Chest pain resident survival guide (pediatrics): Difference between revisions

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{{CMG}} {{AE}} {{Sara.Zand}}
{{CMG}} {{AE}} {{Sara.Zand}}
{{SK}}


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==Overview==
==Overview==
[[ Chest pain]] is the second [[cardiac]] symptom after [[cardiac murmur]] that is referred to a [[pediatric]] [[cardiologist]] for evaluation. the most common cause of [[chest pain]] in [[children]] is idiopathic without finding any specifice underlying problem and the second cause is [[musculoskeletal]]. Although there are high worries among parents about the [[cardiac]] origin of [[chest pain]] in [[children]], it consists in low percentage the causes of [[chest pain]]. Evaluation of [[chest pain]] includes assessments of the [[respiratory system]], [[gastrointestinal system]], [[cardiac]] diseases and [[psychologic]] factors.
[[ Chest pain]] is the second common [[cardiac]] [[symptom]] after [[cardiac murmur]] referred to a [[pediatric]] [[cardiologist]] for evaluation. The most common cause of [[chest pain]] in [[children]] is idiopathic without finding any specific underlying [[pathology]] and the second cause is [[musculoskeletal]]. Although there are high worries among parents about the [[cardiac]] origin of [[chest pain]], it consists in low percentage cause of [[pediatric]] [[chest pain]]. Evaluation of [[chest pain]] includes assessments of [[respiratory system]], [[gastrointestinal system]], [[cardiovascular]] system and [[psychologic]] factors.


==Causes==
==Causes==
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* [[Abdominal aorta]] dissection with propagation to [[thoracic aorta]]
* [[Abdominal aorta]] dissection with propagation to [[thoracic aorta]]
* Perforated [[peptic ulcer]]
* Perforated [[peptic ulcer]]
* Air leak syndrome such as [[Pneumothorax]], [[pneumomediastinum]]
* Air leak syndrome such as [[pneumothorax]], [[pneumomediastinum]]
 
===Common Causes===
===Common Causes===
<ref name="pmid23769502">{{cite journal |vauthors=Friedman KG, Alexander ME |title=Chest pain and syncope in children: a practical approach to the diagnosis of cardiac disease |journal=J Pediatr |volume=163 |issue=3 |pages=896–901.e1–3 |date=September 2013 |pmid=23769502 |pmc=3982288 |doi=10.1016/j.jpeds.2013.05.001 |url=}}</ref><ref name="pmid1697801">{{cite journal |vauthors=Aeschlimann A, Kahn MF |title=Tietze's syndrome: a critical review |journal=Clin Exp Rheumatol |volume=8 |issue=4 |pages=407–12 |date=1990 |pmid=1697801 |doi= |url=}}</ref><ref name="Heinz1977">{{cite journal|last1=Heinz|first1=George J.|title=Slipping Rib Syndrome|journal=JAMA|volume=237|issue=8|year=1977|pages=794|issn=0098-7484|doi=10.1001/jama.1977.03270350054023}}</ref><ref name="pmid4000782">{{cite journal |vauthors=Selbst SM |title=Chest pain in children |journal=Pediatrics |volume=75 |issue=6 |pages=1068–70 |date=June 1985 |pmid=4000782 |doi= |url=}}</ref><ref name="Howell1992">{{cite journal|last1=Howell|first1=John M.|title=Xiphodynia: A report of three cases|journal=The Journal of Emergency Medicine|volume=10|issue=4|year=1992|pages=435–438|issn=07364679|doi=10.1016/0736-4679(92)90272-U}}</ref><ref name="Pickering1981">{{cite journal|last1=Pickering|first1=D|title=Precordial catch syndrome.|journal=Archives of Disease in Childhood|volume=56|issue=5|year=1981|pages=401–403|issn=0003-9888|doi=10.1136/adc.56.5.401}}</ref><ref name="pmid1518687">{{cite journal |vauthors=Wiens L, Sabath R, Ewing L, Gowdamarajan R, Portnoy J, Scagliotti D |title=Chest pain in otherwise healthy children and adolescents is frequently caused by exercise-induced asthma |journal=Pediatrics |volume=90 |issue=3 |pages=350–3 |date=September 1992 |pmid=1518687 |doi= |url=}}</ref><ref name="EvangelistaParsons2000">{{cite journal|last1=Evangelista|first1=Juli-anne K.|last2=Parsons|first2=Marytheresa|last3=Renneburg|first3=Anne K.|title=Chest pain in children: diagnosis through history and physical examination|journal=Journal of Pediatric Health Care|volume=14|issue=1|year=2000|pages=3–8|issn=08915245|doi=10.1016/S0891-5245(00)70037-X}}</ref><ref name="BarthRoberts1986">{{cite journal|last1=Barth|first1=Charles W.|last2=Roberts|first2=William C.|title=Left main coronary artery originating from the right sinus of valsalva and coursing between the aorta and pulmonary trunk|journal=Journal of the American College of Cardiology|volume=7|issue=2|year=1986|pages=366–373|issn=07351097|doi=10.1016/S0735-1097(86)80507-1}}</ref><ref name="LipsitzMasia2005">{{cite journal|last1=Lipsitz|first1=Joshua D.|last2=Masia|first2=Carrie|last3=Apfel|first3=Howard|last4=Marans|first4=Zvi|last5=Gur|first5=Merav|last6=Dent|first6=Heather|last7=Fyer|first7=Abby J.|title=Noncardiac chest pain and psychopathology in children and adolescents|journal=Journal of Psychosomatic Research|volume=59|issue=3|year=2005|pages=185–188|issn=00223999|doi=10.1016/j.jpsychores.2005.05.004}}</ref><ref name="LeeGilleland2013">{{cite journal|last1=Lee|first1=Jennifer L.|last2=Gilleland|first2=Jordan|last3=Campbell|first3=Robert M.|last4=Simpson|first4=Patricia|last5=Johnson|first5=Gregory L.|last6=Dooley|first6=Kenneth J.|last7=Blount|first7=Ronald L.|title=Health care utilization and psychosocial factors in pediatric noncardiac chest pain.|journal=Health Psychology|volume=32|issue=3|year=2013|pages=320–327|issn=1930-7810|doi=10.1037/a0027806}}</ref><ref name="pmid2403723">{{cite journal |vauthors=Selbst SM |title=Chest pain in children |journal=Am Fam Physician |volume=41 |issue=1 |pages=179–86 |date=January 1990 |pmid=2403723 |doi= |url=}}</ref><ref>{{cite journal|doi=10.7759/2Fcureus.3690}}</ref><ref>{{cite journal|doi=10.2147/2FOAEM.S29942}}</ref><ref>{{cite journal|doi=10.1007/2Fs00383-011-2874-8}}</ref><ref name="pmid26692880">{{cite journal |vauthors=Chun JH, Kim TH, Han MY, Kim NY, Yoon KL |title=Analysis of clinical characteristics and causes of chest pain in children and adolescents |journal=Korean J Pediatr |volume=58 |issue=11 |pages=440–5 |date=November 2015 |pmid=26692880 |pmc=4675925 |doi=10.3345/kjp.2015.58.11.440 |url=}}</ref><ref>{{cite journal|doi=10.1161/2FCIRCULATIONAHA.113.006702}}</ref><ref name="Swap2005">{{cite journal|last1=Swap|first1=Clifford J.|title=Value and Limitations of Chest Pain History in the Evaluation of Patients With Suspected Acute Coronary Syndromes|journal=JAMA|volume=294|issue=20|year=2005|pages=2623|issn=0098-7484|doi=10.1001/jama.294.20.2623}}</ref>
Common Causes of Chest pain in children include:<ref name="pmid23769502">{{cite journal |vauthors=Friedman KG, Alexander ME |title=Chest pain and syncope in children: a practical approach to the diagnosis of cardiac disease |journal=J Pediatr |volume=163 |issue=3 |pages=896–901.e1–3 |date=September 2013 |pmid=23769502 |pmc=3982288 |doi=10.1016/j.jpeds.2013.05.001 |url=}}</ref><ref name="pmid1697801">{{cite journal |vauthors=Aeschlimann A, Kahn MF |title=Tietze's syndrome: a critical review |journal=Clin Exp Rheumatol |volume=8 |issue=4 |pages=407–12 |date=1990 |pmid=1697801 |doi= |url=}}</ref><ref name="Heinz1977">{{cite journal|last1=Heinz|first1=George J.|title=Slipping Rib Syndrome|journal=JAMA|volume=237|issue=8|year=1977|pages=794|issn=0098-7484|doi=10.1001/jama.1977.03270350054023}}</ref><ref name="pmid4000782">{{cite journal |vauthors=Selbst SM |title=Chest pain in children |journal=Pediatrics |volume=75 |issue=6 |pages=1068–70 |date=June 1985 |pmid=4000782 |doi= |url=}}</ref><ref name="Howell1992">{{cite journal|last1=Howell|first1=John M.|title=Xiphodynia: A report of three cases|journal=The Journal of Emergency Medicine|volume=10|issue=4|year=1992|pages=435–438|issn=07364679|doi=10.1016/0736-4679(92)90272-U}}</ref><ref name="Pickering1981">{{cite journal|last1=Pickering|first1=D|title=Precordial catch syndrome.|journal=Archives of Disease in Childhood|volume=56|issue=5|year=1981|pages=401–403|issn=0003-9888|doi=10.1136/adc.56.5.401}}</ref><ref name="pmid1518687">{{cite journal |vauthors=Wiens L, Sabath R, Ewing L, Gowdamarajan R, Portnoy J, Scagliotti D |title=Chest pain in otherwise healthy children and adolescents is frequently caused by exercise-induced asthma |journal=Pediatrics |volume=90 |issue=3 |pages=350–3 |date=September 1992 |pmid=1518687 |doi= |url=}}</ref><ref name="EvangelistaParsons2000">{{cite journal|last1=Evangelista|first1=Juli-anne K.|last2=Parsons|first2=Marytheresa|last3=Renneburg|first3=Anne K.|title=Chest pain in children: diagnosis through history and physical examination|journal=Journal of Pediatric Health Care|volume=14|issue=1|year=2000|pages=3–8|issn=08915245|doi=10.1016/S0891-5245(00)70037-X}}</ref><ref name="BarthRoberts1986">{{cite journal|last1=Barth|first1=Charles W.|last2=Roberts|first2=William C.|title=Left main coronary artery originating from the right sinus of valsalva and coursing between the aorta and pulmonary trunk|journal=Journal of the American College of Cardiology|volume=7|issue=2|year=1986|pages=366–373|issn=07351097|doi=10.1016/S0735-1097(86)80507-1}}</ref><ref name="LipsitzMasia2005">{{cite journal|last1=Lipsitz|first1=Joshua D.|last2=Masia|first2=Carrie|last3=Apfel|first3=Howard|last4=Marans|first4=Zvi|last5=Gur|first5=Merav|last6=Dent|first6=Heather|last7=Fyer|first7=Abby J.|title=Noncardiac chest pain and psychopathology in children and adolescents|journal=Journal of Psychosomatic Research|volume=59|issue=3|year=2005|pages=185–188|issn=00223999|doi=10.1016/j.jpsychores.2005.05.004}}</ref><ref name="LeeGilleland2013">{{cite journal|last1=Lee|first1=Jennifer L.|last2=Gilleland|first2=Jordan|last3=Campbell|first3=Robert M.|last4=Simpson|first4=Patricia|last5=Johnson|first5=Gregory L.|last6=Dooley|first6=Kenneth J.|last7=Blount|first7=Ronald L.|title=Health care utilization and psychosocial factors in pediatric noncardiac chest pain.|journal=Health Psychology|volume=32|issue=3|year=2013|pages=320–327|issn=1930-7810|doi=10.1037/a0027806}}</ref><ref name="pmid2403723">{{cite journal |vauthors=Selbst SM |title=Chest pain in children |journal=Am Fam Physician |volume=41 |issue=1 |pages=179–86 |date=January 1990 |pmid=2403723 |doi= |url=}}</ref><ref>{{cite journal|doi=10.7759/2Fcureus.3690}}</ref><ref>{{cite journal|doi=10.2147/2FOAEM.S29942}}</ref><ref>{{cite journal|doi=10.1007/2Fs00383-011-2874-8}}</ref><ref name="pmid26692880">{{cite journal |vauthors=Chun JH, Kim TH, Han MY, Kim NY, Yoon KL |title=Analysis of clinical characteristics and causes of chest pain in children and adolescents |journal=Korean J Pediatr |volume=58 |issue=11 |pages=440–5 |date=November 2015 |pmid=26692880 |pmc=4675925 |doi=10.3345/kjp.2015.58.11.440 |url=}}</ref><ref>{{cite journal|doi=10.1161/2FCIRCULATIONAHA.113.006702}}</ref><ref name="Swap2005">{{cite journal|last1=Swap|first1=Clifford J.|title=Value and Limitations of Chest Pain History in the Evaluation of Patients With Suspected Acute Coronary Syndromes|journal=JAMA|volume=294|issue=20|year=2005|pages=2623|issn=0098-7484|doi=10.1001/jama.294.20.2623}}</ref>
 
