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Surgical sieve
💔 Chest pain
Six killers first: ACS, PE, dissection, tension pneumothorax, tamponade, oesophageal rupture.
| Acute coronary syndrome Must exclude | Central, crushing, radiating to jaw/arm; diaphoresis; nausea. Diabetics and the elderly present atypically.ECG within 10 min, troponin, aspirin 300mg. |
|---|---|
| Pulmonary embolism Must exclude | Pleuritic, dyspnoea, tachycardia, hypoxia. Often no leg signs.Wells score → D-dimer or CTPA. |
| Aortic dissection Must exclude | Tearing, maximal at onset, radiating to back. BP differential between arms, new AR murmur.CT aortogram. Do NOT anticoagulate. |
| Cardiac tamponade Must exclude | Beck's triad: hypotension, raised JVP, muffled heart sounds. Pulsus paradoxus.Urgent echo. |
| Tension pneumothorax Must exclude | Absent breath sounds, hyper-resonance, tracheal deviation, haemodynamic collapse.Clinical diagnosis — needle decompression BEFORE imaging. |
| Oesophageal rupture (Boerhaave) Must exclude | Severe pain after forceful vomiting; surgical emphysema; very unwell.CT with contrast, urgent surgical referral. |
| Pneumonia Time-sensitive | Pleuritic pain, fever, productive cough, focal crackles.CXR, CURB-65, cultures. |
| Pericarditis / myocarditis Time-sensitive | Sharp, positional — worse lying flat, better sitting forward. Rub. Saddle ST elevation.ECG, echo, troponin. |
| Simple pneumothorax Time-sensitive | Sudden pleuritic pain and dyspnoea. Tall thin young men, or COPD.CXR; size and symptoms guide management. |
| Musculoskeletal / costochondritis Common | Reproducible on palpation, worse on movement. A diagnosis of exclusion. |
| GORD / oesophageal spasm Common | Burning, related to food or lying flat, responds to antacids. Can mimic ACS exactly. |
| Herpes zoster Consider | Dermatomal, burning, precedes the rash by days. |
| Anxiety / panic Consider | Associated paraesthesia, hyperventilation. Never the first diagnosis in a new presentation. |
13 differentials · 9 open a full pathway in the app.