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Probability diagnosis

Musculoskeletal (chest wall pain):

  • cough strain (10%)

  • injury

  • muscle strain

  • costochondritis

  • precordial catch syndrome (stitch in side)

  • asthma

Note: Most cases are unknown (21%).

Serious disorders not to be missed


  • ischaemic pain: structural cardiac conditions

  • arrhythmias (e.g. PSVT)


  • pericarditis

  • myocarditis

  • pneumonia

  • herpes zoster


  • pneumothorax

  • POTS syndrome

Pitfalls (often missed)

Kawasaki syndrome

Breast disorders


  • Bornholm disease

  • oesophagitis or gastric pain

Is the patient trying to tell me something?

Psychogenic: stress, anxiety, depression (10%).

Key history

  • Usual features of the pain including aggravating and relieving factors such as movement, exercise, rest, swallowing, breathing and eating.

  • Note associated symptoms such as fever, cough, dizziness, overexertion, syncope and recent viral illness.

  • Note family history, especially cardiac disease including unexplained sudden death, recent stressful events and drug history.

Key examination

  • Vital signs especially pulse (including nature) and temperature

  • Palpation of chest wall to determine any tenderness or signs of injury

  • Basic cardiovascular and respiratory examination

Key investigations

  • No investigation usually required

  • Consider ECG and CXR

Diagnostic tips

  • Most cases of chest pain in children are of unknown aetiology and probably psychogenic.

  • Chest pain is more common in adolescents.

  • Less than 5% of cases are caused by cardiac disease.

  • Myocardial ischaemia is rare in children but consider it in any child with exercise-induced pain, adolescents with longstanding diabetes and children with sickle cell anaemia.

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