,      disorder                    pneumonia, pneumothorax /     Kawasaki disease),            - GI causes (2-8%):
               slipping rib                                         pneumomediastinum, pulmonary  arrhythmia, HOCM,             GERD, gastritis,
               syndrome                                             embolism                      pulmonic stenosis, MVP,       esophageal dysmotility
                                                                                                  pericarditis, myocarditis     - Breast tenderness
Signs &        - Hx of direct trauma - Stressful events (e.g. - Pain induced by exercise (may - Pain with exertion,             (puberty)
Symptoms or strain (wrestling, recent death, illness or suggest asthma)                           palpitations, or syncope      - Vaso-occlusive crisis or
               carrying heavy        accident in the family, - Accompanied by other               - Presence of predisposing acute chest syndrome
               books, exercising)    family separations,        symptoms of URI (cough,           conditions: diabetes,         (sickle cell disease)
               - Chest tenderness or school changes)            congestion, coryza)               Kawasaki disease, chronic - Aortic dissection
               pain with movement - Other recurrent             - Tachypnea, respiratory distress anemia, cocaine               (Marfan syndrome
               of the torso or upper somatic complaints         - Wheezing heard on auscultation - Murmur, pericardial          - Pleural effusions
               extremities           (e.g. headache,            - Diminished breath sounds        friction rub, or an abnormal (vascular collagen
                                     abdominal or extremity suggestive of consolidation           pulse or blood pressure       diseases)
                                     pain)                      - Fever, elevated WBC             - Cardiomegaly on CXR         - Shingles
                                     - Lightheadedness or       suggestive of infection           - Arrhythmia on ECG
                                     paresthesias secondary - CXR demonstrating pneumonia - Structural abnormality on
                                     to hyperventilation        - Decreased peak flow (asthma) echocardiogram
Diagnosis - Clinical diagnosis - Clinical diagnosis             - Clinical diagnosis based on     - Referral to pediatric
               - Other causes        - Other causes             history, objective findings, and  cardiologist
               reasonably ruled out reasonably ruled out        response to therapy (e.g.         - ECG/Holter,
                                                                albuterol trial)                  echocardiogram
Treatment - Rest                     - Reassurance              Depends on etiology:              Treat underlying cause:
               - Analgesics          - Additional counseling - Asthma: β-agonist, inhaled         - Surgery (if anatomical)
               - Cortisone           or psychiatric referral corticosteroids                      - β-blockers
               injections (for       as needed                  - Pneumonia: antibiotics          - Pacemaker/ICD
               refractory                                       - Viral URI: Symptomatic
               costochondritis)                                 support
* Cardiac causes of chest pain are uncommon in children; patients with anginal pain, pain with exertion not attributed to respiratory disease,
palpitations, or syncope should be referred to a pediatric cardiologist for further evaluation.
Abbreviations: „Hx‟ = history; „CXR‟ = chest x-ray; „ECG‟ = electrocardiogram; „EGD‟ = esophagogastroduodenoscopy; „GI‟ = gastroenterological; „URI‟ = upper
respiratory infection; „WBC‟ = white blood cell; „CAD‟ = coronary artery disease; „HOCM‟ = hypertrophic cardiomyopathy; „MVP‟ = mitral valve prolapsed; „ICD‟ =
implantable cardioverter-defibrillator; „GERD‟ = gastroesophageal reflux disease

Sources:   Geggel RL et al. “Approach to chest pain in children.” Accessed May 2011.
           Nelson Textbook of Pediatrics 17th ed.
           Selbst SM. “Consultation with the specialist. Chest pain in children.” Pediatr Rev. 1997 May;18(5):169-73.

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