What precipitates pain Are there associated symptoms

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Chest pain precipitated by exercise should be taken seriously (suggesting cardiac disease or, more commonly, exercise-induced asthma). History of trauma, rough play, or choking on a foreign body may be relevant. Chest pain associated with syncope or palpitations is more significant and may also relate to cardiac disease. History of fever suggests an infectious process (eg, pneumonia, myocarditis).

C. What is patient's past medical and family history? Past medical history may reveal asthma that places patient at risk for more serious causes of pain. Previous heart disease or conditions such as diabetes mellitus (hyperlipidemia) or Kawasaki disease (coronary artery aneurysms) may increase risk of cardiac pathology. Obtain family history, because cardiac disorders can be familial. Patients with hypertrophic cardiomyopathy may relate a family history of chest pain or sudden death.

D. How severe is pain? Determine if pain is frequent, severe, or interrupts child's daily activity. Pain that awakens child from sleep is more likely to have an organic etiology.

E. How is pain characterized (location, quality)? Young children may be imprecise in language and description, which can decrease usefulness of the history. Suspect esophagitis if burning sternal pain is present; pericarditis if there is sharp pain that is relieved by sitting up and leaning forward and associated with fever.

F. How old is patient? Young children are more likely to have a cardiorespiratory cause for their pain (eg, cough, asthma, pneumonia, or heart disease); adolescents are more likely to have pain associated with stress or a psychogenic disturbance.

■ III. Differential Diagnosis

A. Cardiac Causes. Previously undiagnosed cardiac disease is a rare cause of chest pain in children (< 5%).

1. Myocardial ischemia or infarction. Conditions that place children at risk of angina or myocardial infarction include anomalous coronary arteries, long-standing diabetes mellitus, past medical history of Kawasaki disease, chronic anemia (eg, sickle cell disease), and cocaine use. In many cases, exercise induces chest pain with these disorders because coronary blood flow is limited. Therefore, pain with exertion or syncope, or both, especially in these children should always be carefully evaluated.

2. Arrhythmia. Associated with palpitations or abnormal cardiac exam. Supraventricular tachycardia is the most common of these arrhythmias, but premature ventricular contractions can also lead to brief, sharp chest pain.

3. Structural cardiac abnormalities. Hypertrophic obstructive cardiomyopathy has an autosomal dominant pattern of inheritance; therefore, a family history may exist. These children are at risk for ischemic chest pain, especially when exercising, and have a murmur that is best heard with standing or Valsalva maneuver. Most other cardiac structural disorders rarely cause chest pain; however, severe pulmonic stenosis with associated cyanosis and aortic valve stenosis can lead to ischemia. In these latter conditions, pain is described as squeezing, choking, or a pressure sensation in the sternal area. These conditions are almost always diagnosed before child presents with pain, and associated murmurs are found on physical exam. Mitral valve prolapse may cause chest pain by papillary muscle or left ventricular endocardial ischemia. Midsystolic click and late systolic murmur are found in many cases. However, studies show that mitral valve prolapse is no more common in children with chest pain than in the general population.

4. Cardiac infections. Uncommon cause of pediatric chest pain. Pericarditis presents with sharp stabbing pain that improves when patient sits up and leans forward. Child is usually febrile and has respiratory distress, friction rub, distant heart sounds, neck vein distention, and pulsus paradoxus. Myocarditis is somewhat more common and can present in more subtle fashion. After a few days of fever and other systemic symptoms such as vomiting and lightheadedness, patient may develop pain with exertion and shortness of breath. Exam may reveal muffled heart sounds, fever, gallop rhythm, or tachycardia that is out of proportion to degree of fever present. Patient also may have orthostatic changes in pulse or BP. This is often misinterpreted as volume depletion, because child with this infection may not be taking oral fluids well and may indeed have mild dehydration. However, if orthostatic vital signs do not improve with fluid resuscitation, cardiogenic causes such as myocarditis should be suspected.

B. Musculoskeletal Disorders. One of the most common diagnoses in children with chest discomfort.

1. Muscle strain. Active children frequently strain chest wall muscles while wrestling, carrying heavy books, or exercising. Pain is generally reproducible by palpation or with movement of the torso and upper extremities.

2. Costochondritis. A related disorder that is common in children. Diagnosis is made by eliciting tenderness (reproducible pain) over costochondral junctions with palpation. Pain may be sharp, bilateral, and exaggerated by physical activity or breathing, and may persist for several months.

3. Direct chest wall trauma. Some children suffer direct trauma to the chest, resulting in mild contusion of the chest wall or, with more significant force, rib fracture, hemothorax, or pneumothorax. In most cases there is a straightforward history of trauma, and diagnosis is clear. Careful physical exam reveals chest tenderness or pain with movement of torso or upper extremities.

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