Chest pain physical examination: Difference between revisions

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Latest revision as of 21:50, 7 December 2022

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Sara Zand, M.D.[2] Aisha Adigun, B.Sc., M.D.[3],Nuha Al-Howthi, MD [4]

Overview

In patients presenting with chest pain, initial physical examination should focus on evaluating acute coronary syndrome or other potentially life-threatening causes of chest pain including aortic dissection, pulmonary embolism, esophageal rupture and complications. A complete physical exam should be done, which includes a thorough cardiac, lung, and abdominal exam.

Physical Examination

Table bellow shows the physical exam findings in patients with chest pain

^[1]

Clinical syndrome	Aspect
❑ ACS	❑ Diaphoresis ❑ Tachypnea ❑ Tachycardia ❑ Hypotension ❑ Crackles ❑ S3 ❑ Mitral Regurgitation murmur ❑ Normal examination in uncomplicated cases
❑ Pulmonary embolism	❑ Tachycardia ❑ Tachypnea ❑ Pleuritic chest pain
❑ Aortic dissection	❑ Connective tissue disorder (Marfan syndrome) ❑ Differential extremity pulses (30% of patients, type A> B) ❑Severe chest pain ❑ Abrupt onset chest pain ❑ Pulse differential ❑ Widend mediastinum on CXR ❑ Syncope >10% ❑ Aortic Regurgitation 40-75% (type A)
❑ Esophageal rupture	❑Emesis ❑Subcutaneous emphysema ❑Pneumothorax (20% of patients) ❑Unilateral decreased or absent breath sounds
❑ Non coronary causes of chest pain (Aortic Stenosis, Aortic Regurgitation, Hypertrophic cardiomyopathy)	❑ AS ❑ Systolic murmuur, tardus or parvus carotid pulse ❑ AR ❑ Diastolic murmus at right sternal border ❑Rapid carotid upstroke ❑HCM ❑Increased or displaced left ventricular impulse ❑Systolic murmur ❑ Prominent a wave in jugular venous pressure
❑ Pericarditis	❑ Fever ❑Pleuritic chest pain ❑Increased in supine position ❑ Friction rub
❑ Myocarditis	❑ Fever ❑ Chest pain ❑ Heart failure ❑ S3
❑ Esophagitis, peptic ulcer disease, gall bladder disease	❑ Epigasteric tenderness ❑Right upper quadrant tenderness ❑Murphy sign
❑ Pneumonia	❑ Fever ❑ Localized chest pain ❑ Pleuritic chest pain ❑ Friction rub ❑ Dullness on percussion ❑ Egophony
❑ Pneumothorax	❑Dyspnea or chest pain on inspiration ❑Unilateral absence of breath sounds
❑ Costochonritis, Tietze syndrome	❑ Tenderness on costochondral joints
❑ Herpes zoster	❑ Chest pain on dermatomal distribution ❑Triggered by tough ❑ Dermatomal rash distribution

The above table adopted from 2021 AHA/ACC/ASE Guideline^[1]

Vitals

Temperature (pericarditis, pleuritis, fever can precipitate ischemic attacks)
Absent or decreased pulses in limbs (aortic dissection all four limbs), tachycardia (pulmonary embolism)
Blood pressure in both the arms (aortic dissection)

Neck

Elevated jugular venous pulse

Heart

Auscultation
- Third and fourth heart sound
- Carotid bruit
- Pericardial rub (pericarditis)
- Murmur (systolic murmur in hypertrophic cardiomyopathy, aortic stenosis)

Lung

Palpation - shift in trachea from midline (tension pneumothorax)
Auscultation - decreased breath sound (pulmonary edema), pleural rub (pleuritis, pneumonia)

Abdomen

Inspection, palpation and auscultation to evaluate for gastrointestinal etiologies of chest pain
May show distension, RUQ tenderness.
Rectal examination - occult bleeding (peptic ulcers)

Neurologic

Musculoskeletal/Extremities

Palpation with pain reproducibility
Unilateral extremity enlargement, pain, and erythema (deep vein thrombosis)
Limb pulse differential (aortic dissection)

Skin

Hyperesthesia and rash (zoster)
Subcutaneous emphysema (Boerhaave syndrome, pneumothorax).

