TREATMENTS &
RESEARCH

Search the
latest
treatment
information
here.

Dr. Huntley's
Diagnosis
Checklist

Have a symptom?
See what questions
a doctor would ask.
 
Next Prev
Symptoms » Chest discomfort » Book Sections
 

Chest Pain

Although chest pain is common complaint inchildren and adolescents, serious underlying disease presentingas chest pain is uncommon in this population.

Principal Causes of Chest Pain

  1. Musculoskeletaldisorders
    1. Muscle
      1. Trauma(strain, contusion, laceration)
      2. Stitch
      3. Precordial catch
      4. Sickle cell pain episodes
    2. Bone/cartilage
      1. Trauma(contusion, rib fracture)
      2. Costochondritis
      3. Sickle cell pain episodes
      4. Slipping-rib syndrome
      5. Tietze syndrome
      6. Osteomyelitis
      7. Neoplasm
  2. Trachea and proximal bronchi disorders
    1. Infection/inflammation
      1. Bronchitis
      2. Tracheitis
      3. Pneumonia
      4. Cystic fibrosis
    2. Asthma
    3. Foreign body
  3. Parietal pleura disorders
    1. Pneumonia
    2. Pleurodynia
    3. Empyema
    4. Pneumothorax
    5. Hemothorax
    6. Pneumomediastinum
    7. Postpericardiotomy syndrome
    8. Pulmonary embolism
    9. Neoplasm
  4. Cardiac disorders
    1. Myocardialischemia including infarction
    2. Pericarditis
    3. Mitral valve prolapse
    4. Arrhythmias
  5. Diaphragm disorders
    1. Subphrenicabscess
    2. Hepatic abscess
    3. Fitz-Hugh-Curtis syndrome
  6. Gastrointestinal disorders
    1. Esophagus
      1. Gastroesophagealreflux
      2. Caustic ingestion
      3. Foreign body
      4. Hiatal hernia
      5. Spasm
      6. Tear
    2. Referred pain
      1. Gastritis
      2. Peptic ulcer disease
      3. Cholesystitis
      4. Pancreatitis
  7. Neurologic disorders
    1. Intercostalnerve
      1. Trauma
      2. Herpes zoster neuritis
    2. Dorsal root
      1. Trauma
      2. Radiculitis
  8. Psychologic disorders
    1. Anxietywith or without hyperventilation
    2. Depression
    3. School phobia
    4. Hypochondriasis
    5. Conversion reaction
  9. Idiopathic chest pain

Clinical Features and Diagnosis

Musculoskeletal Disorders

Muscle

Trauma

  • Normal activitycan strain chest wall musculature.
  • Participation in athletics or overexertionalso may injure specific muscle groups of chest wall.
  • Blunt trauma from accidents, athleticinjuries, or physical abuse can cause chest wall contusions.

    • Stitch

  • Definedas sharp pain occurring in upper quadrants of abdomen under costalmargin during strenuous activity.
  • Resolves when exercise is over.
  • Stress on peritoneal ligaments is thoughtto be the cause.

    • Precordial Catch

  • Also calledTexidor twinge and defined as benign self-limited disorder of unknown cause.
  • Characterized by acute onset of sharppain, usually localized over cardiac apex and occurring at restor with mild activity.
  • Usually lasts up to 1 min but may befollowed by dull ache.
  • Deep inspiration may aggravate pain.

    • Sickle Cell Pain Episodes

    Chest pain can occur during vasoocclusiveepisode and usually involves muscle ache.

    Bone/Cartilage

    Trauma

  • Accidentalor nonaccidental trauma may produce rib fractures.
  • Localized bone tenderness suggestsrib contusion or fracture.
  • Chest radiography should be performed.

    • Costochondritis

  • Common causeof chest pain in adolescence.
  • Localized pain and tenderness occurover the affected costochondral junction. Left fourth and fifthjunctions are most commonly involved.

    • Sickle Cell Disease (Thoracic Bone Infarction)

  • Chest painmay occur as result of thoracic bone infarction that may affectribs, sternum, or vertebrae.
  • Nuclear scintigraphy can demonstrateinfarction.

    • Slipping-Rib Syndrome

  • Pain isthought to arise from eighth, ninth, or tenth ribs overriding theone above.
  • Diagnosis may be confirmed by graspingcostal margin and pulling anteriorly to reproduce pain (hookingmaneuver). Same maneuver may produce palpable click as cartilagesslip over one another.

