Common Symptoms
Chest Pain
Chest pain in the outpatient setting is one of the highest-stakes complaints. The first question is not 'what is it?' but 'does this patient need a higher level of care today?' This page walks through the can't-miss diagnoses (ACS, pulmonary embolism, aortic dissection, pneumothorax, esophageal rupture, pneumonia/sepsis, cardiac tamponade), the red flags that mandate ED transfer, the minimum safe first-pass workup including ECG within 10 minutes, HEART score, and Wells/PERC, what can be managed outpatient with a clear return plan (musculoskeletal, GERD, costochondritis after thoughtful exclusion), explicit escalation criteria, defensive documentation patterns showing ACS was considered, and explicit safety-net return precautions. Written for NPs, PAs, and MDs in outpatient practice.
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Common Symptoms
Chest Pain
Why this symptom matters
Chest pain is one of the highest-stakes outpatient complaints. The first question is not "what is it?" but "does this patient need a higher level of care today?"
What must I not miss first?
- Acute coronary syndrome (ACS / STEMI / NSTEMI / unstable angina)
- Pulmonary embolism
- Aortic dissection
- Pneumothorax (especially tall, thin, smokers)
- Esophageal rupture / perforation
- Pneumonia / sepsis
- Pericarditis with tamponade
Red flags — escalate or work up urgently
- Exertional pain, pressure-like, radiating to arm/jaw, with diaphoresis or nausea
- Hypotension, tachycardia, hypoxia, or new murmur
- Sudden tearing pain radiating to back (dissection)
- Pleuritic pain with tachycardia, hypoxia, recent immobility/surgery (PE)
- Sudden unilateral pleuritic pain with decreased breath sounds (pneumothorax)
- New ECG changes
- Anticoagulated patient with new severe pain
Minimum safe first-pass workup
- Vitals + pulse oximetry immediately
- 12-lead ECG within 10 minutes for any concerning chest pain
- Focused cardiopulmonary exam, equal breath sounds, equal pulses bilaterally
- Consider POC troponin if available; otherwise lower threshold to send to ED
- CXR if pulmonary cause suspected
- Wells/PERC score before considering D-dimer
What can usually be managed outpatient
- Reproducible musculoskeletal chest wall pain in young, well-appearing patient with normal exam and ECG
- Stable, known GERD with classic features and recent reassuring workup
- Stable angina with prior workup and an established cardiology plan
- Costochondritis with normal vitals and benign exam
When to escalate to ED / higher level of care
- Any concerning ECG change
- Hemodynamic instability or hypoxia
- Persistent or progressive pain despite initial management
- Suspected ACS, PE, dissection, pneumothorax, or perforation
- Older adult, diabetic, or anticoagulated patient with atypical pain you can't fully explain
What to document when the diagnosis is still uncertain
- Exact pain description, onset, duration, triggers, radiation, associated symptoms
- ACS/PE/dissection considered and why ruled out today
- ECG findings (or absence of changes), vitals, pulse ox
- Why imaging or troponin was or was not obtained
- Specific return precautions and follow-up plan
Safety-net & return precautions to give
- Call 911 / go to ED for chest pain that returns, worsens, lasts >15 min, or comes with sweating, nausea, jaw/arm pain, shortness of breath, fainting, or palpitations.
- Return today for any new fever, leg swelling, or coughing up blood.
- Follow up in [X days] regardless of symptoms.
Educational guidance for clinicians. Not a substitute for clinical judgment. Always individualize to the patient and your local resources.
Evidence sources
- · AHA/ACC Chest Pain Guideline 2021
- · ACEP Clinical Policies
Review status
Last reviewed: 2026-04
Reviewed by the MyClinicianGuide editorial team. Cadence: annual.
Educational reference for licensed clinicians (NP, PA, MD, DO). Not a substitute for clinical judgment, institutional protocols, or specialty consultation. Apply in context of the full clinical picture, patient goals, and current standards of care. See About AI guidance for AI-related limitations.
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