Chest Pain
ABCs
- assess airway, breathing, circulation
- full vitals + cardiac monitor
- measure BP in both arms
- O₂ if hypoxic
- secure IV access
red flags
don’t miss
- hemodynamic instability
- typical cardiac pain (exertional, substernal, radiating)
- sudden severe pain (tearing or ripping)
- respiratory compromise
- autonomic symptoms (diaphoresis, N/V)
- neurological signs or syncope
- unequal pulses or BP difference > 20 mmHg
- new murmur or distant heart sounds
- signs of DVT
- chest wall crepitus
HPI & examination
- pain characteristics
- character: heaviness vs sharp
- exertional vs pleuritic
- radiation: arm, jaw, back
- associated symptoms
- diaphoresis, palpitations, N/V
- dyspnea, orthopnea, PND
- fever, cough
- DVT symptoms
- history & exam
- PMH: IHD, lung disease, asthma, reflux
- full cardiorespiratory exam
- lower-limb exam (DVT signs)
workup
- cardiac monitor, IV access, O₂ if hypoxic
- ECG → troponin
- CXR
- contact cardiology early if typical pain or abnormal ECG/troponin
differentials
| condition | clues | do |
|---|---|---|
| ACS | typical pain, ECG or troponin changes | cardiology, antiplatelets, anticoagulation, urgent reperfusion if STEMI |
| Aortic dissection (unstable) | shock, severe tearing pain | call for assistance, hemodynamic support, urgent TEE or POCUS |
| Cardiac tamponade | Beck’s triad, hypotension | urgent echo, pericardiocentesis |
| PE | SOB, tachycardia, DVT signs | CTPA if stable; anticoagulation; bedside echo if unstable |
| Aortic dissection (stable) | tearing pain, BP difference | CTA, control BP (SBP 100–120), HR ≤ 60, β-blocker |
| Pneumothorax | unilateral reduced breath sounds | urgent CXR, needle decompression if tension |
| Pneumonia / HAP | fever, cough | bloods, cultures, empiric antibiotics |
| MSK pain | localized, reproducible | paracetamol IV |
studying for the IM exam? the IM Rapid Review covers chest pain in the same format. see the sample chapter.
Last reviewed · May 2026