Chest pain

Question 1

What are your differentials for chest pain?

Answer 1

Muscle strain
costochondritis
contusion

Question 2

• Most common cause of chest pain (15-76%)

Answer 2

Muscle strain

CH ?: MUSCLE STRAIN
- Most common cause of chest pain (15-76%)
- Precordial catch syndrome (intercostal muscle
cramping): irritation of the parietal pleura that
produces a stabbing pain along the left sternal border
- Most often related to muscle overuse or trauma
involving the pectoral, upper back, or shoulder muscles

Question 3

clinical manifestations of muscle strain

Answer 3

CM
1. Sharp (acute) or dull (chronic) chest pain
2. Swelling, muscle spasms, difficulty moving the affected area, pain while breathing, bruising

Question 4

Diagnosis of muscle strain

Answer 4

Dx
- Primary clinical. Labs to r/o other diseases
1. CXR, MRI
2. ECG

Question 5

management of muscle strain

Answer 5

Mgt
1. Rest. Light activity x 2 d after injury
2. Ice/cold pack x 20 min on affected area TID
3. Compression – if with inflammation using elastic bandage
4. Keep chest elevated while sleeping
5. NSAIDs

Question 6

What is the other term for costochondritis?

Answer 6

• Tietze’s syndrome

CH ?: COSTOCHONDRITIS
- Tietze’s syndrome
- Inflammation of the costochondral junctions
- Isolated swelling of the upper costochondral area
- Most are idiopathic; others due to direct trauma,
aggressive exercise, prior URTI with cough
- Benign and self-limited

Question 7

Clinical manifestations of costochondritis

Answer 7

CM
1. Sharp and stabbing Localized tenderness and pain of the anterior chest wall, usually unilateral and ICS 2-5

2. Typically insidious (days to weeks), some acute
3. May radiate to chest, back, upper abdomen
4. Exacerbated by cough, sneezing, deep inspirations, movt of upper torso and upper extremities
5. Relieved by rest, ice or heat
6. Tenderness over the costochondral junction –diagnostic; localized and MC at sternocostal cartilage
   at ICS 2-5. Palpation should reproduce tenderness.
7. N PE

Question 8

Diagnostics for costochondritis

Answer 8

Dx
- Mainly clinical
1. CXR, CT, MRI – to r/o other causes

Question 9

Management of costochondritis

Answer 9

Mgt
1. Reassurance
2. NSAIDs
3. Cough suppressants – if cough is an aggravating factor
4. Stretching exercises
5. Ice x 20 min
6. Rest of UE and avoidance of exacerbating activities

Question 10

What is contusion?

Answer 10

CH ?: CONTUSION
- Chest wall bruise due to blunt trauma (car accident, fall)

CM
1. Chest pain, tenderness, bruising and swelling
2. May have broken ribs and injured muscles
3. Serious dyspnea

Dx
1. CXR, CT, MRI – r/o other dx, broken ribs

Mgt
1. Rest
2. Ice pack x 20 min q1-2h on D1, then TID for next days. WThen warm compress after 1-2d.
3. Pillow over affected area can ease pain
4. NSAIDs

Question 11

What is pleural effusion?

Answer 11

Patho
- Pleural fluid comes from the capillaries of the parietal pleura and is absorbed from the pleural space via pleural stomas and lymphatics
- Only 4-12ml of fluid is present in the pleural space and if formation exceeds clearance, fluid will accumulate as pleural effusion
- Transudative = renal, cardiac etiology
- Exudative = TB, infection, CA, empyema, SLE, etc

Question 12

Differentiate Dry vs serofibrinous/serosanguineous vs empyema or purulent effusion

Question 13

Differentiate Dry vs serofibrinous/serosanguineous vs empyema or purulent effusion

Question 14

B. Pleural Fluid Analysis

Answer 14

• culture for bacterial, fungal, mycobacterial, gram stain
• protein, LDH, glu (<60 mg/dL in CA, TB, rheumatoid ds)
• amylase
• specific gravity and pH
• Total cell count and differential, cytologic examination (to reveal
  malignant cells)