2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines ^[1]

Recommendation for physical examination

Class I
1.In patients presenting with chest pain, a focused cardiovascular examination should be performed initially to aid in the diagnosis of ACS or other potentially serious causes of chest pain (eg, aortic dissection, PE,or esophageal rupture) and to identify complications. (Level of Evidence: C-EO)

References

↑ ^1.0 ^1.1 ^1.2 Gulati M, Levy PD, Mukherjee D, Amsterdam E, Bhatt DL, Birtcher KK, Blankstein R, Boyd J, Bullock-Palmer RP, Conejo T, Diercks DB, Gentile F, Greenwood JP, Hess EP, Hollenberg SM, Jaber WA, Jneid H, Joglar JA, Morrow DA, O'Connor RE, Ross MA, Shaw LJ (November 2021). "2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines". Circulation. 144 (22): e368–e454. doi:10.1161/CIR.0000000000001029. PMID 34709879 Check |pmid= value (help).

[pmid34709879-1] 1.0 ^1.1 ^1.2 Gulati M, Levy PD, Mukherjee D, Amsterdam E, Bhatt DL, Birtcher KK, Blankstein R, Boyd J, Bullock-Palmer RP, Conejo T, Diercks DB, Gentile F, Greenwood JP, Hess EP, Hollenberg SM, Jaber WA, Jneid H, Joglar JA, Morrow DA, O'Connor RE, Ross MA, Shaw LJ (November 2021). "2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines". Circulation. 144 (22): e368–e454. doi:10.1161/CIR.0000000000001029. PMID 34709879 Check |pmid= value (help).

[1]

