The physical examination is often normal. Abnormalities in vital signs include hyper- or hypotension, sinus tachycardia, or bradycardia. Tachycardia often results from increased sympathetic tone and decreased left ventricular stroke volume, while bradycardia is often present among patients with inferior wall ischemia.
Patients with acute ischemia have a higher incidence of abnormal heart sounds such as a diminished S -,, a paradoxically split S2, and/or an S3 or S4 due to changes in ventricular function or compliance. Auscultation of the lungs may reveal the presence of ischemia-induced congestive heart failure. However, none of these findings are uniformly present, nor are they diagnostic. Chest wall tenderness reproducing the patient's pain is somewhat suggestive of a musculoskeletal etiology. However, reproducible chest wall tenderness has also been reported in up to 15 percent of patients with confirmed MI; therefore, this finding should never be used to exclude the diagnosis of myocardial ischemia.6 Despite a lack of specific diagnostic findings, a thorough physical examination remains essential, as it may provide clues to a nonischemic origin of the patient's symptoms and is often helpful in identifying or excluding other life-threatening causes of chest pain.
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