defect (VSD) is present Eisenmenger syndrome is severe pulmonary hypertension from an uncorrected congenital heart disease leading to cyanosis from right-to-left shunting of blood Isolated anatomic abnormalities such as ASD have been known to present with chest pain and may or may not display the classic findings of a hyperactive precordium, widely split fixed second heart sounds, and both a systolic and diastolic murmur Unrecognized disease rarely causes isolated chest pain in a child who otherwise appears well, but the physician should consider drug exposure (e.g., cocaine; methamphetamine; nicotine; beta-agonist abuse; the triptans; combination of cold medications containing chlorpheniramine, dextromethorphan, and phenylpropanolamine; and herbal medications mentioned previously) Although cardiac conditions are infrequent, attention should be paid to diagnosing the rare patient with hypertrophic cardiomyopathy, angina, mitral valve prolapse, or early pericardial or myocardial inflammation (see Chapter 86 Cardiac Emergencies ) Pulmonary diseases are common and account for approximately 12% to 21% of chest pain cases A first episode of reactive airway disease should be suspected when an associated night cough, history of wheezing, or family history of atopy is present There is a high incidence of exercise-induced asthma which often presents with chest tightness, shortness of breath, and wheezing with exercise These historical features are important as the physical examination may be completely normal during the ER visit Infectious diseases of the respiratory tract are associated with fever, malaise, cough, and coryza, and may involve several family members simultaneously Patients with pneumonia (see Chapter 99 Pulmonary Emergencies ) often present with tachypnea and hypoxia in addition to fever and cough Spontaneous (nontraumatic) pneumomediastinum and pneumothorax may occur in patients with reactive airway disease, cystic fibrosis, or as a result of barotrauma (i.e., Valsalva maneuver, forceful vomiting, or coughing) The pain of a pneumothorax is often unrelenting and pleuritic in nature If the pneumothorax is moderate or large, then patients present with significant respiratory distress and decreased breath sounds on the affected side Spontaneous (nontraumatic) pneumomediastinum is most often reported in male adolescents without underlying lung disease and those with asthma It appears to occur with any activity that involves straining against a closed glottis This is thought to cause a rise in intra-alveolar pressure and subsequently a rupture of the alveoli releasing air into the interstitial space Air then dissects along facial planes of the hilum into the mediastinum and neck Those with spontaneous pneumomediastinum present with substernal chest pain which frequently radiates