Physical examination
The focused physical examination is used to support or disprove hypotheses generated by the history. Thus, the extent of the examination is primarily

determined by the diagnoses that are being considered. A brief, "core" examination may suffice to diagnose life-threatening and common etiologies of chest pain.

The general

appearance of the patient suggests the severity and possibly the seriousness of the symptoms. A full set of vital signs can provide valuable clues to the clinical significance of the pain, and may in some cases aid in establishing its origin. A marked
difference in blood pressure between the two arms suggests the presence of aortic dissection. Palpation of the chest wall may evoke pain; if so the patient should be asked if this sensation is identical to the chief complaint. Chest wall tenderness may be present concomitantly with myocardial ischemia. Hyperesthesia, particularly when associated with a rash, is often due to herpes zoster. A complete cardiac examination including auscultation and palpation should be performed in a sitting and supine position to establish the presence of a pericardial rub or signs of acute aortic insufficiency or aortic stenosis. Ischemia may result in a mitral insufficiency murmur or an S4 or S3 gallop; there may also be abnormal precordial movement, especially at the apex.
Determine if the breath sounds are symmetric and if wheezes, crackles or evidence of consolidation is present. A careful examination of the abdomen is important, with attention to the right upper quadrant, epigastrium. and the abdominal aorta.

Ancillary studies
Ancillary studies including an ECG (when a cardiac etiology is possible) and chest radiography (when cardiac or pulmonary disease is a consideration) may support the initial diagnosis and help avoid missing serious etiologies of chest pain such as acute myocardial infarction or pneumothorax.

The absence of any acute or diagnostic ECG changes may therapeutically allay patient anxiety and reduce short-term disability. Further investigations, such as exercise ECG, myocardial perfusion, or echocardiographic stress testing, a diagnostic course of acid suppression, or lung perfusion, bone, or chest CT scanning may occasionally be required to establish specific etiologies for the chest pain.

Normal electrocardiogram
A normal ECG markedly reduces the probability that chest pain is due to acute myocardial infarction, but does not exclude a serious cardiac etiology (particularly unstable angina). ECG findings must be considered in the context of the history and physical examination. Patients with unstable angina are much more likely to have a normal ECG than those with acute myocardial infarction. The likelihood ratio of acute myocardial infarction in a patient with a normal initial ECG is 0.1 to 0.3. However, if the history and physical examination suggest a high pretest probability of an acute myocardial infarction, a normal ECG does not fully eliminate this diagnosis. A normal ECG in a patient with the recent onset of chest pain can also be found in patients with a less acute coronary syndrome such as table angina. Aortic dissection should be considered in patients with ongoing pain and a normal ECG.

Abnormal electrocardiogram

An abnormal ECG that contains specific findings (eg, ST segment elevation, ST segment depression, or new Q waves) remains an important predictor of an acute coronary syndrome (acute myocardial infarction or unstable angina). Patients with an acute myocardial infarction who present with a positive initial ECG are more likely to require invasive therapy, have a complicated hospital course, or die. An ECG that is nonspecifically abnormal (eg, there are nonspecific ST and T wave abnormalities) is commonly seen and may or may not indicate heart disease.

Chest radiograph
(See Table-2)
A chest radiograph may assist in the diagnosis of chest pain if a cardiac, pulmonary, or neoplastic etiology is being considered. It is also useful in the acute setting to help avoid missing infrequent but dangerous diagnoses such as aortic dissection, pneumothorax, and pneumomediastinum.


ossiva06, India

my father is suffering from chest pain . which doctor i want to consult in chennai

Edphil, United Kingdom

I have a right side chest pain that radiates to the arm.I have been feeling this pain in a dull manner for more than six months now but the radiation to the arm started recently.I have been for a chest x-ray and waiting for the result.The pain goes off temporarily if I indulge in exercise for more than 30 minutes but comes back in the morning.Today it was persistent that I can hardly raise my right arm or carry my baby.I am waiting for the test result before I get back to the GP.Please tell me what to do.

shaanZee, India

my husband age 33 has a pain in chest from few days if he walk fast

MandarS, India

Recently I Lost my mother by heart attached on 21.09.2010, she got chest pain at 10.30pm I call doctor near to me (BAMS) she miss guide me that chest pain due to acidity becouse my mother BP and heart beat is normal at that time and chest pain is in centre part of chest as inform by that doctor.

Still for safer side we moved her to cardiologst he take ECG & infor its start of heart attack, he gave her sorbitol & some liquid syrup & asked to move to ICCU.
I call abilance from Wackharts but during trasit she got attack and she pass away.

The mistake we have done,
Loss the time to investigate reason of chest pain
Suggession :-
Do not wait to invetigate rason for chest pain, just move to the hospital who can investigate & treat the chest pain reason whatever maybe.

nancyk, United States

I have chest pain on the right side and in right arm. Chest Pain started early morning before sun came up. Right arm started around lunch time. Should I go to emergency room?