Chest pain physical examination

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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

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

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).

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

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)