Chest Pain (Case 52)

Chapter 95 Chest Pain (Case 52)



Steven M. Selbst, MD




Case


A 7-year-old boy was hanging drywall when he felt a sharp pain in his left shoulder. The pain has persisted and he has shortness of breath with exertion.




Differential Diagnosis




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Speaking Intelligently


When I evaluate a child with chest pain, I recognize that the etiology of chest pain in children is usually not related to the heart. Still, each patient must be taken seriously, because occasionally a child with chest pain is found to have a serious medical problem. My first step is to ascertain that the child is hemodynamically stable before I proceed with a detailed evaluation. I connect the child to a monitor and evaluate cardiac rate, rhythm, and oxygen saturation. It is crucial to be sure the patient does not need cardiovascular or respiratory support immediately. If there are signs of poor perfusion, I start an intravenous line and give a bolus of normal saline, 20 mL/kg over the next hour. Although many children with chest pain (especially chronic pain) do not need laboratory or diagnostic studies, a chest radiograph and an electrocardiogram can be helpful in determining if the chest pain and other associated signs and symptoms are related to cardiac or pulmonary pathology.



Patient Care



Clinical Thinking



• Support airway and breathing.

• Support circulation.


History



• History of trauma is concerning. A minor chest wall injury or muscle strain should improve over time.

• The description of pain is sometimes helpful. “Burning pain,” worse with lying down, is associated with esophagitis.

• Nausea, vomiting, and anorexia are often related to gastrointestinal (GI) disorders, but these are very nonspecific.

• Dizziness with standing suggests dehydration but could also be related to cardiac insufficiency.

• Shortness of breath and pain worse with exertion are very concerning. These symptoms make a respiratory or cardiac cause seem more likely.

• Onset of pain is important. Acute pain (<48 hours) is more likely to have an organic cause. Chronic pain (>6 months) is more likely to be psychogenic or idiopathic. In an older child with sudden onset of pain, consider an arrhythmia, pneumothorax, or musculoskeletal injury. In a young child with sudden onset of pain, consider a foreign body (coin) in the esophagus or chest injury.

• Ask about family history.

• Severity and frequency of chest pain is sometimes revealing.

• Determine if the pain is induced by exercise or exertion.

• Consider recent use of cocaine.

• Inquire about recent significant stress (e.g., move, death of loved one, serious illness).

• Determine if there are associated complaints.

• Past medical history is sometimes revealing.


Physical Examination



• If the child is in significant distress, emergency care and stabilization are required. Consider pneumothorax or arrhythmia.

• Vital signs give crucial information. Orthostatic changes suggest depleted intravascular volume (dehydration) but could relate to cardiac insufficiency (pump failure).

• Fever is notable and serves as a “branch point” in narrowing the differential diagnosis.

• An abnormal cardiac examination (heart murmur, rub, arrhythmia) clearly points to a cardiac condition. Absence of such findings does not rule out cardiac disease.

• If the child appears chronically ill, chest pain may be part of a serious illness such as malignancy (Hodgkin lymphoma) or systemic lupus erythematosus.

• If skin bruising is present, chest pain may be related to unrecognized trauma.

• If the abdominal examination is abnormal, chest pain may be related to a GI disorder with pain referred to the chest.

• If arthritis is present, consider a collagen vascular disease, which may manifest as pleural effusion and chest pain.

• If the child is unusually anxious, consider pain related to stress.

• If the chest examination reveals rubs, decreased breath sounds, or wheezing, this may suggest pneumonia or asthma with overuse of chest wall muscles. If subcutaneous emphysema is palpable on chest or neck, consider a pneumothorax or pneumomediastinum.

• Tenderness of the chest wall or costochondral junctions suggests musculoskeletal pain or costochondritis. However, this finding may be nonspecific.


Tests for Consideration



• Electrocardiogram (ECG) $150

• Exercise stress test $290
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Jul 18, 2016 | Posted by in PEDIATRICS | Comments Off on Chest Pain (Case 52)

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