Acute coronary syndrome resident survival guide: Difference between revisions

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** Check for alertness, and orientation with time, place, and person
** Check for alertness, and orientation with time, place, and person
** Patient leaning forward can point towards pericarditis
** Patient leaning forward can point towards pericarditis
* '''Cardiovascular''':
*'''HEENT''':
** Pulse Rate (rate, rhythm. volume, quality, symmetry, all 4 limbs. [[Aortic dissection]]- Diminution or absence of pulses)
** Blood pressure (check for symmetry in all the limbs)
** Auscultate [[carotid artery]] (check for bruit)
** Auscultate [[carotid artery]] (check for bruit)
** [[Jugular venous distension]], check for [[hepatojugular reflex]]
** [[Jugular venous distension]], check for [[hepatojugular reflex]]
* '''Cardiovascular''':
** Vital signs
*** Pulse Rate (rate, rhythm. volume, quality, symmetry, all 4 limbs. [[Aortic dissection]]- Diminution or absence of pulses)
***Blood pressure (check for symmetry in all the limbs)
** '''Inspection''': Check for displacement of the apex.  
** '''Inspection''': Check for displacement of the apex.  
** '''Palpation''': Confirm the findings of inspection (cardiac apex), musculo-skeletal tenderness, crepitus (esophageal rupture,subcutaneous emphysema), feel for any thrill (possible regurgitation), heave (right ventricular hypertrophy)
** '''Palpation''': Confirm the findings of inspection (cardiac apex), musculo-skeletal tenderness, crepitus (esophageal rupture,subcutaneous emphysema), feel for any thrill (possible regurgitation), heave (right ventricular hypertrophy)

Revision as of 14:57, 28 September 2012

Patient Presentation

Common presentation

Initial Evaluation and Orders

Important!
Follow up with all pending tests and lab results as soon as these become available. For information on evaluating the results go to the apppropriate section on this page.

History and Symptoms

History of Present Illness:

  • Chest pain history; ask about onset, duration, nature, intensity, location, progression, radiation (to arm, neck, jaw= acute coronary syndrome, or back=aortic dissection), aggravating (pleurtic and pericarditis chest pain worsens with respiration) and relieving factors (relieved by nitrates), constant or intermittent. Ask about any precipitating factors (trauma, physical strain, emotional distress).
  • Ask if pain is associated with (head to toe). Headache, confusion, fever, photophobia, vision changes, bleeding, nausea, vomiting, apetite, weight loss, shortness of breath, palpitations, cough, sputum, abdominal pain, bowel symptoms, urinary symptoms.

Physical Examination

  • General
    • Check for alertness, and orientation with time, place, and person
    • Patient leaning forward can point towards pericarditis
  • HEENT:
  • Cardiovascular:
    • Vital signs
      • Pulse Rate (rate, rhythm. volume, quality, symmetry, all 4 limbs. Aortic dissection- Diminution or absence of pulses)
      • Blood pressure (check for symmetry in all the limbs)
    • Inspection: Check for displacement of the apex.
    • Palpation: Confirm the findings of inspection (cardiac apex), musculo-skeletal tenderness, crepitus (esophageal rupture,subcutaneous emphysema), feel for any thrill (possible regurgitation), heave (right ventricular hypertrophy)
    • Auscultation:
  • Respiratory:
    • Inspection: Observe for symmetry of chest movement, evidence of flail chest, tracheal deviation (pneumothorax).
    • Palpation : Check for muscle tenderness, tracheal deviation, and chest wall movement.
    • Percussion: Percuss all lung fields for dullness (effusion), or hyperresonance to percussion on the affected side (pneumothorax).
    • Auscultation: Decreased breath sounds (effusion and tension pneumothorax), crackles (pleural effusion) rales (heart failure).
  • Extremities: Check for pedal edema.

Differential Diagnosis

EKG Findings

Electrocardiogram in Unstable angina / NSTEMI

The resting electrocardiogram in the patient with unstable angina / non ST elevation MI may show any of the following:


ST Depression in a patient with unstable angina

Electrocardiogram in STEMI

The electrocardiographic definition of ST elevation MI requires the following: at least 1 mm (0.1 mV) of ST segment elevation in 2 or more anatomically contiguous leads.[1] While these criteria are sensitive, they are not specific as thromboctic coronary occlusion is not the most common cause of ST segment elevation in chest pain patients.[2]

Chest X Ray Findings

Other Diagnostic Work-up

  1. Smith SW, Whitwam W (2006). "Acute coronary syndromes". Emerg. Med. Clin. North Am. 24 (1): 53–89, vi. doi:10.1016/j.emc.2005.08.008. PMID 16308113. Unknown parameter |month= ignored (help)