Chest Pain

Can’t Miss – Think about these etiologies first (quickly lethal)

  • Myocardial Infarction
  • Pulmonary Embolism
  • Pneumothorax
  • Aortic dissection
  • Esophageal perforation

A quick, focused history helps:

  • Do they have typical (see ACS) anginal pain? Do they have risk factors for myocardial infarction?
  • Have they ever had blood clots before? A history of recent immobility?
  • Do they have risk factors for a pneumothorax (COPD, etc.)?
  • Is the pain a “ripping”/”tearing” quality with radiation to the back?
  • Have they been vomiting?

Regardless, a patient presenting with chest pain is likely to receive a chest x-ray, EKG, and troponin to make sure these etiologies aren’t missed. Depending on the level of suspicion for a pulmonary embolism or aortic dissection, a CTA can be obtained (see Pulmonary Embolism)

Once these are ruled out, we can go one-by-one through the layers of the thoracic cavity to guide the differential.

Chest Wall

  • Skin
    • Shingles
      • Diagnosis: History and physical exam
  • Subcutaneous Tissue
  • Muscles
    • Costochondritis
      • Diagnosis: History and physical exam (pain reproducible with palpation)
  • Bones
    • Fractures
      • Diagnosis: Chest X-Ray


  • Pneumothorax
    • Diagnosis: Physical Exam and Chest X-Ray
  • Pulmonary Embolism
    • Diagnosis: CTA (see PE)
  • Pneumonia
    • Diagnosis: History/Physical Exam and Chest X-Ray
  • Neoplasm (presentation more likely to be subacute/chronic)
    • Diagnosis: Imaging (likely Chest X-Ray followed by CT)
  • Pleurisy
    • Diagnosis: History and physical exam (pain worse with inspiration)


  • Myocardial Infarction
    • Diagnosis: EKG, Troponin, Echocardiogram (see ACS)
  • Pericarditis
    • Diagnosis: History (pain worse with inspiration, relieved by sitting forward), EKG (pan-ST-elevation), Echocardiogram (pericardial effusion)

Esophagus (all diagnosed by history)

  • Mallory-Weiss Syndrome
  • Boerhaave Syndrome
  • GERD
  • Esophagitis


  • Aortic Dissection
    • Diagnosis: CTA

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