@@ Line 1: / Line 1: @@
 __NOTOC__
 {{Chest pain}}
-{{CMG}}{{AE}}{{Aisha}}
+{{CMG}}{{AE}} {{Sara.Zand}} {{Aisha}},{{nuha}}
 ==Overview==
-Physical examination should focus on evaluating for the life-threatening causes of chest pain first. A complete physical exam should be done, which includes a thorough cardiac, lung, and abdominal exam.
+In [[patients]] presenting with [[chest pain]], initial [[physical examination]] should focus on evaluating [[acute coronary syndrome]] or other potentially life-threatening causes of [[chest pain]] including [[aortic dissection]], [[pulmonary embolism]], [[esophageal rupture]] and complications. A complete [[physical exam]] should be done, which includes a thorough [[cardiac]], [[lung]], and [[abdominal]] exam.
 ==Physical Examination==
-===Vitals===
-* Temperature ([[pericarditis]], [[pleuritis]], [[fever]] can precipitate ischemic attacks)
-* Absent or decreased pulses in limbs ([[aortic dissection]] all four limbs), [[tachycardia]] ([[pulmonary embolism]])
-* Blood pressure in both the arms ([[aortic dissection]])
-===Neck===
+===Table bellow shows the [[physical exam]] findings in [[patients]] with [[chest pain]]===
-* Elevated [[jugular venous pulse]]
+<ref name="pmid34709879">{{cite journal |vauthors=Gulati M, Levy PD, Mukherjee D, Amsterdam E, Bhatt DL, Birtcher KK, Blankstein R, Boyd J, Bullock-Palmer RP, Conejo T, Diercks DB, Gentile F, Greenwood JP, Hess EP, Hollenberg SM, Jaber WA, Jneid H, Joglar JA, Morrow DA, O'Connor RE, Ross MA, Shaw LJ |title=2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines |journal=Circulation |volume=144 |issue=22 |pages=e368–e454 |date=November 2021 |pmid=34709879 |doi=10.1161/CIR.0000000000001029 |url=}}</ref>
+{| class="wikitable"
+|-
+|- bgcolor="LightBlue"
+|''' Clinical syndrome'''
+| bgcolor="LightBlue" |
+'''Aspect'''
+|-
+|- bgcolor="LightBlue"
+| ❑ [[ACS]]
+| bgcolor="LightBlue" |
+❑ [[Diaphoresis]]<br>
+❑ [[Tachypnea]]<br>
+❑ [[Tachycardia]]<br>
+❑ [[Hypotension]]<br>
+❑ [[Crackles]]<br>
+❑ [[S3]]<br>
+❑ [[Mitral Regurgitation]] [[murmur]]<br>
+❑ Normal examination in uncomplicated cases<br>
+|-
+|- bgcolor="LightBlue"
+|❑ [[Pulmonary embolism]]
+| bgcolor="LightBlue" |
+❑ [[Tachycardia]]<br>
+❑ [[Tachypnea]]<br>
+❑ [[Pleuritic]] [[chest pain]]<br>
-===Heart===
+|-
-* Auscultation
+|- bgcolor="LightBlue"
-** Third and fourth heart sound
+|❑ [[Aortic dissection]]
-** [[Carotid bruit]]
+| bgcolor="LightBlue" |
-** [[Pericardial rub]] ([[pericarditis]])
+❑ [[Connective tissue disorder]] ([[Marfan syndrome]])<br>
-** Murmur (systolic murmur in [[hypertrophic cardiomyopathy]], [[aortic stenosis]])
+❑ Differential extremity [[pulses]] (30% of [[patients]], type A> B)<br>
+❑Severe [[ chest pain]]<br>
+❑ Abrupt onset [[chest pain]]<br>
+❑ Pulse differential<br>
+❑ [[Widend mediastinum]] on [[CXR]]<br>
+❑ [[Syncope]] >10%<br>
+❑ [[Aortic Regurgitation]] 40-75% (type A)  <br>
-===Lung===
+|-
-* [[Palpation]] - shift in trachea from midline ([[tension pneumothorax]])
+|-
-* [[Auscultation]] - decreased breath sound ([[pulmonary edema]]), pleural rub ([[pleuritis]], [[pneumonia]])
+|- bgcolor="LightBlue"
+|❑ [[Esophageal rupture]]
+| bgcolor="LightBlue" |
+❑[[Emesis]]<br>
+❑[[Subcutaneous emphysema]]<br>
+❑[[Pneumothorax]] (20% of [[patients]])<br>
+❑Unilateral decreased or absent [[breath sounds]]<br>
+|-
+|-
+|- bgcolor="LightBlue"
+|❑ Non coronary causes of [[chest pain]] ([[Aortic Stenosis]], [[Aortic Regurgitation]], [[Hypertrophic cardiomyopathy]])
+| bgcolor="LightBlue" |
+*❑ [[AS]]
+❑ [[Systolic murmuur]], [[tardus]] or [[parvus]] [[carotid pulse]]<br>
+*❑ [[AR]]<br>
+❑ [[Diastolic murmus]] at right sternal border<br>
+❑Rapid [[carotid]] upstroke<br>
+*❑[[HCM]]<br>
+❑Increased or displaced [[left ventricular]] [[impulse]]<br>
+❑[[Systolic murmur]]<br>
+❑ Prominent a wave in [[jugular venous pressure]]<br>
