Causes |
History |
Assessment & Investigations |
Cardiac |
Myocarditis |
- Non-specific symptoms mimicking respiratory disease or sepsis
- Recent viral illness eg coxsakie, parvovirus, influenza
- Recent (1-14 days post) mRNA vaccine received (higher risk adolescent males and after 2nd dose)
- Dizziness or syncope
- Feelings of palpitations
|
- Abnormal BP and or heart rate
- ECG changes possible (eg sinus tachycardia, non-specific ST segment and T wave changes)
- CXR changes possible
- Troponin raise possible
- CRP / ESR raise possible
- (see
COVID-19)
|
Pericarditis |
- Retrosternal chest pain
- Pain improved by sitting upright or leaning forward
- Recent (1-14 days post) mRNA vaccine received (higher risk adolescent males and after 2nd dose)
|
- Tachycardia
- Pericardial rub
- ECG changes possible (eg diffuse ST elevation with PR depression; T wave flattening; deep symmetrical T wave inversion)
- CXR changes possible (if effusion present)
- Troponin raise possible
- CRP/ESR raise possible
- (see
COVID-19)
|
Endocarditis |
- Fever of unknown origin
- Congenital or acquired cardiac condition
- Cardiac surgery history
- Valvulopathy or replacement
- Aboriginal or Torres Strait Islander
- Recent dental procedure
- Recent skin infection or procedure
|
- Dukes Criteria for IE
- CXR changes possible
- Cardiac echo
|
Aortic dissection |
- Acute onset ‘tearing’ chest pain
- Pain radiates to back
- Known connective tissue disease eg Marfan, Ehlers-Danlos
- History of Kawasaki disease
- Known aortic root dilatation
|
- New murmur with no alternative aetiology
- Difference in BP’s upper limbs
- Pericardial effusion
- Pleural effusion
- CXR changes possible
|
Arrhythmias |
- Palpitations
- Exertional chest pain
- Syncope
- Dizziness
- Family history of arrhythmias eg Brugada
- Family history of sudden cardiac death
|
- Abnormal BP +/- heart rate
- ECG abnormalities possible
- Electrolytes abnormalities
|
Cardiac ischaemia |
- Pain radiating to arm or neck
- Blunt chest trauma
- Cocaine, methamphetamine or synthetic cannabinoids use
- Known cardiac disease or cardiac surgery
- Kawasaki disease history
- Hypercoagulability history eg SLE
- Hyperlipidaemia history or family history
- Long standing diabetes history
|
- Abnormal BP and or heart rate
- Arrhythmias
- ECG changes (ST and T wave changes)
- Raised troponin
|
Pericardial effusion |
Screen for risk factors:
- infective (recent viral, bacterial, TB, fungal)
- auto-immune history eg lupus
- neoplastic eg neoplastic
- post procedure (recent cardiac / thoracic surgery)
- post MI (unlikely paediatrics)
- uremic (chronic renal failure, especially if pre-dialysis stage)
- recent treatment radiation
- drugs (rare)
|
- Hypotension
- Distended neck veins
- Muffled heart sounds
- CXR changes possible
|
Pulmonary |
Pulmonary embolus |
- Recent surgery or immobility
- Malignancy
- Hyepercoagulability history
- CVAD in situ or recent
- Pleuritic pain
- Haemoptysis
- Dyspnoea
|
- Hypoxia with no other cause
- Tachycardia with no other cause
- Tachypnoea with no other cause
- ECG changes possible (eg tachycardia, RBBB, right sided T wave changes)
- CXR changes possible
|
Pneumothorax |
- Tall/thin adolescents
- Acute pain or dyspnoea after cough/Valsalva manoeuvre
- Acute onset, severe, stabbing chest pain
- Can be pleuritic
|
- Can have normal exam
- Sweating
- Tachypnoea and or tachycardia
- Decreased/absent breath sounds
- Hyper resonance on percussion
- Asymmetric lung expansion
- CXR changes
|
Acute Chest Syndrome |
- Known sickle cell disease
- Current or recent infection, dehydration, fever, hypoxia, sedatives or surgery
|
- Fever/dehydration signs
- Tachypnoea/tachycardia
- CXR changes possible
|
Exercise Induced Asthma |
- Exercise induced chest pain with dyspnoea/cough
- Previous history asthma
- Other atopic history
- Salbutamol responsive
|
- Tachypnoea
- Talking short sentences