 
 
 
 
 
 
 
 
 
 
 
* [[Ideopathic]]
* [[Ideopathic]]
* [[Respiratory]]  
* [[Respiratory]]
* [[Musculoskeletal]]  
* [[Musculoskeletal]]
* [[Cardiac]]
* [[Cardiac]]
* [[Gastrointestinal]]
* [[Gastrointestinal]]
*[[Psychiatric]]
*[[Psychiatric]]  
{| class="wikitable"
{| class="wikitable"
|-
|-
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|-
|-
|- bgcolor="LightBlue"
|- bgcolor="LightBlue"
| ❑Ideopathic (73.6%)
| ❑ Ideopathic (73.6%)
| bgcolor="LightBlue" |
| bgcolor="LightBlue" |
❑ Normally otherwise<br>   
❑ Normally otherwise<br>   
|-
|-
|- bgcolor="LightBlue"
|- bgcolor="LightBlue"
|❑[[Respiratory]] (9.3%)
|❑ [[Respiratory]] (9.3%)
| bgcolor="LightBlue" |
| bgcolor="LightBlue" |
❑[[Asthma]]<br>
❑ [[Asthma]]<br>
❑[[Acute bronchitis]]<br>
❑ [[Acute bronchitis]]<br>
❑[[Pneumonia]]<br>
❑ [[Pneumonia]]<br>
❑[[Pneumomediastinum]]<br>
❑ [[Pneumomediastinum]]<br>
❑[[Pneumothorax]] <br>
❑ [[Pneumothorax]] <br>
|-
|-
|- bgcolor="LightBlue"
|- bgcolor="LightBlue"
|❑[[Musculoskeletal]] (8.8%)
|❑ [[Musculoskeletal]] (8.8%)
| bgcolor="LightBlue" |
| bgcolor="LightBlue" |
❑ [[Chest wall tenderness]]<br>
❑ [[Chest wall tenderness]]<br>
Line 84: Line 68:
|-
|-
|- bgcolor="LightBlue"
|- bgcolor="LightBlue"
|❑[[Cardiac]] (3.8%)
|❑ [[Cardiac]] (3.8%)
| bgcolor="LightBlue" |
| bgcolor="LightBlue" |
❑ [[ASD]]<br>
❑ [[ASD]]<br>
❑[[Pulmonary artery stenosis]]<br>
[[Pulmonary artery stenosis]]<br>
❑[[VSD]]<br>
❑ [[VSD]]<br>
❑[[Aortic arch anomaly]]<br>
❑ [[Aortic arch anomaly]]<br>
❑ Large [[PDA]] with [[eisenmenger]]<br>
❑ Large [[PDA]] with [[eisenmenger]]<br>
❑[[Arrhythmia]]<br>
❑ [[Arrhythmia]]<br>
|-
|-
|-
|-
|- bgcolor="LightBlue"
|- bgcolor="LightBlue"
|❑[[Gastrointestinal]] (2.9%)
|❑ [[Gastrointestinal]] (2.9%)
| bgcolor="LightBlue" |
| bgcolor="LightBlue" |
❑[[Gastritis]]<br>
❑ [[Gastritis]]<br>
❑[[GERD]]<br>
❑ [[GERD]]<br>
❑Acute [[gastroenteritis]]<br>
❑ Acute [[gastroenteritis]]<br>
❑[[Dyspepsia]]<br>
❑ [[Dyspepsia]]<br>
|- bgcolor="LightBlue"
|- bgcolor="LightBlue"
|❑[[Psychiatric]] (1.4%)
|❑ [[Psychiatric]] (1.4%)
| bgcolor="LightBlue" |
| bgcolor="LightBlue" |
❑ [[Anxiety disorder]]<br>
❑ [[Anxiety disorder]]<br>
❑[[Panic disorder]]<br>
❑ [[Panic disorder]]<br>
|-
|-
|}
|}
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# [[Serratus muscle]]<br>
# [[Serratus muscle]]<br>
#[[Trapezius muscle]]<br>
#[[Trapezius muscle]]<br>
❑[[Thoracic outlet obstruction]]<br>
❑ [[Thoracic outlet obstruction]]<br>
❑[[Ankylosis spondylitis]]<br>
❑ [[Ankylosis spondylitis]]<br>
❑[[Spondylolisthesis]]<br>
❑ [[Spondylolisthesis]]<br>
❑[[Discitis]]<br>
❑ [[Discitis]]<br>
❑[[Herniated disc]]<br>
❑ [[Herniated disc]]<br>
❑[[Transverse myelitis]]<br>
❑ [[Transverse myelitis]]<br>
❑[[Costochondritis]]<br>
❑ [[Costochondritis]]<br>
❑[[Tietze syndrome]]<br>
❑ [[Tietze syndrome]]<br>
❑[[Cervical rib]] (C7)<br>
❑ [[Cervical rib]] (C7)<br>
❑[[Slipping rib]]<br>
❑ [[Slipping rib]]<br>
❑[[Precordial catch syndrome]]<br>
❑ [[Precordial catch syndrome]]<br>
❑[[Trauma]]<br>
❑ [[Trauma]]<br>
❑[[Child abuse]]<br>
❑ [[Child abuse]]<br>
❑Fractured or contused [[clavicle]] or [[ribs]]<br>
❑ Fractured or contused [[clavicle]] or [[ribs]]<br>
❑[[Xiphoidalgia]]<br>
❑ [[Xiphoidalgia]]<br>
❑[[Osteomyelitis]]<br>
❑ [[Osteomyelitis]]<br>
❑[[Rhabdomyosarcoma]]<br>
❑ [[Rhabdomyosarcoma]]<br>
❑[[Myositis]]<br>
❑ [[Myositis]]<br>
|D03=<div style="float: left; text-align: left; width: 12em; padding:1em;"> '''[[Pulmonary]]:'''<br>
|D03=<div style="float: left; text-align: left; width: 12em; padding:1em;"> '''[[Pulmonary]]:'''<br>
❑[[Reactive airway disease]]<br>
❑ [[Reactive airway disease]]<br>
❑[[Pneumothorax]]<br>
❑ [[Pneumothorax]]<br>
❑[[Pneumonia]] ([[viral]], [[bacterial]], [[mycobacterial]], [[fungal]])<br>
❑ [[Pneumonia]] ([[viral]], [[bacterial]], [[mycobacterial]], [[fungal]])<br>
❑Chronic [[cough]]<br>
❑ Chronic [[cough]]<br>
❑[[Pleural effusion]]<br>
❑ [[Pleural effusion]]<br>
❑[[Pleurodynia]]<br>
❑ [[Pleurodynia]]<br>
❑[[Pulmonary embolism]]<br>
❑ [[Pulmonary embolism]]<br>
❑[[Foriegn body aspiration]]<br>  
❑ [[Foriegn body aspiration]]<br>  
❑[[Adenoma]], [[carcinoma]]<br>|D05=<div style="float: left; text-align: left; width: 12em; padding:1em;"> '''[[Gastrointestinal]]:'''<br>
❑ [[Adenoma]], [[carcinoma]]<br>|D05=<div style="float: left; text-align: left; width: 12em; padding:1em;"> '''[[Gastrointestinal]]:'''<br>
❑[[Esophagitis]]<br>
❑ [[Esophagitis]]<br>
❑[[Esophagial diverticulum]]<br>
❑ [[Esophagial diverticulum]]<br>
❑[[Esophagial spasm]]<br>
❑ [[Esophagial spasm]]<br>
❑[[Esophageal rupture]] ([[boerhaave syndrome]]<br>
❑ [[Esophageal rupture]] ([[boerhaave syndrome]]<br>
❑[[Mallory weiss tear]]<br>
❑ [[Mallory weiss tear]]<br>
❑[[Achalasia]]<br>
❑ [[Achalasia]]<br>
❑[[Gastrointestinal reflex disease]] ([[GERD]]) <br>
❑ [[Gastrointestinal reflex disease]] ([[GERD]]) <br>
❑[[Gastritis]]<br>
❑ [[Gastritis]]<br>
❑[[Peptic ulcer disease]]<br>
❑ [[Peptic ulcer disease]]<br>
❑[[Zollinger ellison syndrome]]<br>
❑ [[Zollinger ellison syndrome]]<br>
❑[[Hiatal hernia]]<br>
❑ [[Hiatal hernia]]<br>
❑[[Foreign body ingestion]]<br>
❑ [[Foreign body ingestion]]<br>
❑[[Cholecystitis]]<br>
❑ [[Cholecystitis]]<br>
❑[[Subdiaphragmatic abcess]]<br>
❑ [[Subdiaphragmatic abcess]]<br>
❑[[Fitz-hugh-curtis syndrome]]<br>
❑ [[Fitz-hugh-curtis syndrome]]<br>
❑[[Pancreatis]]<br>
❑ [[Pancreatis]]<br>
|C03=<div style="float: left; text-align: left; width: 12em; padding:1em;"> '''[[Mediastinal tumors]]:'''
|C03=<div style="float: left; text-align: left; width: 12em; padding:1em;"> '''[[Mediastinal tumors]]:'''
❑[[Hodgkin disease]]<br>
❑ [[Hodgkin disease]]<br>
❑T-cell [[lymphoma]]<br>
❑ T-cell [[lymphoma]]<br>
❑[[Thymoma]]<br>
❑ [[Thymoma]]<br>
❑[[Thymolipoma]]<br>
❑ [[Thymolipoma]]<br>
❑[[Teratoma]]<br>
❑ [[Teratoma]]<br>
❑[[Germ cell tumor]]<br>
❑ [[Germ cell tumor]]<br>
❑[[Liposarcoma]]<br>|C04=<div style="float: left; text-align: left; width: 12em; padding:1em;"> '''[[Breast disease]]:'''
❑ [[Liposarcoma]]<br>|C04=<div style="float: left; text-align: left; width: 12em; padding:1em;"> '''[[Breast disease]]:'''
❑[[Gynecomastia]]<br>
❑ [[Gynecomastia]]<br>
❑[[Thelarce]]<br>
❑ [[Thelarce]]<br>
❑[[Mastitis]]<br>
❑ [[Mastitis]]<br>
❑[[Adenocarcinoma]]<br>|C05=<div style="float: left; text-align: left; width: 12em; padding:1em;"> '''[[Ingestion]]:'''
❑ [[Adenocarcinoma]]<br>|C05=<div style="float: left; text-align: left; width: 12em; padding:1em;"> '''[[Ingestion]]:'''
❑[[Cocaine]]<br>
❑ [[Cocaine]]<br>
❑[[Tobaco]]<br>
❑ [[Tobaco]]<br>
❑[[Methamphetamine]]<br>
❑ [[Methamphetamine]]<br>
❑[[Sympathomimetic decongestants]]<br>|C06=<div style="float: left; text-align: left; width: 12em; padding:1em;"> '''Miscellaneous:'''
❑ [[Sympathomimetic decongestants]]<br>|C06=<div style="float: left; text-align: left; width: 12em; padding:1em;"> '''Miscellaneous:'''
❑[[Diabetes mellitus]]<br>
❑ [[Diabetes mellitus]]<br>
❑[[Hyperthyroidism]]<br>
❑ [[Hyperthyroidism]]<br>
❑[[Cystic fibrosis]]<br>
❑ [[Cystic fibrosis]]<br>
❑[[Neurofibromatosis]]<br>
❑ [[Neurofibromatosis]]<br>
❑[[Marfan syndrome]]<br>
❑ [[Marfan syndrome]]<br>
❑[[Ehler-Danlos syndrome]]<br>
❑ [[Ehler-Danlos syndrome]]<br>
❑[[Homocysteinuria]]<br>
❑ [[Homocysteinuria]]<br>
❑[[Sickle-cell disease]] with [[vasoocclusive crisis]]<br>
❑ [[Sickle-cell disease]] with [[vasoocclusive crisis]]<br>
❑[[Shingles]]<br>
❑ [[Shingles]]<br>
❑[[Echinococcous]]<br>
❑ [[Echinococcous]]<br>
❑[[Mediterranean fever]]<br>
❑ [[Mediterranean fever]]<br>
❑[[Spinal cord meningioma]]<br>
❑ [[Spinal cord meningioma]]<br>
❑[[Spinal cord]] compression<br>
❑ [[Spinal cord]] compression<br>
❑[[Hypercoagulation syndrome]]<br>|C06=<div style="float: left; text-align: left; width: 12em; padding:1em;"> '''[[Psychiatric]]:'''