+|- bgcolor="LightBlue"
+|❑ [[Pericarditis]]
+| bgcolor="LightBlue" |
+❑ [[Fever]]<br>
+❑[[Pleuritic chest pain]]<br>
+❑Increased in supine position<br>
+❑ [[Friction rub]]<br>
+|-
+|- bgcolor="LightBlue"
+|❑ [[Myocarditis]]
+| bgcolor="LightBlue" |
+❑ [[Fever]]<br>
+❑ [[Chest pain]]<br>
+❑ [[Heart failure]]<br>
+❑ [[S3]]<br>
+|-
+|-
+|- bgcolor="LightBlue"
+|❑ [[Esophagitis]], [[peptic ulcer]] disease, [[gall bladder disease]]<br>
+| bgcolor="LightBlue" |
+❑ [[Epigasteric tenderness]]<br>
+❑[[Right upper quadrant tenderness]]<br>
+❑[[Murphy sign]]<br>
+|-
+|-
+|- bgcolor="LightBlue"
+|❑ [[Pneumonia]]
+| bgcolor="LightBlue" |
+❑ [[Fever]]<br>
+❑ [[Localized]] [[chest pain]]<br>
+❑ [[Pleuritic chest pain]]<br>
+❑  [[Friction rub]]<br>
+❑ Dullness on [[percussion]]<br>
+❑ [[Egophony]]<br>
+|-
+|- bgcolor="LightBlue"
+|❑ [[Pneumothorax]]
+| bgcolor="LightBlue" |
+❑[[Dyspnea]] or [[ chest pain]] on [[inspiration]]<br>
+❑Unilateral absence of [[breath sounds]]<br>
+|-
+|-
+|- bgcolor="LightBlue"
+|❑ [[Costochonritis]], [[Tietze syndrome]]
+| bgcolor="LightBlue" |
+❑ Tenderness on [[costochondral joints]]<br>
-===Abdomen===
+|-
-*Inspection, palpation and auscultation to evaluate for gastrointestinal etiologies of chest pain
+|-
-* May show distension, RUQ tenderness.
+|- bgcolor="LightBlue"
-* [[Rectal examination]] - occult bleeding ([[peptic ulcers]])
+|❑ [[Herpes zoster]]<br>
+| bgcolor="LightBlue" |
+❑ [[Chest pain]] on [[dermatomal]] distribution<br>
+❑Triggered by [[tough]]<br>
+❑ Dermatomal [[rash]] distribution<br>
+|}
+{|
+! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 AHA/ACC/ASE Guideline<ref name="pmid34709879">{{cite journal |vauthors=Gulati M, Levy PD, Mukherjee D, Amsterdam E, Bhatt DL, Birtcher KK, Blankstein R, Boyd J, Bullock-Palmer RP, Conejo T, Diercks DB, Gentile F, Greenwood JP, Hess EP, Hollenberg SM, Jaber WA, Jneid H, Joglar JA, Morrow DA, O'Connor RE, Ross MA, Shaw LJ |title=2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines |journal=Circulation |volume=144 |issue=22 |pages=e368–e454 |date=November 2021 |pmid=34709879 |doi=10.1161/CIR.0000000000001029 |url=}}</ref>
+|-
+|}
-===Neurologic===
+===Vitals===
-* [[Cerebrovascular accident]]s ([[aortic dissection]])
-* [[Paraplegia]]
-===Musculoskeletal/Extremities===
+*Temperature ([[pericarditis]], [[pleuritis]], [[fever]] can precipitate ischemic attacks)
-* Palpation with pain reproducibility
+*Absent or decreased pulses in limbs ([[aortic dissection]] all four limbs), [[tachycardia]] ([[pulmonary embolism]])
-* Unilateral extremity enlargement, pain, and erythema (deep vein thrombosis)
+*Blood pressure in both the arms ([[aortic dissection]])
-===Skin===
+===Neck===
-* Hyperesthesia and rash (zoster)
-* Subcutaneous emphysema (Boerhaave syndrome, pneumothorax)
-==Overview==
+*Elevated [[jugular venous pulse]]
-Patients with [disease name] usually appear [general appearance]. Physical examination of patients with [disease name] is usually remarkable for [finding 1], [finding 2], and [finding 3].
-OR
+===Heart===
-Common physical examination findings of [disease name] include [finding 1], [finding 2], and [finding 3].
+*Auscultation
+**Third and fourth heart sound
+**[[Carotid bruit]]
+**[[Pericardial rub]] ([[pericarditis]])
+**Murmur (systolic murmur in [[hypertrophic cardiomyopathy]], [[aortic stenosis]])
-OR
+===Lung===
-The presence of [finding(s)] on physical examination is diagnostic of [disease name].
+*[[Palpation]] - shift in trachea from midline ([[tension pneumothorax]])
+*[[Auscultation]] - decreased breath sound ([[pulmonary edema]]), pleural rub ([[pleuritis]], [[pneumonia]])
-OR
+===Abdomen===
-The presence of [finding(s)] on physical examination is highly suggestive of [disease name].
+*Inspection, palpation and auscultation to evaluate for gastrointestinal etiologies of chest pain
