While the most common reasons for chest pain in the young aren’t related to the heart, providers need to be certain before they can reassure worried parents. In this presentation for the PCP, pediatric cardiologist Walter Li, MD, breaks down cardiac and noncardiac causes and describes symptom and history details that point to a need for cardiac studies. Included are keys to the physical exam, such as localizing the pain, and tips on appropriate use of specific tests.
So I'm gonna talk about chest pain and Children today, um, seems to be a pretty appropriate topic for valentine's day and any kind of heartbreaks that may or may not occur today. Um, uh, please feel free to put questions into the Q and a section. And towards the end of the talk will do my best to address them as best as possible. So, first things first, I have no disclosures. Um, I'll take applications of course, but I have no disclosures except to say thank you for giving me a porch in your day during your lunch, probably lunch hour to, to speak. So the objectives of this talk are to review what are the causes of chest pain in kids and get a sense of what is the relative prevalence? Both in terms of generally how, how often is it due to cardiovascular conditions and how often is to do to something else? Hopefully I'll be able to give some key um, questions and historical perspectives that will give everyone, um, the ability to quickly um, determine if this is a very concerning chest pain from, from a child versus um, something that is, um, um, uh, where we can provide reassurance rather quickly. Um, we'll also talk about, certainly in pediatric, what are the ages limiting factors and what kind of makes our jobs all much more challenging than necessarily adults. And um, lastly, I do want to go over the appropriate or at least my perception was appropriate use in terms of testing that can be done or should be done in the assessments of Children with chest pain. So in terms of non cardiac ideologies that is By far the most common reasons for chest pain among individuals under 20 years of age, most commonly cost of musculoskeletal radiologists of cost of contractors. So specifically that cartilage that attaches one of the ribs to the sternum, there's also Precor catch syndrome, which is very untypical towards the apex of the heart and its political short and stabbing, very prototypical a sign of recording catch syndrome. Certainly any kind of muscular trauma, particularly among um, uh younger athletes who may be having repetitive motion kind of issues with their shoulders and um very common among particularly um adolescents who are perhaps doing some bench pressing and things like that for to have that kind of muscular trauma and strained their And there is an ideology of hypersensitive typhoid syndrome, which is where literally the typhoid process just underneath the bottom part of the sternum is very sensitive for a very, very small percentage of the population. And certainly one needs to be cognizant of the possibility of sickle cell disease causing chest pain. And then moving on from musculoskeletal radiologist, pulmonary pulmonary causes certainly can result in chest pain, whether it's longstanding known history of asthma or whether it's an acute illness of some sort of pneumonia or some sort of upper restaurant infection. Um, and then pneumothorax is certainly something we need to be cognizant of because that could be potentially um um very, very dangerous. And then Palm ambulance is probably the one I would like to have as a point of emphasis for everyone to have on the radar in terms of the assessments. So in terms of cardiac ideologies and this is probably the reason why it is of such concern for a lot of our patients whom and their families when we take care of. These are the things that we need to be assessing too and hopefully be able to provide reassurance to our patient populations and say, look, these are the things we need to kind of worry about and this is a B C. D. E, why I don't think we need to be worried about it. So the ideology is to be concerned about pericarditis, an inflammation of the pericardium myocarditis, which is the inflammation of the heart muscle itself. Aortic dissection in certain patient population should make us pause and really, really make sure that we get the correct assessment quickly. Perhaps the most um well described one is Mark instagram, for which we have the most robust amount of data in terms of that risk. Although one can certainly extend is the connective tissue disorders such as louis Dietz syndromes and potentially things like L. A. Dance clothes aside from that taco cardiac arrhythmias is something we should be cognizant about and particularly scenarios in which we have this episodic chest pain here and there and hopefully we have patients who are able to tell us that they're feeling like their heartbeats, unusual during these scenarios these times and then finally, perhaps most rarely in terms of cardiac ideologies, chest pains, although certainly from most of our families and patients, what they're most