Question 15

Differentiate Exudates vs transudate

Answer 15

Exudates (vs. Transudate) have >1 of the ff:
1. Protein >3 g/dL
2. pH <7.20
3. Pleural fluid:serum protein ratio >0.5*
4. Pleural fluid:serum LDH ratio >0.6*
5. Pleural fluid LDH level >200 IU/L or pleural fluid LDH
>2/3 serum LDH upper limit of normal*
*=Light’s criteria

Question 16

C. Pleural fluid analysis in empyema

Answer 16

C. Pleural fluid analysis in empyema
1. Bacteria is present on gram stain
2. pH is <7.20
3. >100,000 neutrophils/uL
4. Pneumococcal empyema: culture is (+) in 58%
5. If negative culture for pneumococcus: do
pneumococcal PCR analysis

Question 17

Transudate vs exudate

Answer 17

—–Transudate—–
clear
cell count <1000 (lympho, monocytes)
LDH <200 U/L
Pleural/serum LDH ratio: <0.6
Protein >3g: unusual
Pleural/serum CHON ratio: <0.5
GLUCOSE: normal
PH: Normal (7.4-7.6)

—–Exudate—–
cloudy
cell count >1000 (PMNs)
LDH >2000 U/L
Pleural/serum LDH ratio: >0.6
Protein >3g: COMMON
Pleural/serum CHON ratio: >0.5
GLUCOSE: low
PH: 7.2-7.4

—–Complicated emphysema—–
purulent
cell count >5000 PMNs
LDH >1000 U/L
Pleural/serum LDH ratio: >0.6
Protein >3g: COMMON
Pleural/serum CHON ratio: >0.5
GLUCOSE: very low
PH: <7.2, chest tube placement required

*****Decreased glucose or LDH seen in malignant effusion, TB, esophageal rupture, SLE

Question 18

Diagnosis of Dry or Plastic Effusion

Answer 18

CXR: diffuse haziness at the pleural surface; dense, sharply demarcated shadow

Chest UTZ: if radiographs are negative, UTZ or CT scan of the chest may be done

Question 19

Diagnosis of Serofibrinous or Serosanguineous Effusion

Answer 19

CXR: homogenous density obliterating the normal lung markings;
If small effusion: obliterated costophrenic or cardiophrenic angles or widening of the interlobar septa;
Examine the patient in both supine and upright positions to demonstrate a shift of effusion

Chest UTZ: helpful guide to the thoracentesis if effusion is loculated

Question 20

Diagnosis of Empyema or Purulent effusion

Answer 20

CXR: similar findings with any pleural effusion; the absence of fluid shift with change in position indicates a loculated empyema

Chest UTZ: helpful guide to the thoracentesis if effusion is loculated

Question 21

Management of Dry or plastic effusion

Answer 21

Tx directed at the underlying disorder
patients with pleurisy and pneumonia should always be screened for TB
analgesia with NSAIDS will be helpful

Question 22

Management of serofibrinous or serosanguineous effusion

Answer 22

Tx directed at the underlying disorder
*therapeutic thoracentesis unless small effusion only
*rapid removal of ≥1L of pleural fluid may be associated with re-expansion pulmonary edema
*If underlying problem is adequately treated, further drainage is usually unnecessary

*Tube drainage is done for:
1. fluid re-accumulation leading to respiratory compromise
2. Older children with parapneumonic effusion, and the pleural fluid pH is ,7.20 or pleural fluid glucose level is <50mg/dL

Question 23

Management of empyema or purulent effusion

Answer 23

Antibiotics: choice of antibiotics is based on in vitro sensitivities of the responsible organism
Clinical response is slow even with antibiotics (may have little improvement for as long as 2 weeks)
For staphylococcal infections: treatment for 3-4 weeks

Chest tube drainage: controlled by underwater seal and continuous suction; usually continued for 5-7 days; fibrinolytic agents are instilled to promote drainage, decrease fever, lessen need for surgical intervention and shorten hospitalization

Surgery:
If px remains febrile and dyspneic for >72 hours after systemic antibiotics and chest tube drainage –surgical decortication via VATS
If VATS is ineffective, open decortication is performed

Question 24

CTT - >50-75% pleural eff, loculated, pH<7
Abx (NAGCOM):

Answer 24

• Complete HiB vax: Penicillin G 200000 U/kg/d q6 /
  Ampicillin 200mkd q6
• Incomplete/no HiB: Ampicillin-Sulbactam 100mkd q6
  or Cefuroxime 100mkd q8 or Ceftriaxone 100mkd q12

Question 25

What is lung abscess and its cause?

