Patients with heartburn usually appear discomfortable, but the symptoms are commonly mild and frequent. Occasionally the patients may appear ill due to the pain in a emergency department setting. Common physical examination may include hoarseness of voice, laryngitis, otitis media, and lung wheezes.

• Patients with heartburn usually appear uncomfortable due to the retrosternal pain.

• Hypertension spicking specially in patients already with pre-existing hypertension, due to the pain.^[1]

• Hoarseness of voice
• Laryngitis
• Otitis media
• Dental erosions

• Wheezes
• Bronchitis^[2]

• Epigastric tenderness, which may be severe and sometimes be mistaken with acute coronary syndrome or other causes of acute abdomen.

• CREST syndrome presents with calcinosis, Raynaud’s phenomenon, esophageal dysmotility, sclerodactyly, and telangiectasia.^[3]

In the evaluation of a patient presenting with ACS, hypotension (systolic blood pressure <100 mm Hg), tachycardia (pulse >100) and bradycardia (pulse <60 bpm) indicate that the patient is at higher risk.

• Patients may present signs of cardiac failure, such as a 3rd heart sound, a 4th heart sound or a new/increased systolic murmur of mitral regurgitation.
• The presence of a pericardial rub would suggest pericarditis instead of ACS.