    • Tietze Syndrome

  • Syndromeof unknown cause characterized by swelling at right sternoclavicularor second sternochondral junction.
  • Pain may last for weeks with frequentremissions and exacerbations.

    • Osteomyelitis

  • Localizedpain and tenderness along with fever characterize osteomyelitisof sternum or rib.
  • S. aureus is most common pathogen.
  • Nonspecific lab findings are leukocytosisand increased erythrocyte sedimentation rate.
  • Although chest radiograph may be normalearly in illness, nuclear scintigraphy reveals localized uptakeof radionuclide.
  • In 10–14 days, chest radiographyshows periosteal bone formation and destructive lesions.
  • Bone aspiration or biopsy is usuallydiagnostic.

    • Neoplasm

  • Bone tumorsof chest wall are rare; however, neoplastic disease may cause localized ribor sternal pain.
  • Acute lymphoblastic leukemia may involvesternum or ribs. Chest pain is not infrequent during course of thisillness but is rarely presenting symptom. Metastatic neuroblastomaalso may cause bone pain.
  • See Chap.1, Abdominal Masses and Chap. 38, Lymphadenopathy.

    • Trachea and Proximal Bronchi Disorders

  • Tracheobronchialpain usually occurs in neck or chest where inflammation is.
  • See Chap.10, Cough.

    • Parietal Pleura Disorders

    Intercostal nerves conduct pain impulsesfrom parietal pleura to spinal cord.

    Pneumonia

  • Most commoncause of pleuritic chest pain is pneumonia.
  • Pain is localized, sharp, stabbing,and knifelike and usually occurs with inspiration. Shallow breathsminimize pain, whereas laughing and coughing aggravate it. Pleuralfriction rub indicates pleural involvement.
  • Chest radiograph shows infiltrate andsometimes pleural effusion.
  • See Chap.10, Cough).

    • Pleurodynia

  • Self-limitedillness usually caused by enteroviral infection.
  • Fever and paroxysms of sharp chestpain without evidence of pneumonia are usual presenting clinicalfeatures. Pain usually subsides within 1 wk.
  • Positive pharyngeal viral culture or4-fold increase in antibody titer is diagnostic.

    • Empyema

  • Definedas presence of pus in pleural space and usually occurs from extensionof bacterial pneumonia.
  • Most common pathogen in pediatric populationis S. pneumoniae.
  • High spiking fever, respiratory distress,and occasional chest pain characterize empyema. Usually no breathsounds are heard over affected area.
  • Chest radiograph shows effusion, butthoracentesis must be performed for specific diagnosis. Analysisof fluid should include white cell and differential counts; Gramand acid-fast stains; protein; glucose; and aerobic, anaerobic,fungal, and acid-fast cultures.

    • Pneumothorax

  • Definedas accumulation of air in pleural space.
  • Common causes include penetrating woundsof chest, rib fracture, positive pressure ventilation, pneumonia,cystic fibrosis, and idiopathic.
  • Although chest pain is acute, unilateral,and severe, degree of respiratory distress depends on how largepneumothorax is. Large pneumothorax results in hyperresonance topercussion on involved side.
  • Chest radiography is diagnostic.

    • Hemothorax

  • Definedas collection of blood in pleural space.
  • Most common cause is trauma, surgicalor nonsurgical.
  • Degree of respiratory distress dependson size of hemothorax. Decreased breath sounds and dullness to percussionover affected side of chest usually occur.
  • Chest radiograph that shows collapseof lung surrounded by opacification suggests presence of hemothorax.
  • Diagnosis is confirmed by thoracentesis.

    • Pneumomediastinum

  • Definedas presence of air or gas in mediastinum that can cause acute, severechest pain that may be referred to back, shoulders, and neck.
  • Palpation of subcutaneous air in softtissues of chest wall or neck signifies presence of mediastinalemphysema.
  • Common causes include pneumothoraxwith dissection of air into mediastinum, asthma, cystic fibrosis,and chest trauma with disruption of tracheobronchial tree.
  • Chest radiography is diagnostic.

