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Approach to chest pain

The same eight steps, every presentation: threats first, then the history and exam that discriminate, one honest sentence, a mechanism-grouped differential, and the tests read in order.

  1. Immediate threats

    • ACS: the ECG within 10 minutes of arrival
    • Aortic dissection: tearing pain, pulse or pressure differentials, widened mediastinum
    • PE and tension pneumothorax
    • Esophageal rupture after violent vomiting

  2. History that discriminates

    • Character, onset, radiation, exertional relationship, relieving factors
    • Pleuritic and positional features (pericarditis leans forward)
    • Risk factors: age, diabetes, smoking, family history, VTE setup
    • Associated: diaphoresis, nausea, syncope, dyspnea

  3. Examination

    • Both arms' blood pressures; pulses
    • Heart sounds (rub, new murmur), lungs, chest wall reproduction (a partial reassurance only)
    • Signs of failure complicating the pain

  4. Problem representation

    Exertional pressure radiating to the jaw with diaphoresis in a 61-year-old smoker (ACS weight) versus sharp positional pain with a rub in a 28-year-old after a viral illness (pericarditis weight).

  5. Differential, by mechanism

    Cardiac

    • ACS
    • Pericarditis
    • Myocarditis
    • Aortic dissection

    Pulmonary

    • PE
    • Pneumothorax
    • Pneumonia with pleurisy

    GI

    • Reflux and esophageal spasm
    • Esophageal rupture
    • Biliary and pancreatic pain

    Wall and other

    • Musculoskeletal
    • Herpes zoster
    • Panic attack (exclusion)

  6. Investigations

    • ECG first and repeated: a single normal tracing excludes nothing
    • High-sensitivity troponin with a timed delta
    • CXR for the wide mediastinum, pneumothorax, and mimics
    • CTPA or CT aorta when the respective weights demand

  7. Interpretation

    • Territorial ST elevation with reciprocal depression is reperfusion, now
    • Troponin means injury, not automatically infarction: context and delta decide
    • The pain's story outvotes any single reassuring test early on

  8. Next steps

    • Serial ECGs and troponins live on a schedule, not on vibes
    • Chest pain leaves the department with a named pathway (ruled out, observed, admitted), never with a shrug

Connected

ECGInferior STEMICompareSTEMI vs pericarditis

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