1 approach to cardiac patient.pdf

Upload: brandon-muro

Post on 13-Feb-2018

219 views

Category:

Documents


0 download

TRANSCRIPT

  • 7/23/2019 1 Approach to Cardiac Patient.pdf

    1/14

    !"# %&&'(%)" *( *"#

    )%'+,%) &%-#.*/

    0"12,)%3 #4%56789:;#?'@%'1 =AB ;C=;

    D%'1. E#1.(3+2B 967

    F22,2*%.* 0'(G#22(' (G D%'+,(3(H1

    )'#1.(3+2I32@J#+@

    K?L#)-M#2

    N#%'. *( (?*%,. % H((+ )%'+,(M%2)@3%' ",2*('1

    E#)(H.,O# *"# )(55(. 215&*(52 (G )%'+,%)

    +,2#%2# P.+#'2*%.+ *"# #3#5#.*2 (G % )%'+,(M%2)@3%'

    &"12,)%3 #4%5,.%-(.

    P.+#'2*%.+ *"# .('5%3 %.+ %?.('5%3 "#%'*

    2(@.+2

    !"# 5#+,)%3 ",2*('1

    F H((+ 5#+,)%3 ",2*('1 ,2 ,.M%3@%?3# %.+ )%./

    82*%?3,2" *"# &'#2#.)# (G % )%'+,%) &'(?3#5

    Q#3& +,R#'#.-%*# ?#*S##. )%'+,%) %.+

    '#2&,'%*('1 +,2#%2#

    Q#3& 5(.,*(' +,2#%2# )(@'2# %.+ '#2&(.2# *(

    *"#'%&1

    T,H.%35#.*

  • 7/23/2019 1 Approach to Cardiac Patient.pdf

    2/14

    Q,2*('1

    >%5,31 ",2*('1

    !'%M#3

    8.M,'(.5#.*B())@&%-(.

    9,#*

    0'#M#.-M# "#%3*")%'# 2*%*@2

    0'#2#.-.H )(5&3%,.*

    T,H.2

    &'(H'#22,(.

    9,%H.(2-) *#2*2

    !"#'%&,#2

    9(2#2B +@'%-(.

    E#2&(.2#

    U#.#'%3 2*%*@2 %.+212*#52 )"#)V

    Q,2*(',)%3 #M,+#.)# 2@HH#2-M# (G

    )%'+,(M%2)@3%' +,2#%2# T,H.2 (G '#2&,'%*('1

    )(5&'(5,2#

    D(@H",.H

    F?+(5,.%3 +,2*#.2,(.

    N#*"%'H1WS#%V.#22

    84#'),2# ,.*(3#'%.)#

    T1.)(

    T*@.*#+ H'(S*"

    0#',&"#'%3X2@?)@*%.#(@2Y #+#5%

    F)@*# ?3,.+.#22

    8&,2*%4,2

    F)@*# &%'%312,2W&%'#2,2

    Z#,H"* 3(22

    9,%''"#%B ())%2,(.%331M(5,-.H

    0,H5#.*@',%

    0"12,)%3 84%5,.%-(.

    0"12,)%3 #4%5 %.+ ",2*('1 %'# *"# 5(2*

    ,5&('*%.* )(5&(.#.*2 (G *"# )%'+,%)

    #M%3@%-(.

    U8[8EFN \[T08D!\K[

  • 7/23/2019 1 Approach to Cardiac Patient.pdf

    3/14

    \.2)-(. (G ?'#%*",.H

    !"# '%*# %.+ )"%'%)*#' (G '#2&,'%-(.2 2"(@3+ ?# .(*#+

    D"%.H#2 ,. '#2&,'%*('1 '%*# %.+ #R('* %'# )(55(.

