Chest Pain


Orders: EKG, Trop, CXR, cbc, bmp+Mg, tele, Echo?

-- DDX:
HEART

  • ACS / MI → EKG, troponin serials
    (pressure/heaviness, exertional, diaphoresis, radiation to arm/jaw)

  • Arrhythmia → EKG, tele, BMP/Mg
    (palpitations, dizziness, syncope)

  • Pericarditis → EKG, troponin, ESR/CRP, echo if effusion
    (pleuritic pain, better leaning forward, worse lying flat

  • Tamponade → Bedside echo
    (hypotension, JVD, tachycardia, dyspnea)

  • Aortic dissection → CTA chest/abdomen, CBC/CMP, type & screen
    (sudden tearing pain to back, pulse/BP asymmetry,HTN, may hypotensive if rupture)

LUNGS

  • PE → CTA PE, troponin/BNP, VBG/ABG, D-dimer if low risk
    (pleuritic pain, tachycardia, SOB, hypoxia, unilateral leg swelling
    (PERT, Heparin)

  • Pneumothorax → CXR / bedside US
    (sudden unilateral pleuritic pain, ↓ breath sounds)
    (stabe vs unstbale Needle decompression/C-tube)

  • Pneumonia / pleurisy → CXR, CBC
    (fever, cough, sputum, pleuritic pain)
    (ABX)

  • COPD/asthma → CXR, VBG, peak flow (if able)
    (wheeze, SOB, chest tightness)
    (Duonebs, steroids)

GI / OTHER

  • GERD / esophageal spasm → clinical dx, trial GI cocktail, trop/EKG first
    (burning after meals, worse lying down)
    (Maalox 30 mL PO x1_antacid) 15-30 min) +/- (antoprazole, Omeprazole) 1-4 hr

  • Esophageal rupture (after vomiting) → CT chest w contrast
    (severe pain after vomiting)
    (call Sargent)

  • MSK / costochondritis → reproducible pain, minimal workup after cardiac ruled out

  • Anxiety / panic → diagnosis of exclusion
    (fear, tingling, hyperventilation)
    (ativan 1mg, alternative: Hydroxyzine 25–50 mg PO)

  • Herpes zoster → rash, clinical

NOTE:
Called to bedside for chest pain. Patient evaluated at bedside, hemodynamically stable at time of assessment. Described chest discomfort; no immediate respiratory distress
Workup/Orders:

  • STAT Electrocardiography

  • Serial Troponin Test

  • Chest X-ray

  • CBC

  • BMP + Mg

  • Continuous telemetry monitoring added

  • Consider Echocardiography pending clinical course

Differential considered:

  • Cardiac: Acute Coronary Syndrome, arrhythmia, pericarditis, tamponade, Aortic Dissection

  • Pulmonary: Pulmonary Embolism, Pneumothorax, Pneumonia, Chronic Obstructive Pulmonary Disease / asthma

  • GI/MSK/Other: Gastroesophageal Reflux Disease, esophageal spasm, costochondritis, anxiety/panic

Plan:

  • Follow serial troponins and review repeat EKGs as indicated

  • Follow pending CBC/BMP/Mg/CXR results

  • Continue telemetry and close vital sign monitoring

  • Escalate imaging (CTA chest, echo, etc.) if symptoms persist or worsen

  • Treat underlying etiology once identified (ACS protocol, PE workup, bronchodilators, GI cocktail, anxiolysis, etc.)

  • Low threshold to re-evaluate / escalate level of care if recurrent pain or instability develops.