Principles of Patient Assessment
in EMS
By:
Bob Elling, MPA, EMT-P
&
Kirsten Elling, BS, EMT-P
Chapter 13 – Focused History &
Physical Exam of the Cardiac
Patient
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Objectives
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Describe the most common cardiovascular
chief complaints found in the prehospital
setting.
Describe why the patient’s history is so
important when making a field impression
of acute coronary syndrome (ACS).
List several ways to ask a patient if he is
experiencing chest pain.
List several causes of chest pain that are
not cardiac related.
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Objectives
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(continued)
Explain why “rule out” is no longer an
acceptable term for the EMS provider
when making a field impression of a
patient.
Using OPQRST describe specific
information pertaining to the FH of the
patient with a CC or chest pain.
Using SAMPLE describe specific
information pertaining to the FH of the
patient with a CC of chest pain.
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Objectives
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(continued)
Describe the significance of JVD in a
patient with chest pain.
Describe possible abnormal lung sounds
that may be detected in a patient with
chest pain or dyspnea.
Describe the normal heart sounds S1 and
S2.
Describe the abnormal heart sounds S3
and S4.
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Objectives (continued)
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Describe the location of the PMI and its
significance.
List abnormal features found on the chest
of a patient with a cardiac history.
Describe the locations on the body that
the EMS provider may appreciate
dependent edema.
List the diagnostic tools the EMS provider
may use to assess the patient with a
possible ACS.
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Objectives (continued)
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List medications that may cause a
syncopal event.
Describe the possible findings associated
with a silent MI.
Describe why dyspnea is a very common
symptom associated with MI.
List the causes of non-cardiac syncope.
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Introduction
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Suspicion of an acute coronary syndrome
is primarily based on the patient’s history.
The PE and use of diagnostic tools are
necessary, but a complete history is the
most helpful in diagnosing a cardiac
problem.
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Introduction
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The EMS provider treating a patient with
ACS needs to work fast and efficiently.
Efficiency depends on the EMS provider’s
ability to obtain a FH & PE in an effort to
recognize less vague conditions such as
pneumonia, pleurisy or anxiety reactions.
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
The Focused History
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The FH is a key step in formulating a
rational course of treatment.
The approach must be orderly to avoid
missing important information, possibly
leading to less successful outcomes.
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
The Focused History
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(Continued)
Interviewing is a tool the EMS provider
needs to develop:
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Be deductive and learn to ask the same
question in a variety of ways
A patient may deny chest pain but will admit
having pressure or discomfort
While collecting info, give careful
consideration to the obvious symptoms,
clinical signs, as well as subtle cues, found in
the FH
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
The Focused History (continued)
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Obtain the history of the present illness
(HPI) by using the acronym OPQRST, as
well as the SAMPLE history.
Formulate a field impression (working
diagnosis) of the patient’s condition by
considering the list of potential causes of
the chest pain.
Listen carefully to the patient and note the
level of distress.
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Focused History (continued)
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The EMS provider does not do a specific
ACS, rather he begins to differentiate the
info obtained. In most cases the patient
interview is conducted simultaneously with
the PE.
Consider that pain anywhere from the
navel to the jaw is cardiac ischemia until
proven otherwise.
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Focused History (continued)
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Not all patients have “substernal” chest
pain when experiencing ACS (i.e.: women,
elderly, and diabetics). They may
complain of feeling weak, have mild
dyspnea or “just do not feel right” when
experiencing an ACS.
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Focused History (continued)
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O – How did the symptom begin?
P – What was the patient doing at the time of
onset?
Q – Have the patient describe the type of pain in
his own words.
R – Ask the patient to point to the location of
the pain.
S – Compare to a similar experience or on a
scale of 1 to 10.
T – How long has the symptom been present?
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Focused History (continued)
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S – symptoms associated with ACS may include:
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Chest pain, pressure, tightness, squeezing, heartburn,
palpations
Radiating pain to stomach, arm, neck, jaw, or back
Shortness of breath
Indigestion, nausea, vomiting, dizziness, lightheaded
Anxiety, a feeling that something is wrong
Weakness, fatigue, AMS, near fainting or syncope
Sweating (diaphoresis)
Tingling or numbness
Swelling of the feet, legs, hands (peripheral edema)
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Focused History (continued)
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A – do you have any allergies to med?
M – do you take any prescribed, OTC,
homeopathic, herbal, of recreational
drugs?
P – ask about pertinent PMH like: heart
condition, pacemaker, CABG, stent,
breathing problems, last Dr. visit, etc?
L – what was you last oral intake?
E – any exertional or non-exertional
events leading up to symptoms?
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Physical Exam
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Assess mental status
Suspect cardiac related conditions if any of
the following are discovered during the IA:
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AMS – may indicate decreased perfusion due
to poor cardiac output
Skin CTC – pale or diaphoretic due to shock
ABCs – dyspnea, abnormal breathing
patterns, or adventitious breath sounds
Abnormal distal pulses: weak or absent,
unequal, irregular, tachycardia, or bradycardia
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Physical Exam (continued)
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Focus on the cardiovascular and
respiratory systems.
