What to do with a patient with no acute distress and normal physical exam results?

Management of a Patient with No Acute Distress and Normal Physical Examination

For a patient with no acute distress and normal physical examination findings, the appropriate approach is to categorize them into one of four diagnostic categories (noncardiac diagnosis, chronic stable angina, possible ACS, or definite ACS) and proceed with risk stratification to determine the need for further evaluation or discharge. 1

Initial Assessment and Risk Stratification

When evaluating a patient with normal physical examination findings:

1. Integrate all available information:

   • History (including nature of any presenting symptoms)
   • Physical examination findings (which are normal in this case)
   • 12-lead ECG
   • Initial cardiac biomarker tests

2. Categorize the patient based on presentation:

   • If the patient is pain-free, hemodynamically stable, with normal/unchanged ECG and normal cardiac biomarkers → diagnostic challenge rather than therapeutic emergency 1
   • If the patient has no history of chest discomfort or other concerning symptoms → likely noncardiac or very low risk

Management Algorithm

For Patients with No Symptoms and Normal Exam:

• If no concerning history and normal exam → routine follow-up as appropriate
• If patient had recent symptoms but is currently asymptomatic with normal exam:
  • Obtain baseline ECG and cardiac biomarkers
  • Consider likelihood of coronary artery disease (CAD) based on risk factors

For Patients with Recent Chest Pain/Discomfort (Now Resolved):

1. Low Likelihood of CAD:

   • Evaluate for non-cardiac causes:
     • Musculoskeletal pain
     • Gastrointestinal disorders (esophageal spasm, gastritis, peptic ulcer)
     • Intrathoracic disease (pneumonia, pleurisy, pneumothorax)
     • Neuropsychiatric disorders 1

2. Possible ACS with Normal Initial Tests:

   • If patient had recent chest discomfort not entirely typical of ischemia but is now pain-free with normal ECG and biomarkers:
     • Observe in a facility with cardiac monitoring (chest pain unit or telemetry ward)
     • Obtain repeat ECG and cardiac biomarkers at predetermined intervals (6-12 hours after symptom onset) 1
     • If follow-up tests remain normal, consider stress testing within 72 hours 1

3. Low-Risk ACS Patients:

   • If stress test is negative → manage as outpatient
   • Provide precautionary medications while awaiting test results:
     • Aspirin
     • Sublingual nitroglycerin
     • Consider beta-blockers 1

Discharge Planning

For patients being discharged:

• Provide specific instructions for activity and medications
• Schedule additional testing if indicated
• Arrange follow-up with primary care physician within 72 hours 1
• Counsel regarding when to return for care (recurrent symptoms, new symptoms)

Common Pitfalls to Avoid

1. Premature discharge without adequate risk stratification in patients with recent symptoms
2. Failure to consider non-cardiac diagnoses when exam is normal
3. Overreliance on normal physical exam without considering cardiac biomarkers and ECG
4. Missing subtle signs of potential cardiovascular disease that might not be evident on initial examination
5. Lack of clear follow-up instructions for patients being discharged

Remember that even patients with normal physical examinations who had recent concerning symptoms should have appropriate risk stratification before determining disposition. The absence of abnormal findings on physical examination does not exclude significant underlying pathology, particularly in cardiovascular disease.