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C. Obtain Focused History And Physical Examination

OBJECTIVE

Perform expedited and focused history and physical examination to elicit characteristics of MI, evidence for complications, and contraindications to reperfusion therapy.

ANNOTATION

Patients presenting with an acute STEMI should have an expedited and focused history and physical examination and ECG within 10 minutes of presentation, to assess for eligibility of reperfusion therapy, complications from an AMI, and contraindications to reperfusion therapy.

Specific clinical history questions should include the following:

  • Characteristics of MI
    • Character of symptoms
    • Time of onset
    • Duration of symptoms
    • Prior cardiac symptoms and evaluation
    • Current medical therapy including sildenafil
  • Complications of MI
    • Syncope
    • Shortness of breath
    • Orthopnea
    • Weakness or other symptoms suggestive of a neurologic event
  • Contraindications to Reperfusion Therapy
    • Medication allergies
    • Prior use of thrombolytic agents
    • Contraindications to thrombolytic therapy (see Annotation H)

A focused physical examination should include the following:

  • Vitals Signs
    • Heart rate greater than 60 and less than 100
    • Systolic blood pressure greater than 90 mmHg and less than 160 mmHg
  • Skin
    • Pallor
    • Cool extremities
  • Lungs
    • Character of breath sounds (e.g., vesicular or diminished)
    • Rales
    • Wheezes
  • Heart
    • Point of maximal impact (PMI)
    • Jugular vein distention/abdominal jugular reflux (JVD/AJR)
    • S3
    • Murmurs
    • Rubs
  • Abdomen
    • Presence or absence of bowel sounds (PMI)
    • Abdominal tenderness
    • Murphy's sign
    • Rebound
    • Guarding
  • Peripheral Vascular
    • Character of radial, femoral, dorsalis pedis, and posterior tibial pulses
  • Neurological
    • Limited evaluation for focal neurological findings (e.g., cranial nerves, motor, and reflexes)
EVIDENCE

Table 3. Focused Clinical History, Physical Examination and ECG
  Recommended Actions Sources of Evidence QE   R
1 Focused evaluation of patient's clinical history:
  • Character of symptoms
  • Prior coronary events
  • Contraindications to therapy
  • Complications of MI
ACC/AHA AMI, 1996 III   A
2 Focused physical examination and a 12-lead ECG, within 10 minutes of presentation. ACC/AHA AMI, 1996 III   A
QE = Quality of Evidence; R = Recommendation (See Introduction.) *Note: This link will take you out of Module A.