Chapter 013. Chest Discomfort (Part 5)

Approach to the Patient: Chest DiscomfortThe evaluation of the patient with chest discomfort must accommodate two goals—determining the diagnosis and assessing the safety of the immediate management plan. The latter issue is often dominant when the patient has acute chest discomfort, such as patients seen in the emergency department. In such settings, the clinician must focus first on identifying patients who require aggressive interventions to diagnose or manage potentially life-threatening conditions, including acute ischemic heart disease, acute aortic dissection, pulmonary embolism, and tension pneumothorax. If such conditions are unlikely, the clinician must address questions such as the safety of...
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Chapter 013. Chest Discomfort (Part 5) Chapter 013. Chest Discomfort (Part 5) Approach to the Patient: Chest Discomfort The evaluation of the patient with chest discomfort must accommodate twogoals—determining the diagnosis and assessing the safety of the immediatemanagement plan. The latter issue is often dominant when the patient has acutechest discomfort, such as patients seen in the emergency department. In suchsettings, the clinician must focus first on identifying patients who requireaggressive interventions to diagnose or manage potentially life-threateningconditions, including acute ischemic heart disease, acute aortic dissection,pulmonary embolism, and tension pneumothorax. If such conditions are unlikely,the clinician must address questions such as the safety of discharge to home,admission to a non-coronary care unit facility, or immediate exercise testing.Table 13-3 displays a sequence of questions that can be used in the evaluation ofthe patient with chest discomfort, with the diagnostic entities that are mostimportant for consideration at each stage of the evaluation. Table 13-3 Considerations in the Assessment of the Patient with ChestDiscomfort 1. Could the chest discomfort be due to an acute, potentially life-threatening condition that warrants immediate hospitalization and aggressiveevaluation? Acute ischemic heart disease Pulmonary embolism Aortic dissection Spontaneous pneumothorax 2. If not, could the discomfort be due to a chronic condition likely to lead toserious complications? Stable angina Aortic stenosis Pulmonary hypertension 3. If not, could the discomfort be due to an acute condition that warrantsspecific treatment? Pericarditis Pneumonia/pleuritis Herpes zoster 4. If not, could the discomfort be due to another treatable chroniccondition? Esophageal reflux Cervical disk disease Esophageal spasm Arthritis of the shoulder or spine Peptic ulcer disease Costochondritis Gallbladder disease Other musculoskeletal disordersOther gastrointestinal conditions Anxiety state