of acute anemia and its cause If an intra-abdominal source for chest pain from diaphragmatic irritation is under consideration, a serum amylase may be obtained in the workup of pancreatitis The evaluation of a possible right-sided subdiaphragmatic abscess would include liver function tests and further delineation by ultrasound or CT scan Findings of low PaO2 , EKG abnormalities, and a positive D -dimer are suggestive of pulmonary embolism This suspected diagnosis requires the performance of a helical CT scan for confirmation Esophageal causes of chest pain may often be diagnosed clinically in the ED with a trial of antacid therapy followed by H2 antagonist or proton pump inhibitors To confirm the findings of a hiatal hernia, esophagitis, or a radiolucent foreign body, a barium study or endoscopy may be required The clinician may consider peak expiratory flow testing and/or therapeutic trial of bronchodilators when asthma is suspected as the cause of chest pain Consultation with a pediatric cardiologist acutely for conditions such as myocarditis, pericarditis, acute MI, or significant findings on EKG may be necessary to assist with further workup and tests such as echocardiograms The decision to obtain an urgent echocardiogram depends on the clinical suspicion for diseases such as myocarditis, pericarditis, pericardial effusion, or signs of congestive heart failure Urgent consultation with a pediatric cardiologist should be considered for cases where there is chest pain with palpitations, syncope or chest pain radiating to back, jaw or left arm, patients with high-risk medical history, abnormal physical examination findings such as sustained tachycardia, tachypnea, bradycardia, noninnocent heart murmur, distant heart sounds, gallop, friction rub, increased pulmonic component of heart sounds, edema or swollen extremities or abnormal EKG findings such as low QRS voltages, ventricular hypertrophy, atrial enlargement, AV block, prolonged QTc, (S1, Q3, inverted T3) pattern, PR depression, ST-T segment changes, PVCs, WPW, or delta waves Typically, these patients should also receive a CXR as part of their evaluation Follow-up with a cardiologist, with exercise restriction until follow-up, may also be warranted for a concerning history such as exercise-induced chest pain without other cardiovascular symptoms, significant family history (see discussion under “Child With No Thoracic Trauma”) that places the child at high risk for cardiopulmonary disease, or borderline EKG findings that not meet full criteria for being abnormal Not infrequently, the workup of chest pain including tests such as an EKG or CXR is helpful in allaying parental fears of cardiac disease However, the clinician should be aware that in some cases where a cardiac or respiratory