Action
Patient presents with complaint of chest pain
Decision
Patient is ill-appearing or has an abnormal cardiac examination?
- Abnormal vitals sign
- Altered mental status
- Abnormal color or perfusion
- Diaphoresis
- Hypoxia
Background
Cardiac examination involves identification of pathologic and particularly new murmurs, friction rubs, and gallops. A newly identified fixed and narrowly split S2 suggests increased pulmonary vascular pressure seen with long-standing left-to-right shunt or idiopathic pulmonary hypertension. Distant or muffled heart tones can be appreciated in patients with pericardial effusion. A murmur on the left sternal border that radiates to the axilla or back and worsens with the Valsalva maneuver should raise concerns for hypertrophic cardiomyopathy (HCM). A cardiac examination is not complete without an assessment of the peripheral vasculature and specifically pulse quality. Chest pain caused by pathology impacting cardiac output due to poor contractility or outflow obstruction will often result in decreased or differential peripheral pulses. The chest wall should be inspected for deformities, and joints should be assessed for laxity in patients for whom connective tissue disorders and aortic dissection are considered. Epigastric tenderness in the patient who gets some relief from H-2 blockers or antacids suggests gastritis and reflux. Palpating a liver edge or lower extremity edema can suggest heart failure.
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