palpitations, and physical examination findings such as a gallop rhythm and a murmur secondary to mitral valve insufficiency Inflammatory conditions such as pericarditis and myocarditis can present with chest pain and systemic symptoms Pericardial disease includes pericarditis, pericardial effusions, and cardiac tamponade Pericarditis often presents with fever, a stabbing chest pain that improves with sitting up and leaning forward, respiratory distress, a friction rub, and distant heart sounds Pericarditis and pericardial effusions can restrict outflow leading to neck vein distention and in severe cases of tamponade, pulsus paradoxus (see Chapter 86 Cardiac Emergencies ) The presentation of myocarditis can be more subtle with mild chest pain and fatigue for several days followed by the development of fever, dyspnea, and worsening chest pain The examination often shows tachycardia (or bradycardia when severe), orthostatic changes not improved by fluid resuscitation, pulsus paradoxus, and a gallop rhythm Both pericarditis and myocarditis are usually associated with a preceding viral illness Endocarditis is most often seen in children with a history of congenital heart disease but can present in those with no known predisposing condition Patients are often ill appearing with a history of prolonged fever and may have signs of embolization Other illnesses that can present with carditis include rheumatic heart disease and Kawasaki disease Chest pain associated with mitral valve prolapse is controversial Studies have shown that mitral valve prolapse is not more common in those with chest pain than in the general population and other etiologies of the chest pain may exist in a patient with this condition However, chest pain in patients with mitral valve prolapse may be secondary to papillary muscle or left ventricular endocardial ischemia A midsystolic click and late systolic murmur should be found on physical examination Pain secondary to mitral valve prolapse should be considered only when no other etiology may be found Patients with connective tissue disorders such as Marfan syndrome have the potential to develop aortic dilation, aortic dissection, and rupture Symptoms of aortic dissection/rupture include generalized distress with unrelenting severe chest pain, decreased cardiac output, dyspnea, and often abdominal pain Children who present with chest pain days to months after cardiac surgery should be evaluated for signs of pericardial effusion known as postpericardiotomy syndrome Patients with pulmonary hypertension may present with exercise intolerance, palpitations, and syncope The resultant right ventricular dilatation may be found on physical examination as a narrowed second heart sound, hepatomegaly, and cyanosis if an atrial septal defect (ASD) or ventricular septal