Key Physical Findings
Table 7 shows the key physical findings associated with conditions presenting with chest pain in the emergency department. Pivotal physical signs, or combinations of signs, which are highly suggestive of the relevant diagnoses, are shown in bold. Aortic dissection is renowned for being very difficult to diagnose, with the classic clinical signs occurring infrequently, see percentage of occurrence within the brackets.(6) Diagnosing PE is also a challenge because the symptoms and signs are common and not specific, Table 8(9)
Learning bite
Various combinations of physical findings can be pathognomonic for non-ischaemic chest pain conditions
Table 7: Key physical findings associated with conditions causing chest pain
| Diagnosis | Physical findings |
|---|---|
| Acute coronary syndrome | Diaphoresis, tachycardia, tachypnoea, pallor |
| Complications of acute MI | Hypotension, third heart sound, pulmonary crepitations, elevated JVP, bradycardia, new murmur |
| Aortic dissection | Diaphoresis, hypotension, hypertension, tachycardia, differential blood pressures and/or pulses (27%), new murmur (aortic regurgitation 32%), focal neurological findings (12%) |
| Pulmonary embolism | Acute respiratory distress, diaphoresis, hypotension, tachycardia, hypoxaemia, elevated JVP, pleural rub |
| Pneumonia | Fever, signs of pulmonary collapse / consolidation, tachycardia, tachypnoea |
| Oesophageal rupture | Diaphoresis, hypotension, tachycardia, fever, Hamman’s sign*, subcutaneous emphysema, epigastric tenderness |
| Simple pneumothorax | Tachypnoea, tachycardia, unilateral diminished air entry and breath sounds, subcutaneous emphysema |
| Tension pneumothorax | Tachypnoea, hypotension, tachycardia, hypoxaemia, elevated JVP, unilateral diminished air entry and breath sounds, subcutaneous emphysema, tracheal deviation |
| Pericarditis | Tachycardia, fever, pericardial rub |
| Myocarditis | Hypotension, tachycardia, fever, third heart sound, pulmonary crepitations, displaced apex beat |
| Mediastinitis | Tachycardia, fever, Hamman’s sign*, subcutaneous emphysema, hypotension |
| Cholecystitis | Diaphoresis, fever, tachycardia, right upper quadrant tenderness |
| *Hamman’s sign: audible systolic noise on cardiac auscultation | |
Certain physical signs, or combinations of signs, are highly suggestive of certain diagnoses and are highlighted in bold.
* Hamman’s sign: audible systolic noise on cardiac auscultation
Table 8: Prevalence of Symptoms and Signs in Patients with suspected PE according to final diagnosis.(9)
| Symptoms of PE | PE confirmed (n=219) | PE Excluded (n=546) |
| Dyspnoea | 80% | 59% |
| Pleuritic Chest Pain | 52% | 43% |
| Substernal Chest Pain | 12% | 8% |
| Cough | 20% | 25% |
| Haemoptysis | 11% | 7% |
| Syncope | 19% | 11% |
| Signs of PE | ||
| Tachypnoea (> 20/min) | 70% | 68% |
| Tachycardia >100 | 26% | 23% |
| Signs of DVT | 15% | 10% |
| Fever (>38.5oc) | 7% | 17% |
| Cyanosis | 11% | 9% |