Pediatric Primary Care (72 page)

f.  Congenital heart disease or previous cardiac surgery is important factor in determining cardiac origin of chest pain; also increases likelihood of dysrhythmia as origin for chest pain.

D.  Physical findings.

1.  Most commonly patients will have no significant physical exam findings. Physical exam findings may be clues to origin of chest pain.

2.  Stigmata of certain syndromes: Marfan, Turner.

3.  Cardiac murmur.

4.  Evidence of congestive heart failure.

a.  Tachypnea, increased work of breathing, retractions, flaring, tachycardia, weak peripheral pulses, cool extremities, delayed capillary refill, rales, enlarged liver, easily fatigued, edema.

5.  Obesity: increased incidence of gastroesophageal reflux (GER).

6.  Reproducible pain with palpation.

7.  Signs of trauma to chest wall.

8.  Decreased breath sounds.

E.  Diagnostic tests.

1.  Refer to pediatrician/specialist if chest pain of cardiac origin is suspected; may conduct the following tests as part of evaluation.

2.  Chest X-ray (CXR).

a.  Evaluate for cardiomegaly. May also reveal rib fractures or pneumonia.

3.  Electrocardiogram.

a.  Clue to cardiac origins: hypertrophied atria or ventricles, long QT syndrome, congenital heart disease, infarcts, dysrhythmias.

4.  Echocardiography.

a.  Structural abnormalities.

b.  Coronary artery anatomy.

c.  Cardiac function.

5.  Exercise testing.

a.  ST segment response to exercise.

b.  May provoke dysrhythmias.

c.  May provoke exercise-induced asthma.

6.  May reassure patient and parents if normal.

F.   Differential diagnosis.

1.  Musculoskeletal.

a.  Costochondritis.

•  Most often at 2nd to 5th costal cartilages.

•  Often reproducible pain with pressure at costochondral junctions.

•  Treated with nonsteroidal anti-inflammatory drugs (NSAIDs).

b.  Slipping rib syndrome.

•  Pain at lower costal margin, often associated with click.

•  Reproducible at times with anterior motion of lower rib.

•  Treated with avoidance of inciting movements.

c.  Trauma (nonaccidental or accidental).

•  Point tenderness at site of trauma.

•  Pain is worse with movement of chest, self-limited.

d.  Muscular pain.

•  History of new physical activity, pain is worse if affected muscles are used.

e.  Precordial catch.

•  Sharp pain in anterior chest, often when child is bent over.

•  Short, intermittent pain, relieved by shallow respirations.

f.  Pleural pain.

•  Infection affecting intercostal and upper abdominal muscles, intensified with coughing.

•  Tender muscles lasting 3-7 days.

•  Intense pain separated by pain-free intervals.

2.  Pulmonary.

a.  Asthma, particularly exercise-induced asthma.

b.  Pneumonia.

c.  Foreign body aspiration.

d.  Pleuritis: often is remote occurrence to viral infection.

e.  Diaphragmatic irritation.

f.  Pulmonary embolus: associated with dyspnea, usually is acute episode.

g.  Pneumothorax: associated with dyspnea, usually is acute episode.

3.  Gastrointestinal: typically localized to substernal area.

a.  GER.

b.  Related to mealtimes. Exacerbated by supine positioning.

c.  Esophagitis.

d.  Biliary colic.

e.  Acute pancreatitis: pain radiates to back.

f.  Peptic ulcer disease.

4.  Psychogenic causes: often have witnessed episodes of chest pain in family members.

G.  Treatment.

1.  Musculoskeletal.

a.  Analgesics and anti-inflammatories.

b.  Avoidance of inciting movements, rest.

2.  Pulmonary.

a.  Asthma: trial of bronchodilators, particularly if exercise-induced symptoms.

b.  Immediate referral for concern of pulmonary embolus or pneumothorax.

3.  Gastrointestinal.

a.  GER: H
₂
blockers, dietary modifications, weight loss if obesity contributing to symptoms.

b.  Referral to specialist if initial medical therapy does not relieve symptoms.

4.  Psychogenic.

a.  Frank discussion with patient, family about nonorganic cause of chest pain.

•  Changes in patient's life leading to stress or depression?

•  Assess for secondary gain that pain yields patient.

•  Counseling may be indicated.

b.  Refer to specialist.

5.  Cardiac causes.

a.  Refer to specialist.

b.  Coronary artery anomalies, valvular defects: medical management, surgical repair.

c.  Infectious etiologies.

•  Cardiomyopathy/myocarditis.

•  Treatment of inciting infection if elucidated.

•  Supportive care until recovery of function.

•  Consideration for transplantation if function does not recover.

d.  Kawasaki disease (see later section).

e.  Myocardial issues.

•  Obstructive cardiomyopathy.

•  Activity restriction.

•  Consideration of medical or surgical therapy.

f.  Dysrhythmias.

•  Identification of dysrhythmia.

•  Antidysrhythmic agents.