concerned about is is whether or not this is a heart attack, myocardial ischemia and the patient populations for whom we need to be most concerned about in terms of predisposing factors, or patients who have had Kawasaki disease, which did have coronary involvement from the onset of the illness, Williams syndrome, for which some patients may have uh narrowing of their coronary arteries. And finally, and perhaps most controversial is the possibility of anomalous coronary arteries with an inter arterial course. So, going from a historical vantage point for decades and decades now, we've had the gestalt, the sense that chest pain in younger patients is rarely, or very, very rarely due to a primary heart condition. And this is a paper from the 1980s that is showing in this author's um, In their data set. How often or what types of chest pain or what were the radiologist, chest pain back in their data set in the 1980s. And you see from here, the vast majority of them percentage wise, non cardiac ideologies Looking at it from the 90s and updated um, uh, dataset. Different authors, different patient populations. We see fairly similar distributions in terms of this is a cardiac very small percentage of time in Hoffman. Is are these other general broad categories. In fact, when they wrote the textbook Early to mid to late 2000s, this is the congenital cardiac um textbook that pretty much every pediatric cardiologist reads during our training, the frequency of chest pain in those editors experience. And to which they decided to devote seven out of 1000 nearly 1400 page textbook, they decided to develop seven pages in terms of talking about chest pain in pediatric patients because it is in terms of cardiac causes. It's that rare. Well, we have even more data at this point in which that in which to refer to that is in my opinion, very reassuring for ourselves and for our patients. So this is what we turned this camp study. So this was conducted at the Children's Hospital in boston in the two thousands and it looked at patients who came into pediatric cardiologist office for an assessment of chest pain. And I refer to this study pretty much universally whenever I see patients for chest pain in office And I try to convey the information as plainly as possible to all the patients tell them over 3000 patients were assessed in in this case. And yes, small percentage time there are cardiac issues. What I found interesting from this study and if you look at the ideologies listed here from the authors is that, yes, some of these things are pretty dangerous. But a number of them. And I would and even totalling the numbers here, total The majority of them don't primarily cause chest pain. They may have chest pain in addition to feeling palpitations, feeling tired. But in terms of what potentially could just primarily cause chest pain, it's actually the minority even among that 1% of the time. And I should also add that this is a patient population that was specific. They were patients referred to pediatric cardiologist office. So you can imagine that, um, that this is 1% of patients coming to the pediatric cardiologist office and then you can probably derived from your own experience from in clinical, how often are there other patients for whom it's clearly musculoskeletal. So they don't even come to see the pediatric cardiologist. So the possibly the incidence of cardio causes of chest pain are thankfully very, very small. Well, if we do look at the patients who do have cardiac causes of chest pain, well, what are the relative incidences of it and the by far and large. And, and um, what I hope everyone can kind of take from this is that it's primarily for different things. And I wouldn't even say primarily three different things. So my rock artist paris artists and pulmonary embolism and to that and it's very advantageous because it will show us and inform us in terms of what types of testing will be very helpful in terms of high yield and what is the appropriate use in terms of these assessments. I'll come back to this in a little bit. This is another state, which I found to quite quite fascinating. So this was a study conducted again in the 2000s out of an emergency department in Turkey. And it was quite an intense study. So 380 Children, all of whom coming to an emergency department, Um, all had these four core studies and then depending upon the specifics of the history, additional testing was done. And what I find to be quite quite quite interesting is that in an emergency room based patient population, they're all pediatric patients. So this is very severe, very concerning chest pain In terms of cardiac causes of chest pain, things that are potentially dangerous. Out of 380 patients, one, One out of 380 had chest pain, those primarily cardiac um, in ideology. So hopefully none of none of us as a cardiologist are having dis disposition when we were answering a question about chest pain from our perspective and often times, yes, I do acknowledge. I do have have seen this situation for what we say it's not the heart. However, I would amend