Answer 25

CH 402: LUNG ABSCESS
- in localized areas composed of thick-walled purulent material
- primary lung abscess: in previously healthy px with no underlying medical disorder, usually solitary
- secondary lung abscess: underlying or predisposing condition

patho
- Lung infection that destroys the lung parenchyma –> resulting in cavitations and central necrosis –> lung abscess
- RF: aspiration, PN, cystic fibrosis, GERD, TEF,
immunodeficiency, postoperative complications of tonsillectomy and adenoidectomy, sz, neuro ds
- Aspiration of infected material/FB: MC source of org in children

Question 26

Etiology of lung abscess

Answer 26

Etiology
- Mixed aerobic (Streptococcus, S.aureus, E.coli, Klebsiella pneumoniae, Pseudomonas, Mycoplasma) and anaerobic bacteria (Bacteroides, Fusobacterium,
Peptostreptococcus).
- Fungi in immunocompromised pxs

Question 27

What are the clinical manifestations of lung abscess?

Answer 27

CM
1. Location: R for primary abscess, L for secondary abscess
2. Cough, fever, tachypnea, chest pain, vomiting, sputum production, weight loss, hemoptysis
3. Tachypnea, dyspnea, retractions, dec breath sounds, dullness to percussion in the affected area, crackles, prolonged expiratory phase
4. Should be differentiated from pneumatocele: thin, smooth
walled localized air collections with/ without air-fluid level.
Resolve spontaneously with tx of PN

Question 28

Diagnostics for lung abscess

Answer 28

Dx
1. CXR – parenchymal inflammation with a cavity containingair-fluid level

2. CT scan – better anatomic definition of abscess, location,and size
3. CBC, BCS, sputum GS/CS – pronounced leukocytosis, anemia of chronic ds
4. Elev ESR, CRP
5. TST, DSSM, TB GeneXpert – r/o TB

Question 29

Management of lung abscess and prognosis

Answer 29

Mgt
1. Antibiotics IV x 2-3 weeks then po to complete 4-6 wks
Nelson: Clindamycin or Ticarcillin/Clavulanic acid + Aminoglycoside

1st line: Clindamycin 25-40 mkd + Ceftriaxone 50-100 mkdq24
2nd line: Vancomycin 40mkd q6 + Ceftriaxone 50-100 mkd q24 + Metronidazole 30mkd q6

2. CT-guided Percutaneous aspiration – for severely ill/ fail to improve with IV abx after 7-10d

Prognosis
- Excellent. Asx’c within 7-10d.
- CXR resolve in 1-3 mo but can persist for years

Question 30

Lung PE

Answer 30

—–Pleural effusion—–
decreased breath sounds
dullness on percussion
decreased vocal fremitus
tracheal deviation: away from side of lesion

—–Emphysema—–
decreased breath sounds
hyper-resonant
decreased fremitus
tracheal deviation: away from side of lesion

—–Atelectasis—–
decreased breath sounds
dullness on percussion
decreased fremitus
tracheal deviation: TOWARD side of lesion

—–Pneumothorax—–
decreased breath sounds
hyper-resonant
decreased fremitus
tracheal deviation: away from side of lesion

—–Consolidation—–
bronchial, crackles
dullness on percussion
increased fremitus
tracheal deviation: away from side of lesion

—–Lung abscess—–
decreased breath sounds
dullness on percussion
decreased fremitus
tracheal deviation: away from side of lesion

Question 31

What is esophagitis?

