This is a 6 year old male who presents to the 
emergency department at 10:30 pm with chest pain and 
difficulty breathing.  He has had the pain since the 
afternoon which is located in his anterior chest but its 
quality is difficult for him to characterize.  His pain is 
worse when coughing and taking a deep breath.  He 
has been coughing a lot and this has  been worsening 
over the past 2 days.  He felt warm last night, but his 
temperature was not measured.  He has not had a 
fever since then.
     His past medical history is negative for asthma, 
pneumonia and heart disease.  He has been largely 
healthy to date.  His immunizations are up to date.  His 
family history is unremarkable.
     Exam:  VS T37.5, P125, R25, BP 107/65, oxygen 
saturation 97% in room air.  He is alert and comfortable 
in no acute distress.  He is not toxic and not irritable.  
HEENT unremarkable except for minimal nasal 
congestion.  Neck supple without adenopathy.  His 
chest wall is non-tender over the ribs and sternum.  He 
does have some increased chest pain with deep 
inspiration.  Heart regular, good tones, no rubs, 
murmurs or gallops.  Lung auscultation reveals 
moderately decreased aeration.  No wheezing is heard 
but he is not moving air well.  He has a bronchospastic 
sounding cough.  Abdomen soft, non-tender, bowel 
sounds are active.  His back is non-tender.  His 
extremities show good pulses and perfusion.  No 
peripheral edema is evident.
     A chest radiograph and an EKG are ordered.

View chest radiographs.
View PA.


View lateral.


     His 12-lead EKG is normal.  His chest radiographs 
demonstrate the cause of his pain.
     The differential of chest pain in children includes 
cardiogenic causes such as percarditis, myocarditis, 
endocarditis, etc., due to various etiologies.  Coronary 
artery disease in children is uncommon.  
Non-cardiogenic causes include musculoskeletal 
etiologies, pneumonia, pulmonary air leaks, other 
pulmonary conditions, abdominal etiologies, aortic 
conditions, etc.  Most of these conditions can be 
recognized or at least suspected on routine chest 
radiographs.
     Our patient's chest radiographs demonstrate a 
pneumomediastinum.  





     There is evidence of subcutaneous emphysema in 
the neck on the PA view.  Note the air densities in the 
patient's neck which is more prominent on the patient's 
right (arrows), there is also some air dissection on the 
patient's left (arrow).  The remainder of the PA view is 
unremarkable.  The usual vertical air densities seen 
closer to the lungs in a pneumomediastinum on the PA 
view are not evident here.  The lateral view shows a 
prominent air collection anterior to the heart just above 
the diaphragm (arrow).  There is a prominent air density 
outline of the trachea on the lateral view (arrow points 
to a double outline of the tracheal air column) which is 
again suggestive of pneumomediastinum.  The 
common finding of seeing thymic demarcation and 
linear air densities in the anterior mediastinum is not 
evident here.  
     Refer to  Case 7 of Volume 1 (Hamman's Sign) for a 
more complete discussion of pneumomediastinum.

     He is given an albuterol aerosol which results in 
improvement in his aeration.  Mild wheezing is noted.  
He feels much better and his chest pain is minimal.  He 
is discharged on an albuterol inhaler with a spacer with 
instructions to return if his discomfort worsens.  He is to 
see is primary care physician in the morning.