a. Hypotension. May be present in cases of tension pneumothorax, myocarditis, or myocardial infarction. All of these diagnoses are quite rare in children.
c. Fever. May be a sign of infection (eg, pneumonia, myocarditis, or pericarditis).
d. Tachycardia. May be related to pain or could indicate an arrhythmia such as supraventricular tachycardia or ventricular tachycardia (less common).
2. General assessment. Differentiate child in severe distress who needs immediate treatment for life-threatening conditions (eg, pneumothorax). Hyperventilation can be distinguished from respiratory distress by absence of cyanosis or nasal flaring. Next, look for signs of chronic disease (pallor, poor growth), which may suggest that chest pain is one symptom of a more complex problem (eg, tumor or collagen vascular disease). Consider Marfan syndrome if patient is tall and thin with an upper extremity span that exceeds his or her height. Note any signs of anxiety that could indicate emotional stress.
3. Skin. Examine child for rashes or other skin lesions. Bruises on parts distant from the chest may indicate unrecognized trauma to the chest.
4. Abdomen. This area deserves careful evaluation because it may be a source of pain that is referred to the chest.
5. Chest. Exam may reveal rales, wheezes, or decreased breath sounds if there is pulmonary pathology. Murmurs, rubs, muffled heart sounds, or arrhythmias may be noted if there is cardiac pathology. A murmur that intensifies with Valsalva maneuver and the standing position is the hallmark of hypertrophic cardiomyopathy. Evaluate the chest wall for signs of trauma, tenderness (suggesting musculoskeletal pain), or subcutaneous air (suggesting pneumothorax or pneumomediastinum).
B. Laboratory Data. If history and physical exam do not lead to a specific diagnosis for chest pain, it is unlikely that laboratory tests will be helpful. Laboratory studies usually confirm previously known disorders or abnormal findings that are suspected clinically. These studies are probably unnecessary in children with chronic pain, normal physical exam, and no history to indicate cardiac or pulmonary disease (Table I-8).
1. Blood counts and ESR. Of limited value unless sickle cell disease, collagen vascular disease, infection, or malignancy is suspected.
2. Drug screening for cocaine. May be indicated in older children with acute pain associated with anxiety, tachycardia, hypertension, or shortness of breath.
3. Cardiac enzymes. Rarely of value unless there are specific concerns from history or exam.
C. Radiographic and Other Studies. Chest x-rays and ECGs should not be routinely ordered unless indicated by history and physical exam.
1. Chest x-ray. Helpful if patient has fever, respiratory distress, decreased or abnormal breath sounds, or other pulmonary disease. Fever with chest pain is highly correlated with pneumonia. Chest film may lead to diagnoses of pericarditis or myocarditis if cardiomegaly is found in a febrile child with chest pain. Children with asthma and chest pain may have pneumothorax or pneumomediastinum.
2. ECG. Warranted if patient has an abnormal cardiac exam, including unexplained tachycardia, arrhythmia, murmur, rub, or click.
3. Chest x-ray plus ECG. Both studies are indicated if history reveals pain that is acute in onset (ie, began in past 2 or 3 days)
TABLE I-8. INDICATIONS FOR LABORATORY STUDIES IN CHILDREN WITH CHEST PAIN
■ WORRISOME HISTORY
Acute onset of pain Pain on exertion History of heart disease
Serious associated medical problems (eg, diabetes mellitus, asthma, Marfan syndrome, Kawasaki disease, sickle cell anemia, systemic lupus erythematosus) Use of drugs (cocaine, oral contraceptives) Associated complaints (syncope dizziness, palpitations) Significant trauma Foreign body ingestion or aspiration Fever
■ ABNORMAL PHYSICAL EXAM
Palpation of subcutaneous air
Decreased breath sounds
Cardiac findings (eg, murmurs, rubs, arrhythmias)
Trauma or is otherwise concerning for cardiac disease. If there is pain with exertion, be particularly concerned about cardiac disease or asthma and obtain an eCg and chest x-ray. If patient has a history of heart disease, chest x-ray or ECG may also be desirable.
4. Echocardiogram. It may be wise to refer child for this study if structural heart disease is suspected. It is not necessary to obtain an echocardiogram on all children with ill-defined chest pain to look for mitral valve prolapse.
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