Chest pain resident survival guide (pediatrics): Difference between revisions
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{{CMG}} {{AE}} {{Sara.Zand}} | {{CMG}} {{AE}} {{Sara.Zand}} | ||
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==Overview== | ==Overview== | ||
[[ Chest pain]] is the second [[cardiac]] symptom after [[cardiac murmur]] | [[ 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 [[ | * 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%) | ||
| 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> | ||
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|- | |- | ||
|- 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> | |||
❑[[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> | |||
❑[[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> | |||
❑[[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> | |||
❑[[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| |,|-|-|+|-|-|-|.| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }} | ||
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❑ 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> | |||
❑[[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>❑ [[ | {{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> | ❑ [[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]] | 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= | {{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 | {{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 | {{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> | '''Ambulatory [[ECG]]'''<br>❑ [[Chest pain ]], [[palpitation]]<br>❑ Suspected [[atrial arrhythmia]],[[ ventricular arrhythmia]], [[intermittent heart block]]<br> | ||
---- | ---- | ||
'''Exercise stress test'''<br> | '''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}} | ||
Line 321: | Line 302: | ||
{{Family tree| | | | | | | | A02 | | | |A02=[[Medical history]], [[cardiac]] [[examination]] }} | {{Family tree| | | | | | | | A02 | | | |A02=[[Medical history]], [[cardiac]] [[examination]] }} | ||
{{Family tree| | | | | |,|-|-|^|-|-|.| | }} | {{Family tree| | | | | |,|-|-|^|-|-|.| | }} | ||
{{Family tree| | | | | A03 | | | | A04 |-|-|. | {{Family tree| | | | | A03 | | | | A04 |-|-|-|.| | | |A03= Abnormal [[history]] or [[cardiac]] [[examination]]| A04= Normal [[history]] and [[cardiac]] [[examination]]}} | ||
{{Family tree| | | |,|-|^|-|-|.| | | | | | |! | {{Family tree| | | |,|-|^|-|-|.| | | | | | | |!| | |}} | ||
{{Family tree| | | |A05| | |A06|-|-|.| | | | | {{Family tree| | | |A05| | |A06|-|-|.| | |!| | | | | |A05=Yes|A06=NO}} | ||
{{Family tree| | | |!| | | | | | | | | |!| |! | {{Family tree| | | |!| | | | | | | | | |!| | |!| | |}} | ||
{{Family tree| | | |A0 | | | | | |A9 |-|-| | {{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|}} | ||
Line 333: | Line 314: | ||
{{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}} | ||
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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: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.
- Cardiac causes such as life-threatening arrhythmia, acute coronary syndrome, acute pulmonary embolism, tamponade
- Abdominal aorta dissection with propagation to thoracic aorta
- Perforated peptic ulcer
- Air leak syndrome such as pneumothorax, pneumomediastinum
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 |
❑ Musculoskeletal (8.8%) | |
❑ Cardiac (3.8%) |
❑ ASD |
❑ Gastrointestinal (2.9%) |
❑ Gastritis |
❑ Psychiatric (1.4%) |
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]
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 | |||||||||||||||||||||||
❑ ECG ❑ Abnormal physical exam, exertional chest pain, palpitation ❑ Suspected myocarditis, cardiomyopathy, pulmonary hypertension, pericarditis Echocardiography: ❑ Troponin Ambulatory ECG Exercise stress test ❑ Exertional chest pain, exertional syncope, palpitation ❑ Suspected coronary ischemia, exercise induced asthma | |||||||||||||||||||||||
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
- Quickly evaluate cardiac examination in children presented with chest pain and syncope.[26]
- Arrhythmia leading chest pain in children include: paroxysmal supraventricular tachycardia (PSVT), premature ventricular contraction (PVC), atrial flutter, mobitz type2 block ,atrial tachycardia, atrial premature contraction.[27]
- Asthma is the most common cause of chest pain in the pulmonary group presenting with exertional chest pain.
