Our patient was seen immediately by the attending cardiologist to agree that angiographic study should be carried out. While the catheterization laboratory was preparing for the patient, a focused, but complete, cardiovascular bedside examination was performed. While the following interactive presentation will take time for you to review, the patient's actual bedside examination was completed in a matter of minutes. Leading the discussions that will follow will be Dr. Michael S. Gordon, Professor of Medicine at the University of Miami Miller School of Medicine.
Introduction to examination
Our patient is a middle age female with a history completely consistent with acute myocardial infarction - substernal chest distress radiating into the arms. A female, do not be dissuaded because the patient is a female. Too often we think of coronary artery disease and acute myocardial infarction as a male disease. It is also a leading cause of death and disability in females, albeit, it may present at a more advanced age than in the male population. Not only is her history consistent with acute myocardial infarction, but her electrocardiogram is typical of changes that occur with an anterior wall myocardial infarction.
Now, the most important thing in any patient is their very survival, and what can we say about the survival of our patient? It really depends upon three things: one, that we make the diagnosis early, and we have moved along well in terms of the history, the electrocardiogram. But also, we must remember that the physical examination can contribute, a focused physical examination can often tell you about the myocardial infarction; the second point is that it is the extent of the infarction that may often determine the survival of the patient, and there are many clues at the bedside on the extent of the myocardial infarction; the last point is that survival depends upon early treatment, early treatment. So, we diagnose early, we assess the extent of the infarct and we intervene early.
Appearance
The first step in the patient's physical examination is an evaluation of the patient's general appearance. Our patient appears anxious and she was diaphoretic and mildly dyspneic.
BP presentation
Let us begin the evaluation of our patient by determining her blood pressure, placing the diaphragm of the stethoscope over the brachial artery, inflating the cuff exceeding the systolic pressure and watching the sphygmomanometer. I'm slowly deflating the cuff and we shall observe. [Cut-away]
Our patient's blood pressure is 120/95. Now, what does that tell us? Well, let's put it in the total clinical context. Many patients with acute mayocardial infarction may initially have some elevation of their blood pressure because of the outporing of catecholamines that occurs in that setting and that, in turn, increases peripheral resistance. The second thing to put it in clinical perspective is that you should always know your patient's history. Do they have hypertension? Was it treated? Was it controlled? Now, what about our patient specifically? Well, our patient presented with a blood pressure of 140/110 and now it is 120/95. That may be a clue, that may be a clue to that not only is there an outporing of catecholamines, but there may be also a reduction of cardiac output, and if there is a reduction of cardiac output, as reflected in the narrow pulse pressure, that could be that our patient is having an extensive myocardial infarction.
BP discussion
Our patient's blood pressure decreased since her initial evaluation. In addition to her reduction in cardiac output, other explanations include a decrease in catecholamine levels and a consequence of intravenous nitroglycerin therapy.