Chest pain in children and adolescents–understanding the differential diagnosis and evaluation

Question 1

What percentage of children complain of chest pain?

Answer 1

98%

Question 2

What is the prevalence of a cardiac origin in children who present with chest pain?

Answer 2

Less than 6%

Question 3

What is the differential diagnosis for child presenting with chest pain?

Answer 3

1. Musculoskeletal
2. Pulmonary
3. Gastrointestinal
4. Miscellaneous
5. Cardiac

Question 4

What are the signs and symptoms, physical findings and lab imaging findings for musculoskeletal chest pain?

Answer 4

Signs symptoms history: Reproducible chest pain on the rib cage
Physical exam: Point tenderness that can develop gradually or started suddenly
Imaging: Chest x-ray to look for bony lesions

Question 5

What are the signs and symptoms, physical findings and labs/imaging findings or evaluation for pulmonary origin of chest pain?

Answer 5

Signs symptoms: Increased work of breathing, increased cough, dyspnea, severe sudden chest pain
Physical findings: Wheezing, crackles, rhonchi, hypoxia
Chest x-ray or imaging: Lung pathology, collapsed lung or radiodensity

Question 6

What are the signs/symptoms, physical findings and lab/imaging findings or evaluation for gastrointestinal origin of chest pain?

Answer 6

Signs/symptoms: Chest pain associated with certain foods or medications, pain improves after taking in an acid
Physical exam: Pain in the right upper quadrant that can spread to the right shoulder blade or back, burning epigastric pain
Labs/imaging: H. pylori testing

Question 7

What are the signs/symptoms, physical findings and lab/imaging findings or evaluation for miscellaneous origin of chest pain?

Answer 7

Signs/symptoms: Chest pain associated with precipitating stressful events, recurrent somatic complaints, lightheadedness, and paresthesias
Physical exam: Chest pain associated with numbness, weakness, or vesicular rash
Labs/imaging: Tests cluster of vesicles for herpes and MRI of spine if chest pain associated with numbness or weakness

Question 8

What are the signs/symptoms, physical exam, lab/imaging findings or evaluation for any inflammatory cardiac origin of chest pain?

Answer 8

Signs/symptoms: Sharp chest pain, palpitations, and shortness of breath
Physical findings: This and for murmurs or arrhythmias
Labs/imaging: Chest x-ray, ECG, and echo

Question 9

What are the signs/symptoms, physical exam, lab/imaging findings or evaluation for a cardiac origin of chest pain involving increased myocardial demand or decreased supply?

Answer 9

Signs/symptoms: Family history of genetic or connective tissue disorder (Marfan syndrome) and palpitations
Physical exam heart murmur or arrhythmia
Labs/imaging: Chest x-ray, ECG, and echo

Question 10

What are the signs/symptoms, physical exam, labs/imaging findings were evaluation for a cardiac origin of chest pain due to coronary artery abnormalities?

Answer 10

Signs/symptoms: Chest pain with history of Kawasaki disease, COVID-19, coronary vasculopathy and heart transplant patient.
Labs/imaging chest x-ray, ECG, and echo

Question 11

What are the signs/symptoms, physical exam, lab/imaging findings or evaluation for a cardiac origin of chest pain due to miscellaneous cardiac causes?

Answer 11

Signs/symptoms: Sudden severe, sharp pain in chest or upper back
Physical exam: Heart murmur, low blood pressure, rapid weak pulse
Chest x-ray, EKG, and echo.

Question 12

What are the signs/symptoms, physical exam, lab and imaging findings for a cardiac origin of chest pain due to drugs?

Answer 12

Signs/symptoms: Chest pain with tobacco smokers, cocaine, and other sympathomimetic drugs
Physical exam: Vasoconstrictive activity of drugs lead to myocardial ischemia
Labs/imaging: Chest x-ray, EKG, and echo

Question 13

What are the 7 items in the musculoskeletal differential for noncardiac chest pain?

Answer 13

1. Costochondritis
2. Tietze syndrome
3. Slipped rib syndrome
4. Trauma/muscular strain/overuse injury
5. Xiphoid pain or xiphoidalgia
6. Sickle cell vaso-occlusive crisis
7. Nonspecific/idiopathic

Question 14

What are the 8 subcategories of pulmonary differential for chest pain?

Answer 14

1. Bronchial asthma
2. Exercise-induced/cough variant asthma
3. Bronchitis
4. Pleurisy
5. Pneumonia
6. Pneumothorax
7. Pulmonary embolism
8. Acute chest syndrome (a potential fatal complication of sickle cell disease and is accompanied by fever, respiratory symptoms, and new radiodensity on chest x-ray)

Question 15

What are the 5 subcategories for the gastrointestinal differential diagnosis of chest pain?

