whose upper-extremity span exceeds his or her height and with overextensible fingers During the examination, it is useful to relate normal findings to the child and family because this reassurance often serves as the major “treatment” of selflimited or functional problems Some families and patients are simply looking for reassurance that the chest pain is not cardiac in origin Concerning physical examination findings such as fever, persistent tachycardia, persistent hypertension, hypotension, pathologic murmurs, a gallop rhythm, abnormal pulses, abnormal perfusion, hypoxia, and syncope warrant further investigation Pulse oximetry is a quick and inexpensive screen that is helpful in determining the severity of any suspected pulmonary disease An EKG should be performed in almost all cases of chest pain if cardiac disease is a possibility Studies have shown that most cases of cardiac-related chest pain can be picked up based on history, past medical history, concerning family history, physician examination, and an EKG The EKG will be normal in almost all children with chest pain in which the physical examination is unremarkable However, it may show abnormalities to narrow down the differential diagnosis EKG findings may show signs of cardiac strain or ischemia with valvular heart disease, diseases of outflow obstruction, or ischemia Acute cocaine exposure may present with classic signs of myocardial ischemia or cardiomyopathy A decreased QRS wave voltage and electrical alternans suggest the presence of a pericardial effusion in the child with muffled heart sounds Decreased voltages, ST elevations, and T-wave abnormalities may also be seen in diseases such as myocarditis and pericarditis Heart block and arrhythmias, such as atrial fibrillation and supraventricular tachycardia, can occur secondary to anatomic, ischemic, inflammatory, and drug-induced conditions These electrical disturbances may be identified by careful evaluation of a rhythm strip The S1 -Q3 -inverted T3 pattern may be seen on EKG evaluation in those with a pulmonary embolism Finally, concerning findings such as ventricular hypertrophy, QT abnormalities and other pathologic EKG patterns can be found Chest radiographs (CXRs) are not necessary for all patients who present with nontraumatic chest pain They should be used selectively in patients in whom there is a clinical concern for a pulmonary or cardiac cause of the chest pain One may consider obtaining a CXR in a patient with pulmonary symptoms such as cough or shortness of breath, unilateral chest pain, associated shoulder pain, a concerning medical history, or abnormal physician examination findings such as abnormal breath sounds, unilateral breath sounds, a murmur, or abnormal vital signs such as tachypnea or tachycardia The CXR may reveal findings consistent with asthma,