    • Postpericardiotomy Syndrome

  • Thoughtto be immunologic reaction associated with introduction or reactivationof virus at time of intrapericardial surgery.
  • Usually occurs 1–3 wks aftersurgery in children >2 yrs.
  • Clinical manifestations include fever,chest pain, pericardial and pleural effusions, and sometimes pulmonaryparenchymal disease. Sharp or dull pain is precordial in locationand worsens with inspiration and lying down. Pleural and pericardialfriction rubs may be heard, unless there are significant effusions.
  • Pericardial effusions can be life threateningif they are large.
  • Serum may be positive for antiheartantibody.
  • Average duration of illness is 2–3wks, but recurrences sometimes occur months or years later.

    • Pulmonary Embolism

  • Definedas thrombus or any foreign material (e.g., air or fat) in pulmonaryarteries that causes obstruction of pulmonary blood flow.
  • Risk factors in pediatric populationinclude deep venous thrombosis, central venous catheter, prolongedimmobilization, ventriculoatrial shunt, right-sided endocarditis,intravenous drug use, septicemia, and severe dehydration.
  • Chest pain associated with pulmonaryembolism is acute and can be pleuritic or nonpleuritic. Usuallyassociated with dyspnea. Other findings include sweating, nausea,vomiting, palpitations, syncope, and anxiety.
  • Physical exam commonly reveals tachycardia,dyspnea or tachypnea, and fever. Other findings include crackles,wheezes, pleural friction rub, prominent RV impulse, accentuatedpulmonary closure sound, S4 gallop, systolic ejection murmur alongsternal border, hepatomegaly, and edema.
  • Chest radiograph is normal or showsconsolidation, atelectasis, or pleural effusion.
  • ECG findings include ST-segment orT-wave changes in right precordial leads and RV hypertrophy.
  • Pulmonary isotope lung perfusion scanthat shows bilateral segmental defects strongly suggests presenceof pulmonary emboli, whereas normal scan effectively excludes pulmonaryemboli. If scan is abnormal, ventilation (xenon) scan should beperformed. With pulmonary emboli, perfusion scan should be abnormaland ventilation scan normal.
  • MRI also may be useful in diagnosisof pulmonary embolism. If diagnosis is still uncertain, pulmonaryangiogram is best way to establish presence of pulmonary embolism.

    • Neoplasm

  • Primarychest neoplasms are rare in children.
  • Chest pain is usually secondary topleural metastases, which can occur with Wilms tumor, osteogenicsarcoma, neuroblastoma, or rhabdomyosarcoma.
  • Chest radiography may show mass ormetastases.
  • Chest CT locates and defines extentof mass or metastases.
  • Histologic diagnosis is definitive.

    • Cardiac Disorders

  • Cardiacdisorders that cause chest pain usually produce myocardial ischemiaor inflammation of parietal pericardium.
  • Middle and inferior cardiac nervesconduct myocardial pain impulses to upper thoracic rami, sympatheticchain, and spinal cord. Pain impulses from upper parietal pericardiumtravel along intercostal nerves, and those from lower pericardiumtravel along phrenic nerves and then to spinal cord.

    • Myocardial Ischemia Including Infarction

  • Myocardialischemia causes angina, which has been described as gripping, crushing, sharp,knifelike pain in retrosternal or left chest areas that usuallyfollows exercise or exertion and is relieved by rest. Pain may betransmitted to neck, shoulder, arm, or back. In some cases, myocardialinfarction may occur. Tachypnea, tachycardia, gallop rhythm, sweating,nausea, and vomiting are common findings.
  • Causes of myocardial ischemia includesevere aortic stenosis, coronary artery anomalies (including anomalouscoronary artery from pulmonary artery), myocarditis, cardiomyopathy,Kawasaki disease, familial dysproteinemias, and cocaine use.
  • ECG changes may indicate myocardialischemia or injury. ECG leads overlying subepicardial or transmuralischemic area show inverted T waves. Symmetric tall peaked T wavesare seen in leads overlying subendocardial ischemic area. Leadsoverlying subendocardial injury show ST depression with concaveor flat contour, whereas those overlying subepicardial injury showST elevation with upwardly convex or concave contour. Within hoursto days of myocardial infarction, Q waves and inverted T waves appearin leads overlying infarction.
  • 2-D echocardiogram may show local orgeneralized myocardial dysfunction.
  • Elevation of creatine kinase MB fractionor troponin T is usually found with destruction of myocardial tissue.
  • Nuclear scintigraphy of myocardiummay show decreased local uptake.
  • Cardiac catheterization and angiographyare necessary in some cases for definitive diagnosis.