    5%.,G#2*%-(.2 (G )%'+,%) (' '#2&,'%*('1 +,2#%2#

    !%)"1&.#%

    912&.#%

    K'*"(&.#%

    D(@H"

    7(2* )(55(. &'#2#.-.H )(5&3%,.* ,. +(H2 S,*"

    2,H.,])%.* "#%'* +,2#%2#

    9@# *(/

    N#^_2,+#+ "#%'* G%,3@'# )%@2,.H &@35(.%'1 #+#5%

    K' )%'+,(5#H%31 )%. )%@2# )(5&'#22,(. (G *"# ?'(.)",

    Q(S#M#'B +(H2 S,*" &',5%'1 '#2&,'%*('1 +,2#%2#2 %32(

    &'#2#.* S,*" )(@H"B 2( 5('# +,%H.(2-) ,.G('5%-(. ,2

    .#)#22%'1 *( +#*#'5,.# *"# )%@2#

    D(@H",.H )%*2 %'# 3,V#31 *( "%M# &',5%'1 3(S#' %,'S%1

    +,2#%2#

    84#'),2# ,.*(3#'%.)#

    N(S )%'+,%) (@*&@* '#2@3*2 ,. +#)'#%2#+ (41H#.

    +#3,M#'1 *( 2V#3#*%3 5@2)3#2

    0%-#.*2 S,*" "#%'* G%,3@'# '%.H# G'(5 % +#)'#%2#

    ,. *"# %?,3,*1 *( 'G('5 .('5%3 %)-M,-#2 *(

    ,.%?,3,*1 *( %5?@3%*# %* %33

    `JJD%*2a

    [@*',-(.%3 2*%*@2

    D%'+,%) )%)"#4,%

    N(22 (G 3#%.

    ?(+1 5%22 !"#

    &%*"(&"12,(3(H1

    ,2 5@3-G%)*(',%3

    %.+ )(5&3#4 9#)'#%2#+ %&-*#

    7%3%?2('&-(. G'(5 U\ )(.H#2-(.

    \.+@)-(. (G ,.b%55%*('1 )1*(V,.#2 2@)" %2 *@5('

    .#)'(2,2 G%)*(' X![>Y

    Increase in work of breathing

    Increase in rate of breathing

    Shortness of breat

    when lying flat

  • 7/23/2019 1 Approach to Cardiac Patient.pdf

    4/14

    F2),*#2

    D(55(. ,. +(H2 S,*" ',H"* "#%'* G%,3@'#

    Q,H" ',H"* %*',%3 &'#22@'#!",H" "1+'(2*%-) &'#22@'#

    ,. 212*#5,) M#,.2!b@,+ ,. %?+(5#.

    D%'+,%) )%@2#2/

    6(3@5# (M#'3(%+

    0'#22@'# (M#'3(%+

    E#+@)#+ ',H"*

    "#%'* ]33,.H

    0#',&"#'%3 #+#5%

    T@?)@*%.#(@2 #+#5% )%. '#2@3* G'(5 "#%'* G%,3@'#

    P.)(55(. ,. +(H2 %.+ )%*2

    D(55(. 2,H. (G "#%'* G%,3@'# ,. 3%'H# %.,5%32 >3@,+ %))@5@3%*#2 ,. *"# +#.+#.* %'#%2 (G *'@.V %.+

    +,2*%3 3,5?2

    0%'#2,2 (' &%'%312,2

    0((' 'G@2,(. (G 2V#3#*%3 5@2)3#2 )%. )%@2#

    &'(G(@.+ S#%V.#22

    6%2)@3%' ())3@2,(. G'(5 %'*#',%3

    *"'(5?(#5?(3,25

    D(55(. &'#2#.*%-(. (G )%*2 S,*" "#%'*

    +,2#%2#

    F22(),%*#+ S,*" %)@*#B 2#M#'# &%,.