❑ [[Hypercoagulation syndrome]]<br>|C06=<div style="float: left; text-align: left; width: 12em; padding:1em;"> '''[[Psychiatric]]:'''
❑[[Somatoform]] disorder<br>
❑ [[Somatoform]] disorder<br>
❑[[Stress]]<br>
❑ [[Stress]]<br>
❑[[Depression]]<br>
❑ [[Depression]]<br>
❑[[Hyperventillation syndrome]]<br>
❑ [[Hyperventillation syndrome]]<br>
❑[[Panic attack]]<br>
❑ [[Panic attack]]<br>
❑[[Bulemia]] nervosa<br>
❑ [[Bulemia]] nervosa<br>
❑[[Manchhausen syndrome]]<br>|}}
❑ [[Manchhausen syndrome]]<br>|}}
{{familytree| | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |}}
{{familytree| | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |}}
{{familytree| |,|-|-|+|-|-|-|.| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree| |,|-|-|+|-|-|-|.| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}
Line 217: Line 201:
❑ Severe [[pulmonary stenosis]]<br>
❑ Severe [[pulmonary stenosis]]<br>
❑ [[Arrhythmogenic right ventricular dysplasia]]<br>|E02=<div style="float: left; text-align: left; width: 12em; padding:1em;"> '''Acquired lesions:'''
❑ [[Arrhythmogenic right ventricular dysplasia]]<br>|E02=<div style="float: left; text-align: left; width: 12em; padding:1em;"> '''Acquired lesions:'''
❑[[Dilated cardiomyopathy]]<br>
❑ [[Dilated cardiomyopathy]]<br>
❑[[Hypertrophic cardiomyopathy]]<br>
❑ [[Hypertrophic cardiomyopathy]]<br>
❑[[Restrictive cardiomyopathy]]<br>
❑ [[Restrictive cardiomyopathy]]<br>
❑[[Endocarditis]]<br>
❑ [[Endocarditis]]<br>
❑[[Kawasaki]]<br>
❑ [[Kawasaki]]<br>
❑[[Myocarditis]]<br>
❑ [[Myocarditis]]<br>
❑[[Rheumatic fever]]<br>
❑ [[Rheumatic fever]]<br>
❑[[Myocardial infarction]]<br>
❑ [[Myocardial infarction]]<br>
❑[[Coronary vasospasm]]<br>
❑ [[Coronary vasospasm]]<br>
❑[[Accelerated atherosclerosis]]<br>
❑ [[Accelerated atherosclerosis]]<br>
❑[[Dissection of aorta aneurysm]] ([[marfan disease]])<br>
❑ [[Dissection of aorta aneurysm]] ([[marfan disease]])<br>
❑[[Pericarditis]] ( [[infection]], [[inflammation]], [[constriction]])<br>
❑ [[Pericarditis]] ( [[infection]], [[inflammation]], [[constriction]])<br>
❑[[Post pericardiothomy syndrome]]<br>
❑ [[Post pericardiothomy syndrome]]<br>
❑Partial absent of the [[pericardium]]<br>
❑ Partial absent of the [[pericardium]]<br>
❑[[Pulmonary hypertension]] (primary, secondary]]<br>
❑ [[Pulmonary hypertension]] (primary, secondary]]<br>
❑[[Eisemenger syndrome]]<br>
❑ [[Eisemenger syndrome]]<br>
❑[[Takayaso arthritis]]<br>
❑ [[Takayaso arthritis]]<br>
❑[[Cardiac tumor]]<br>
❑ [[Cardiac tumor]]<br>
❑[[Pericardial neoplasm]]<br>
❑ [[Pericardial neoplasm]]<br>
❑[[Cardiac transplant]] (rejection, accelerated [[atherosclerosis]])<br>|E03=<div style="float: left; text-align: left; width: 12em; padding:1em;"> '''[[Arrhythmia]]:'''
❑ [[Cardiac transplant]] (rejection, accelerated [[atherosclerosis]])<br>|E03=<div style="float: left; text-align: left; width: 12em; padding:1em;"> '''[[Arrhythmia]]:'''
❑[[Premature atrial contraction]]<br>
❑ [[Premature atrial contraction]]<br>
❑[[Atrial flutter]]<br>
❑ [[Atrial flutter]]<br>
❑[[Atrial fibrillation]]<br>
❑ [[Atrial fibrillation]]<br>
❑[[Supraventricular tachycardia]]<br>
❑ [[Supraventricular tachycardia]]<br>
❑[[Premature ventricular contraction]]<br>
❑ [[Premature ventricular contraction]]<br>
❑[[Ventricular tachycardia]]<br>
❑ [[Ventricular tachycardia]]<br>
}}
}}
{{familytree/end}}
{{familytree/end}}
Line 248: Line 232:
==FIRE: Focused Initial Rapid Evaluation==
==FIRE: Focused Initial Rapid Evaluation==
A Focused Initial Rapid Evaluation (FIRE) should be performed to identify patients in need of immediate intervention.<ref>{{cite journal|doi=10.3345/2Fkjp.2015.58.11.440}}</ref><ref name="CavaSayger2004">{{cite journal|last1=Cava|first1=Joseph R.|last2=Sayger|first2=Pamela L.|title=Chest pain in children and adolescents|journal=Pediatric Clinics of North America|volume=51|issue=6|year=2004|pages=1553–1568|issn=00313955|doi=10.1016/j.pcl.2004.07.002}}</ref><ref name="pmid15518121">{{cite journal |vauthors=Lawrence PR, Delaney AE |title=Chest pain in children and adolescents: most causes are benign |journal=Adv Nurse Pract |volume=12 |issue=10 |pages=61–2, 64, 66 passim |date=October 2004 |pmid=15518121 |doi= |url=}}</ref><ref name="LiesemerCasper2012">{{cite journal|last1=Liesemer|first1=Kirk|last2=Casper|first2=T. Charles|last3=Korgenski|first3=Kent|last4=Menon|first4=Shaji C.|title=Use and Misuse of Serum Troponin Assays in Pediatric Practice|journal=The American Journal of Cardiology|volume=110|issue=2|year=2012|pages=284–289|issn=00029149|doi=10.1016/j.amjcard.2012.03.020}}</ref>
A Focused Initial Rapid Evaluation (FIRE) should be performed to identify patients in need of immediate intervention.<ref>{{cite journal|doi=10.3345/2Fkjp.2015.58.11.440}}</ref><ref name="CavaSayger2004">{{cite journal|last1=Cava|first1=Joseph R.|last2=Sayger|first2=Pamela L.|title=Chest pain in children and adolescents|journal=Pediatric Clinics of North America|volume=51|issue=6|year=2004|pages=1553–1568|issn=00313955|doi=10.1016/j.pcl.2004.07.002}}</ref><ref name="pmid15518121">{{cite journal |vauthors=Lawrence PR, Delaney AE |title=Chest pain in children and adolescents: most causes are benign |journal=Adv Nurse Pract |volume=12 |issue=10 |pages=61–2, 64, 66 passim |date=October 2004 |pmid=15518121 |doi= |url=}}</ref><ref name="LiesemerCasper2012">{{cite journal|last1=Liesemer|first1=Kirk|last2=Casper|first2=T. Charles|last3=Korgenski|first3=Kent|last4=Menon|first4=Shaji C.|title=Use and Misuse of Serum Troponin Assays in Pediatric Practice|journal=The American Journal of Cardiology|volume=110|issue=2|year=2012|pages=284–289|issn=00029149|doi=10.1016/j.amjcard.2012.03.020}}</ref>
{{familytree/start |summary=Sample 8}}{{familytree/start |summary=PE diagnosis Algorithm.}}
{{familytree/start |summary=Sample 8}}{{familytree/start |summary=PE diagnosis Algorithm.}}
{{familytree/start}}
{{familytree/start}}
Line 257: Line 238:
{{familytree | | | | | | C01 |-|-|-|-|-| C02 |-|-|-|-|-| C03 | | | |C01=''[[Ideopathic]]'', No evidence of any organic etiology or any [[psychologic]] factors|C02='''Characteristics of [[chest pain]]'''|C03=Squeezing, sharp, dull, duration of [[chest pain]]}}
{{familytree | | | | | | C01 |-|-|-|-|-| C02 |-|-|-|-|-| C03 | | | |C01=''[[Ideopathic]]'', No evidence of any organic etiology or any [[psychologic]] factors|C02='''Characteristics of [[chest pain]]'''|C03=Squeezing, sharp, dull, duration of [[chest pain]]}}
{{familytree | | | | | | | | | | D01 |-|'|!|`|-| D02 | | | | | | | |D01= ''[[Musculoskeletal]] origin'', [[chest wall tenderness]],[[Pain]] aggravated with [[inspiration]],[[Muscle pain]] with movement,[[Tenderness]] on [[palpation]] of [[costochondral junction]]|D02=''[[Respiratory]] related'',[[Chest pain]] secondary to acute onset of [[cough]],[[wheezing]], [[asthma]]}}
{{familytree | | | | | | | | | | D01 |-|'|!|`|-| D02 | | | | | | | |D01= ''[[Musculoskeletal]] origin'', [[chest wall tenderness]],[[Pain]] aggravated with [[inspiration]],[[Muscle pain]] with movement,[[Tenderness]] on [[palpation]] of [[costochondral junction]]|D02=''[[Respiratory]] related'',[[Chest pain]] secondary to acute onset of [[cough]],[[wheezing]], [[asthma]]}}
{{familytree | | | | | | | | | | | | | | B01 | | | | | | | | | |B01=<div style="float: left; text-align: left; height: 40em; width: 17em; padding:1em;"> '''Symptoms associated with [[Chest pain]] in [[children]] and [[adolescence]]:'''<br>❑ [[Cough]] (23.4%) <br> ❑ [[Dyspnea]] (11%) <br> ❑ [[Abdominal pain]] (9.7%)  <br> ❑ [[Palpitation]] (9.7%)  <br> ❑ [[Respiratory related]] (9%) <br> ❑ [[Dizziness]] (5.8%)<br>❑ [[Post nasal drip]] (4.4%) <br>❑ [[Fever]] (5.2%) <br> ❑ [[Exercise induced]] (2.6%)  <br>❑ [[Syncope]] (2.6%) <br>'''Physical examination '''<br>❑[[Tachypnea]]<br>❑[[Tachycardia]]<br>❑[[Rale]]<br> ❑[[Wheeze]]<br>❑[[Gallop rhythm]]<br>❑[[Hematemesis]]<br>❑ [[Hemoptysia]]<br>❑[[Melena]]<br> </div>}}
