What should I do on physical exam for a patient with chest pain radiating to the back after a fall?

Physical Examination for Chest Pain Radiating to the Back After a Fall

A focused cardiovascular examination should be performed immediately to evaluate for potentially life-threatening causes of chest pain, with particular attention to signs of aortic dissection, which should be strongly suspected in a patient with chest pain radiating to the back after a fall. 1

Initial Assessment

• Vital signs: Check blood pressure in both arms (unequal readings suggest aortic dissection), heart rate, respiratory rate, oxygen saturation, and temperature 1
• General appearance: Look for diaphoresis, pallor, respiratory distress, and level of consciousness

Cardiovascular Examination

Heart

• Auscultate for:
  • Murmurs (especially new aortic regurgitation murmur suggesting aortic dissection)
  • S3 gallop (suggests LV dysfunction)
  • Pericardial friction rub (suggests pericarditis)
  • Abnormal heart sounds or rhythm

Vascular

• Pulse examination: Compare pulses in all extremities; unequal or absent pulses suggest aortic dissection 1
• Auscultate for bruits: Presence suggests extracardiac vascular disease and higher likelihood of significant CAD 1

Chest Examination

• Inspection: Look for chest wall deformity, bruising, or ecchymosis from the fall
• Palpation:
  • Check for chest wall tenderness (note that reproducible pain with palpation makes ACS less likely, LR 0.2-0.3) 2
  • Assess for subcutaneous emphysema (suggests pneumothorax)
  • Evaluate for crepitus (suggests rib fractures)
• Percussion: Assess for dullness (pleural effusion) or hyperresonance (pneumothorax)
• Auscultation: Listen for decreased or abnormal breath sounds, rales (suggesting LV dysfunction) 1

Back Examination

• Examine for point tenderness along the spine and paraspinal muscles
• Assess for bruising or deformity
• Evaluate for vertebral tenderness suggesting fracture

Neurological Assessment

• Perform a focused neurological exam to assess for any deficits that might suggest spinal cord involvement
• Check for sensory and motor function in all extremities

Abdominal Examination

• Palpate for tenderness, especially in the epigastric region
• Assess for pulsatile abdominal mass (suggesting abdominal aortic involvement)

Key Diagnostic Considerations

1. Aortic dissection: Prioritize this diagnosis in a patient with chest pain radiating to the back after trauma. Look for:

   • Unequal pulses or blood pressures between arms
   • New murmur of aortic regurgitation
   • Neurological deficits
   • Signs of shock or hypoperfusion 1

2. Acute coronary syndrome: While less likely with radiation to the back, still consider:

   • Signs of hemodynamic compromise
   • Diaphoresis
   • Nausea/vomiting 1

3. Traumatic injuries:

   • Rib fractures
   • Pneumothorax (decreased breath sounds, hyperresonance)
   • Hemothorax (decreased breath sounds, dullness)
   • Pulmonary contusion

Important Caveats

• The physical examination alone cannot rule out serious conditions like aortic dissection or ACS; further diagnostic testing is essential 3
• In older patients (≥75 years), ACS should be strongly considered when chest pain follows a fall, as this may represent an "unexplained fall" precipitated by a cardiac event 1
• Do not be falsely reassured by reproducible chest wall tenderness, as serious conditions can coexist with musculoskeletal pain 2

Remember that the physical examination findings must be interpreted in conjunction with the history, ECG (which should be obtained within 10 minutes of arrival), and cardiac biomarkers to guide appropriate management decisions 1.