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CLINICAL PRESENTATIONS: CHEST PAIN

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A variety of cardiac, pulmonary, and esophageal lesions can result in chest pain. Pericarditis causes severe substernal chest pain that is exacerbated by movement or respiration. Patients sometimes report that the pain diminishes when assuming an upright position and leaning forward. Tachyarrhythmias can compromise myocardial blood flow and result in ischemic pain, often in association with lightheadedness, syncope, or palpitations. The pain associated with aortic dissection varies according to the site of the lesion. Dissection in the ascending aorta causes anterior chest pain. Dissection in the upper portion of the arch or descending aorta causes pain that radiates to the back.

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Pulmonary conditions are important considerations in the differential diagnosis of chest pain in children. Spontaneous pneumothorax causes acute onset of unilateral chest pain. The pain is often difficult to localize and may be accompanied by dyspnea. Pain caused by pleural irritation (pleuritic pain) is typically exacerbated during inspiration; physical examination may demonstrate a pleural rub. Pleural irritation can occur as a result of a viral infection or as a complication of bacterial pneumonia. Chest pain is part of the constellation of symptoms in many children with pneumonia. The acute onset of chest pain in a child with sickle cell disease is an important clinical indicator of acute chest syndrome. Chest pain in children with pulmonary embolism may be accompanied by cough, dyspnea, or hemoptysis, and sometimes includes a pleuritic component.

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Esophageal pathology can produce symptoms localized to the thorax. The pain associated with esophagitis tends to be localized to the retrosternal region and has a burning character. Because gastroesophageal reflux is the usual underlying cause, assuming the supine position may worsen the pain. An esophageal foreign body may cause substantial retrosternal pain.

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Chest pain in children without a known underlying cardiac or pulmonary abnormality is usually musculoskeletal in origin; for example, rib fracture, muscle strain, contusion, or costochondritis. Pain in these patients is usually less severe than pain associated with substantial intrathoracic pathology. The chest wall pain may be localized and non-radiating, and is often exacerbated by exercise or palpation.1

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Costochondritis is an inflammatory process of one or more of the costochondral cartilages that causes localized tenderness and pain of the anterior chest wall at the costochondral and/or costosternal articulations. Most cases in children are idiopathic. Others are a result of trauma, exercise, or irritation because of forceful coughing. Some patients have an underlying systemic condition, such as an autoimmune disorder, chronic renal failure, or thyroid disease. In most patients, there is no appreciable soft-tissue swelling on physical examination. Diagnostic imaging studies are often normal. CT sometimes shows cartilaginous irregularity/enlargement, local soft-tissue swelling, and resorption of adjacent bone. Signal alteration in the inflamed cartilage is sometimes visible on MRI. The pain tends to be unilateral, and most frequently is localized in the region of the fourth through sixth costochondral junctions. The onset of ...

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