Chest pain physical examination

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

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.

Physical Examination

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

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

• Cerebrovascular accidents (aortic dissection)
• Paraplegia

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).