    • Pericarditis

  • Most commoncauses in children are viral infection, acute rheumatic fever, andpostpericardiotomy syndrome. Less common are purulent pericarditis,uremia, systemic lupus erythematosus, juvenile rheumatoid arthritis,and radiation therapy.
  • Triad of fever, chest pain, and pericardialfriction rub signify pericarditis.
  • Chest pain is usually acute and substernalwith radiation to neck, shoulders, and arms. Sitting up and leaningforward eases pain, whereas deep breathing, coughing, and lyingdown aggravate it.
  • ECG shows elevated ST segments in nearlyall leads that progress to T-wave flattening and inversion in someof the leads, which may persist for months after acute lesion hasresolved.
  • 2-D echocardiography commonly revealspericardial effusion.

    • Mitral Valve Prolapse

  • Associationof chest pain and mitral valve prolapse has been seriously questioned, bothin adults and children. Mechanism of pain, which is ill definedand usually nonexertional, is uncertain. Other causes of chest painshould be considered in children with chest pain and mitral valveprolapse.
  • Midsystolic click or late systolicmurmur (mitral incompetence) or both are heard at apex.
  • M-mode or 2-D echocardiography confirmsdiagnosis of mitral valve prolapse.

    • Arrhythmias

  • Supraventriculartachycardia may cause some chest discomfort as well as cardiac failure.
  • Sinus tachycardia or premature ventricularcontractions have been associated with palpitations.
  • Important to differentiate by historywhether child is having chest pain or different sensation causedby palpitations.
  • ECG rhythm strip confirms diagnosisof arrhythmia. If cardiac rhythm is normal, Holter monitoring maybe useful.
  • With intermittent chest pain and suspectedarrhythmia, event recorder is another useful diagnostic technique.

    • Diaphragm Disorders

  • Intercostalnerves conduct impulses from peripheral diaphragm to spinal cord. Phrenicnerves (C3–C5) conduct pain impulses from central diaphragmto spinal cord.
  • With diaphragmatic irritation, painmay radiate to lower chest or shoulder, depending on extent of involvement.
  • Possible causes include subphrenicor hepatic abscess and perihepatitis (Fitz-Hugh-Curtis syndrome).

    • Gastrointestinal Disorders

    Esophagus

    Gastroesophageal Reflux

  • Common causeof transient chest pain is reflux of gastric contents from stomachinto esophagus. Severe reflux may lead to esophagitis with persistentchest pain.
  • Monitoring for 24 hrs with esophagealpH probe can determine presence and severity of reflux. Endoscopywith biopsy can diagnose esophagitis.
  • See Chap.55, Regurgitation and Vomiting).

    • Caustic Ingestion

  • Ingestionof caustic substances may cause sharp or burning pain in midsternaland lower chest.
  • Esophagoscopy is diagnostic.

    • Foreign Body

  • Foreignbody lodged in esophagus commonly causes choking, drooling, anddifficulty swallowing. Associated dull ache also may occur.
  • Chronically impacted foreign body maycause esophagitis.
  • If foreign body is radiopaque, maybe seen on chest radiograph. Otherwise, filling defect may be seenon esophagram.
  • Esophagoscopy is diagnostic for chronicallyimpacted foreign body.

    • Hiatal Hernia

  • Definedas sliding hernia with gastroesophageal junction lying above diaphragm.
  • Symptoms of hiatal hernia are thoseof gastroesophageal reflux with epigastric and lower chest paincommonly occurring after meals.
  • Sometimes large hiatal hernia may beseen on plain radiograph with retrocardiac mass extending to rightlateral chest wall.
  • Upper GI series is diagnostic.

    • Spasm

  • May causechoking episodes during feeding, difficulty in swallowing, and substernal chestache.
  • May be related to stress, rapid eating,and drinking cold liquids.
  • Upper GI series with video playbackcapability is diagnostic.

    • Tear

  • Persistentsevere vomiting may produce acute esophageal tear, which causeschest pain along with hematemesis.
  • Esophagoscopy is diagnostic.

    • Referred Pain

  • Gastritis,peptic ulcer disease, cholecystitis, and pancreatitis may causereferred chest pain.
  • See Chap.2, Abdominal Pain.

    • Neurologic Disorders

    Intercostal Nerve

    Trauma

    Injury to intercostal nerve may produce painin dermatome supplied by nerve.

