Chest Pain

Question 1

Into what two categories should pediatric chest pain be divided in order to best guide diagnosis?

Answer 1

Acute-onset, severe vs chronic and recurrent

Question 2

What is the most common cause of cardiac chest pain in children?

Answer 2

Pericarditis

Question 3

Describe the typical presentation for pericarditis.

Answer 3

It is usually described as severe, substernal chest pain that is squeezing or tightening in character. The pain is worse with movement and exacerbated by breathing. Classically, the patient is leaning forward to alleviate the pain, does not want to lie down, and there is a pericardial friction rub on exam.

Question 4

Which illicit drug can cause acute MI in adolescents?

Answer 4

Cocaine

Question 5

What would be the typical presentation for a child presenting with myocardial infarction?

Answer 5

Pain is severe, pressure-like, and substernal. It can radiate to the neck or arms, is worse with exercise, and improves with rest. There may be signs of ischemia on EKG, as well as elevated cardiac enzymes.

Question 6

What are the typical EKG changes associated with acute myocardial infarction?

Answer 6

ST-segment elevation and T-wave changes in the area of the affected myocardium, as well as reciprocal ST-segment depression in the corresponding opposite leads.

Question 7

If a child presents with true acute myocardial infarction, what underlying conditions should one consider?

Answer 7

Cocaine use in the adolescent, familial hyperlipidemia, or a history of Kawasaki disease

Question 8

What is the most likely cause of acute chest pain if arrhythmia is the underlying etiology?

Answer 8

Supraventricular tachycardia

Question 9

An adolescent with Marfan syndrome presents with acute chest pain that is tearing and radiates to his back. What are you immediately concerned about?

Answer 9

Aortic dissection

Question 10

How is the pain associated with aortic dissection usually described?

Answer 10

Sharp, tearing, and radiating to the neck or back.

Question 11

Which conditions increase the risk for aortic dissection?

Answer 11

Marfan syndrome, Ehlers-Danlos syndrome, severe thoracic trauma.

Question 12

What is the recommended diagnostic workup and management of suspected aortic dissection?

Answer 12

Aortic dissection can be visualized with MRI, CT, or transesophageal ECHO. Urgent surgical intervention is required.

Question 13

What condition should be suspected in a patient who develops sudden, severe, unilateral chest pain accompanied by dyspnea?

Answer 13

Spontaneous pneumothorax

Question 14

Which conditions increase the risk for developing a spontaneous pneumothorax?

Answer 14

Asthma, cystic fibrosis, Marfan syndrome, and trauma.

Question 15

What are the typical physical exam findings for a spontaneous pneumothorax?

Answer 15

Diminished breath sounds and hyperresonant percussion on the affected side.

Question 16

Which pathogen should be considered as a possible cause of severe chest pain in adolescents with HIV risk factors?

Answer 16

Pneumocystis

Question 17

How might one distinguish the chest pain caused by angina from that caused by GERD?

Answer 17

Usually with GERD the pain has a strong correlation to meal-time and is aggravated with supine positioning.

Question 18

What are three GI causes for acute pediatric chest pain?

Answer 18

GERD, esophageal spasm, and esophageal foreign body.

Question 19

Which conditions may cause chest pain by irritating the diaphragm?

Answer 19

Lower lobe pneumonia, hepatic and splenic abscesses, and pancreatitis.

Question 20

What is the most common cause of chest pain in children?

Answer 20

Musculoskeletal chest wall pain

Question 21

What is the typical presentation of musculoskeletal chest wall pain?

Answer 21

The pain is usually localized, does not radiate, is reproducible with palpation, and can become worse with exercise.

Question 22

What type of chest pain occurs over the rib/cartilage junction and is often reproducible with palpation over the area?

Answer 22

Costochondritis

Question 23

What is the recommended treatment for musculoskeletal chest wall pain?

Answer 23

Reassurance and mild analgesics (Acetaminophen/NSAIDs)

Question 24

What is Tietze syndrome?

Answer 24

Pain and swelling of the anterior chest wall, normally involving the 2nd or 3rd costochondral junction on one side. Pain and swelling come and go and can last months to years.

Question 25

What condition can present alongside Tietze syndrome?

Answer 25

Varicella zoster

Question 26

What is a precordial catch?

Answer 26

It is the sudden onset of severe, sharp, or shooting chest pain that is recurrent and localized to the cardiac apex. The pain lasts 30 seconds to a few minutes before resolving. It typically occurs at rest and can recur several times per day. It is worse with deep inspiration and its etiology is unknown.

Question 27

What is slipping rib syndrome?

Answer 27

It occurs when a lower rib (8, 9, 10) moves up and overrides an upper rib, resulting in severe pain that can last for hours or days.

Question 28

What are the two most common pulmonary causes of pediatric chest pain?

Answer 28

Asthma (exercise-induced and chronic) and pneumonia

Question 29

What are four GI causes of chronic chest pain in children?

Answer 29

GERD, esophageal spasm, achalasia, and esophageal foreign body.

Question 30

What is the most common coronary anomaly in children?

Answer 30

Anomalous origin of the left coronary artery

Question 31

What are three (rare) causes of chronic cardiac chest pain?

Answer 31

Known cardiomyopathy, obstruction (AS), or coronary disease.

Question 32

Which cardiac problem should be considered in any child who presents with chest pain with exercise?

Answer 32

Left coronary artery arising from the right coronary sinus

Question 33

What is the most common acquired coronary artery disease in children?

Answer 33

Kawasaki disease

Question 34

In an otherwise well child, what is the likelihood that chest pain is cardiac in origin?

Answer 34

In an otherwise well child, it is very rare for chest pain to be cardiac in origin.