Clinical Commander

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symptom.chest_pain.ed_undifferentiated.v1

Undifferentiated chest pain (ED)

symptomacuteundifferentiatedadultacute
Start encounter →Print handoutPRODUCTION

Phase C shard-3 symptom-workup TEMPLATE (2026-05-14) — first symptom-engine in the shard at PRODUCTION; pattern for the remaining ~28 symptom engines (dyspnea, abdominal_pain, syncope, weakness, etc.). Engine scope: ED triage + risk-stratification + disposition ONLY. Downstream confirmed diagnoses route to dedicated engines: cardio.stemi.core.v1, cardio.nstemi.core.v1, cardio.aortic-dissection.core.v1, pulm.pe.core.v1, pulm.pneumothorax.core.v1, cardio.pericarditis.core.v1. Bayesian linkage (LR+, LR−, T_treat, T_test, conditional dependencies, pre-test priors) lives in companion depth bundle _briefs/symptom.chest_pain.ed_undifferentiated.v1.depth.md — schema has no first-class likelihood-ratio field. 7 sibling-differentiation rows cover the 7 look-alike pairs in user spec (STEMI / NSTEMI / PE / dissection / PTX / pericarditis / GERD); MSK pivot lives in design brief look-alike map (no dedicated MSK chest-wall engine target). 8 severity triggers (≥6 per spec): stemi_pattern_ecg + dissection_pattern + massive_pe_pattern + tension_pneumothorax + tamponade_physiology + dynamic_troponin_or_ecg + hemodynamic_instability + repeat_ecg_evolution. Schema-blocked emitted: calc.edacs (EDACS-ADP — Than Emerg Med Australas 2014; competing low-risk pathway to HEART) — owner shard-0 (clinical-tools-registry). Regimen_axes intentionally empty — engine is triage-only. Supportive drug actions (O2, ASA, nitroglycerin, IV fluids, esmolol/labetalol) live in setting_playbooks.ed.drug_actions; definitive treatment is owned by downstream routed engines. Manifest pointer routes to existing prisma/seed/manifests/symptom.chest_pain.ed_undifferentiated.core.v1.ts (legacy `.core.v1` filename; dossier engine_id intentionally drops `.core` per user spec).

Entry points (6)

  • symptom
    Acute chest pain presenting to ED (AHA/ACC 2021 Class I — ECG within 10 min)
    acute_chest_pain
  • symptom
    Chest pressure radiating to jaw / arm / back ± diaphoresis ± nausea (Gulati 2021)
    chest_pressure_with_radiation
  • symptom
    Tearing chest / interscapular pain — dissection suspicion (AHA 2022 Acute Aortic Disease)
    tearing_chest_or_back_pain
  • symptom
    Sharp pleuritic chest pain ± dyspnea — PE / pericarditis / PTX suspicion (ESC 2019 PE)
    pleuritic_chest_pain
  • symptom
    Chest pain with syncope or pre-syncope — high-risk for PE / dissection / ACS (Gulati 2021)
    chest_pain_with_syncope
  • vital_abnormality
    SBP <90 OR HR >120 OR SpO2 <90% with chest pain — life-threat triage (AHA/ACC 2021)
    hemodynamic_instability_with_chest_pain

Required inputs (25)