{{familytree | | | | | | | | | | | | | | B01 | | | | | | | | | |B01=<div style="float: left; text-align: left; height: 40em; width: 17em; padding:1em;"> '''Symptoms associated with [[Chest pain]] in [[children]] and [[adolescence]]:'''<br>❑ [[Cough]] (23.4%) <br> ❑ [[Dyspnea]] (11%) <br> ❑ [[Abdominal pain]] (9.7%)  <br> ❑ [[Palpitation]] (9.7%)  <br> ❑ [[Respiratory related]] (9%) <br> ❑ [[Dizziness]] (5.8%)<br>❑ [[Post nasal drip]] (4.4%) <br>❑ [[Fever]] (5.2%) <br> ❑ [[Exercise induced]] (2.6%)  <br>❑ [[Syncope]] (2.6%) <br>'''Physical examination '''<br>❑ [[Tachypnea]]<br>❑ [[Tachycardia]]<br>❑ [[Rale]]<br> ❑ [[Wheeze]]<br>❑ [[Gallop rhythm]]<br>❑ [[Hematemesis]]<br>❑ [[Hemoptysis]]<br>❑ [[Melena]]<br> </div>}}
{{familytree | | | | | | | | | | | | | | |!| | | | | | | | | | | | |}}
{{familytree | | | | | | | | | | | | | | |!| | | | | | | | | | | | |}}
{{familytree | | | | | | | | | | | | | | F01 | | | | | | | | | | | |F01=<div style="float: left; text-align: left; height: 30em; width: 17em; padding:1em;"> '''Is there any red flag about [[cardiac]] etiology?:'''<br>
{{familytree | | | | | | | | | | | | | | F01 | | | | | | | | | | | |F01=<div style="float: left; text-align: left; height: 30em; width: 17em; padding:1em;"> '''Is there any red flag about [[cardiac]] etiology?:'''<br>
----
----
❑ History of acquired or [[congenital cardiac disease]] <br> ❑ Exertional [[syncope]] <br> ❑ Exertional [[chest pain]]  <br> ❑ [[Hypercoagulable]] state  <br> ❑ [[Hypercholesterolemia]] state ❑ [[Family history]] of [[sudden death]] under 35 years of age<br> ❑[[Family history]] of premature [[coronary artery disease]]<br>❑[[Inheritted arrhythmia]] in the first relative <br>❑[[ICD]] implantation <br>❑ [[Connective tissue disease]]<br>❑ Using [[cocaine]], [[amphetamine]]<br> </div>}}
❑ History of acquired or [[congenital cardiac disease]] <br> ❑ Exertional [[syncope]] <br> ❑ Exertional [[chest pain]]  <br> ❑ [[Hypercoagulable]] state  <br> ❑ [[Hypercholesterolemia]] state<br> ❑ [[Family history]] of [[sudden death]] under 35 years of age<br> ❑ [[Family history]] of premature [[coronary artery disease]]<br>❑ [[Inheritted arrhythmia]] in the first relative <br>❑ [[ICD]] implantation <br>❑ [[Connective tissue disease]]<br>❑ Using [[cocaine]], [[amphetamine]]<br> </div>}}
{{familytree| | | | | | | | | | | | | | |!| | | | | |}}
{{familytree| | | | | | | | | | | | | | |!| | | | | |}}
{{familytree  | | | | | | | | | | | | |  G01| | | | | G01=<div style="float: left; text-align: left; height: 30em; width: 17em; padding:1em;"> '''Laboratory investigation in suspicion of [[cardiac ]] etiology:'''<br>
{{familytree  | | | | | | | | | | | | |  G01| | | | | G01=<div style="float: left; text-align: left; height: 30em; width: 17em; padding:1em;"> '''Laboratory investigation in suspicion of [[cardiac ]] etiology:'''<br>
----
----
❑ [[EKG]] <br> ❑ [[CXR]]<br> ❑ [[Echocardiography]] <br> ❑ [[Holter monitoring]]  <br>
❑ [[EKG]] <br> ❑ [[CXR]]<br> ❑ [[Echocardiography]] <br> ❑ [[Holter monitoring]]  <br>
❑  [[Exercise stress test]]<br> ❑ [[Dobutamin stress test]] <br> ❑ [[Thalium scan]] <br> ❑ [[Serum creatine kinase with MB fraction]]<br> ❑ [[Serum troponin I]]<br> ❑[[Lipid ]]profile<br>❑[[Pericardiocenthesis]]<br>❑[[Endomyocardial biopsy]]<br>❑ [[Catheterization]]<br> </div>}}
❑  [[Exercise stress test]]<br> ❑ [[Dobutamin stress test]] <br> ❑ [[Thalium scan]] <br> ❑ [[Serum creatine kinase with MB fraction]]<br> ❑ [[Serum troponin I]]<br> ❑ [[Lipid ]]profile<br>❑ [[Pericardiocenthesis]]<br>❑ [[Endomyocardial biopsy]]<br>❑ [[Catheterization]]<br> </div>}}
{{familytree | | | | | |,|-|-|-|v|-|-|-|+|-|-|-|.| | | | | }}
{{familytree | | | | | |,|-|-|-|v|-|-|-|+|-|-|-|.| | | | | }}
{{familytree | | | | | K01 | | K02 | | K03 | | K04 | | |K01=<div style="float: left; text-align: left; height: 30em; width: 17em; padding:1em;"> '''Laboratory investigation in suspicion of [[pulmonary ]] etiology:'''<br>
{{familytree | | | | | K01 | | K02 | | K03 | | K04 | | |K01=<div style="float: left; text-align: left; height: 30em; width: 17em; padding:1em;"> '''Laboratory investigation in suspicion of [[pulmonary ]] etiology:'''<br>
----
----
❑[[CXR]]<br>❑[[Chest CT scan]]<br>❑[[Magnetic resonance imaging]] of the [[chest]]<br>❑[[Pulmonary function test]] <br>❑[[Bronchoscopy]]<br>❑[[Ventilation perfusion scan]]<br>❑[[Sweat test]]<br></div>|}}
❑ [[CXR]]<br>❑ [[Chest CT scan]]<br>❑ [[Magnetic resonance imaging]] of the [[chest]]<br>❑ [[Pulmonary function test]] <br>❑ [[Bronchoscopy]]<br>❑ [[Ventilation perfusion scan]]<br>❑ [[Sweat test]]<br></div>|
K02=<div style="float: left; text-align: left; height: 30em; width: 17em; padding:1em;"> '''Laboratory investigation in suspicion of [[gastrointestinal ]] etiology:'''<br>
K02=<div style="float: left; text-align: left; height: 30em; width: 17em; padding:1em;"> '''Laboratory investigation in suspicion of [[gastrointestinal ]] etiology:'''<br>
----
----
❑ [[Gastric lavage]]<br> ❑[[PH]] probe<br>❑[[Upper GI series]]<br>❑[[Upper endoscopy]]<br>❑[[Abdominal sonography]]<br>❑[[Liver function test]]<br>❑[[Lipase]], [[amylase]]<br>❑[[Serum]] [[gastrin]] level<br>❑[[Stool]] [[guaic]] testing<br></div>|}}
❑ [[Gastric lavage]]<br> ❑ [[PH]] probe<br>❑ [[Upper GI series]]<br>❑ [[Upper endoscopy]]<br>❑ [[Abdominal sonography]]<br>❑ [[Liver function test]]<br>❑ [[Lipase]], [[amylase]]<br>❑ [[Serum]] [[gastrin]] level<br>❑ [[Stool]] [[guaic]] testing<br></div>|
K03=<div style="float: left; text-align: left; height: 30em; width: 17em; padding:1em;"> '''Laboratory investigation in suspicion of [[musculoskeletal ]] etiology:'''<br>
K03=<div style="float: left; text-align: left; height: 30em; width: 17em; padding:1em;"> '''Laboratory investigation in suspicion of [[musculoskeletal ]] etiology:'''<br>
----
----
❑[[Skeletal radiography]]<br>❑[[Spine]] [[ CT scan]]<br>❑ Spine [[MRI]]<br>❑[[Nuclear bone scan]]<br>❑[[Creatine kinase]] with MM fraction<br></div>|}}
❑ [[Skeletal radiography]]<br>❑ [[Spine]] [[ CT scan]]<br>❑ Spine [[MRI]]<br>❑ [[Nuclear bone scan]]<br>❑ [[Creatine kinase]] with MM fraction<br></div>|
K04=<div style="float: left; text-align: left; height: 30em; width: 17em; padding:1em;"> '''Laboratory investigation for other etiology:'''<br>
K04=<div style="float: left; text-align: left; height: 30em; width: 17em; padding:1em;"> '''Laboratory investigation for other etiology:'''<br>
----
----
❑ [[Viral]], [[bacterial]] antibody level<br>❑[[Psychologic testing]]<br>❑[[Culture]] of [[blood]], [[pericardial fluid]], [[sputum]]<br>❑[[Urine]], [[serum]] toxicology<br>❑[[Serum compelement level]]<br>❑Glycosylated [[Hb A1C]]<br>❑[[Hemoglobin electrophoresis]]<br>❑[[Cell blood count]]<br>❑[[Coagulation ]]study<br>❑[[ESR]]<br>❑[[Mamography]]<br>❑ [[Breast sonography]]<br>❑[[Breast biopsy]]<br>❑[[Thyroid function test]]<br></div>|}}
❑ [[Viral]], [[bacterial]] antibody level<br>❑ [[Psychologic testing]]<br>❑ [[Culture]] of [[blood]], [[pericardial fluid]], [[sputum]]<br>❑ [[Urine]], [[serum]] toxicology<br>❑ [[Serum compelement level]]<br>❑ Glycosylated [[Hb A1C]]<br>❑ [[Hemoglobin electrophoresis]]<br>❑ [[Cell blood count]]<br>❑ [[Coagulation ]]study<br>❑ [[ESR]]<br>❑ [[Mamography]]<br>❑ [[Breast sonography]]<br>❑ [[Breast biopsy]]<br>❑ [[Thyroid function test]]<br></div>}}
{{familytree | | | | | | | | | | | | | | | | | | | | | | |}}
{{familytree | | | | | | | | | | | | | | | | | | | | | | |}}
{{familytree/end}}
{{familytree/end}}


