Wednesday, September 11, 2013

Physical Examination for Chest Pain

                A history-directed physical exam is not a full physical exam. Base on information obtained in the history, the directed exam should confirm a suspected diagnosis or narrow a differential diagnosis list. Much like the focused history, a directed exam should rapidly and accurately characterize the cest pain and screen for life-threatening findings. Most of the few minutes spent examining the patient should be focused on the cardiovascular and pulmonary exams. Clinical pearls for a chest pain-directed exam listed  below
1. Blood pressure
- Check both arms, especially if considering aortic dissection
- Severe hypertension and hypotension require urgent intervention
- Pulsus paradoxus: drop of  >10 mm Hg in SBP at end- inspiration (tamponade)

2. Jugular Veins
- Start with patient reclined at 45 degrees. Patients with significantly elevited JVP may need to be sitting up at 90 degrees before the jugular venous pulse can be seen.
- Hepatojugular reflex: sustained distention of jugular veins with pressure on abdomen (heart failure)

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