Chest Pain
Chest pain is a frequent complaint in pediatrics, especially in the adolescent age group. Although rarely cardiac in etiology, this often represents the patient's/family's greatest fear. A careful history and physical exam, with attention to the needs of the patient/family and appropriate reassurance, are often all that are required.
Differential Diagnosis
- Musculoskeletal
–Sharp, stabbing pain that is usually very well localized, often worsened by deep breath or cough
–Costochondritis: Tender parasternal pain at insertion of ribs into cartilage en route to sternum; increases with palpation or mild chest compression (possibly postviral)
–Injury to chest wall
- Pulmonary
–Very common cause, usually associated with respiratory symptoms: Shortness of breath, cough, exercise intolerance
–Asthma (most common), often only EIA; may have personal/family history of atopy (asthma, eczema, seasonal allergies); shortness of breath is usually primary complaint, with feeling of chest tightness/pain as a secondary symptom
–Pleuritic chest pain: Sharp, stabbing pain with deep breaths, indicates pleural space inflammation, probably postinfectious (especially viral)
–Pneumonia: Chest pain secondary to cough or pleural involvement
–Pneumothorax can occur spontaneously, especially in tall, thin athletes
- Gastrointestinal
–GERD and PUD: Burning, substernal pain with eating, worse at night
–Rarely pancreatitis (with back pain too), cholecystitis, hiatal hernia, hepatitis
- Cardiac: Rare in children
–Precordial catch syndrome: Sharp, brief (seconds) chest pain usually associated with rising from lying or sitting; unclear etiology, but of no significance
–Pericarditis: Inflammation of the pericardium; often postviral, may represent connective tissue/autoimmune, cancer, bacterial infection (very ill appearing with fever), or post-cardiac surgery; patients often lean forward to decrease the pain
–MI (rare): Congenital coronary anomaly, post-Kawasaki, cocaine use, hypertrophic cardiomyopathy
–Aortic dissection: Consider if features or history of Marfan syndrome is present
Workup and Diagnosis
- History
–Activity at onset, (chest pain with exercise is a red flag!), precipitating/relieving factors, quality of pain (sharp vs dull)
–Associated symptoms (shortness of breath, diaphoresis, cough/wheeze, nausea/vomiting), recent illness, response to eating, sleeping, different foods (caffeine, chocolate, spicy, or high-fat foods)
–Personal/family history of asthma, allergies, eczema
–Recent diagnosis of heart disease or death in a family member often generates fear in the patient or parent, prompting the evaluation of chest pain
–Social history: Recent life stressors (school problems, family discord, etc.); drug use, especially cocaine
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Physical exam
–Reproducible with palpation likely musculoskeletal
–Chest exam: Wheezing, rales, crepitus
–Cardiac exam: Usually normal, even with cardiac
causes; pericarditis is associated with rub
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Chest X-ray for infiltrates, pneumonia, pneumothorax
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ECG and cardiac enzymes are rarely required but relatively inexpensive and readily available, and can rule out MI and provide reassurance for families
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Cardiac stress test
–Continuous ECG monitoring while the patient exercises to evaluate for coronary insufficiency
–Used for patients with exercise-induced chest pain and/or coronary abnormalities
Treatment
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Most patients/families with chest pain simply want reassurance that symptoms are not cardiac in origin
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A careful history and physical exam are most important; however, a normal CXR and ECG provide therapeutic reassurance to the patient/family
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Further cardiology consultation is rarely required but should be considered with patients experiencing chest pain with exercise, a history of Kawasaki disease, Marfan syndrome (this is an emergency), and for those patients with persistent chest pain
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Costochondritis: Treated with NSAIDs until resolved
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Pericarditis: Treated with aspirin or NSAIDs; requires cardiology follow-up until resolved, rarely requires pericardiocentesis
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Appropriate therapy of identified pulmonary, gastrointestinal, or musculoskeletal problems
Book Source Details
- Book Title: In A Page: Pediatric Signs and Symptoms
- Author(s): Jonathan E. Teitelbaum, Kathleen O. Deantonis, Scott Kahan
- Year of Publication: 2007
- Copyright Details: In A Page: Pediatric Signs and Symptoms, Copyright © 2007 Lippincott Williams & Wilkins.
Other Book Chapters Related to Pectus excavatum
Read excerpts from these other book chapters related to Pectus excavatum:
Medical Books Excerpts
- CHEST PAIN
- "Algorithmic Diagnosis of Symptoms and Signs" (2003)
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- Chest pain
- "Handbook of Signs & Symptoms (Third Edition)" (2006)
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- Chest Pain
- "A Pocket Manual of Differential Diagnosis" (1999)
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- Chest pain
- "Professional Guide to Signs & Symptoms (Fifth Edition)" (2006)
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- Chest pain
- "Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series" (2007)
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- Chest pain
- "Signs & Symptoms: A 2-in-1 Reference for Nurses" (2007)
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- Chest Pain
- "The Diagnostic Approach to Symptoms and Signs in Pediatrics" (2006)
- [ read ]
Copyright Details: In A Page: Pediatric Signs and Symptoms, Copyright © 2008 Williams & Wilkins.
More About Causes of Pectus excavatum
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More About This Book:
Title: In A Page: Pediatric Signs and Symptoms
Authors: Jonathan E. Teitelbaum, Kathleen O. Deantonis, Scott Kahan
Publisher: Lippincott Williams & Wilkins
Copyright: 2007
ISBN: 1-4051-0427-9
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CHEST PAIN (Differential Diagnosis in Primary Care)
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