that to say, okay, let's say it's not the heart, but well, if we're saying that, make sure we don't say it's not, you know, we don't miss myocarditis. Mark Carney scheme or pulmonary embolism. So what's helpful in terms of the assessment? Well, I think history, so, learn knowing the past medical history will give us a sense of whether this is a vulnerable patient to whom we should be diverting more resources to the assessment. And to me, the scenarios in which is more concerning our patients who may have um, a potential risk to the coroner artist from past or past or underlying illnesses. That's Kawasaki disease or willing syndrome. But the other patient population would be very concerned. That would be more concerned in terms of the risk of aortic dissection. So hopefully this is something we can help uh, determine uh, very early on whether this is something this is a patient we need to triage quickly to emergency services or have a more expedited assessment. The context in which the chest pain has been experienced. I think it's very, very informative. I worry a great more a great deal more about patients who are having exertion, All chest pain because to me that is concerning for the possibility not inevitability but possibility of coronary ischemia. Um, if it happens with respirations, specifically, a deep breath causes the pain to be worse. Oftentimes that points to a pulmonary unknowing point price or a muscle skeletal process because we're having stretch stretches of the different intercostal muscles and the muscle groups overlying the chest wall. Sometimes we have very insightful patients who will give us the answer already and they'll say, yeah, at the time, the chest pain and keep pushing on this one spot here it hurts. In which case it makes our job much, much, much easier to say, Yeah, that's probably very likely musculoskeletal. Other social symptoms may be helpful in terms of of helping us in terms of determining how concerning or what the underlying ideologies are palpitations. Sometimes they're helpful, particularly palpitations occurring before the onset of chest pain may point us to the possibility of a of attack of cardiac arrhythmia to shortness of breath. Perhaps the patients themselves can't initially articulate that. Oh, yeah, I feel the pain a lot more. So when I take a deep breath. But then when you prompt, you know, when they say, you know, I have some shortness of breath and can prompt us to say, well, are you having shortness breath? Because when you take a deep breath it hurts a little more. And sometimes that kind of helps trigger the memory a little bit in terms of what, what the possibilities are. Review of symptoms can be helpful. So, if you have symptoms of an upper respiratory infection or or past history of Covid or a pneumonia that can potentially be helpful and reassuring in terms of nothing imminently dangerous. Family history. Um, Oftentimes in these scenarios, we get a family history of grandfather, uncle parent who's had symptoms of myocardial scheme, which helps us kind of understand like, okay, what are some of the other issues are going on here. Perhaps that is feeding into a pediatric patient who has a type A personality who now says, oh gosh, that's gonna be, that's gonna be me. In which case then we're starting to get more sense. Like, you know, maybe there's a little bit of stress here, a little bit of anxiety kind of going on here. But we understand that because of the family history. Um, other times we are, if we understand that, hey, this is an elite athlete who wants to exercise all the time. They're having some chest in here that may put that frame that patients concern a little bit more so and help help us kind of guide us in terms of figure out, hey, what's the best way that we can provide reassurance for these different patients? So I think particularly in this, you know, chest pain and Children, I think that physical exam can be extremely, extremely informative and particularly reassuring. And one of the reasons is that on his exam, sometimes we can localize that that pain to the point where we can be so, so, so specific that we can help persuade families and patients say, you know, this is very clearly chest wall pain. This is very clear to muscle felt and ideology or oftentimes this is clearly caustic arthritis and the way and as with most things in life, the devil is always in the details exactly. How do we go about that? And for me, it's not just a matter of just generally, hey, where the area is, it's finding that out from the onset from the patient. But then going point by point and for me, what I do is I actually go fingertip point by point until I get closer and closer and closer to that one spot And about probably about 70, of time we can locate. Like, Yep, that's that one spot. That's the spot that that that bothers me, that's causing me to paint. You may radiate to other places but instigating that and explain to the families and to the patient like, look, this is chest wall, there's no way I can affect your heart by pushing just with my fingertips here. So