- Hypoxia
- Widespread wheeze
|
Pneumonia |
- Fever
- Cough
- Increased WOB
|
- Lethargic
- Fever
- Tachypnoea and WOB
- Hypoxia
- Localised crackles or absent breath sounds
|
Pleural Effusion and Empyema |
- Chest pain, can be pleuritic
- Fever >48 hrs despite antibiotics
- Lethargy
- Dyspnoea/WOB
- Unilateral chest pain
- Refusal to lie on one site
|
- Localised decreased air entry
- Localised dull percussion
- Decreased chest expansion
- Apparent scoliosis (due to pain/muscle spasm)
- CXR changes
|
Pleurisy |
- Sharp stabbing localised chest pain
- Pain worse with deep breathing, coughing, movement, certain positions (pleuritic)
- May have recent or current cough or fever
- May be entirely well apart from new pleuritic chest pain
|
- May hear pleuritic rub over area of chest pain
- CXR normal (unless underlying condition causing pleuritic pain eg pleural effusion)
|
Inhaled Foreign Body |
- High degree suspicion children
<4 years age
- High degree suspicion older children with developmental impairment
- Might present days to weeks after event
- Persistent cough,fever, wheeze or consolidation
- Haemoptysis
- Increased WOB/stridor
- Colour changes if acute event
|
- May have normal exam
- Stridor/voice changes
- Tachypnoea
- Hypoxia
- Focal wheeze
- Localised decreased air entry
- Asymmetrical chest movement
- CXR might appear normal, look for air trapping
- Ask for inspiratory, expiratory and lateral decubitus views
|
Musculoskeletal |
Muscle Strain / Trauma |
- Recent trauma
- Recent overuse (ask about activities, hobbies, jobs)
- Chronic cough
- Localised area of chest pain
- Worse with movement or deep breathing
|
- Localised area or muscle groups of tenderness
- Reproducible with palpation, movement, deep breathing
- Bruising
|
Precordial Catch |
- Sudden and sharp onset chest pain
- Pain along left lower sternal border or cardiac apex area
- Onset can be during rest or activity but not during sleep
- The episode can lead to shallow breathing as a way to cope with pain and feelings of intense anxiety due to pain
- Episodes are intense but brief lasting 30 seconds to 3 minutes
|
- Normal exam
- No special investigations
|
Costochondritis |
- Sharp or dull chest pain
- Gradual or rapid onset
- Pin point area to 2 or 3 adjacent ribs
- Reproducible with palpation, movement or deep breathing
|
- Tenderness to palpation of costochondral junctions Reproducible localised pain or discomfort
- Usually unilateral
- Usually ribs 2 to 5
- No swelling
|
Bone destruction:
Osteomyelitis /
Bone neoplasm |
- Localised chest pain
- Can be subacute or chronic pain
- Night time pain or awakening from sleep
- Pain persisting after minor trauma
|
- May be well clinically
- Non-specific localised bony tenderness
- Localised soft tissue swelling
- CXR changes possible
|
Gastro-intestinal |
Gastro-oesophageal reflux/ oesophagitis |
- Heartburn
- Non-specific chest pain
- Epigastric discomfort or pain
- Recurrent vomiting
- Odynophagia
- Food refusal
|
- Possible epigastric discomfort/tenderness
|
Other |
Breast tenderness |
- Localised to breast tissue area
- Premenstrual or cyclic: PMS
- Non-cyclic pain: consider fibro-adenoma, breast cyst or breast abscess
|
- Breast lump right under the areola = breast bud
- Other features puberty supports breast bud diagnosis
- Consider ultrasound if breast pathology suspected
- Fever, redness or axillary lymphadenopathy indicates possible infection
|
Shingles |
- Prodrome of pain or hyperalgesia over one or more dermatome that does not cross midline
- History of previous shingles
- Confirmed contact
|
- If rash present: clusters of vesicles on red bases that is confined to one more dermatome that does not cross midline
|
Psychogenic |
- Mental health history
- Drug/alcohol use
- Social stressors
- Consider HEEADSSS screen
|
- Transient hyperventilation +/- tachycardia
- Normal exam
- Normal ECG
|