• acute MI
• angina pectoris
• pericarditis
• aortic dissection
• pulmonary embolism
• pneumothorax
• GI causes (reflux, esophageal spasm, PUD, pancreatitis, biliary colic)
• musculoskeletal

• Previous hx of CAD? Symptoms typical of angina?
• Location, radiation, severity of pain.
• Precipitating and relieving factors (inspiration, cough=ptx, pericarditis, pleurisy; movement=musculoskeletal; recumbency=esophageal; relief with nitroglycerin within 1-5 minutes=myocardial ischemia.)

Vital signs

• New hypotension suggests potentially catastrophic cause (massive MI, cardiac tamponade, tension PTX, massive PE, dissecting aortic aneurysm.) Hypertension can be caused by pain, but of concern in context of acute MI or dissection.
• Fever from MI, PE, pneumonia, pericarditis.
• Tachycardia from pain, arrhythmia.
• Bradycardia from IWMI.
• Tachypnea from PE, heart failure, tamponade.

Neck

• tracheal deviation?

Lungs

• Breath sounds absent on one side?
• Evidence of consolidation, CHF?

Heart

• Heart tones muted and distant?
• New AI?

Abdominal exam

• epigastric tenderness?

Plan: (tailor to history and severity of presentation)

• ECG (on all patients)
• Trial of sublingual nitroglycerin 0.4 mg if systolic BP >90.
• Serial cardiac enzymes.
• If etiology of chest pain still unclear obtain CXR to look for PTX, widening of mediastinum.
• If dyspneic, consider anticoagulation and urgent V/Q scan.
• Trial of Maalox 30 cc q 6hrs.
• Motrin 800 mg q 8 for costrochondritis.