==Complete Diagnostic Approach==
==Complete Diagnostic Approach==
Shown below is an algorithm summarizing the diagnosis of pediatric [[chest pain]] according the the [...] guidelines.<ref name="pmid23769502">{{cite journal |vauthors=Friedman KG, Alexander ME |title=Chest pain and syncope in children: a practical approach to the diagnosis of cardiac disease |journal=J Pediatr |volume=163 |issue=3 |pages=896–901.e1–3 |date=September 2013 |pmid=23769502 |pmc=3982288 |doi=10.1016/j.jpeds.2013.05.001 |url=}}</ref><ref>{{cite journal|doi=10.3345/2Fkjp.2015.58.11.440}}</ref><ref name="IvesDaubeney2010">{{cite journal|last1=Ives|first1=A.|last2=Daubeney|first2=P. E. F.|last3=Balfour-Lynn|first3=I. M.|title=Recurrent chest pain in the well child|journal=Archives of Disease in Childhood|volume=95|issue=8|year=2010|pages=649–654|issn=0003-9888|doi=10.1136/adc.2008.155309}}</ref>
Shown below is an algorithm summarizing the diagnosis of pediatric [[chest pain]].<ref name="pmid23769502">{{cite journal |vauthors=Friedman KG, Alexander ME |title=Chest pain and syncope in children: a practical approach to the diagnosis of cardiac disease |journal=J Pediatr |volume=163 |issue=3 |pages=896–901.e1–3 |date=September 2013 |pmid=23769502 |pmc=3982288 |doi=10.1016/j.jpeds.2013.05.001 |url=}}</ref><ref>{{cite journal|doi=10.3345/2Fkjp.2015.58.11.440}}</ref><ref name="IvesDaubeney2010">{{cite journal|last1=Ives|first1=A.|last2=Daubeney|first2=P. E. F.|last3=Balfour-Lynn|first3=I. M.|title=Recurrent chest pain in the well child|journal=Archives of Disease in Childhood|volume=95|issue=8|year=2010|pages=649–654|issn=0003-9888|doi=10.1136/adc.2008.155309}}</ref>
 
