What should I assess on physical exam in a patient with chest pain to determine the differential diagnosis?

Physical Examination Approach for Chest Pain Differential Diagnosis

A focused cardiovascular examination should be performed initially in all patients with chest pain to aid in the diagnosis of acute coronary syndrome (ACS) or other potentially serious causes of chest pain and to identify complications. 1

Initial Vital Signs Assessment

• Check vital signs immediately:
  • Blood pressure (measure in both arms if aortic dissection is suspected)
  • Heart rate and rhythm
  • Respiratory rate
  • Temperature
  • Oxygen saturation

Cardiovascular Examination

Signs of ACS/Cardiac Ischemia

• Look for:
  • Diaphoresis
  • Tachypnea, tachycardia
  • Hypotension
  • Pulmonary crackles
  • S3 gallop
  • New mitral regurgitation murmur 1

Signs of Heart Failure

• Assess for:
  • Jugular venous distention
  • Peripheral edema
  • Pulmonary rales (LR+ 3.0 for MACE within 30 days) 2
  • S3 heart sound

Signs of Aortic Dissection

• Check for:
  • Pulse differentials between extremities (present in 30% of patients, more common in type A) 1
  • New aortic regurgitation murmur (present in 40-75% of type A dissections) 1
  • Features of connective tissue disorders (e.g., Marfan syndrome) 1
  • Blood pressure difference between arms

Pulmonary Examination

Signs of Pulmonary Embolism

• Look for:
  • Tachycardia and dyspnea (present in >90% of patients) 1
  • Pain that worsens with inspiration 1
  • Accentuated P2 heart sound 1
  • Signs of deep vein thrombosis

Signs of Pneumothorax

• Check for:
  • Unilateral decreased or absent breath sounds 1
  • Hyperresonance to percussion
  • Respiratory distress

Signs of Pneumonia

• Assess for:
  • Fever
  • Localized chest pain, often pleuritic
  • Friction rub
  • Regional dullness to percussion
  • Egophony 1

Other Important Examinations

Gastrointestinal Causes

• Check for:
  • Epigastric tenderness (esophagitis, peptic ulcer disease)
  • Right upper quadrant tenderness, Murphy sign (gallbladder disease) 1
  • Tympanic abdomen with severe pain (possible esophageal rupture) 1

Musculoskeletal Causes

• Assess for:
  • Tenderness of costochondral joints (costochondritis, Tietze syndrome) 1
  • Pain reproducible by palpation (LR+ 0.3 for cardiac causes, making cardiac cause less likely) 2

Dermatological Causes

• Look for:
  • Characteristic rash in unilateral dermatomal distribution (herpes zoster) 1

Examination Pearls and Pitfalls

Key Pearls

1. A normal physical examination does not rule out ACS - uncomplicated cases may present with normal findings 1

2. Chest pain reproducible by palpation significantly decreases the likelihood of cardiac ischemia but does not completely rule it out 2

3. Presence of pulmonary rales significantly increases the probability of cardiac events (LR+ 3.0) 2

4. In patients ≥75 years, consider ACS even with atypical presentations such as shortness of breath, syncope, acute delirium, or unexplained falls 1

5. Women often present with atypical symptoms - maintain high suspicion even without classic presentation 1

Common Pitfalls

1. Failing to perform a complete cardiovascular examination in patients with reproducible chest wall tenderness

2. Dismissing cardiac causes in women or elderly patients with atypical presentations

3. Not checking for pulse differentials in patients with severe, sudden-onset chest pain

4. Overlooking signs of pericarditis (friction rub, pain worsening when supine)

5. Relying solely on physical examination without obtaining an ECG within 10 minutes of arrival for patients with suspected ACS 1

Special Considerations

Women

• Women are at risk for underdiagnosis - maintain high suspicion for cardiac causes
• Pay special attention to accompanying symptoms more common in women with ACS 1

Elderly Patients (≥75 years)

• Consider ACS when accompanying symptoms such as:
  • Shortness of breath
  • Syncope
  • Acute delirium
  • Unexplained falls 1

Diverse Patient Populations

• Address language barriers with formal translation services
• Cultural competency is essential for accurate assessment 1

By systematically examining these key areas, you can effectively narrow your differential diagnosis and identify potentially life-threatening causes of chest pain that require immediate intervention.