Objective signs include fever before the onset of

myxedema, and history of autoimmune disease. Objective signs include fever before the onset of pain,
tachycardia, and pericardial friction rub. The rub is pathognomonic for pericarditis but is found in only 60% to
70% of patients with pericarditis. Diagnostic tests show elevated white blood cells and ESR and ECG showing
diffuse ST ­ segment elevation in the early stages. Chest radiography can be normal or show effusion with an
increase in cardiac shadow.
Aortic stenosis
Aortic stenosis can cause exertional chest pain. Associated symptoms include fatigue, palpitations, dyspnea on
exertion, dizziness, and syncope. Physical examination reveals a loud, harsh crescendo–decrescendo murmur,
best heard at the second right intercostal space, with the patient leaning forward. The murmur can radiate to the
neck and is often associated with a thrill. An echocardiogram will provide diagnostic evidence of aortic stenosis.
Mitral regurgitation
Symptoms of mitral regurgitation are similar to those of aortic stenosis: they include exertional substernal chest
pain, fatigue, palpitations, dizziness, dyspnea on exertion, and syncope. The murmur associated with mitral
regurgitation is holosystolic and blowing and often is heard best at the apex in the left lateral position. The
murmur decreases with inspiration and can radiate to the left axilla and occasionally to the back. Again,
echocardiography will provide evidence of mitral regurgitation.
Pneumonia
Signs and symptoms of pneumonia include pleuritic chest pain; a productive, moist cough with dark sputum;
shortness of breath; and fever and chills. Risk factors include ineffective cough reflex, inability to swallow,
advanced age, or very young age. Auscultation of the lungs reveals diminished breath sounds over affected
areas, and crackles and wheezes can be heard. Rales and rhonchi are frequently heard on auscultation. Dullness
with percussion is heard over areas of consolidation. Vocal fremitus is heard. In addition,
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physical findings can include tachycardia, tachypnea, bronchophony, and egophony. Chest radiography,
sputum culture, and ABGs will further support the diagnosis of pneumonia. Follow ­ up chest radiographs are
indicated after pneumonia because lung tumors can be hidden by pneumonia. Very young and very old
patients may be hospitalized for observation and treatment of pneumonia.
Mitral valve prolapse
Patients with chest pain from MVP report a range of signs and symptoms, including arrhythmias, palpitations,
fatigue, and anxiety. Patients may have a history of rheumatic fever. Physical examination can be normal or a
midsystolic click can be heard over the apex, while the patient is sitting or squatting. An echocardiogram will
provide evidence of MVP.