+*May show distension, RUQ tenderness.
+*[[Rectal examination]] - occult bleeding ([[peptic ulcers]])
-==Physical Examination==
+===Neurologic===
-Physical examination of patients with [disease name] is usually normal.
-OR
+*[[Cerebrovascular accident]]s ([[aortic dissection]])
+*[[Paraplegia]]
-Physical examination of patients with [disease name] is usually remarkable for [finding 1], [finding 2], and [finding 3].
+===Musculoskeletal/Extremities===
-OR
+*[[Palpation]] with pain reproducibility
+*Unilateral extremity enlargement, pain, and [[erythema]] (deep vein thrombosis)
-The presence of [finding(s)] on physical examination is diagnostic of [disease name].
+*Limb pulse differential ([[aortic dissection]])
-OR
-The presence of [finding(s)] on physical examination is highly suggestive of [disease name].
-===Appearance of the Patient===
-*Patients with [disease name] usually appear [general appearance].
-===Vital Signs===
-*High-grade / low-grade fever
-*[[Hypothermia]] / hyperthermia may be present
-*[[Tachycardia]] with regular pulse or (ir)regularly irregular pulse
-*[[Bradycardia]] with regular pulse or (ir)regularly irregular pulse
-*Tachypnea / bradypnea
-*Kussmal respirations may be present in _____ (advanced disease state)
-*Weak/bounding pulse / pulsus alternans / paradoxical pulse / asymmetric pulse
-*High/low blood pressure with normal pulse pressure / [[wide pulse pressure]] / [[narrow pulse pressure]]
 ===Skin===
-* Skin examination of patients with [disease name] is usually normal.
-OR
-*[[Cyanosis]]
-*[[Jaundice]]
-* [[Pallor]]
-* Bruises
-<gallery widths="150px">
-UploadedImage-01.jpg | Description {{dermref}}
-UploadedImage-02.jpg | Description {{dermref}}
-</gallery>
-===HEENT===
-* HEENT examination of patients with [disease name] is usually normal.
-OR
-* Abnormalities of the head/hair may include ___
-* Evidence of trauma
-* Icteric sclera
-* [[Nystagmus]]
-* Extra-ocular movements may be abnormal
-*Pupils non-reactive to light / non-reactive to accommodation / non-reactive to neither light nor accommodation
-*Ophthalmoscopic exam may be abnormal with findings of ___
-* Hearing acuity may be reduced
-*[[Weber test]] may be abnormal (Note: A positive Weber test is considered a normal finding / A negative Weber test is considered an abnormal finding. To avoid confusion, you may write "abnormal Weber test".)
-*[[Rinne test]] may be positive (Note: A positive Rinne test is considered a normal finding / A negative Rinne test is considered an abnormal finding. To avoid confusion, you may write "abnormal Rinne test".)
-* [[Exudate]] from the ear canal
-* Tenderness upon palpation of the ear pinnae/tragus (anterior to ear canal)
-*Inflamed nares / congested nares
-* [[Purulent]] exudate from the nares
-* Facial tenderness
-* Erythematous throat with/without tonsillar swelling, exudates, and/or petechiae
-===Neck===
-* Neck examination of patients with [disease name] is usually normal.
-OR
-*[[Jugular venous distension]]
-*[[Carotid bruits]] may be auscultated unilaterally/bilaterally using the bell/diaphragm of the otoscope
-*[[Lymphadenopathy]] (describe location, size, tenderness, mobility, and symmetry)
-*[[Thyromegaly]] / thyroid nodules
-*[[Hepatojugular reflux]]
-===Lungs===
-* Pulmonary examination of patients with [disease name] is usually normal.
-OR
-* Asymmetric chest expansion OR decreased chest expansion
-*Lungs are hyporesonant OR hyperresonant
-*Fine/coarse [[crackles]] upon auscultation of the lung bases/apices unilaterally/bilaterally
-*Rhonchi
-*Vesicular breath sounds OR distant breath sounds
-*Expiratory wheezing OR inspiratory wheezing with normal OR delayed expiratory phase
-*[[Wheezing]] may be present
-*[[Egophony]] present/absent
-*[[Bronchophony]] present/absent
-*Normal/reduced [[tactile fremitus]]