    N#22 )(55(.W'%'# ,. (*"#' 2),#2

    8cF7\[F!\K[ K> !Q8 Q8F9 F[9 [8Dd

  • 7/23/2019 1 Approach to Cardiac Patient.pdf

    5/14

    84%5,.%-(. (G "#%+

    9#*#'5,.#"1+'%-(. 2*%*@2

    7#5?'%.# )(3(' 0%33('

    D1%.(2,2 D%&,33%'1 '#]33 -5#

    [('5%3 ,2 =_;2#)(.+2

    e= 2#)(.+

    6%2(+,3%-(.B"1'_

    +1.%5,) 2"()V

    f; 2#)(.+2 D%'+,(H#.,)

    2"()V

    Q1&(M(3#5,)2"()V

    !#5'%*@'# (G #%'-&

    7('# "#%+ %.+ .#)V

    0%3&%*# G(' *"1'(,+ 5%22

    0%3&%*# *'%)"#%

    0%3&%*# #2(&"%H@2 E#-.%3 #4%5,.%-(.

    6#.(@2 #.H('H#5#.*

    E#-.%3 "#5(''"%H#

    E#-.%3 +#*%)"5#.*

    D#.*'%3 '#-.%3 +#H#.#'%-(.

    \.2)-(. (G L@H@3%' M#,.2

    D3(2# ,.2)-(. (G L@H@3%'

    M#,.2 ,2 %. ,5&('*%.*

    )(5&(.#.* (G *"# #4%5 !"# L@H@3%' M#,.2 %'# b%* ,.

    .('5%3 &%-#.*2

    0@32%-(. (' M,2,?3# L@H@3%'

    M#,.2 %?(M# =Wg @& *"#

    .#)V ,.+,)%*#2 #3#M%*#+

    ',H"* %*',%3 &'#22@'#

    h@H@3%' &@32#2

  • 7/23/2019 1 Approach to Cardiac Patient.pdf

    6/14

    84%5,.%-(. (G *"# %?+(5#.

    F2),*#2

    7(+#'%*# *( 2#M#'# %2),*#2 )%. ?# &%3&%*#+

    %.+ b@,+ S%M# +#*#)*#+ S,*" ?%33(i#5#.* 7,3+ %2),*#2 5%1 .##+ ,5%H,.H X'%+,(H'%&"2 ('

    @3*'%2(@.+Y (' %?+(5,.()#.*#2,2 *( +#*#)*

    F.%312,2 (G %?+(5,.%3 #R@2,(. ,2 5(+,]#+

    *'%.2@+%*# ,. )(.H#2-M# "#%'* G%,3@'#

    Q#&%*(5#H%31

    Q,H" M#.(@2 &'#22@'# '#2@3*2 ,. "#&%-)

    )(.H#2-(.

    84%5,.%-(. (G *"# #4*'#5,-#2

    8+#5%

    D(3+ *#5'%*@'#

    D(3(' (G &%+2 %.+ .%,3?#+2

    FE!8E\FN 0PNT8T

    F'*#',%3 &@32# #4%5,.%-(.Palpate femoral artery

  • 7/23/2019 1 Approach to Cardiac Patient.pdf

    7/14

    0@32# -5,.H

    0%3&%*# &@32#2 S",3# 3,2*#.,.H *( "#%'* 2(@.+2

    !"#'# 2"(@3+ ?# % &@32# G(' #M#'1 "#%'*?#%*

    !"#$% '%()*+5#%.2 *"#'# ,2 % "#%'*?#%* *"%*+(#2 .(* &'(+@)# % &%3&%?3# &@32#

    0@32# )"%'%)*#' %.+ 2*'#.H*"

    0@32# 2*'#.H*" %.+ )"%'%)*#'

    T*'#.H*" (G &%3&%?3# &@32# ,2 +#.+2 (. G('S%'+ 2*'(V# M(3@5#B

    '%*# (G #L#)-(.B +,2*#.2,?,3,*1 (G *"# M%2)@3%' ?#+B 212*#5,)

    M%2)@3%' '#2,2*%.)#B %.+,"#$% ,-%$$"-%. 0@32# &'#22@'# j 212*(3,) &'#22@'# k +,%2*(3,) &'#22@'#

    !"# %?2(3@*# ?3((+ &'#22@'# )%. .(* ?# +#*#'5,.#+ ?1 +,H,*%3

    &%3&%-(.