 
{{familytree/start |summary=PE diagnosis Algorithm.}}
{{familytree/start |summary=PE diagnosis Algorithm.}}
{{familytree | | | | | | | | | |,|-| A01 |-| A02 | | | |A01=[[Cardiac]] |A02=Underlying congenital or acquired [[heart]] disease, [[arrhythmia]], [[crushing]] [[chest pain]], exercised induced [[chest pain]], [[persistent tachycardia]], [[hypotension]], [[gallop rhythm]], [[syncope]], [[pericardial rub]]|}}
{{familytree | | | | | | | | | |,|-| A01 |-| A02 | | | |A01=[[Cardiac]] |A02= Presence of underlying congenital or acquired [[heart]] disease, [[arrhythmia]], [[crushing]] [[chest pain]], exercised induced [[chest pain]], [[persistent tachycardia]], [[hypotension]], [[gallop rhythm]], [[syncope]], [[pericardial rub]]|}}
{{familytree | | | | | | | | | |!| | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | | | |!| | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | | | |)|-| B01 |-| B02 | | | |B01=[[Pulmonary]] |B02= [[Hemoptysia]], [[tachypnea]], [[rales]],[[cyanosis]], [[ wheeze]], [[pleural rub]]|}}
{{familytree | | | | | | | | | |)|-| B01 |-| B02 | | | |B01=[[Pulmonary]] |B02= [[Hemoptysia]], [[tachypnea]], [[rales]],[[cyanosis]], [[ wheeze]], [[pleural rub]]|}}
Line 298: Line 277:
{{familytree | | | | | | | | | |`|-| D01 |-| D02 | | | |D01=Other |D02= [[Febrile]], [[psychosis]], [[suisidal ideation]] }}
{{familytree | | | | | | | | | |`|-| D01 |-| D02 | | | |D01=Other |D02= [[Febrile]], [[psychosis]], [[suisidal ideation]] }}
{{familytree/end}}
{{familytree/end}}