- Think about pneumothorax among young adult male presented with tachypnea, persistent pleuritic chest pain for 1-2 days and take a chest-X-ray for evaluation of air leak syndrome.
- If the CXR is undiagnostic for evaluation of pneumomediastinum, chest CT-scan is considered.[16]
- In patients with chest pain and hypoxia, pulmonary embolism should be noticed.[28]
- Acute chest syndrome or pulmonary infarction can be the manifestation of sickle cell disease among children.[29]
- In patients presented with GERD or gastritis, chest pain is described as burning pain in epigastric area related to taking food.[30]
- Hyperventilation in patients with panic disorder or anxiety disorder may lead to chest pain, paresthesia, dizziness, shortness of breath.
- Chest pain may be initial presentation of deformities in chest wall such as scoliosis due to nerve root compression.
- Mitral valve prolapse may be present with atypical chest pain in children.
- In case of marfan disease with sudden onset severe chest pain with radiation to the back, dissection aorta aneurysm should be evaluated.
- In patients with history of arterial switch in transposition of the great arteries (d-TGA), ostial coronary artery stenosis should be noticed.[31]
- Homozygous familial hypercholesterolemia may lead to coronary artery disease and ischemic chest pain in the first two decades in children.[32]
Don'ts
- Do not hesitate for urgent evaluation of patients presented with chest pain accompanied by dyspnea or unstable hemodynamic.
References
- ↑ 1.0 1.1 Friedman KG, Alexander ME (September 2013). "Chest pain and syncope in children: a practical approach to the diagnosis of cardiac disease". J Pediatr. 163 (3): 896–901.e1–3. doi:10.1016/j.jpeds.2013.05.001. PMC 3982288. PMID 23769502.
- ↑ Aeschlimann A, Kahn MF (1990). "Tietze's syndrome: a critical review". Clin Exp Rheumatol. 8 (4): 407–12. PMID 1697801.
- ↑ Heinz, George J. (1977). "Slipping Rib Syndrome". JAMA. 237 (8): 794. doi:10.1001/jama.1977.03270350054023. ISSN 0098-7484.
- ↑ Selbst SM (June 1985). "Chest pain in children". Pediatrics. 75 (6): 1068–70. PMID 4000782.
- ↑ Howell, John M. (1992). "Xiphodynia: A report of three cases". The Journal of Emergency Medicine. 10 (4): 435–438. doi:10.1016/0736-4679(92)90272-U. ISSN 0736-4679.
- ↑ Pickering, D (1981). "Precordial catch syndrome". Archives of Disease in Childhood. 56 (5): 401–403. doi:10.1136/adc.56.5.401. ISSN 0003-9888.
- ↑ Wiens L, Sabath R, Ewing L, Gowdamarajan R, Portnoy J, Scagliotti D (September 1992). "Chest pain in otherwise healthy children and adolescents is frequently caused by exercise-induced asthma". Pediatrics. 90 (3): 350–3. PMID 1518687.
- ↑ Evangelista, Juli-anne K.; Parsons, Marytheresa; Renneburg, Anne K. (2000). "Chest pain in children: diagnosis through history and physical examination". Journal of Pediatric Health Care. 14 (1): 3–8. doi:10.1016/S0891-5245(00)70037-X. ISSN 0891-5245.
- ↑ Barth, Charles W.; Roberts, William C. (1986). "Left main coronary artery originating from the right sinus of valsalva and coursing between the aorta and pulmonary trunk". Journal of the American College of Cardiology. 7 (2): 366–373. doi:10.1016/S0735-1097(86)80507-1. ISSN 0735-1097.
- ↑ Lipsitz, Joshua D.; Masia, Carrie; Apfel, Howard; Marans, Zvi; Gur, Merav; Dent, Heather; Fyer, Abby J. (2005). "Noncardiac chest pain and psychopathology in children and adolescents". Journal of Psychosomatic Research. 59 (3): 185–188. doi:10.1016/j.jpsychores.2005.05.004. ISSN 0022-3999.
