Chest Assessment — JRCALC 2025

Chest

Assessment

JRCALC 2025 · Adults & Children · v1.0

🚨 If TIME-CRITICAL features present — do not complete this assessment. Immediate transfer.

Time-Critical — Immediate Transfer

Tap if any present — ATMIST pre-alert and go

STEMI / ACS with cardiogenic shock or arrhythmia

Suspected tension pneumothorax — decompress per local guideline

Suspected cardiac tamponade

Massive PE with haemodynamic compromise

Suspected ruptured / dissecting aorta with shock

Peri-arrest presentation

Patient Demographics

♂ Male

♀ Female

👶 Child

<16 yrs

Under 50

50–69

Cardiac risk ↑

70+

Mandatory referral if non-convey

Unknown

Pain Location — Tap to Select

UPPER LEFT

Lung apex · Shoulder

CENTRAL

Heart · Aorta · Oesophagus

UPPER RIGHT

Lung apex · Ribs

LEFT LATERAL

Lung · Pleura · Ribs

EPIGASTRIC

Inferior MI · GORD

RIGHT LATERAL

Lung · Liver edge

LEFT BACK

Aorta · Lung base

INTERSCAPULAR

Aortic dissection

RIGHT BACK

Lung base · Ribs

Radiation

Jaw / Neck

Left arm

Right arm

Back / Interscapular

Shoulder tip

No radiation

Character of Pain

Crushing / Tight / Heavy

Sharp / Stabbing

Pleuritic — worse on inspiration

Burning

Tearing / Ripping

Reproducible on palpation

Constant

Intermittent

Onset

Sudden / Abrupt

Rapid (<1hr)

On exertion

At rest

Gradual

Chronic / Recurrent

Severity (1–10)

Associated Symptoms

Shortness of breath

Sweating / Diaphoresis

Nausea / Vomiting

Palpitations

Syncope / Presyncope

Cough

Haemoptysis

Fever

Unilateral calf swelling / pain

Sense of impending doom

Worse lying flat / relieved sitting forward

Relieved by GTN

Tingling / numbness hands or perioral

History

Previous MI / ACS / Stent / CABG

Known angina

Hypertension

Diabetes

High cholesterol

Smoking history

Family history — cardiac disease <60yrs

COPD

Asthma

Recent chest infection / URTI

Previous DVT / PE

Active malignancy

Recent immobility / surgery <4wks

Long haul travel

Pregnant / postpartum <6wks

Oral contraceptive / HRT

Marfan / aortic valve disease

Known aortic aneurysm / dissection

Recent chest trauma

Cocaine / stimulant use

History of anxiety / panic attacks

Regular NSAIDs

Chest Examination

Expose the chest where dignity/environment allow. Compare both sides throughout.

Inspection

Accessory muscle use

Cyanosis

Pallor

Sweaty / clammy

Asymmetrical chest expansion

Raised JVP

Visible bruising / chest wall trauma

Normal

Palpation

Chest wall tenderness

Surgical emphysema / crepitus

Reduced expansion one side

Normal

Percussion

Hyper-resonant one side

Dull / stony dull one side

Normal / resonant both sides

Auscultation

Reduced / absent breath sounds one side

Wheeze

Crackles / crepitations

Pleural rub

Muffled heart sounds

New murmur

Normal breath & heart sounds

Special Tests

Tracheal Position

Gently palpate in the suprasternal notch. Positive if trachea is deviated away from the affected side.

Positive → Tension pneumothorax

DEVIATED

CENTRAL

NOT ASSESSED

GTN Response

If given per guideline and not contraindicated — does the pain resolve or significantly reduce?

Relief supports (but does not confirm) cardiac cause

RELIEVED

UNCHANGED

NOT GIVEN

Chest Wall Palpation

Palpate the chest wall over the site of pain. Positive if this reproduces the patient's pain exactly.

Positive → Musculoskeletal cause

POSITIVE

NEGATIVE

NOT DONE

Calf Examination (DVT signs)

Inspect and palpate both calves. Positive if unilateral swelling, warmth, or tenderness on deep palpation.

