Chapter 013. Chest Discomfort (Part 5) Approach to the Patient: Chest Discomfort The 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 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 of the patient with chest discomfort, with the diagnostic entities that are most important for consideration at each stage of the evaluation. Table 13-3 Considerations in the Assessment of the Patient with Chest Discomfort 1. Could the chest discomfort be due to an acute, potentially life- threatening condition that warrants immediate hospitaliza tion and aggressive evaluation? 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 to serious complications? Stable angina Aortic stenosis Pulmonary hypertension 3. If not, could the discomfort be due to an acute condition that warrants specific treatment? Pericarditis Pneumonia/pleuritis Herpes zoster 4. If not, could the discomfo rt be due to another treatable chronic condition? Esophageal reflux Cervical disk disease Esophageal spasm Arthritis of the shoulder or spine Peptic ulcer disease Costochondritis Gallbladder disease Other musculoskeletal disorders Other gastrointestinal conditions Anxiety state . Chapter 013. Chest Discomfort (Part 5) Approach to the Patient: Chest Discomfort The evaluation of the patient with chest discomfort must accommodate two. chest discomfort, with the diagnostic entities that are most important for consideration at each stage of the evaluation. Table 13-3 Considerations in the Assessment of the Patient with Chest. evaluation. Table 13-3 Considerations in the Assessment of the Patient with Chest Discomfort 1. Could the chest discomfort be due to an acute, potentially life- threatening condition that warrants