    0@32#2 )%. ?#/

    %?2#.*

    S#%V

    .('5%3

    ?(@.+,.H X"1'V,.#-)Y

    l5(+#'%*#m

    l2.%&&1m

    F'*#',%3 &@32#2

    Z#%V &@32#2

    9#)'#%2#+ 2*'(V# M(3@5# )%@2#2 +#)'#%2#+ &@32# &'#22@'#

    9,R#'#.-%32/

    Q1&(M(3#5,%

    Q#%'* G%,3@'#

    T@?%('-) 2*#.(2,2

    !%)"1)%'+,%

    n(@.+,.H X"1'V,.#-)Y &@32#2

    D%@2#+ ?1 ,.)'#%2#+ 212*(3,) &'#22@'# (' +#)'#%2#+ +,%2*(3,)

    &'#22@'# X(' ?(*"aY

    9,R#'#.-%32/

    Q1'V,.#-) 2*%*#2

    F('-) '#H@'H,*%-(.

    0%*#.* +@)*@2 %'*#',(2@2

    n'%+1)%'+,%

    T),]) &@32# %?.('5%3,-#2

    0@32@2 %3*#'.%.2

    F3*#'.%-.H &@32# 2*'#.H*"

    0@32@2 ?,H#5,.@2 0'#5%*@'# ?#%* #M#'1 2#)(.+ ?#%*

    0@32# +#]),*

    Q#%'* 2(@.+ ?@* .( &@32#

    Q,H"31 M%',%?3# &@32# 2*'#.H*"

    F*',%3 ]?',33%-(.

    0@32@2 &%'%+(4@2

    \.)'#%2# ,. &@32# &'#22@'# (. #4&,'%-(. %.+ +#)'#%2# (.

    ,.2&,'%-(.

    Fever, hyperthyroid, pregnancy (anything

    that increases metabolic demands)

    Decreased diastolic

    pressure

    Not on test

    Pulse feels stronger than normal

  • 7/23/2019 1 Approach to Cardiac Patient.pdf

    8/14

    84%5,.%-(. (G *"# *"('%4

    9#G('5,-#2 (G *"# ',?B 2*#'.@5B 2&,.#o

    0%3&%*# )%'+,%) ,5&@32# X%V% % ?#%*Y

    [('5%3 &(2,-(. ,. *"('%4

    9(H2 k 3#^B :*"_

  • 7/23/2019 1 Approach to Cardiac Patient.pdf

    9/14

    7r F00EKFDQ !K FPTDPN!F!\K[

    0%3&%*#

    N#^ % N#^ "#%'* ?%2#

    (for apex beat)

    S1sound S2 soundPDA detected here

    Semilunar valvesMitral valve

  • 7/23/2019 1 Approach to Cardiac Patient.pdf

    10/14

    E,H"* 2,+#

    N#^ %&,)%3 %'#%

    N#^ ?%2,3%' %'#%

    E,H"* 2,+#

    D%*2aa

    D%'+,%) %@2)@3*%-(. ,. )%*2

    F@2)@3* M#.*'%331B (M#' *"#

    2*#'.@5

    D%'+,%) %@2)@3*%-(.

    N,2*#. G('/

    Q#%'* 2(@.+2

    7@'5@'2

    F''"1*"5,%2

    Exactly opposite from left apex

    beat

    Tricuspid valve

  • 7/23/2019 1 Approach to Cardiac Patient.pdf

    11/14

    !'%.2,#.* "#%'* 2(@.+2

    n',#G %@+,*('1 M,?'%-(.2

    [('5%3 *'%.2,#.* "#%'* 2(@.+2

    T=

    F22(),%*#+ S,*" F6 M%3M# )3(2@'#

    7%'V2 *"# ?#H,..,.H (G 212*(3#

    N(@+#2* %* 3#^ %

    T;

