Complaint · Chest pain

Chest pain: documentation that holds up

Evidence-based · cited·Reviewed Jun 2026

Your scribe captures the story. This is the reasoning it can't hear — the questions to ask, the can't-miss diagnoses to exclude on paper, and the validated tools that make the exclusion defensible.

▸Critical pathway

Original, evidence-based synthesis — the critical diagnoses you cannot miss, the tests that catch them, and the interventions that can’t wait. Apply local protocol and judgment.

① Immediate
  • 12-lead ECG within 10 minutes of arrival; continuous cardiac monitor, IV access, and full vitals including bilateral blood pressure and SpO₂.
  • If unstable (hypotension, hypoxia, or severe distress): resuscitate while considering STEMI, massive pulmonary embolism, tension pneumothorax, and aortic dissection in parallel.
② Critical tests
  • 12-lead ECG, repeated if pain is ongoing or evolving
  • Serial high-sensitivity troponin
  • Chest X-ray
  • Targeted CT angiography (dissection or PE) and bedside echo / lung ultrasound
③ Can’t-miss → act

STEMI / acute coronary syndrome

Trigger
Ischemic ECG changes, or ongoing pain with a suggestive risk story
Test
ECG plus serial troponin; HEART score to risk-stratify
Intervention
Aspirin; activate the cath lab for STEMI; cardiology and anticoagulation for high-risk NSTE-ACS

Aortic dissection

Trigger
Tearing or migratory pain, a pulse or blood-pressure differential, or a widened mediastinum
Test
CT angiography of the aorta
Intervention
Impulse control — IV beta-blocker (esmolol or labetalol) to a heart rate below 60, then a vasodilator to SBP 100–120; emergent surgery for type A

Pulmonary embolism

Trigger
Pleuritic pain, dyspnea, or VTE risk factors
Test
Pretest probability (Wells / PERC), then d-dimer or CT pulmonary angiography
Intervention
Anticoagulation; consider thrombolysis for massive PE with shock

Tension / spontaneous pneumothorax

Trigger
Decreased breath sounds; hypotension with tracheal deviation signals tension
Test
Chest X-ray or lung ultrasound — do not delay decompression for tension
Intervention
Immediate needle or finger thoracostomy, then chest tube

Esophageal rupture (Boerhaave)

Trigger
Forceful vomiting followed by chest pain with subcutaneous emphysema
Test
CT chest with contrast or esophagram
Intervention
NPO, broad-spectrum antibiotics, and urgent surgical / GI consultation
④ Disposition

Risk-stratify with HEART (plus Wells/PERC when PE is in play): a low score with negative serial troponin supports shared-decision discharge; intermediate warrants observation with serial troponin; high risk is admitted with cardiology involvement.

01What's at stake

Missed acute coronary syndrome and missed aortic catastrophe are among the highest-liability misses in emergency medicine. The chart has to show you actively considered them and why you judged them unlikely — not just the diagnosis you landed on.

02Can't-miss differential

  • Acute coronary syndrome — ECG + serial troponin + a risk story.
  • Pulmonary embolism — pretest probability drives imaging.
  • Aortic dissection — tearing, maximal-at-onset, migratory pain; pulse/BP differential.
  • Tension/spontaneous pneumothorax and esophageal perforation — examination and imaging.

03History — the questions that change your decision

Protective (ask & chart the negatives):

  • Tearing, maximal-at-onset, migratory pain? → dissection
  • Associated syncope? → dissection / PE / arrhythmia

Risk-tool inputs (these are the scores):

  • Exertional, pressure, radiation, diaphoresis? → HEART history
  • Cardiac risk factors? → HEART risk factors
  • Hemoptysis · recent surgery/immobilization · prior VTE · unilateral leg swelling · estrogen use? → Wells & PERC

Skip the typing

Answer these in the Workup and it fills the HEART, Wells, and PERC tools and assembles a copy-paste decision-making block — your differential and the reasoning for why the can't-miss diagnoses are less likely.

04Risk tools & evidence

  • HEART — risk-stratifies ACS for disposition; low scores (0–3) identify a low-risk group. Six AJ, Backus BE, Kelder JC. Neth Heart J. 2008.
  • Wells (PE) — pretest probability that, with d-dimer, guides imaging. Wells PS, et al. Thromb Haemost. 2000.
  • PERC — in a low-probability patient, zero criteria makes PE testing unnecessary. Kline JA, et al. J Thromb Haemost. 2004.

05What to document

▼ weak
"Chest pain, ECG and troponin normal. Discharged."
▲ defensible
"Atypical, non-exertional pain; no tearing/migratory features; no hemoptysis, immobilization, prior VTE, or leg swelling. ECG without ischemia, serial troponins negative, HEART score low. ACS and PE judged unlikely; dissection without high-risk features."

06Where charts fail

  • Documenting the result ("troponin normal") without the reasoning it supports.
  • No pertinent negatives for dissection — the cheapest, most defensible line to add.
  • Citing no tool when one fits, leaving risk stratification implicit.

07Sources

  • Six AJ, Backus BE, Kelder JC. Chest pain in the emergency room: value of the HEART score. Neth Heart J. 2008.
  • Wells PS, et al. Derivation of a simple clinical model for pulmonary embolism. Thromb Haemost. 2000.
  • Kline JA, et al. Criteria to safely rule out PE without testing (PERC). J Thromb Haemost. 2004.

© 2026 Kim Trinh, MD. All rights reserved. Educational only. Synthetic examples. Not medical advice — apply local protocol and judgment.

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