The Problem of Chest "Pain"

THE ALGORITHM presented here emphasizes the workup of a patient who has chest "pain" whose clinical features might be associated with myocardial ischemia caused by coronary atherosclerosis. Note that the arrows in the algorithm are numbered and correspond to related numbered paragraphs in the discussion. The discussion highlights some of the variables one needs to consider in order to move from one place in the algorithm to another. The physician whose goal is to give comprehensive care should define in advance the items in the history, physical examination, and laboratory workup (which includes a chest roentgenogram and ECG) that should be done on every patient. Items done occasionally are not included in the initial data-gathering process. With this approach, the physician should be able to identify the cause of the chest discomfort in the majority of instances without resorting to additional diagnostic studies. More often than not, the chest pain