we're in a good spot. We're okay. It also gives us stopping on physical exam to take a listen. So it wouldn't be unheard of to basically hear diminished breath sounds like, oh gosh, this is uh this is unorthodox. And I need a little bit of help here. Sometimes we hear very diminished heart sounds and we begin to, you know, begin to be concerned about pneumonia and things. Certainly chest wall deformities can be helpful. So, it's not necessarily a patient has Marfan syndrome who have may have, um, uh practice abnormality for which that can be painful, in which case that is. We know where that patient will get the most optimal or most direct care in terms of perhaps potentially a surge in terms of assessing that um, that possibly facialist dwarfism may give us some insight some clue that perhaps this is a patient has Williams syndrome and perhaps we need to be assessing for those possibilities of different arterial narrowings. Certainly vital signs will help us triage and help the terms like, how much do I need to be worried about myocarditis in this patient? Or pulmonary pulmonary embolisms. So all those different basic routine vital signs that were always kind of getting these patients could be extremely, extremely helpful. So, with that, well, one of the things we have to kind of watch out what are the specific um, details and symptoms that point as to the possibility of myocarditis. Well, interesting thing. It's not, it's as with most things in, in our field, it's never usually just one thing. It's usually multiple things and that's what I like from this kind of. This first table, here's usually not any one thing. Usually there are multiple things kind of going on that kind of clue us in. It's not always just the fact that I have chest pain for patients with myocarditis and it makes sense if you think about, well, what is the meaning of myocarditis is, Well, the heart muscle is inflamed. Typically it doesn't work super duper well, in which case the ability of the heart to receive blood, push blood gets impaired and then blood typically backs up. So typically these are patients who have both chest pain. They also will have to keep nia there. Have you struggled a little bit to be, particularly when we get to a very dangerous spot. Hopefully we're not at a point where we're seeing hyper fusion but uses a combination of things in terms of symptoms in terms of pediatric myocarditis and these are the other different factors that we see in terms of physical exam findings. It's usually a number of these different things, not any one particular, not chest pain and isolation. The other one I think is really important for us to always assess for it and and um look out for is Parmalee embolism. Yes, chest pain is definitely one of those symptoms, but typically we're seeing a number of other symptoms with with that and we're seeing other vital signs to Kaka Correa takinmia, low auction saturation for these patients here. However, one thing I do want to kind of put as a point of emphasis, it's not super duper, it's not the majority of patients without any underlying issues for home, whole metabolism is commonly seen. In fact, there are number of underlying conditions for which should prompt us to say. I really need to think about minimalism. Now, yes, patients who are await and yes, that's a increasing problem and an issue that we we all see as uh the recent controversy from the american Academy pediatrics in terms of bariatric surgery and such I think informs us about. But in terms of things where we'll know ahead of time. Yeah maybe someone had an indwelling catheters part of their congenital heart surgery. Or maybe it's someone who's followed with nephrology from from neurotic syndrome. Or perhaps they've previously palmettos. And these are the scenarios in which we need to be much more cognizant of the possibility of minimalism. And usually it's not just one thing, it's multiple things. So this is an emergency uh department based study in terms of hey what are the different factors we're kind of seeing here? So usually it's multiple different things that we're seeing. So differential symptoms. So this is this is much more adult base because um it's not, thankfully with a pediatric patient population, we don't see Marquardt skiing paralyzed implement as much. But these are some of the differentiating factors here. So with with in terms of the character that pain, the less traumatic the pain is the more concerned I am about the possibility of of a heart issue. So market ischemia, they tend to be pressure, like heavy squeeze. Not just dramatic. Oh my goodness. Someone spot that really kind of really really hurts. But you contrast that to things like characteristic palmer embolism. It's very different positional changes points us more towards the possibility of pericarditis. Um The E. K. G. To me this is a particularly helpful differentiating factor here because they will look very very different. So if that rare occasion where we're seeing myocardial ischemia causing chest pain. It's going to be localized to the segments of