    F22(),%*#+ S,*" 2#5,3@.%' M%3M# )3(2@'#

    7%'V2 *"# #.+ (G 212*(3#

    N(@+#2* %* 3#^ ?%2#

    T&3,* "#%'* 2(@.+2 )%. ())@' ,G *"# M%3M#2 +( .(* )3(2#

    21.)"'(.(@231

    !'%.2,#.* "#%'* 2(@.+2

    F?.('5%3 *'%.2,#.* "#%'* 2(@.+2

    Tg

    8%'31 +,%2*(3,) 2(@.+ XL@2* %^#' T;Y (G '%&,+ M#.*',)@3%' ]33,.H

    F?.('5%3 ,. )%*2 %.+ +(H2 D%. ?# )%@2#+ ?1 N6 +,3%-(.

    TA

    N%*# +,%2*(3,) 2(@.+ XL@2* ?#G('# T=Y (G %*',%3 )(.*'%)-(.

    F?.('5%3 ,. )%*2 %.+ +(H2

    D%@2#+ ?1 %*',% G('),.H ?3((+ ,.*( % (M#'_+,2*#.+#+ M#.*',)3#

    F/0##1, 5#%.2 Tg (' TA %'# %@+,?3#

    F $2$+1#*) )#*)3 ,2 % ",H" G'#q@#.)1 2(@.+ *"%* ())@'2 ,. 5,+_

    212*(3# S"#. %. %?.('5%3 5,*'%3 M%3M# &'(3%&2#2 ,.*( *"# 3#^

    %*',@5

    !'%.2,#.* "#%'* 2(@.+2 7@'5@'2

    7@'5@'2 %'# &'(3(.H#+ %@+,*('1 M,?'%-(.2

    #5%.%-.H G'(5 *"# "#%'* (' ?3((+ M#22#32

    [('5%3 ?3((+ b(S ,2 3%5,.%'J 7@'5@'2 %'#

    )%@2#+ ?1 !"#$"%&'!b(S

    >%)*('2 *"%* +#*#'5,.# S"#*"#' b(S *"'(@H" %

    *@?# ,2 3%5,.%' (' *@'?@3#.* %'#/ +#.2,*1 %.+

    M,2)(2,*1 (G *"# b@,+B M#3(),*1 (G b(SB %.+ *@?#

    +,%5#*#'

  • 7/23/2019 1 Approach to Cardiac Patient.pdf

    12/14

    !@'?@3#.* ?3((+ b(S

    N%5,.%' b(S Q,H" M#3(),*1 b(S N()%3 (?2*'@)-(. \.)'#%2# ,. +,%5#*#'

    \. *"# "#%'*B *@'?@3#.* b(S )%. ?# +@# *(/

    >3(S *"'(@H" %?.('5%3 )(55@.,)%-(.2

    ?#*S##. )%'+,%) )"%5?#'2

    >3(S *"'(@H" 2*#.(-) (' ,.2@s),#.* M%3M#2 F3*#'%-(.2 ,. ?3((+ M,2)(2,*1 X%.#5,%Y

    N%'H# M#22#3 +,%5#*#'

    !,5,.H (G 5@'5@'2

    T12*(3,) 5@'5@'

    9,%2*(3,) 5@'5@'2

    D(.-.@(@2

    \.*#.2,*1 (G 5@'5@'2

    7@'5@' 3(@+.#22 ,2 H'%+#+

    9(#2 '(!.#)#22%',31 )(''#2&(.+ S,*" +,2#%2# 2#M#',*1

    N()%-(. (G 5@'5@'2

    FV% &(,.* (G 5%4,5%3 ,.*#.2,*1 X07\Y

    F'#% S"#'# 5@'5@' ,2 3(@+#2*

    !"# 07\ (G 5(2* 5@'5@'2 ,2 (.# (G *"#2# '#H,(.2

    N#^ %&,)%3

    N#^ ?%2,3%'

    E,H"* 2,+#

    N#^ %&,)%3

    %'#%

    N#^ ?%2,3%'

    %'#%

  • 7/23/2019 1 Approach to Cardiac Patient.pdf

    13/14

    >@'*"#' )"%'%)*#',O%-(. (G

    5@'5@'2 E%+,%-(.

