RIME – Chest Pain
Andrew Hughey, MSIII
May 2011
History Intake
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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,
palpitations
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
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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
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CXR (if suspect pulmonary/cardiac), ECG / Holter monitor / echocardiogram / (if suspect cardiac), EGD /
manometry / 42 hr pH testing (if suspect GI)
Differential Diagnosis
Musculoskeletal
(15-31%)
Anxiety, conversion
disorder
Respiratory
(2-11%)
Cardiac *
(2-8%)
Miscellaneous
CAD (ischemia/infarction, - IDIOPATHIC (21-45%)
Kawasaki disease),
- GI causes (2-8%):
arrhythmia, HOCM,
GERD, gastritis,
pulmonic stenosis, MVP,
esophageal dysmotility
pericarditis, myocarditis
- Breast tenderness
(puberty)
- Hx of direct trauma - Stressful events (e.g. - Pain induced by exercise (may - Pain with exertion,
Signs &
- Vaso-occlusive crisis or
palpitations, or syncope
Symptoms or strain (wrestling, recent death, illness or suggest asthma)
carrying heavy
accident in the family, - Accompanied by other
- Presence of predisposing acute chest syndrome
(sickle cell disease)
books, exercising)
family separations,
symptoms of URI (cough,
conditions: diabetes,
- Chest tenderness or school changes)
congestion, coryza)
Kawasaki disease, chronic - Aortic dissection
(Marfan syndrome
pain with movement - Other recurrent
- Tachypnea, respiratory distress anemia, cocaine
- Pleural effusions
of the torso or upper somatic complaints
- Wheezing heard on auscultation - Murmur, pericardial
extremities
(e.g. headache,
- Diminished breath sounds
friction rub, or an abnormal (vascular collagen
diseases)
abdominal or extremity suggestive of consolidation
pulse or blood pressure
- Shingles
pain)
- Fever, elevated WBC
- Cardiomegaly on CXR
- Lightheadedness or
suggestive of infection
- Arrhythmia on ECG
paresthesias secondary - CXR demonstrating pneumonia - Structural abnormality on
to hyperventilation
- Decreased peak flow (asthma) echocardiogram
- Clinical diagnosis based on
- Referral to pediatric
Diagnosis - Clinical diagnosis - Clinical diagnosis
- 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
- Reassurance
Depends on etiology:
Treat underlying cause:
Treatment - Rest
- 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.
Causes
Costochondritis,
trauma / contusion,
slipping rib
syndrome
Psychological
(0-30%)
Asthma, severe cough,
pneumonia, pneumothorax /
pneumomediastinum, pulmonary
embolism
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.” Uptodate.com. 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.