Chest Pain

History

The goal of a thorough history of a patient with chest pain is to determine if the etiology is life threatening, a manifestation of a chronic condition with possible serious complications, a specific acute cause, or multiple acute and/or chronic causes. Although chest pain affects children and adolescents of all ages equally, the age of a child can assist in diagnosis. Adolescents are more likely to have musculoskeletal or psychogenic causes of chest pain, while younger children have more respiratory disorders and vague complaints.

One possible approach includes a stepwise, directed history that includes:

• Description of pain

• Assessment for red-flag symptoms (see Table 8.2 ), including targeted family history

• Medication review

• Review of known illnesses

• Review of systems including psychosocial evaluation

Eliciting the basics of the chest pain’s duration, quality, propensity to radiate, severity, and timing is essential. Details that have been noted to be particularly helpful include duration, aggravating and relieving factors, and associated symptoms. Severe pain that lasts only a few seconds up to 1 or 2 minutes is often from the chest wall, but chest pain that persists longer is more likely to be organic in nature. Aggravating and alleviating factors can include position changes that accompany the pain from pericarditis or onset after eating spicy foods in gastroesophageal reflux. The character and location of the pain in pediatric patients are less helpful in the diagnostic evaluation due to often vague descriptions; nonetheless, medical providers should continue to obtain this information to understand the whole picture. Providers should remember that children often complain of chest pain when the pain is in a different place, such as the epigastrium or flank. Finally, it is important to determine whether the chest pain has had an impact on the child’s activity ( Table 8.3 ).

Red-flag symptoms (see Table 8.2 ) are high-yield, must-know characteristics of a child’s or an adolescent’s chest pain. Oftentimes, after a patient’s complete description of the pain, a medical provider will already know the answers to multiple red-flag symptoms, such as when the pain occurs, if it wakes the patient from sleep, and if it is associated with syncope. A targeted family history includes asking about inherited conditions such as familial hypercholesterolemia, hypertrophic cardiomyopathy, and Marfan syndrome. It also can provide information regarding relatives with adult-onset cardiac illnesses associated with chest pain, such as heart failure or ischemia, which may be providing added anxiety for the family.

Medications that the child may already be taking are important to consider. Some medications have specific links to etiologies of chest pain, such as tetracyclines with erosive esophagitis or oral contraceptives with pulmonary embolism. Other recreational drugs such as cocaine, other sympathomimetic agents (such as amphetamines, synthetic marijuana), and vaping have been associated with chest pain. A child’s known underlying illnesses and surrounding medical complaints discovered in a review of systems can complete the clinical picture for medical providers. The presence of joint pain or rash could suggest collagen vascular disease, or the presence of increased drooling could represent an esophageal foreign body.

A full psychosocial review should be performed on each patient to ensure that details of personal stressors and behaviors emerge. It is useful to learn about these aspects of the child’s chest pain from the child and the parent/family separately. Make sure to interview the patient alone if the child is older or an adolescent. It is difficult for children to discuss areas of difficulty, such as family relationships, school difficulties, or concerns about physical development, with family present. It is useful to ask, “What are you concerned that this pain is caused by?” of both the patient and the family. This question frequently gives information about overriding fears and concerns that can help medical providers know how to appropriately reassure the family in the likely event that the chest pain has a benign, noncardiac etiology.

Musculoskeletal

Musculoskeletal chest wall pain is perhaps the most identifiable cause of chest pain due to its association with localized tenderness elicited by specific manipulation of the thorax ( Fig. 8.1 ). Pain can involve the ribs, costochondral junctions (such as in costochondritis), costal cartilages, intercostal muscles, sternum, clavicle, or spine. The pain is often worse with movement, coughing, and inspiration. In considering musculoskeletal etiologies, thoroughly consider any trauma to the chest wall. Both contusion and rib fracture can have exquisite tenderness on palpation and pain on inspiration. Table 8.4 highlights common causes of musculoskeletal chest pain.

TABLE 8.4

Manifestations and Causes of Musculoskeletal Chest Pain

Signs and Symptoms	Diagnosis
Aching, localized pain after new or intense exercise or repetitive coughing Can appear up to 2 days later Can have localized swelling or erythema Pain reproduced by range-of-motion testing or palpation	Muscular strain
Sharp, anterior pain over costochondral junctions, often along the sternal border Exacerbated by deep breathing First through fifth ribs are most common and often more than one costochondral junction affected Can be related to growth spurts	Costochondritis (also called costosternal syndrome, parasternal chondrodynia, or anterior chest wall syndrome)
Can be considered a variant of costochondritis Sharp, localized pain at only one costochondral junction Area is swollen, ± warm, erythematous bulbous or fusiform 1–4 cm mass Second or third costochondral junction is most common Age predominance in adolescence and early 20s	Tietze syndrome
Pain and increased mobility due to subluxation of 8th, 9th, or 10th ribs (which are not attached to the sternum), resulting in impingement of superior intercostal nerve Intermittent sharp pain in chest or upper abdomen Brought on by exertion, especially sudden upward and anterior movement (“hooking maneuver”; see Fig. 8.2 ) Can have popping sensation at onset of pain Caused by trauma or dislocation of these ribs	Slipping rib syndrome (lower rib pain syndrome)
Brief (30 sec–3 min), nonradiating, well-localized, sharp pain in the left parasternal area or cardiac apex (“Texidor twinge”) Occurs at rest or with mild activity Exacerbated with inspiration and alleviated by shallow breathing or straightened position Related to poor posture	Precordial catch syndrome
Pain over both anterior chest and back Spasm in muscles innervated by nerve root causes pain No midline spine bony tenderness History of vertigo, headache, pain after prolonged recumbence or straining	Spinal cord or nerve root compression, typically lower cervical or upper thoracic spine
Chronic aching and stiffness Multiple points of tenderness on palpation of muscle with minimal pressure Associated with fatigue and sleep disturbance	Fibromyalgia

In general, chest wall pain can result from the strain of any muscle group present in the chest; however, multiple syndromes have been described in relation to specific patterns of muscular pain ( Fig. 8.2 ). Some of these syndromes include pectoral syndrome (pain in a band across the anterior parasternal chest wall on the right or the left), coracoid syndrome (pain at the site of the pectoralis minor muscle with tenderness at its insertion onto the coracoid process), and xiphoid process syndrome (pain over the xiphoid process).