    Herpes Zoster Neuritis

  • Herpes zostercan cause painful, vesicular lesions along ≥1 dermatomes correspondingto intercostal nerves.
  • Positive viral culture of lesion isconfirmatory.

    • Dorsal Root

  • Trauma (fractures)or spinal disease (tumor, osteomyelitis, epidural abscess) can involvecervical or upper thoracic dorsal roots and cause chest pain.
  • Pain often occurs with body motionor after coughing, sneezing, or laughing. Hypesthesia to pin prickor light touch may be found in affected dermatomes.
  • Useful diagnostic tests include cervicaland thoracic spine radiographs, nuclear scintigraphy, CT, and MRI.

    • Psychologic Disorders

  • Anxietywith or without hyperventilation, depression, school phobia, hypochondriasis,and conversion reactions are common causes of chest pain, especiallyin adolescence.
  • Pain has no particular characteristicsand usually diminishes once patients can talk about problem andreceive reassurance that they are not seriously ill.
  • Hyperventilation attacks are most commonin girls and may produce air hunger, dizziness, syncope, palpitations,and paresthesias.
  • Generally, specific stressful situationthat is related to onset of chest pain can be identified.
  • Family history of chest pain and occurrenceof recurrent somatic complaints (e.g., headache and abdominal pain)are also common.
  • To make diagnosis of psychogenic chestpain, positive clinical psychologic evidence must exist.
  • Onset of pain in association with stressfulemotional situation suggests that pain is manifestation of psychologicproblem.
  • In general, psychologic symptoms donot occur in isolation but are accompanied by other signs of unhappinessand anxiety.
  • Psychosocial history is most usefulclinical tool in making diagnosis of psychogenic chest pain.

    • Idiopathic Chest Pain

  • Most commoncause of chest pain in childhood and adolescence is idiopathic.Such pain is nonspecific but may be recurrent or chronic.
  • This is diagnosis of exclusion.

    • Diagnostic Approach

  • Most commoncauses of chest pain in pediatric population are idiopathic, musculoskeletal,and psychologic.
  • If complaint has been present for >6mos, organic cause is less likely.
  • History and physical exam are diagnosticin many cases.
  • Chest radiography should be performedwith localized rib or bone pain, any respiratory distress, or suspectedpulmonary disorder.
  • With suspected heart disease, ECG shouldbe performed.
  • 2-D echocardiography may be necessary,depending on suspected diagnosis.
  • Psychologic causes must be substantiatedby clinical psychologic evidence.
  • Children in whom no definite causecan be found are more likely to complain recurrently, presumablyfor secondary gain.
  • In adolescence, chest pain is frequentcomplaint, but it is usually benign. Knowledge about recent lifeevents and individual's beliefs about the symptom are importantin managing this problem.

    • References

    1. Bellet PS, et al. Incentive spirometryto prevent acute pulmonary complications in sickle cell diseases.N Engl J Med 1995;333:699–703.
    2. Coleman WL. Recurrent chest pain in children. PediatrClin North Am 1984;31:1007–1026.
    3. Duster MC. Chest pain. In: Garson A Jr, et al., eds.The science and practice of pediatric cardiology, 2nd ed. Baltimore:Williams & Wilkins, 1998:2113–2217.
    4. Fleisher GR, Ludwig, eds. Textbook of pediatric emergencymedicine, 4th ed. Philadelphia: Lippincott Williams & Wilkins,2000.
    5. Gartner JC Jr. Chest pain. In: Gartner JC Jr, ZitelliBJ, eds. Common & chronic symptoms in pediatrics. St. Louis:Mosby-Year Book, 1997:33–39.
    6. Gitter MJ, et al. Cocaine and chest pain: clinicalfeatures and outcome of patients hospitalized to rule out myocardialinfarction. Ann Intern Med 1991;115:277–282.
    7. Kirks DR, ed. Practical pediatric imaging, 3rd ed.Philadelphia: Lippincott-Raven, 1998.
    8. Kocis KC. Chest pain in pediatrics. Pediatr Clin NorthAm 1999;46:189–203.
    9. Mooney DP, Shorter NA. Slipping rib syndrome in childhood.J Pediatr Surg 1997;32:1081–1082.
    10. Patterson MD, Ruddy RM. Pain–chest. In: FleisherGR, Ludwig S, eds. Textbook of pediatric emergency medicine, 4thed. Philadelphia: Lippincott Williams & Wilkins, 2000:435–440.
    11. Pickering D. Precordial catch syndrome. Arch Dis Child1981;56:401–403.
    12. Selbst SM. Evaluation of chest pain in children. PediatrRev 1986;8:56–62.
    13. Selbst SM, et al. Chest pain in children: follow-upof patients previously reported. Clin Pediatr 1990;29:374–377.
    14. Selbst SM, et al. Pediatric chest pain: a prospectivestudy. Pediatrics 1988;82:319–323.
    15. Taubman B, Vetter VL. Slipping rib syndrome as a causeof chest pain in children. Clin Pediatr 1996;35:403–405.
    16. Woolf PK, et al. Noncardiac chest pain in adolescentsand children with mitral valve prolapse. J Adolesc Health 1991;12:247–250.