myocardial that are being affected. You contrast that to pericarditis means the entire heart is the lining the hearts everywhere. So that will cause widespread changes everywhere. And I'll show you some examples of this in the in the ensuing slides. And then you contrast that paul minimalism. Well, from a physiological standpoint when it's really, really bad for minimalism will cause strain on to the heart and we'll see those changes limited to the E K. G leads that are affected by the right ventricle function. So what is helpful, you can probably already tell that, I think very strongly that E K G is helpful in this case, and this is one of the E K G and one of the data points that it informs my kind of decision making process. And chest actually can be helpful. But I think the E K G is perhaps a little bit more informative and proponent maybe. Um although you oftentimes find some other things for chest pain not otherwise specified. Um, and if you're waiting for the opponent kind of tell you someone subject, then you kind of have some issues, but it could be helpful, but it's more of a affirming things like I already think this patient's myocarditis. I already think this patient has perry myocarditis. Okay, let's see what someone is like. You know, it's elevated. Okay, yeah, this this makes me more and more convinced that my my presumptive diagnosis is accurate. Sony KGs. So a quick reminder from that pirate slide. So myocarditis, we're going to see diffuse low voltage amplitudes sometimes, particularly if the if the ventricles are really really strange, will see T wave abnormalities contrast the pericarditis. Typically the voltages unless there's a massive pericardial fusion but typically the voltages will all be okay. We'll just see diffuse S A segment elevations everywhere. The EKGs help in terms of assessing actively for the possibility of cardiac arrhythmia and certainly myocardial ischemia but these are localized changes. So we only see them in very specific distributions on the E. K. G. So as an example, myocarditis. So this is I think we can all generally agree the voltage amplitudes here of the our waves are all dressed. We dressed decrease. In fact the only ones that we see anything remotely kind of normal is the right heart distribution here. Sometimes what we're seeing is not so much a very um profound um decrease in the R wave um amplitudes but we're seeing diffused T wave inversions. What oftentimes is referred to as wide QRS T wave angle. In other words, the T wave doesn't fall along with the QRS complex access in pretty much all the leads. This is an example real life example of someone who um was known to have lupus and then for um reasons um that the patient didn't want did not want to share decided just to stop taking all the medications and it was um one of the worst heart functions I've actually seen is someone who is awake and alert contrast anticipation with an example of pericarditis. So we see diffuse S. T. Segment elevations and pretty much just about all the leads here. Another example of this is shown here. So we see perceived here depressions and S. T. Elevations pretty much in every lead. Another example this is a patient whom actually came to the emergency department saying they have chest pain and lo and behold E. K. G. Was done this patient had diffuse sc elevations everywhere contrast that to a patient who is tachycardic and we look and see if they have a normal rhythm. And in this case this patient has S. V. T. Super intricate tachycardia. You see narrow complex tachycardia at a very very elevated heart rate. Sometimes a patient may not be actively having a arrhythmia but we'll see uh a underlying substrate for S. V. T. In wolf Parkinson white. So that's due to an accessory pathway. Extra nerve from the atrium to the ventricle resulting in a short pr interval and a uh slurring or quote unquote delta wave. And this was thankfully it's really rare that we see my we see mara Karlin infarction with with with Children. Uh This is an example of a patient who underwent an electrophysiology study and was having a catheter ablation. Not my patient by the way um whom had a corner injury from their ablation. You can see localized S. T. Elevations with reciprocating S. T. Depressions. Hey mentioned in one of the earlier slides of the possibility of an abnormal coronary. Unfortunately resting H is probably not going to inform us very much because, well the resting, there's no active, increased Marquardt, demand increase, need for coronary perfusion at that point. So typically their E. K. G. Is normal, particularly uh early in terms of the potential of their symptoms. However, let's say this is a patient whom tells us, yeah, I have chest pain any time I exercise or most of the time when I exercise when oftentimes we may ask them to do exercise in the monitor setting. In which case we'll often see this. So we'll see T wave inversions, S. T. Elevations induced by increased work on an exercise test. So this is the same patient by the way between their baseline KJ here and their exercise test here. So, very