Positive → Raises suspicion of PE

POSITIVE

NEGATIVE

NOT DONE

Aortic Dissection Detection Risk Score (ADD-RS)

⚠️ THINK AORTA — complete in any patient with aortic history, or severe sudden/tearing pain

Column A — Predisposing Conditions

Marfan syndrome

Family history of aortic disease

Known aortic valve disease

Recent aortic surgery

Known aortic aneurysm

Column B — Pain Features

Abrupt or rapid onset

Severe intensity

Ripping or tearing character

Column C — Examination Findings

Pulse deficit or BP differential between upper limbs

Focal neurological deficit with pain

New aortic regurgitant murmur with pain

Hypotension or shock

0

ADD-RS Score (0–3)
1 point per column with any positive

Wells Score — Pulmonary Embolism

⚠️ Complete where PE is a differential — sudden SOB, pleuritic pain, haemoptysis, VTE risk factors

Clinical signs/symptoms of DVT (leg swelling, pain on deep palpation) — 3 pts

PE is the #1 diagnosis, or equally likely — 3 pts

Heart rate >100 bpm — 1.5 pts

Immobilisation ≥3 days or surgery in last 4 weeks — 1.5 pts

Previous DVT / PE — 1.5 pts

Haemoptysis — 1 pt

Malignancy (treated within 6 months / palliative) — 1 pt

0

Wells Score
<2 Low · 2–6 Moderate · >6 High (simplified: PE likely if >4)

Red Flags Assessment

Immediate ED — Time-Critical

STEMI / ACS with shock or arrhythmia

Tension pneumothorax

Cardiac tamponade

Massive PE with haemodynamic compromise

Suspected aortic dissection / rupture

SpO₂ <92% on air not correcting with oxygen

New severe hypotension / shock

Reduced consciousness with chest symptoms

Requires Senior HCP Discussion if Non-Conveying

Patient aged 70 or over — mandatory referral to registered HCP if non-conveyance

ADD-RS ≥1 — aortic pathology not excluded

Wells score moderate/high — PE not excluded

Abnormal 12-lead ECG

New murmur or signs of heart failure

Cardiac sounding pain unresolved despite treatment

Known cardiac risk factors with atypical presentation

Differential Diagnoses

Based on symptoms selected. Tap any condition for key features and management notes.

Observations & NEWS2

Vital Signs

RR

SpO₂ %

Temp °C

BP Sys

HR

BM mmol

AVPU

O₂ Therapy

?

NEWS2 Score

Investigations Checklist

12-lead ECG — mandatory, repeat if symptoms change, retain / transmit strip

Serial ECGs if pain ongoing / evolving

Blood glucose

Aspirin given (if ACS suspected, no contraindication)

GTN given (if not contraindicated)

Oxygen titrated to target saturations

Pain score documented — SOCRATES recorded

Pre-alert considered if STEMI / time-critical

Analgesia

If patient is in pain, adequate analgesia should be given. Do not withhold analgesia pending diagnosis.

Refer to ACS and Pain Management in Adults and Children guidelines

Disposition

⚡ Immediate Transfer

STEMI/ACS with shock or arrhythmia · Tension pneumothorax · Tamponade · Massive PE · Aortic dissection/rupture · Peri-arrest

ATMIST pre-alert · Correct ABCDE en-route · Consider most appropriate centre (Cath lab / ED)

🏥 Convey — Not Immediate

Red flags present · Abnormal ECG · ADD-RS ≥1 · Wells moderate/high · Unresolved pain · Uncertain diagnosis · Patient ≥70

Consider ED / SDEC / cardiology pathway depending on local arrangements

🏠 Community / Discharge

Clear MSK cause · No red flags · Normal exam & vitals · Normal 12-lead ECG · Pain resolved

Must discuss with senior HCP if ≥70 · Document all advice given · Send clinical record to GP

Discharge Advice (if appropriate)

Rest and reassurance given

Analgesia advice given

Safety-netting — call back if pain recurs, worsens, or new SOB/collapse

Red flag symptoms explained (worsening SOB, syncope, haemoptysis)

GP follow-up advised if cardiac risk factors present (lipids, further Ix)

GP follow-up arranged / clinical record sent to GP

Documentation complete — all findings, advice and referrals recorded

🏥 Senior HCP discussion before leaving scene where: further advice needed · relevant cardiac/respiratory PMH identified · HCP contact in last 72hrs for same condition · GP referral / urgent outpatient needed

Assessment

Summary

JRCALC 2025 · Aide-memoire only — complete full PCR separately

⚠️ This is an aide-memoire. It does not replace full documentation on your patient care record.

Text Copy — For PRF