{{familytree/start |summary=Sample 10}}{{familytree/start |summary=PE diagnosis Algorithm.}}
{{familytree/start |summary=Sample 10}}{{familytree/start |summary=PE diagnosis Algorithm.}}
{{Family tree/start}}
{{Family tree/start}}
{{familytree  | | | | | B01 | | | | | B01=<div style="float: left; text-align: left; height: 25em; width: 17em; padding:1em;"> '''Cardiac testing in pediatrics chest pain:'''<br>
{{familytree  | | | | | B01 | | | | | B01=<div style="float: left; text-align: left; width: 17em; padding:1em;"> '''Cardiac testing in pediatrics chest pain:'''<br>
❑'''[[ECG]]'''<br> ❑'''[[Echocardiography]]'''<br> ❑'''[[Troponin]] test'''<br> ❑ '''Ambulatory [[ECG]]'''<br>❑'''[[Exercise stress test]]'''<br></div>}}
❑ '''[[ECG]]'''<br> ❑ '''[[Echocardiography]]'''<br> ❑ '''[[Troponin]] test'''<br> ❑ '''Ambulatory [[ECG]]'''<br>❑ '''[[Exercise stress test]]'''<br></div>}}


{{familytree  | | | | | |!| | | | | |}}
{{familytree  | | | | | |!| | | | | |}}
{{familytree  | | | | | C01 | | | | | C01=<div style="float: left; text-align: left; height: 60em; width: 17em; padding:1em;"> ❑ '''ECG'''<br>  ❑ Abnormal [[physical exam]], exertional [[chest pain]], [[palpitation]]  <br>  ❑ Suspected [[myocarditis]], [[cardiomyopathy]], [[pulmonary hypertension]], [[pericarditis]] <br>
{{familytree  | | | | | C01 | | | | | C01=<div style="float: left; text-align: left; width: 17em; padding:1em;"> ❑ '''ECG'''<br>  ❑ Abnormal [[physical exam]], exertional [[chest pain]], [[palpitation]]  <br>  ❑ Suspected [[myocarditis]], [[cardiomyopathy]], [[pulmonary hypertension]], [[pericarditis]] <br>
----
----
'''Echocardiography:'''<br>
'''Echocardiography:'''<br>
Line 312: Line 293:
❑ '''Troponin''' <br> ❑ Suspected [[myocarditis]], [[pericarditis]], [[coronary ischemia]] <br>
❑ '''Troponin''' <br> ❑ Suspected [[myocarditis]], [[pericarditis]], [[coronary ischemia]] <br>
----
----
'''Ambulatory [[ECG]]'''<br>❑[[Chest pain ]], [[palpitation]]<br>❑Suspected [[atrial arrhythmia]],[[ ventricular arrhythmia]], [[intermittent heart block]]<br>
'''Ambulatory [[ECG]]'''<br>❑ [[Chest pain ]], [[palpitation]]<br>❑ Suspected [[atrial arrhythmia]],[[ ventricular arrhythmia]], [[intermittent heart block]]<br>
----
----
'''Exercise stress test'''<br>❑Exertional [[chest pain]], [[exertional syncope]], [[palpitation]]<br>❑Suspected [[coronary ischemia]], [[exercise induced asthma]]<br></div>}}
'''Exercise stress test'''<br>❑ Exertional [[chest pain]], [[exertional syncope]], [[palpitation]]<br>❑ Suspected [[coronary ischemia]], [[exercise induced asthma]]<br></div>}}


{{Family tree/start}}
{{Family tree/start}}
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{{Family tree| | | | | | | | A02 | | | |A02=[[Medical history]], [[cardiac]] [[examination]] }}
{{Family tree| | | | | | | | A02 | | | |A02=[[Medical history]], [[cardiac]] [[examination]] }}
{{Family tree| | | | | |,|-|-|^|-|-|.| | }}
{{Family tree| | | | | |,|-|-|^|-|-|.| | }}
{{Family tree| | | | | A03 | | | | A04 |-|-|.| | | | |A03= Abnormal [[history]] or [[cardiac]] [[examination]]| A04= Normal [[history]] and [[cardiac]] [[examination]]}}
{{Family tree| | | | | A03 | | | | A04 |-|-|-|.| | | |A03= Abnormal [[history]] or [[cardiac]] [[examination]]| A04= Normal [[history]] and [[cardiac]] [[examination]]}}
{{Family tree| | | |,|-|^|-|-|.| | | | | | |!| | | |}}
{{Family tree| | | |,|-|^|-|-|.| | | | | | | |!| | |}}
{{Family tree| | | |A05| | |A06|-|-|.| | | |!| | | | |A05=Yes|A06=NO}}
{{Family tree| | | |A05| | |A06|-|-|.| | |!| | | | | |A05=Yes|A06=NO}}
{{Family tree| | | |!| | | | | | | | | |!| |!| | | |}}
{{Family tree| | | |!| | | | | | | | | |!| | |!| | |}}
{{Family tree| | | |A0 | | | | | |A9 |-|-|-|'| | | |A0=[[Febrile]], [[acute onset symptoms]]|A9=[[Palpitation]], [[chest pain]], positive [[family history]]}}
{{Family tree| | | |A0 | | | | | |A9 |-|-|'| | | | |A0=[[Febrile]], [[acute onset symptoms]]|A9=[[Palpitation]], [[chest pain]], positive [[family history]]}}
{{Family tree| |,|-|^|-|.| | | |,|-|^|-|.| |}}
{{Family tree| |,|-|^|-|.| | | |,|-|^|-|.| |}}
{{Family tree| |A7 | | A8| |A10| |A11| | A7=Yes|A8=NO|A10=NO|A11=Yes|}}
{{Family tree| |A7 | | A8| |A10| |A11| | A7=Yes|A8=NO|A10=NO|A11=Yes|}}
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{{Family tree| | | | | | | | | |C1 | | C2| | |C1=Exertional [[chest pain]]|C2=At rest [[chest pain]] or reproducible on exam }}
{{Family tree| | | | | | | | | |C1 | | C2| | |C1=Exertional [[chest pain]]|C2=At rest [[chest pain]] or reproducible on exam }}
{{Family tree| | | | | | | | | |!| | | |!| |}}
{{Family tree| | | | | | | | | |!| | | |!| |}}
{{Family tree| | | | | | | | | |D1 | | D2| |D1= Suspected [[asthma]]| D2=Low likehood of [[cardiac ]] [[chest pain]]}}
{{Family tree| | | | | | | | | |D1 | | D2|-|D6| |D1= Suspected [[asthma]]| D2=Low likehood of [[cardiac ]] [[chest pain]]|D6=Reassurance}}
{{Family tree| | | | | | | |,|-|^|-|.| | |!|}}
{{Family tree| | | | | | | |,|-|^|-|.| |!| | }}
{{Family tree| | | | | | | D3| | D4| | D5| | |D3=Yes |D4=NO|D5=Reassurance | | |}}
{{Family tree| | | | | | | D3| | | D4| | | | |D3=Yes |D4=No}}
{{Family tree| | | | | | | |!| | |!| | | }}
{{Family tree| | | | | | | |!| | | |!| | | }}
{{Family tree| | | | | | | E1| | E2| | | | | |E1=[[Bronchodilator]]|E2=Refer to [[pediatric cardiologist]]}}
{{Family tree| | | | | | | E1| | | E2| | | | | |E1=[[Bronchodilator]]|E2=Refer to [[pediatric cardiologist]]}}
{{Family tree| | | | | | | |!| | | | | | }}
{{Family tree| | | | | | | |!| | | | | | }}
{{Family tree| | | | | | | |E3 | | | | | |E3=Improvement }}
{{Family tree| | | | | | | E3 | | | | | | |E3=Improvement }}
{{Family tree| | | | | |,|-|^|-|.| | | | }}
{{Family tree| | | | | |,|-|^|-|.| | | | }}
{{Family tree| | | | | |F3 | |F4 | | | | |F3=Keeping management|F4=Refer to [[pediatric cardiologist]] }}
{{Family tree| | | | | F3 | | | F4 | | | | |F3=Keeping management|F4=Refer to [[pediatric cardiologist]] }}
{{Family tree| | | | | | | | | | | | | | }}
{{Family tree| | | | | | | | | | | | | | }}
{{Family tree| | | | | | | | | | | | | | }}
{{Family tree| | | | | | | | | | | | | | }}
{{Family tree| | | | | | | | | | | | | | }}
{{Family tree| | | | | | | | | | | | | | }}
{{Family tree| | | | | | | | | | | | | | }}
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{{Family tree/end}}
{{Family tree/end}}
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==Don'ts==
==Don'ts==
* Do not hesitate for urgent evaluation of [[patients]] presented with [[chest pain]] accompanied by [[dyspnea]] or [[unstable hemodynamic]].
* Do not hesitate for urgent evaluation of [[patients]] presented with [[chest pain]] accompanied by [[dyspnea]] or [[unstable hemodynamic]].
==References==
==References==
{{Reflist|2}}
{{Reflist|2}}


[[Category:Projects]]
[[Category:Resident survival guide]]
[[Category:Resident survival guide]]
[[Category:Pediatrics]]
[[Category:Pediatrics]]
[[Category:Primary care]]

Latest revision as of 09:23, 16 July 2021

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Sara Zand, M.D.[2]

Chest pain resident survival guide (pediatrics) Microchapters
Overview
Causes
FIRE
Diagnosis
Treatment
Do's
Don'ts

Overview

Chest pain is the second common cardiac symptom after cardiac murmur referred to a pediatric cardiologist for evaluation. The most common cause of chest pain in children is idiopathic without finding any specific underlying pathology and the second cause is musculoskeletal. Although there are high worries among parents about the cardiac origin of chest pain, it consists in low percentage cause of pediatric chest pain. Evaluation of chest pain includes assessments of respiratory system, gastrointestinal system, cardiovascular system and psychologic factors.