    Book Source Details

    • Book Title: The Diagnostic Approach to Symptoms and Signs in Pediatrics
    • Author(s): Paul S. Bellet
    • Year of Publication: 2006
    • Copyright Details: The Diagnostic Approach to Symptoms and Signs in Pediatrics, Copyright © 2006 Lippincott Williams & Wilkins.

    Other Book Chapters Related to Chest discomfort

    Read excerpts from these other book chapters related to Chest discomfort:

    Medical Books Excerpts
    • CHEST PAIN
    • "Algorithmic Diagnosis of Symptoms and Signs" (2003)
    • [ read ]
    • FLANK PAIN
    • "Algorithmic Diagnosis of Symptoms and Signs" (2003)
    • [ read ]
    • Chest Pain
    • "In A Page: Pediatric Signs and Symptoms" (2007)
    • [ read ]
    • Chest pain
    • "Handbook of Signs & Symptoms (Third Edition)" (2006)
    • [ read ]
    • Flank pain
    • "Handbook of Signs & Symptoms (Third Edition)" (2006)
    • [ read ]
    • Chest Pain
    • "A Pocket Manual of Differential Diagnosis" (1999)
    • [ read ]
    • Chest pain
    • "Professional Guide to Signs & Symptoms (Fifth Edition)" (2006)
    • [ read ]
    • Flank pain
    • "Professional Guide to Signs & Symptoms (Fifth Edition)" (2006)
    • [ read ]
    • Chest Pain, Atypical
    • "The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter" (2000)
    • [ read ]
    • Chest pain
    • "Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series" (2007)
    • [ read ]
    • Flank pain
    • "Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series" (2007)
    • [ read ]
    • Chest pain
    • "Signs & Symptoms: A 2-in-1 Reference for Nurses" (2007)
    • [ read ]
    • Flank pain
    • "Signs & Symptoms: A 2-in-1 Reference for Nurses" (2007)
    • [ read ]
    • Chest Pain
    • "The Diagnostic Approach to Symptoms and Signs in Pediatrics" (2006)
    • [ read ]
    • Chest pain
    • "Nursing: Interpreting Signs and Symptoms" (2007)
    • [ read ]
    • Flank pain
    • "Nursing: Interpreting Signs and Symptoms" (2007)
    • [ read ]
     

    Copyright Details: The Diagnostic Approach to Symptoms and Signs in Pediatrics, Copyright © 2008 Williams & Wilkins.

    More About Causes of Chest discomfort



    More About This Book:
    Title: The Diagnostic Approach to Symptoms and Signs in Pediatrics
    Authors: Paul S. Bellet
    Publisher: Lippincott Williams & Wilkins
    Copyright: 2006
    ISBN: 0-78172-899-1

     » Next page: Chest expansion, asymmetrical (Nursing: Interpreting Signs and Symptoms)

    Rate This Website

    What do you think about the features of this website? Take our user survey and have your say:

    Website User Survey

    Medical Tools & Articles:

    Next articles:

    Tools & Services:

    Medical Articles:

    Forums & Message Boards
     
    HONcode We subscribe to the HONcode principles

    By using this site you agree to our Terms of Use. Information provided on this site is for informational purposes only; it is not intended as a substitute for advice from your own medical team. The information on this site is not to be used for diagnosing or treating any health concerns you may have - please contact your physician or health care professional for all your medical needs. Please see our Terms of Use.

    Home | Symptoms | Diseases | Diagnosis | Videos | Tools | Forum | About Us | Terms of Use | Privacy Policy | Site Map | Advertise

    Copyright © 2009 Health Grades Inc. All rights reserved.