-===Heart===
-* Cardiovascular examination of patients with [disease name] is usually normal.
-OR
-*Chest tenderness upon palpation
-*PMI within 2 cm of the sternum  (PMI) / Displaced point of maximal impulse (PMI) suggestive of ____
-*[[Heave]] / [[thrill]]
-*[[Friction rub]]
-*[[Heart sounds#First heart tone S1, the "lub"(components M1 and T1)|S1]]
-*[[Heart sounds#Second heart tone S2 the "dub"(components A2 and P2)|S2]]
-*[[Heart sounds#Third heart sound S3|S3]]
-*[[Heart sounds#Fourth heart sound S4|S4]]
-*[[Heart sounds#Summation Gallop|Gallops]]
-*A high/low grade early/late [[systolic murmur]] / [[diastolic murmur]] best heard at the base/apex/(specific valve region) may be heard using the bell/diaphgram of the stethoscope
-===Abdomen===
-* Abdominal examination of patients with [disease name] is usually normal.
-OR
-*[[Abdominal distension]]
-*[[Abdominal tenderness]] in the right/left upper/lower abdominal quadrant
-*[[Rebound tenderness]] (positive Blumberg sign)
-*A palpable abdominal mass in the right/left upper/lower abdominal quadrant
-*Guarding may be present
-*[[Hepatomegaly]] / [[splenomegaly]] / [[hepatosplenomegaly]]
-*Additional findings, such as obturator test, psoas test, McBurney point test, Murphy test
-===Back===
-* Back examination of patients with [disease name] is usually normal.
-OR
-*Point tenderness over __ vertebrae (e.g. L3-L4)
-*Sacral edema
-*Costovertebral angle tenderness bilaterally/unilaterally
-*Buffalo hump
-===Genitourinary===
-* Genitourinary examination of patients with [disease name] is usually normal.
-OR
-*A pelvic/adnexal mass may be palpated
-*Inflamed mucosa
-*Clear/(color), foul-smelling/odorless penile/vaginal discharge
-===Neuromuscular===
-* Neuromuscular examination of patients with [disease name] is usually normal.
-OR
-*Patient is usually oriented to persons, place, and time
-* Altered mental status
-* Glasgow coma scale is ___ / 15
-* Clonus may be present
-* Hyperreflexia / hyporeflexia / areflexia
-* Positive (abnormal) Babinski / plantar reflex unilaterally/bilaterally
-* Muscle rigidity
-* Proximal/distal muscle weakness unilaterally/bilaterally
-* ____ (finding) suggestive of cranial nerve ___ (roman numerical) deficit (e.g. Dilated pupils suggestive of CN III deficit)
-*Unilateral/bilateral upper/lower extremity weakness
-*Unilateral/bilateral sensory loss in the upper/lower extremity
-*Positive straight leg raise test
-*Abnormal gait (describe gait: e.g. ataxic (cerebellar) gait / steppage gait / waddling gait / choeiform gait / Parkinsonian gait / sensory gait)
-*Positive/negative Trendelenburg sign
-*Unilateral/bilateral tremor (describe tremor, e.g. at rest, pill-rolling)
-*Normal finger-to-nose test / Dysmetria
-*Absent/present dysdiadochokinesia (palm tapping test)
-===Extremities===
+*[[Hyperesthesia]] and [[rash]] [[Herpes zoster|(zoster)]]
-* Extremities examination of patients with [disease name] is usually normal.
+*[[Subcutaneous emphysema]] ([[Boerhaave syndrome]], [[pneumothorax]]).
-OR
-*[[Clubbing]]
-*[[Cyanosis]]
-*Pitting/non-pitting [[edema]] of the upper/lower extremities
-*Muscle atrophy
-*Fasciculations in the upper/lower extremity
+== 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines <ref name="pmid34709879" /> ==
+=== Recommendation for physical examination ===
+{| class="wikitable"
+|-
+| colspan="1" style="text-align:center; background:LightGreen" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
+|-
+| bgcolor="LightGreen" |'''1.'''In patients presenting with chest pain, a focused cardiovascular examination should be performed initially to aid in the diagnosis of ACS or other potentially serious causes of chest pain (eg, aortic dissection, PE,or esophageal rupture) and to identify complications. ''(Level of Evidence: C-EO)''
+|}
 ==References==
 {{Reflist|2}}