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Assess head-to-toe
Look at the neck to assess for presence of
JVD (45 degree angle)
Listen to lung sounds, heart sounds, inspect
and palpate the chest and abdomen
Reassess the respiratory rate and breathing
pattern
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Physical Exam (continued)
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Listen to heart sounds
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The normal sounds are S-1 and S-2 or the “lub-dub”
sound
S-1 is the first sound and is produced by the AV
valves during ventricular contraction
S-2 is the second sound and is produced during
ventricular diastole
Abnormal sounds are extra sounds (ie: S-3, S-4,
murmurs, gallops and clicks)
To listen for heart sounds place the bell of the
stethoscope lightly over the point of maximal impulse
(PMI) on the left anterior chest at the 5th intercostal
space and the midclavicular line
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Physical Exam (continued)
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Visually inspect and palpate the chest and
abdomen noting the presence of:
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Surgical scars (ie: pacemakers, defibrillators, cardiac
and abnormal surgeries)
Transdermal patches
Distension from bloating, ascites or dependent edema
Pain reproducible with movement or not
Tenderness, masses, and pulsations
Location of the PMI
Peripheral edema
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Diagnostic Tools
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Primary components are utilized with
diagnosis of an MI:
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Medical history including CC or primary
symptom
ECG analysis
Cardiac enzyme analysis
An ECG abnormality alone does not
diagnose or exclude an AMI, but can be
helpful to guide treatment.
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Diagnostic Tools (continued)
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When an MI is occurring a 12 lead ECG
may help to identify the location of
ischemia or infarct.
Additional diagnostic tools include:
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Pulse oximetry
Capnography
Baseline & serial VS
Orthostatic changes
Blood test
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Troponin, myosin, CK-MB over 12-24 hours
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Features of Chest Pain
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Can be caused by many disease
processes, as well as ACS
To help determine origin of chest pain
focus on the following key points:
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Onset
Duration
Precise quality of pain
Radiation
Associated findings
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Features of Chest Pain (continued)
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Classic pain from AMI is often described as
“heaviness or squeezing” or a sudden painful
sensation of pressure.
May radiate to arms, shoulders, neck or back
and usually last more than 20 minutes
Associated signs/symptoms may include:
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Sweating
Nausea/vomiting
Anxiety
No position of comfort
Levine’s sign
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Features of Chest Pain (continued)
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Chest pain that changes intensity with
positioning or breathing may be associated with
pleurisy, pneumothorax, pericarditis, pneumonia,
or musculoskeletal problems.
Any condition that causes inflammation of the
lungs or heart can extend to the pleural surfaces
of the lung and produce chest pain. This is
called pleuritic pain.
Associated signs for pleuritic pain include:
infection, elevated temperature, chills, increased
sputum or coughing.
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Features of Chest Pain (continued)
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Patients with limited mobility are at increased
risk for aspiration, pneumonia, and respiratory
infection.
Pain described as a “tearing” sensation in the
chest or abdomen or back is suggestive of an
AAA.
The “silent MI” is a significant number of
patients who do not have typical MI symptoms.
The elderly, women, diabetics, or patients with
neuropathic conditions experience MI with
atypical and subtle symptoms.
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Features of Chest Pain (continued)
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Atypical symptoms include:
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AMS or syncope
Weakness or fatigue
Dyspnea – mild to severe exertional
Epigastric, back or neck pain
Shortness of breath especially in the elderly or
diabetic may be the primary or only symptom of
AMI or acute heart failure
Shortness of breath, exertional dyspnea, and
paroxysmal nocturnal dyspnea (PND) strongly
suggests a cardiac problem
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Features of Chest Pain (continued)
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CHF and acute exacerbation of COPD are often
difficult to differentiate. Look for a history of
heart failure and any of the following:
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SOB with or without pink tinged sputum
Presence of JVD
Peripheral edema
Chest discomfort
Cardiac dysrhythmias
Inspiratory rales/crackles in the lungs
Diuretic medications or recent medication changes
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Syncope
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In the elderly may be the only clinical sign of a
cardiac problem.
Cardiac causes of syncope include:
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Heart blocks
Dysrhythmias (bradycardia, blocks, SVTs, StokesAdams Syndrome, Sick Sinus Syndrome)
Aortic stenosis, AMI, and angina
Non-Cardiac causes of syncope include:
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Orthostatic or postural hypotension
Medications
Vasovagal faint
Vasodepressor syncope
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Syncope (continued)
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Ask about pre and post syncope
information such as:
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Position of the patient
Chest pain or palpitations
Dyspnea
Dizzyness or weakness
Any similar events
Duration of loss of consciousness (LOC)
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Syncope (continued)
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Duration of LOC is a helpful clue:
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Cardiac and neurologic syncope usually occur
without warning. Recovery is often slow with
confusion, headache, dizziness, orthostatic
changes or local dysfunction
Non-Cardiac syncope often occurs in patients
without a PMH. Usually caused by a stressor
such as pain, emotion or medication and last
briefly with a quick recovery period
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Conclusion
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Utilize the standardized approach to assess the
patient with cardiac problems.
Recognize cardiac related symptoms, obtain a
FH and perform an appropriate PE.
Many etiologies of chest pain are difficult to
differentiate.
The Hx is the most important factor in making a
field impression of ACS. Formulate a field
impression from the FH, OPQRST and SAMPLE.
Be alert for subtle clues, as well as obvious
clinical signs & symptoms.
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.