Chest pain

Ongoing pain, haemodynamic instability, arrhythmia, acute heart failure → high-risk, urgent cardiology

Features of tamponade (raised JVP, hypotension, muffled heart sounds, pulsus paradoxus) → urgent echo ± pericardiocentes

Hypotension/tamponade, neurological deficit, or a widened mediastinum on chest X-ray → immediate imaging and cardiothora

Onset of symptoms (syncope/angina/dyspnoea) in severe AS → urgent referral for valve replacement (poor prognosis untreat

Sepsis/mediastinitis → emergency resuscitation + surgery (high mortality, time-critical)

ALARM features → urgent endoscopy: Anaemia (iron-deficiency), Loss of weight, Anorexia, Recent-onset/progressive symptom

Focal chest signs/consolidation, high CURB-65 features, or systemic sepsis → it's pneumonia → treat accordingly

Fulminant myocarditis (cardiogenic shock, ventricular arrhythmia, high-grade block) → ICU/mechanical support

Mesothelioma (asbestos exposure + pleural effusion/chest pain/pleural thickening) → urgent investigation; it is compensa

First presentation: exclude cardiac/respiratory/endocrine cause before labelling

TENSION pneumothorax (haemodynamic compromise, tracheal deviation) → IMMEDIATE needle/finger decompression then chest dr

Haemodynamic instability (massive PE) → consider thrombolysis; pregnancy (alters imaging choice)

Acute chest syndrome (hypoxia + new infiltrate) → emergency (oxygen, analgesia, antibiotics, transfusion/exchange)

Pain at rest, crescendo pattern, or lasting >15 min with sweating/nausea → suspect ACS, not stable angina → troponin + E

Acute heart failure, cardiogenic shock, LV outflow obstruction or arrhythmia can complicate the acute phase

Suspected PE with instability → emergency; massive PE

Older patient with rapid weight loss and short history → exclude PSEUDOACHALASIA (tumour at the GOJ) with endoscopy

Life-threatening features (silent chest, SpO2 <92%, exhaustion, normal/rising PaCO2) → ITU/anaesthetic involvement — a n

Haemodynamic instability (shock, syncope, ischaemia, heart failure) → emergency synchronised DC cardioversion

Hoarseness, fixed/hard nodule, rapid growth, cervical nodes, or stridor → suspected cancer pathway / urgent

Para-oesophageal hernia with acute severe pain/obstruction → strangulation/gastric volvulus — surgical emergency

Exertional syncope, family history of sudden death, massive LVH, non-sustained VT or abnormal BP response → high sudden-

Haemoptysis/persistent cough/weight loss in a smoker → urgent 2-week-wait referral + urgent CXR (NICE NG12)

Cardiac tamponade (shock + raised JVP + muffled sounds, pulsus paradoxus) → emergency echo-guided pericardiocentesis

CURB-65 high (3–5) / sepsis → hospital/ICU assessment; respiratory failure → oxygen/ventilatory support

Right heart failure/syncope → specialist pulmonary hypertension centre

Haemodynamic instability → synchronised DC cardioversion

Pulseless VT or VF → immediate defibrillation + ALS (shockable arm)

Pain out of proportion, rapid spread, crepitus, dusky/necrotic skin, systemic toxicity → necrotising fasciitis (surgical

Significant/ongoing bleeding → endoscopic therapy