ED Pathway for the Evaluation/Treatment of Chest Pain in Children without Known Cardiac Disease

History and Physical Examination

A thorough history and physical examination will elucidate the etiology or generate a short, specific differential diagnosis. Thus routine laboratory and radiographic testing are not routinely indicated.


Assess VS and general appearance to determine if immediate treatment is needed. Do not immediately assume that the etiology is cardiac. Evaluate the degree of pain and the impact that it has on the patient's life. Determine if the pain is part of an underlying chronic condition. Consider further testing if history or physical exam is concerning. Avoid expensive and invasive testing when pain is chronic and history and physical examination is benign.

History Physical Exam
Pain
  • Onset, frequency, duration
  • Quality, severity
  • Location
  • Radiation, positional
VS
  • Fever
  • HR, RR, BP
  • Pulse oximetry
  • Peripheral pulse, perfusion
Trigger

Exertional

General

Appearance, acute distress, anxiety, chronic appearance

Associated Symptoms
  • Dizziness, near syncope or syncope
  • Dyspnea
  • Palpitations
  • Fever, cough
  • History for foreign body
  • Rash, arthralgia, arthritis
  • Associated with foods
  • Alleviating factors
  • Foreign body/caustic ingestion
Chest
  • Cor
  • Murmur, S2
    Gallop
    Friction Rub

  • Lung
  • Wheeze
    Rales

  • Focal musculoskeletal tenderness
  • Crepitations
  • Asymmetry of chest
Social

Anxiety, depression, substance abuse

Abdomen

HSM, epigastric tenderness

Medications

Recent medications

Other
  • Rash, arthritis
  • Evaluate for evidence of trauma
  • Thrombophlebitis