market market abnormalities. So if I may, I'm advocating for the use of um mostly EKGs, although most of the times we are often asked to say to to see if an echocardiogram is helpful in terms of the patient's assessment. So this was um again the scam said the study conducted in boston and they had some pretty, in my opinion, persuasive data about how useful the echocardiogram is um for um chest pain assessments and this. These are the criteria in which they set uh for their study protocols like for which patients are we going to be doing? Um are we gonna be doing echocardiograms? So you can see they're very delineated E. K. G. Findings, historical findings and that informed that that decision making process. And in terms of historically just over the phone, you know, just patient telling us these are the things I found particularly uh informative and the things that in terms of the underlying ideology these are the things that scare me what potential would scare me. So even in that context, so test is recommended. They also compared when the test is not recommended. And I don't recall why they still went with the echocardiogram. Um even if it wasn't recommended. But probably it's good reasons um that that didn't fall into the state's parameters. The interesting thing is even in the case where the test is recommended. So basically the patient had chest pain with exercise or some other kind of concerning things. Out of over 400 patients, only two had a underlying cardiovascular abnormality that would explain their pain in their series, patients were far far more likely to have an incidental abnormality, not associated chest pain than they were to have a finding on echocardiogram that explained their chest pain add into that a publication from uh in the uh I believe this was american College of Cardiology and this was a pediatric cardiology echocardiography workgroup. And they were saying, okay, what are the times we should be doing echocardiograms for these patients. And they had a section about chest pain here. They reported very very similar findings. So in their case it wind up being running up to 1% but still Extremely extremely small percentage of patients. Even in the context. This is number 30 here. That the numbers are coming from here. Even in the case of exertion, all chest pain. The possibility of finding on echocardiogram in and of itself of the underlying explanation for chest pain. Very, very small. Even in the classic case. The other thing I thought was very very informative helpful from that study from boston and I refer to this um all the time when I talk to patients is that they checked in on all the patients Like 5-10 years after the initial cardiology visit, including the patients who had a heart condition in their series and 5 to 10 years is a pretty good length of time in terms of follow up, no patients had died from the card Alaskan dishes. And in fact in the text of the um of the paper, they even report about any um uh they say there weren't any significant cycle even among the patients who had Karbaschi, even if they survived. Well even though even among the patients all survived, none of them even had something horribly go on and had a significant morbidity from their underlying cardiovascular condition. So okay, hopefully I've given you some some information that's reassuring to say okay well maybe the cargo. Maybe not too terribly helpful. What's what are other things that could be helpful? Well I think in the case of exertion chest pain I think an exercise test could be potentially helpful for, well for one um if you do have someone who has very significant abnormal coronary you pick up on it. But I think the other reason why it can be pretty helpful is helps build reassurance to say hey we have you monitored the whole time. Someone is assessing your testing. We're looking at your E. K. G. The entire time. We're checking the blood pressure the whole time. We're seeing how you're doing. Sometimes we're even doing a full cardiopulmonary exercise test where we even measuring the oxygen consumption and the C. 02 production the whole time. Um This is potentially helpful. This is pictures from our prior exercise uh lab in um in the Parnassus campus. But we have multiple places where we do these types of testing. Um It's potentially very very helpful. And one of the reasons I think we need to be cognizant of like what is helpful. It's because medicine is getting really really expensive over time. And I like to think that we're all good stewards in terms of, hey I want to let's take care of you. Let's take care of you in the most efficient and economically responsible way possible. And for me this is Old data is about 10 years old. So I don't have an updated for inflation and things like that. But to me it's still impressive from 10 years ago. This is how much things cost. So an E. K. G. Relatively speaking is one of the cheapest things we do in all of medicine. To be quite honest, some of these other things that we do when the echocardiogram, I mean it doesn't hurt anything but it's still pretty costly