Causes

Life Threatening Causes

Life-threatening causes include conditions that may result in death or permanent disability within 24 hours if left untreated.

Common Causes

Common Causes of Chest pain in children include:[1][2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18]

Causes of sharp chest pain

Aspect

❑ Ideopathic (73.6%)

❑ Normally otherwise

Respiratory (9.3%)

Asthma
Acute bronchitis
Pneumonia
Pneumomediastinum
Pneumothorax

Musculoskeletal (8.8%)

Chest wall tenderness
Osteomyelitis of sternum

Cardiac (3.8%)

ASD
Pulmonary artery stenosis
VSD
Aortic arch anomaly
❑ Large PDA with eisenmenger
Arrhythmia

Gastrointestinal (2.9%)

Gastritis
GERD
❑ Acute gastroenteritis
Dyspepsia

Psychiatric (1.4%)

Anxiety disorder
Panic disorder

 
 
 
 
 
 
 
 
 
 
 
Causes of pediatric chest pain
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Congenital lesions:

Aortic stenosis
Aortic aneurysm with dissection
Subaortic stenosis
Supravalvular aortic stenosis
❑ Ruptured sinus of valsalva
Coarctation of aorta
❑ Anomalous origin of coronary arteries from pulmonary artery
Coronary artery ostial stenosis or atresia
Left coronary artery arising from anterior cusp
❑ Congenital coronary artery aneurysm
Coronary artery fistula
Mitral valva prolapse
❑ Severe pulmonary stenosis

Arrhythmogenic right ventricular dysplasia
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

FIRE: Focused Initial Rapid Evaluation

A Focused Initial Rapid Evaluation (FIRE) should be performed to identify patients in need of immediate intervention.[19][20][21][22]

 
 
 
 
 
 
 
 
 
 
 
 
 
Psychogenic origin, School problem, family troubles (parents divorce)
 
 
 
 
 
 
 
 
 
 
 
Gastrointestinal origin, chest pain associated with indigestion, heart burn, vomiting,
 
 
 
 
 
 
 
 
Cardiac origin, Congenital heart disease, kawasaki, arrhythmia
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Ideopathic, No evidence of any organic etiology or any psychologic factors
 
 
 
 
 
Characteristics of chest pain
 
 
 
 
 
Squeezing, sharp, dull, duration of chest pain
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Musculoskeletal origin, chest wall tenderness,Pain aggravated with inspiration,Muscle pain with movement,Tenderness on palpation of costochondral junction
 
 
 
 
 
 
 
 
Respiratory related,Chest pain secondary to acute onset of cough,wheezing, asthma
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Symptoms associated with Chest pain in children and adolescence:
Cough (23.4%)
Dyspnea (11%)
Abdominal pain (9.7%)
Palpitation (9.7%)
Respiratory related (9%)
Dizziness (5.8%)
Post nasal drip (4.4%)
Fever (5.2%)
Exercise induced (2.6%)
Syncope (2.6%)
Physical examination
Tachypnea
Tachycardia
Rale
Wheeze
Gallop rhythm
Hematemesis
Hemoptysis
Melena
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Is there any red flag about cardiac etiology?:

❑ History of acquired or congenital cardiac disease
❑ Exertional syncope
❑ Exertional chest pain
Hypercoagulable state
Hypercholesterolemia state
Family history of sudden death under 35 years of age
Family history of premature coronary artery disease
Inheritted arrhythmia in the first relative
ICD implantation
Connective tissue disease
❑ Using cocaine, amphetamine
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Laboratory investigation in suspicion of pulmonary etiology:

CXR
Chest CT scan
Magnetic resonance imaging of the chest
Pulmonary function test
Bronchoscopy
Ventilation perfusion scan
Sweat test
 
Laboratory investigation in suspicion of gastrointestinal etiology:

Gastric lavage
PH probe
Upper GI series
Upper endoscopy
Abdominal sonography
Liver function test
Lipase, amylase
Serum gastrin level
Stool guaic testing
 
Laboratory investigation in suspicion of musculoskeletal etiology:

Skeletal radiography
Spine CT scan
❑ Spine MRI
Nuclear bone scan
Creatine kinase with MM fraction
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Complete Diagnostic Approach

Shown below is an algorithm summarizing the diagnosis of pediatric chest pain.[1][23][24]

 
 
 
 
 
 
 
 
 
 
 
 
Cardiac
 
Presence of underlying congenital or acquired heart disease, arrhythmia, crushing chest pain, exercised induced chest pain, persistent tachycardia, hypotension, gallop rhythm, syncope, pericardial rub
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Pulmonary
 
Hemoptysia, tachypnea, rales,cyanosis, wheeze, pleural rub
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Physical examination
 
 
 
 
Gastrointestinal
 
Hematemesis,hematochezia, melena, epigastric tenderness, organomegaly, trauma
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
musculoskeletal
 
Chest Trauma, chest bruising, chest asymmetry, chest localised swelling, chest localized tenderness, crepitus on palpation, arm limited range of motion
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Other
 
Febrile, psychosis, suisidal ideation
 
 
 
 
 
 


 
 
 
 
Cardiac testing in pediatrics chest pain:
ECG
Echocardiography
Troponin test
Ambulatory ECG
Exercise stress test
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Evaluation of chest pain
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Medical history, cardiac examination
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Abnormal history or cardiac examination
 
 
 
Normal history and cardiac examination
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
NO
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Febrile, acute onset symptoms
 
 
 
 
 
Palpitation, chest pain, positive family history
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
NO
 
NO
 
Yes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Refer to pediatric cardiologist
 
At rest chest pain, exersional chest pain
 
Refer to pediatric cardiologist
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Exertional chest pain
 
At rest chest pain or reproducible on exam
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Suspected asthma
 
Low likehood of cardiac chest pain
 
Reassurance
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Bronchodilator
 
 
Refer to pediatric cardiologist
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Improvement
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Keeping management
 
 
Refer to pediatric cardiologist
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Treatment

Shown below is an algorithm summarizing the treatment of chest pain in children.[25]


 
 
 
 
 
 
 
 
 
 
 
 
Cardiac causes such as IHD, pericarditis, tamponade, arrhythmia
 
Treatment of underlying causes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Musculoskeletal origin
 
Reassurance, rest,analgesic, anti-inflammatory agent (NSAID), warm compression
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Treatment of pediatric chest pain
 
 
 
 
Pulmonary disease ( bronchitis, asthma, pleurisy, pleural effusion, pneumonia, empyema, bronchiectasis, lung abscess),
 
antibiotic therapy, bronchodilator therapy,pleural fluid derenage, chest tube insertion
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Gastrointestinal disorder ( GERD, gastritis, cholecystitis, PUD)
 
Antacid, H.pilory eradication, antibiotic therapy, surgery
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Psychologic
 
Cognitive behavior therapy
 
 
 
 
 
 

Do's

Don'ts

References

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  27. Premkumar S, Sundararajan P, Sangaralingam T (December 2016). "Clinical Profile of Cardiac Arrhythmias in Children Attending the Out Patient Department of a Tertiary Paediatric Care Centre in Chennai". J Clin Diagn Res. 10 (12): SC06–SC08. doi:10.7860/JCDR/2016/21751.8992. PMC 5296536. PMID 28208963.
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  30. Kim YJ, Shin EJ, Kim NS, Lee YH, Nam EW (December 2015). "The Importance of Esophageal and Gastric Diseases as Causes of Chest Pain". Pediatr Gastroenterol Hepatol Nutr. 18 (4): 261–7. doi:10.5223/pghn.2015.18.4.261. PMC 4712539. PMID 26770901.
  31. Villafañe, Juan; Lantin-Hermoso, M. Regina; Bhatt, Ami B.; Tweddell, James S.; Geva, Tal; Nathan, Meena; Elliott, Martin J.; Vetter, Victoria L.; Paridon, Stephen M.; Kochilas, Lazaros; Jenkins, Kathy J.; Beekman, Robert H.; Wernovsky, Gil; Towbin, Jeffrey A. (2014). "D-Transposition of the Great Arteries". Journal of the American College of Cardiology. 64 (5): 498–511. doi:10.1016/j.jacc.2014.06.1150. ISSN 0735-1097.
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