- ↑ Lee, Jennifer L.; Gilleland, Jordan; Campbell, Robert M.; Simpson, Patricia; Johnson, Gregory L.; Dooley, Kenneth J.; Blount, Ronald L. (2013). "Health care utilization and psychosocial factors in pediatric noncardiac chest pain". Health Psychology. 32 (3): 320–327. doi:10.1037/a0027806. ISSN 1930-7810.
- ↑ Selbst SM (January 1990). "Chest pain in children". Am Fam Physician. 41 (1): 179–86. PMID 2403723.
- ↑ . doi:10.7759/2Fcureus.3690. Missing or empty
|title=
(help) - ↑ . doi:10.2147/2FOAEM.S29942. Missing or empty
|title=
(help) - ↑ . doi:10.1007/2Fs00383-011-2874-8. Missing or empty
|title=
(help) - ↑ 16.0 16.1 Chun JH, Kim TH, Han MY, Kim NY, Yoon KL (November 2015). "Analysis of clinical characteristics and causes of chest pain in children and adolescents". Korean J Pediatr. 58 (11): 440–5. doi:10.3345/kjp.2015.58.11.440. PMC 4675925. PMID 26692880.
- ↑ . doi:10.1161/2FCIRCULATIONAHA.113.006702. Missing or empty
|title=
(help) - ↑ Swap, Clifford J. (2005). "Value and Limitations of Chest Pain History in the Evaluation of Patients With Suspected Acute Coronary Syndromes". JAMA. 294 (20): 2623. doi:10.1001/jama.294.20.2623. ISSN 0098-7484.
- ↑ . doi:10.3345/2Fkjp.2015.58.11.440. Missing or empty
|title=
(help) - ↑ Cava, Joseph R.; Sayger, Pamela L. (2004). "Chest pain in children and adolescents". Pediatric Clinics of North America. 51 (6): 1553–1568. doi:10.1016/j.pcl.2004.07.002. ISSN 0031-3955.
- ↑ Lawrence PR, Delaney AE (October 2004). "Chest pain in children and adolescents: most causes are benign". Adv Nurse Pract. 12 (10): 61–2, 64, 66 passim. PMID 15518121.
- ↑ Liesemer, Kirk; Casper, T. Charles; Korgenski, Kent; Menon, Shaji C. (2012). "Use and Misuse of Serum Troponin Assays in Pediatric Practice". The American Journal of Cardiology. 110 (2): 284–289. doi:10.1016/j.amjcard.2012.03.020. ISSN 0002-9149.
- ↑ . doi:10.3345/2Fkjp.2015.58.11.440. Missing or empty
|title=
(help) - ↑ Ives, A.; Daubeney, P. E. F.; Balfour-Lynn, I. M. (2010). "Recurrent chest pain in the well child". Archives of Disease in Childhood. 95 (8): 649–654. doi:10.1136/adc.2008.155309. ISSN 0003-9888.
- ↑ . doi:10.1136/2Fadc.63.12.1457. Missing or empty
|title=
(help) - ↑ . doi:10.1016/2Fj.jpeds.2013.05.001. Missing or empty
|title=
(help) - ↑ 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.
- ↑ . doi:10.4070/2Fkcj.2017.0314. Missing or empty
|title=
(help) - ↑ Jain S, Bakshi N, Krishnamurti L (December 2017). "Acute Chest Syndrome in Children with Sickle Cell Disease". Pediatr Allergy Immunol Pulmonol. 30 (4): 191–201. doi:10.1089/ped.2017.0814. PMC 5733742. PMID 29279787.
- ↑ 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.
- ↑ 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.
- ↑ . doi:10.4274/2Fbalkanmedj.2017.0490. Missing or empty
|title=
(help)