monitors. This is what, how much they cost in terms of doing heart rhythm monitoring. Uh in terms of a chest x ray that's aside from the radiation exposure, that's uh that's that's uh not not cheap an exercise test. Well, it often depends on where we're doing the exercise test. So in a hospital based testing, it's, it can be pretty, pretty darn expensive. Um, these are kind of add on. So if you do pulmonary function tests and we do not, um, nuclear model car profusion. It's additive. That total is additive $2-$3,000. Um, and then certainly an M. R. I. Uh, it can be quite, quite costly. So I think it's really important for us to use these resources in as responsible a manner as possible. So, overall by far and large, most patients, pediatric patients who have chest pain most time. What is needed is reassurance. And to me that reassurance starts with the history and physical. Um I think sharing data, sharing our understanding of the medical literature I think is very helpful. The patients saying like look this is not just my opinion. These are multiple people's opinions. This is the data. This is the research that is available that is widely available that we all kind of look at. So this is has been investigated. So these these these are the pieces of information that's helped me draw this conclusion. So you're it kind of helps build that confidence for for those families like No we you know we we have the right screenings. We know what are things to kind of look out for. I would advocate for the use of the E. K. G. In these situations but I will fully fully acknowledge that I have a little bit of a bias because I do think that universal E. K. G. Screenings are helpful for the population in general. Although I do admit that is a very very controversial topic sometimes, particularly these episodic chest pain. And we have the and then we have the concern for palpitation, the possibility of attack artemia. That ambulatory cardiac rhythm monitoring could be helpful. Not universally could be helpful in select cases. Exercise testing. Again, depending upon the circumstance can be helpful perhaps that a patient who is an athlete who is the high school quarterback who's convinced that he's going to be um leading the Kansas City Chiefs to the Super Bowl. Yeah maybe that patient, you know, needs a little bit more reassurance kind of going forward or this is the, this is the person who's classics that every time I exercise it hurts and I will certainly get to questions at the end. I'm almost done. And then lastly I'm not saying never. I think imaging should be one of those issues that we rarely consider mostly because I think the physiology is there and the physiology we have other means to assess for and can provide those types of reassurance for the most part, knowing what the underlying ideologies are. That is most times they're musculoskeletal cause chest pain, Nonsteroidal anti inflammatory medications can be helpful quite commonly will suggest. Um, it depends on size a week's worth of ibuprofen or whichever non steroidal anti inflammatory one is comfortable with. I usually will recommend that for about a week and to see if it does help. I fully tell the patients this may be helpful. It may not totally extinguished but it's reasonable to try and really what we're trying to do is as homer is trying to tell us here is own your OK Nous, we're trying to empower patients to say, okay, this is why we know you are okay mm. So conclusions, chest pain, very anxiety broken. Yeah, probably rightfully. So because we hear less scary things that happen to adults with, with chest pain fully acknowledging we don't always always have the answer. Although I always kind of like to refer these situations. We are all fallible. We may not know exactly what the right answer is, but I think what our duty is to patients say. Look, I'm assessing for the really scary things. The things that we need to treat now. The things that are potentially dangerous and often times that's helpful. And then we can say, what are the things that make us really, really worried? Well, the cardiac causes? Well, thankfully are really rare and they usually don't present with chest pain. The other thing that can be really helpful in terms of counsel patients and say or kelly. Well, maybe saying has not been reported referring to this game study. Maybe a little bit extreme. I mean, there's I think I would amend that to say it's extremely extreme really. You know, every so often people here of these different actors that perhaps overly overly persuade us one way or another in terms of doing assessments in my opinion, I think the chest of the pediatric chest pain, chest pain and Children often results in excessive amounts of testing. Where as I think what standard lee is helpful history basically. Old school things. Things have been around for decades. You know, hundreds of years. History, physical exam E K. G. I think these are always appropriate. Not saying additional testing. Not helpful, but I think it depends on the context, depends upon what specifically we're looking for