Answer 15

1. GERD
2. Esophageal spasm
3. Peptic ulcer disease
4. Drug-induced esophagitis/gastritis
5. Cholecystitis

Question 16

What are the 6 subcategories for miscellaneous differential diagnosis of chest pain?

Answer 16

1. Panic disorder
2. Hyperventilation
3. Breast related conditions
4. Herpes zoster
5. Psychogenic
6. Spinal cord/nerve root compression

Question 17

What are the 2 subcategories for an inflammatory cardiac origin of chest pain?

Answer 17

1. Pericarditis
2. Myocarditis

Question 18

What are the presenting signs and symptoms in someone with pericarditis?

Answer 18

May present with sharp chest pain, palpitations, and shortness of breath. This is due to inflammation of the heart lining.

Question 19

What are the most common associated diseases, viral infections, and bacterial infections that can cause pericarditis?

Answer 19

Diseases: Post pericardiotomy syndrome, SLE, Crohn’s, and other autoimmune diseases
Viruses: Coxsackie B, adenovirus, hepatitis C, CMV, echovirus, influenza, EBV, and parvovirus B19
Bacteria: Streptococcus, Staphylococcus, pneumococcus
Physical findings may reveal a friction rub with a patient leaning forward on exam

Question 20

What are the presenting signs and symptoms of the patient with chest pain and when and myocarditis?

Answer 20

Myocarditis is caused by inflammation of the heart muscle. May present with acute chest pain, shortness of breath, and arrhythmias.

Question 21

What are the infectious causes both viral and bacterial of myocarditis?

Answer 21

Viral causes: Coxsackie B, adenovirus, herpes see, CMV, echovirus, influenza, EBV, and Parvovirus B19
Bacterial: Staphylococcus, Streptococcus, diphtheria, and beryllia burgdorferi from Lyme disease

Question 22

What are the 3 subcategories for a patient with chest pain of and increased myocardial demand or decreased supply?

Answer 22

1. Cardiomyopathy
2. Left ventricular outflow tract (LVOT) obstruction
3. Arrhythmias

Question 23

What is the cause of a cardiomyopathy, and what are some important features in the history for patient who complains of chest pain from a cardiac origin?

Answer 23

May be dilated or hypertrophic, they may present with chest pain, and a family history of genetic or connective tissue disorders such as Marfan’s

Question 24

What are some of the echo features of left ventricular outflow tract obstruction or LVOT?

Answer 24

Look for aortic stenosis, subaortic stenosis, or supravalvular aortic stenosis on echocardiogram

Question 25

What are some of the physical findings for arrhythmia presenting his chest pain?

Answer 25

Decreased cardiac output, look for chest pain with palpitations

Question 26

For chest pain from a cardiac origin due to coronary artery abnormalities with COVID 2 subcategories in the differential?

Answer 26

1. Congenital coronary artery abnormalities 2. Acquired coronary artery abnormalities

Question 27

What are some of the common congenital coronary artery abnormalities found that may contribute to chest pain.

Answer 27

1. Anomalous left coronary artery from the pulmonary artery or a LCA PA 2. Anomalous left coronary artery from the right coronary sinus or ALCA 3. Coronary fistula

Question 28

What are the findings for coronary artery abnormalities of chest x-ray, echocardiogram, and cardiac catheterization?

Answer 28

Chest x-ray may show an enlarged heart Echocardiogram may provide more definitive diagnosis 3 cardiac catheterization will provide definitive diagnosis

Question 29

What are some of the causes of an acquired coronary artery abnormality?

Answer 29

Kawasaki disease Postsurgical situations Post transplant coronary vasculopathy

Question 30

What are the 6 subcategories for miscellaneous causes of cardiac origin of chest pain?

Answer 30

1. Aortic dissection 2. Rupture of aortic aneurysm 3. Pulmonary hypertension 4. Mitral valve prolapse 5. Atrial myxoma 6. Cardiac device/stent complications

Question 31

What are some of the presenting pain symptoms of a patient with aortic dissection?

Answer 31

Sudden, severe, sharp pain of the chest and upper back, diastolic heart murmur, low blood pressure, rapid weak pulse, heavy sweating, or loss of vision.

Question 32

What are some of the presenting signs and symptoms of the patient with rupture of the aortic aneurysm?

Answer 32

Look for deep, constant pain in the abdomen and back, positive pulse near the umbilicus, hypotension, or loss of consciousness.

Question 33

What are some of the presenting signs and symptoms of a patient with pulmonary hypertension?

Answer 33

Chest pain, fatigue, shortness of breath, syncope, lower extremity edema, or heart palpitations

Question 34

What are some of the signs and symptoms of the patient with mitral valve prolapse?

Answer 34

Palpitations, arrhythmia, or shortness of breath with a heart murmur and a systolic click.