    7@'5@'2 H#.#'%331 '%+,%*# ,. *"# +,'#)-(. (G *"#*@'?@3#.* ?3((+ b(S

    >(' #4%5&3#B *"# 5@'5@' (G %('-) 2*#.(2,2 '%+,%*#2)'%.,%331 *( *"# *"('%),) ,.3#*

    0,*)"

    F@+,?3# G'#q@#.),#2 M%'1 G'(5 ",H" *( 3(S ,.G'#q@#.)1 N(S G'#q@#.),#2 %'# ?#2* "#%'+ S,*" *"# ?#33 (G *"#

    2*#*"(2)(B S",3# ",H" G'#q@#.),#2 %'# ?#2* "#%'+ S,*" *"#+,%&"'%H5

    !"# q@%3,*1 (G % 5@'5@' )%. %32( ?# +#2)',?#+B @2,.H2@?L#)-M# +#2)',&-(.2 2@)" %2 "%'2"B ?3(S,.HB ('5@2,)%3

    D"%'%)*#',O%-(. (G 5@'5@'2

    T"% X)(.]H@'%-(.Y

    !"# ,.*#.2,*1 &'(]3# (G +#.+2 (. *"# )%@2# (G *"#

    5@'5@'J !",2 )(''#2&(.+2 *( *"# 2"% (G *"# 5@'5@'

    (. &"(.()%'+,(H'%5

    T*%.+%'+ *#'5,.(3(H1 G(' *",2 ,.)3@+#2/

    )* ),

    n%.+_2"%+B &3%*#%@B (' '#H@'H,*%.*_*1/

    7,*'%3 '#H@'H,*%-(.

    !',)@2&,+ '#H@'H,*%-(.

    6#.*',)@3%' 2#&*%3 +#G#)*

    9,%5(.+_2"%+B )'#2)#.+(_+#)'#2)#.+(B #L#)-(._*1/

    F('-) 2*#.(2,2

    0@35(.,) 2*#.(2,2

    6#.*',)@3%' 2#&*%3 +#G#)*

    \..()#.* %.+ &"12,(3(H,)

    5@'5@'2 4551)%5+ 6"-6"-$ ())@' S,*" .( &%*"(3(H1J

    )(55(. ,. 1(@.H %.,5%32 Xl&@&&1 5@'5@'mY %.+ "('2#2J

    !72$*1#1/*) 89"5):150#; 6"-6"-$ %'# .(* +@# *( 2*'@)*@'%3"#%'* +,2#%2#J !"#1 %'# 2#)(.+%'1 *( ,.)'#%2#+ )%'+,%) (@*&@*

    (' '#+@)#+ ?3((+ M,2)(2,*1J

    D(55(. )%@2#2 ,.)3@+# %.#5,%B G#M#'B &'#H.%.)1B %.+

    "1'*"1'(,+,25J

    7(2* %'# q@,#* XH'%+# =_gW

  • 7/23/2019 1 Approach to Cardiac Patient.pdf

    14/14

    Q#%'* '%*# %.+ '"1*"5

    9,2*@'?%.)#2 ,. *"# "#%'* '"1*"5 %'# (^#. +#*#)*#+

    +@',.H %@2)@3*%-(.

    !"# "#%'* '"1*"5 )%. .(* ?# +#].,-M#31 +,%H.(2#+(. %@2)@3*%-(.u *"#'#G('# #3#)*'()%'+,(H'%&"1 ,2

    ,.+,)%*#+ ,G %.1 (G *"# G(33(S,.H %'# "#%'+/

    Q#%'* '%*# G%2*#' (' 23(S#' *"%. *"# .('5%3 '%.H#

    G(' *"%* 2),#2

    \''#H@3%' '"1*"52B 2@)" %2

    0'#5%*@'# "#%'* ?#%*2

    0%@2#2

    8''%-) X,''#H@3%'31 ,''#H@3%'Y '"1*"5

    v@#2-(.2o