  • agerequired
    demographic • used at CONTEXT
    Age is a HEART component + shifts ACS / dissection priors (Backus 2013 PMID 23465250; AHA 2022)
  • sexrequired
    demographic • used at CONTEXT
    Female atypical presentation more common; sex shifts ASCVD risk (Gulati 2021 PMID 34709879)
  • pain_onset_timerequired
    symptom • used at FRAME
    Sudden-maximum-intensity flag = dissection / SAH-equivalent; hs-cTn 0/1-h algorithm requires time-since-onset (Reichlin 2009 PMID 22892889)
  • pain_qualityrequired
    symptom • used at FRAME
    Pressure / sharp / tearing / pleuritic / burning — drives ddx prior shift (Gulati 2021)
  • pain_radiationrequired
    symptom • used at ENTRY
    Radiation to BOTH arms LR+ ~7 for ACS (Bösner 2010 PMID 20603345); interscapular = dissection
  • associated_symptomsrequired
    symptom • used at ENTRY
    Diaphoresis + nausea (ACS), pleuritic + leg pain (PE), tearing + neuro deficit (dissection), positional (pericarditis) — anchor differential (Gulati 2021)
  • sbprequired
    vital • used at CONTEXT
    BP differential >20 mmHg between arms is dissection clue (AHA 2022); hypotension flags massive PE / tamponade / cardiogenic shock
  • hrrequired
    vital • used at CONTEXT
    Tachycardia in PE / shock / dissection / pneumothorax (ESC 2019)
  • spo2required
    vital • used at CONTEXT
    Hypoxia in PE / pneumonia / PTX / pulmonary edema (Gulati 2021)
  • rrrequired
    vital • used at CONTEXT
    Tachypnea is non-specific but shifts toward PE / pneumonia / sepsis (ESC 2019)
  • ascvd_risk_factorsrequired
    history • used at CONTEXT
    DM, HTN, smoking, family history, dyslipidemia — HEART risk-factor component (Backus 2013)
  • prior_mi_pci_cabgrequired
    history • used at CONTEXT
    Known CAD shifts prior strongly toward ACS; counts as HEART risk factor (Gulati 2021)
  • recent_surgery_or_immobilityrequired
    history • used at CONTEXT
    PE prior (Wells PE criterion; Pollack 2016 PMID 18318689)
  • aortic_risksrequired
    history • used at CONTEXT
    HTN, Marfan, bicuspid AV, prior dissection, third-trimester pregnancy — dissection prior (AHA 2022)
  • cocaine_or_methamphetamine_userequired
    history • used at CONTEXT
    Cocaine-induced chest pain — ACS / dissection / vasospasm; avoid beta-blocker first (Gulati 2021)
  • anticoagulant_userequired
    history • used at CONTEXT
    Affects PE workup interpretation + bleeding risk if thrombolysis considered (ESC 2019)
  • ecg_12_leadrequired
    imaging • used at INITIAL_WORKUP
    ECG within 10 min of arrival (AHA/ACC 2021 Class I); ST-elevation routes to STEMI; PR depression suggests pericarditis
  • cxr_portablerequired
    imaging • used at INITIAL_WORKUP
    Widened mediastinum (dissection), pneumothorax, pulmonary edema, pneumonia (Gulati 2021)
  • hs_troponinrequired
    lab • used at INITIAL_WORKUP
    Hs-cTn 0/1-h or 0/3-h serial pathway anchors NSTEMI rule-in/rule-out (Reichlin 2009; Thygesen 2018 PMID 30571511)
  • d_dimer_age_adjusted
    lab • used at BRANCHING_WORKUP
    Age-adjusted D-dimer rule-out for PE with low Wells (Klok 2017 PMID 24643601)
  • creatininerequired
    lab • used at CONTEXT
    eGFR for contrast (CTPA / CTA dissection) and DOAC dose adjustment (KDIGO 2026)
  • lactate
    lab • used at INITIAL_WORKUP
    Elevated lactate in shock physiology (massive PE / tamponade / dissection / cardiogenic shock); SSC 2026 sepsis screen
  • ctpa_chest
    imaging • used at BRANCHING_WORKUP
    CT pulmonary angiography for confirmed PE workup when Wells >4 or age-adjusted D-dimer positive (ESC 2019; PIOPED III PMID 16738268)
  • cta_chest_dissection_protocol
    imaging • used at BRANCHING_WORKUP
    CTA chest for dissection workup when BP differential / widened mediastinum / tearing pain (AHA 2022)
  • bedside_echo
    imaging • used at BRANCHING_WORKUP
    POCUS — pericardial effusion / RV strain (PE) / regional wall motion / IVC plethora (Gulati 2021)

12-phase flow (12)

