12
Treatment
Table 2. Physical Examination in Patients With Chest Pain
Clinical Syndrome Findings
Emergency
ACS • Diaphoresis, tachypnea, tachycardia, hypotension,
crackles, S3, MR murmur; examination may be normal in
uncomplicated cases
PE • Tachycardia + dyspnea—>90% of patients; pain with
inspiration
Aortic dissection • Connective tissue disorders (e.g., Marfan syndrome),
extremity pulse differential (30% of patients, type A>B)
• Severe pain, abrupt onset + pulse differential + widened
mediastinum on CXR >80% probability of dissection
• Frequency of syncope >10%, AR 40%–75% (type A)
Esophageal rupture
• Emesis, subcutaneous emphysema, pneumothorax (20%
patients), unilateral decreased or absent breath sounds
Other
Noncoronary cardiac:
AS, AR, HCM
• AS: Characteristic systolic murmur, tardus or parvus carotid
pulse
• AR: Diastolic murmur at right of sternum, rapid carotid
upstroke
• HCM: Increased or displaced left ventricular impulse,
prominent a wave in jugular venous pressure, systolic
murmur
Pericarditis
Myocarditis
• Fever, pleuritic chest pain, increased in supine position,
friction rub
• Fever, chest pain, heart failure, S3
Esophagitis, peptic
ulcer disease, gall
bladder disease
• Epigastric tenderness
• Right upper quadrant tenderness, Murphy sign
Pneumonia • Fever, localized chest pain, may be pleuritic, friction rub
may be present, regional dullness to percussion, egophony
Pneumothorax • Dyspnea and pain on inspiration, unilateral absence of
breath sounds
Costochondritis,
Tietze syndrome
• Tenderness of costochondral joints
Herpes zoster • Pain in dermatomal distribution, triggered by touch;
characteristic rash (unilateral and dermatomal distribution)