Answer 31

• May be eosinophilic, infective, or “pill” esophagitis

Etiology
- Eosinophic Esophagitis (EoE): chronic esophageal
disorder characterized by infiltration of esophageal epithelium by eosinophils; usually with atopic ds
- Infective Esophagitis (InE): Candida, HSV, CMV, diphtheria, TB
- Pill esophagitis (PiE): tetracycline, KCl, FeSO4, NSAIDs, alendronate. Usually drug ingested at bedtime without water.

Question 32

What are the clinical manifestations of esophagitis?

Answer 32

CM
1. Infants: vomiting, feeding problems, poor weight gain
2. Older child: solid food dysphagia, chest or epigastric pain
3. Usually described as burning pain
4. Odynophagia, dysphagia, retrosternal pain, nausea
5. fever (InE)

Question 33

What are the diagnostics for esophagitis?

Answer 33

Dx
1. EoE: peripheral eosinophilia, elevated IgE, endoscopy (esophagus granular, furrowed, ringed or exudative appearance)
2. InE: endoscopy (white plaque (candida), multiple superficial ulcers (HSV), single deep ulcer (CMV)

Question 34

Management of esophagitis

Answer 34

Mgt
1. EE: PPIs, “6 food elimination diet” removing the major food allergens (milk, soy, wheat, egg, peanuts, tree nuts, seafood)
2. InE: abx, analgesics, PPI
3. PiE: supportive

Question 35

What is Myocardial ischemia?

Answer 35

CH ?: MYOCARDIAL ISCHEMIA
- Coronary Artery disease (CAD) extremely rare in pediatric age group
- Acute myocardial infarction (AMI)
- In children, usually acute inflammatory condition of coronary arteries or rare anomalous origin of the left
coronary artery from the pulmonary artery (ALCAPA), or Kawasaki disease

Question 36

Clinical manifestations of myocardial ischemia

Answer 36

CM
1. Irritability with dyspnea, tachycardia, diaphoresis, vomiting
2. Anginal pain
3. Palpitation, weakness, mental confusion, orthostasis, presyncope/syncope, LOC, cardiac arrest, lethargy
4. Tachy/bradycardia, dysrhythmia, hyperdynamic precordium, murmur, hypotension
5. Apnea, brady/tachypnea, RD
6. Cardiogenic shock – cold clammy skin, prolonged CRT, diaphoresis, peripheral cyanosis
7. HF – jugular vein distention, hepatosplenomegaly, ascites, peripheral edema

Question 37

What are the diagnostics for myocardial ischemia?

Answer 37

Dx
1. ECG – deep Q waves, peaked T waves, ST segment changes (elevation in acute, depression in latter stage) (classic of ALCAPA)

2. 2D echo with doppler – confirmatory; ID LCA origin, chamber enlargement, systolic and diastolic dysfunction, CA aneurysm
3. Cardiac catheterization with angiography – definitive dx
4. AST, LDH, CK, CK-MB, Troponin T and I elev
5. CXR – cardiomegaly, pulmo venous congestion

Question 38

What is the management of myocardial ischemia?

Answer 38

Mgt
1. Treat underlying cause
2. Oxygenation (intubation and MV), fluids, ICU admission
3. Diuretics, CHF meds, afterload unloaders, inotropic drugs
4. Surgery for ALCAPA: surgical revascularization, percutaneous coronary interventions

Prognosis: High mortality

Question 39

Anxiety and stress can also cause chest pain in children

Answer 39

CH?: ANXIETY/STRESS
- Common cause in adolescents >12yo

CM
1. Hx of recent significantly stressful event
2. Hyperventilation (anxiety), hysterical behavior
3. Hyperventilation syndrome – lightheadedness, giddiness, dizziness, paresthesia, chest pain
4. Chest pain – highly variable: sharp, shooting/ persistent, aching/ burning, numbness, or dull/ stabbing/ tightness. Only lasts 5-10s, at rest

Question 40

Other differentials for chest pain

Answer 40

DDx: GERD (p.46)
Rhythm disturbances (p.220)