Our patient remains clinically stable following thrombolytic therapy. At this time, a more thorough bedside cardiovascular examination was performed.
Introduction to physical
Our patient has an acute inferior wall myocardial infarction in evolution and there are certain principles we must follow in evaluating our patient – the most important – urgency, because “time is muscle.” With that in mind, we must all work as a team. There is no better example in medicine, from the loved one who might with the patient recognize the symptoms and calls the emergency number, to the paramedics who arrive on the scene and assist in many different ways – not just transporting the patient, but talking to the patient to obtain the initial history, examining the patient, in some cases obtaining the early electrocardiogram and participating in treatment, to the emergency room nurses and physicians to the cardiologist. It is a team effort because “time is muscle.”
Then we examine our patient when they come in in that acute situation in a focused manner, the initial examination very focused. Later we have more time to go over a more detailed examination, and that focused examination can tell you information that can be extraordinarily helpful, even though it’s simple, such as the blood pressure, such as the heart rate, such as rales in the lungs that you hear.
Now we have an opportunity with our patient as they become stable, to do the more thorough examination and, again, we stay focused, we focus on three things: we say to ourselves well, the history and the initial physical, and the electrocardiogram have told us the diagnosis, so why do we examine the patient again? For several reasons. There are three important ones: 1) to determine the extent of the infarct, that is, the severity of the problem, and such things as listening for a third heart sound, not [sounds], but [sounds], that may be a clue to left ventricular failure; the second thing we want to examine our patients for, to stay focused on, is complications, and there are several we must keep in mind – from mitral regurgitation at the apex. Not just [sounds], but [sounds] from papillary muscle dysfunction due to ischemic papillary muscles from the myocardial infarction, to a friction rub, you might hear almost a choo-choo train effect when there is three-components [sounds]. So you use your stethoscope, you examine the patient looking for complications.
And finally, if you don’t find very much on the physical examination, you have accomplished a lot, because you also have a baseline for the next examination. Some of these complications can be delayed, so three things again: you want to know the extent of the infarct on your examination, you want to know the complications, and you want to have a baseline for the next examination that should be carried out intermittently during the patient’s hospital course.
Appearance
The first step in the physical examination is an evaluation of the patient's general appearance. Our patient is a man in his forties who appears to be resting comfortably and is pain free.