Download Chapter 50: Chest pain

State University of New York at Buffalo
Pediatric Emergency Medicine Fellowship
F&L 7th Edition Chapter Review: 9-7-16
Chapter 50: Chest pain
Intro comments: Chest pain is mostly benign in children. Our job is to rule-out “that which
kills”. The best way to do this is with a careful H&P and a few selected tests. What you should
take away from this “Signs & Symptoms” chapter is the H&P/test findings that suggest each of
the following diagnoses…
Q: Child with unrelenting substernal crushing chest pain with or without radiation to neck or
arm, diaphoresis, nausea, dyspnea, syncope; in distress, pallor, gallop rhythm, heart murmur,
decreased perfusion, EKG changes (inverted t-waves, ST depression/elevation, q-waves)
A: MI
Q: Teenager is anxious, confused, combative, tachycardia, hypertension, mydriasis
A: cocaine toxicity
Q: Harry Potter Question: What is the difference between Monk’s Hood and Wolf Bane?
A: “They are the same plant that also goes by the name aconite”
Q: What other herbal medicines have been associated with chest pain?
A: aconite (monk’s hood, wolf bane), ephedra, licorice
Q: Name a congenital heart defect not detected in infancy but causing sudden death or chest pain
with exercise
A: anomalous coronary artery
Q: What is the most common cardiac cause of sudden death?
A: Hypertrophic cardiomyopathy (due to ventricular dysrhythmia)
Q: Autosomal dominant pattern (that’s why we ask about family history of sudden death)—
spontaneous mutations do occur though; patients may have a systolic murmur that becomes more
intense with standing or a Valsalva maneuver, exertional syncope or pre-syncope, pulmonary
congestion symptoms, chest pain, palpitations, EKG findings: asymmetrical septal hypertrophy
produces deep, narrow (“dagger-like”) Q waves in the lateral (V5-6, I, aVL) and inferior (II,
III, aVF) leads.
A: Hypertrophic cardiomyopathy
Q: Child with chest pain, fatigue, exercise intolerance, palpitations, gallop rhythm, a murmur
from mitral valve insufficiency.
A: Dilated cardiomyopathy
Q: Child with fever, stabbing chest pain that improves with sitting up and leaning forward,
respiratory distress, a friction rub, and distant heart sounds; Decreased QRS voltages or electrical
alternans.
A: Pericarditis
Q: Child with a preceding viral illness followed by mild chest pain and fatigue, fever, dyspnea,
worsening chest pain; tachycardia, orthostatic changes not responsive to fluids, pulsus
paradoxus, gallop rhythm.
A: Myocarditis
Q: A child with a history of congenital heart disease, ill appearing, history of prolonged fever,
signs of embolization (splinter hemorrhages)
A: Endocarditis
Q: Patient with arm span greater than height, generalized distress, unrelenting severe chest pain,
decreased cardiac output, dyspnea, and abdominal pain
A: Marfan’s Syndrome with Aortic Dissection
Q: Chest pain several days to months following cardiac surgery should be evaluated for what?
A: Signs of pericardial effusion (postpericardiotomy syndrome)
Q: Teenager with exercise intolerance, palpitations, and syncope
A: Pulmonary hypertension
Q: Infant with uncorrected congenital heart disease leading to severe pulmonary hypertension
leading to cyanosis from right to left shunting
A: Eisenmenger syndrome
Q: Chest pain with night time cough, occasional wheezing and family history of atopy
A: First time RAD episode
Q: Thin teenaged male with unrelenting chest pain which is pleuritic in nature, dyspnea.
A: Pneumothorax
Q: Patient with history of asthma, recent severe cough, substernal chest pain radiating to the
neck, worse with deep inspiration and position changes. Hamman’s sign present (crunching
heart sounds), crepitus in neck
A: Pneumomediastinum
Q: Child with right or left upper quadrant abdominal pain and fever, tachycardia and tachypnea
A: Lower lobe pneumonia or effusion
Q: Child with Pleuritic Chest pain, cough, hypoxia, hemoptysis, dyspnea, sense of impending
doom, obsese, pregnant, smoker, sedentary, history of coagulopathy and has cancer and is still
taking her birth control pills! S1Q3T3; wedge shaped pulmonary infiltrate with an elevated
ipsilateral hemidiaphragm
A: Pulm Embolus
Q: Child with burning chest pain, worse when lying down or when eating, mild epigastric
tenderness
A: GERD
Q: Child with a severe gastroenteritis with forceful vomiting and retching, chest pain, crepitus in
neck, pneumomediastinum on CXR, and hematemesis
A: Spontaneuous esophageal perforation (“Boerhaave syndrome”)
Q: Teenager just starting to train so he can make the school sports team presents with chest pain
which is reproducible by palpation or contraction of his chest muscles
A: Musculoskeletal chest pain or costochondritis
Q: A thin anxious teenager describes a popping or clicking sensation in his chest followed by
chest pain which lasts several minutes. The pain is reproduced by hooking the lower ribs with
the hand and pulling anteriorly.
A: Slipping Rib Syndrome
Q: Patient hit in chest with baseball bat in gang fight, hypotensive, distended neck veins, muffled
heart sounds
A: Cardiac Tamponade
Q: Child ejected from car without seat belt on in high speed mva, poor perfusion, hypotensive,
decreased breath sounds on one side with bruising and tenderness, tachycardic
A: hemothorax
Q: Teenager with acute sharp well-localized pain in left substernal region that has a “splitsecond” onset and is of short duration, worsened by deep inspiration, and occurs at rest or is
related to exercise, relieved by sitting up straight; physical exam does not reproduce the pain
A: Precordial Catch Syndrome or “Texidor’s Twinge”
Q: Healing Rib Fractures in an infant
A: NAT
Q: Chest Pain in a unilateral dermatome distribution followed by onset of rash in that area
A: Zoster