  1. 1FRAME
    ED chest-pain triage; pain quality + onset time + "worst-of-life" flag; hemodynamic state (AHA/ACC 2021)
    inputs: pain_onset_time, pain_quality
    advance: pain characterized + onset clock started
  2. 2ENTRY
    Capture chest pain + radiation + autonomic features + dyspnea + hemodynamic instability flag (Gulati 2021)
    inputs: pain_radiation, associated_symptoms
    advance: entry presentation captured
  3. 3CONTEXT
    Age, sex, ASCVD risk factors, prior MI/PCI/CABG, aortic risks, recent surgery/immobility, cocaine, anticoagulant, vitals, eGFR (AHA/ACC 2021)
    inputs: age, sex, sbp, hr, spo2, rr, ascvd_risk_factors, prior_mi_pci_cabg, recent_surgery_or_immobility, aortic_risks, cocaine_or_methamphetamine_use, anticoagulant_use, creatinine
    advance: context complete + life-threat screen run
  4. 4RED_FLAGS
    ST-elevation (STEMI route); hypotension + suspected dissection; respiratory failure + suspected massive PE; tension PTX physiology; tamponade Beck triad (AHA/ACC 2021; AHA 2022; ESC 2019; ATS/CHEST 2010)
    inputs: sbp
    advance: no immediate life-threat OR routed to dedicated downstream engine
  5. 5INITIAL_WORKUP
    12-lead ECG within 10 min; hs-cTn 0/1-h or 0/3-h algorithm; CXR portable; basic labs; lactate if shock concern (AHA/ACC 2021 Class I; Reichlin 2009)
    inputs: ecg_12_lead, cxr_portable, hs_troponin
    actions: workup.chest_pain, panel.cardiac
    advance: ECG + first hs-cTn + CXR reviewed
  6. 6BRANCHING_WORKUP
    Pivot on findings: ST-elevation → STEMI; dynamic hs-cTn → NSTEMI; pleuritic + Wells/PERC → age-adjusted D-dimer → CTPA; widened mediastinum + tearing → CTA dissection; pericardial findings → echo (Klok 2017; PIOPED III; AHA 2022)
    inputs: d_dimer_age_adjusted, ctpa_chest, cta_chest_dissection_protocol, bedside_echo
    actions: panel.coag, panel.renal
    advance: branching workup results pivot to one of the downstream routes OR confirms low-risk
  7. 7DIFFERENTIAL
    ACS (STEMI/NSTEMI ~10-15%) / PE (~5-7%) / dissection (~0.3%) / PTX (~0.5%) / pericarditis (~5%) / esophageal-GERD (~20-30%) / MSK (~20-30%) / anxiety (~5-10%) — pre-test priors per Goodacre 2002 PMID 11874776 and Bösner 2010 PMID 20603345
    advance: differential ranked with pre-test priors documented
  8. 8RISK_STRATIFICATION
    HEART 0-3 low / 4-6 mod / 7-10 high (Backus 2013); TIMI-NSTEMI 0-2/3-4/5-7 (Antman 2017); GRACE low/intermediate/high (Roffi 2016); Wells-PE >4 likely + PERC negative if 8/8 met (Pollack 2016); sPESI ≥1 not outpatient (ESC 2019)
    inputs: age
    actions: calc.heart, calc.timi_nstemi, calc.grace, calc.wells_pe, calc.perc, calc.spesi
    advance: risk scores documented + band-mapped disposition determined
  9. 9TREATMENT
    Supportive only at this layer: O2 if SpO2 <94% (avoid hyperoxia); nitroglycerin 0.4 mg SL for angina if SBP >100 (caution RV / dissection); ASA 162-325 mg chewed if ACS not excluded (Gulati 2021; AHA/ACC 2021 Class I)
    inputs: sbp, spo2
    advance: supportive Rx initiated; definitive treatment lives in downstream routed engine
  10. 10DISPOSITION
    STEMI → cath lab DTB ≤90 min; high-risk NSTEMI (TIMI ≥3 / GRACE >140) → invasive ≤24 h; intermediate → admit observation; HEART 0-3 + neg serial trop → discharge w/ rapid follow-up; PE confirmed → pulm.pe; dissection → vascular surgery; tension PTX → decompression; tamponade → pericardiocentesis (AHA/ACC 2021; ESC 2019; AHA 2022; ATS/CHEST 2010)
    actions: protocol.stemi
    advance: disposition assigned + downstream handoff complete
  11. 11MONITORING
    Continuous telemetry until rule-out complete; serial hs-cTn per 0/1-h or 0/3-h pathway; repeat ECG q15 min if dynamic changes or ongoing pain; pain reassessment q30 min (Reichlin 2009; AHA/ACC 2021)
    inputs: hs_troponin, ecg_12_lead
    advance: serial workup completes rule-in or rule-out
  12. 12FOLLOWUP
    If discharged low-risk: PCP / cardiology within 72 h; return precautions (chest pain recurrence, dyspnea, syncope, new neurology); ASCVD risk factor counseling; smoking cessation; outpatient lipid panel deferred (Gulati 2021; 2026 ACC/AHA Lipid; 2025 AHA/ACC HTN)
    advance: discharge bundle prescribed + follow-up scheduled