CARDIAC SURGERY HISTORY AND PHYSICAL EXAMINATION
Melanie Cottone- Zarra, DMSc, PA-C
Introduction
The first meeting with the patient is the most important as this is where we gather most of the information needed to make an adequate assessment and risk stratification for cardiac surgical intervention. We can also aid patients and their families through a difficult and stressful time. By approaching each patient in a respectful and professional manner, we can develop a good rapport with the patient, their family, and for our team.
History & Physical Exam
Preparation
Review all charts in a systematic fashion.
⇒ Vital trends
⇒ Intravenous Drips
⇒ I/O (urine, hemodialysis, crystalloid/colloid or blood products given, etc.)
⇒ Lab trends
o Hemoglobin/hematocrit stability
o Electrolyte abnormalities
o Changes in renal function (?contrast induced-nephropathy post cardiac catheterization)
o Liver function
o Urinalysis
⇒ Diagnostic studies
o Chest X-ray
o Electrocardiogram (EKG)
o Echocardiograms
o CT scans
o MRIs
o Etc.
⇒ Medications
o Know why they are taking EVERY medication that is ordered
o Play close attention for antiplatelet or anticoagulant agents
Antiplatelet medications - Plavix/Clopidogrel, Effient/Prasugrel, Brilinta/Ticagrelor
Anticoagulants - Coumadin/Warfarin, Xarelto/Rivaroxaban, Eliquis/Apixaban, Pradaxa/Dabigatran, Heparin, Argatroban
o Review all notes
Other services/consultants can give insight into a current medical problem that you may not have appreciated yet
Interview
Please be sure to introduce yourself. Also confirm or explain why your cardiac surgical team was asked to see them.
Chief Complaint/Reason for Consultation - what the patient complains about; what brought the patient into the hospital/clinic, why you have been asked to evaluate them, etc.
History of Present Illness(HPI) - A concise overview of the events that led up to the diagnosis for which cardiac surgery is evaluating the patient. Be sure to mention pertinent Past Medical or Past Surgical History (as it relates to the diagnosis or a comorbid condition/risk factor for cardiac surgery). This should include a description of symptoms including:
⇒ Onset (with activity or rest)
⇒ Associated symptoms
⇒ Severity (0-10 scale)
⇒ Character
⇒ Radiation of pain
⇒ Location
⇒ Aggravating/alleviating symptoms
⇒ Duration
Also include important diagnostic tests already performed such as: pertinent lab values (i.e: troponins), EKG, Echo, cardiac catheterization results, etc.
Past Medical History - review and confirm with the patient. Best done by using a systems-based approach from head to toe. Try best to not use medical jargon.
o Neuro - strokes, mini-strokes, seizures
o Cardiac - heart disease, high blood pressure, high cholesterol, abnormal heart rhythms, heart valve problems, murmurs
o Pulmonary - asthma, emphysema, COPD, use oxygen at home, blood clots in legs/lungs, radiation to chest
o Gastrointestinal - vomiting blood, ulcers, blood in stool, dark stools, ever had colonoscopy and any significant findings
o Hepatic/Renal - problems with liver or kidneys
o Vascular - varicose veins, swollen legs, cramping in calves when walking
o Endocrine - diabetes, thyroid problems
o Infectious disease - hepatitis, HIV/AIDS, current or recent infections
o Heme/Oncology - bleeding that will not easily stop, clotting to easily, history of cancer
o Miscellaneous - issues with prior general anesthesia, any religious observances that would prohibit from receiving blood products if needed.
Past Surgical History - include all surgeries with dates and places if possible. Vasectomy can induce sperm antibody production causing a potential allergic reaction to protamine.
Social History - asking this information will give you an idea about the patient’s current living situation, social/family support, social habits and potential needs for placement in skilled nursing, long term care, or acute rehabilitation facility post-operatively
o Marital status & children
o Residence
o Occupation (Current or Past)
o Tobacco history
o Alcohol history
o Illicit drug use
o Activity status
o Caffeine usage
Family History - includes significant family history. Include current age or age at time of death. Example: Father died at age 39 of MI
Review of Systems (ROS):
General - fever, chills, fatigue, night sweats, weight changes, weakness
HEENT - problems with vision, sinuses, teeth, hearing, dysphagia, hoarseness, etc.
Lungs - wheezing, cough, hemoptysis, SOB, TB
Cardiac - chest pain, orthopnea, PND, syncope, murmur, history of rheumatic fever
GI - pain, bleeding, N/V/D/C, reflux, PUD, hemorrhoids, hepatitis, history of liver problems
GU - history of kidney problems, dysuria, incontinence, vasectomy, prostate problems
MS/Rheum - arthritis, joint replacements, history of steroid use
Neuro - history of stroke, headaches, seizures, paresthesia/numbness
Skin - rash, easy bruising, or clotting
Endocrine - diabetes, thyroid disease, adrenal insufficiency, pituitary tumor
Psych - anxiety, depression, bipolar disease
Physical Exam
VITAL SIGNS (VS) - heart rate, blood pressure (both arms), respirations, pulse oximetry & pain
NEURO - right handed (for possible radial harvesting), A/O x 3, CN/sensory/motor/strength all normal
HEENT - NC/AT (normocephalic/atraumatic), PERRLA (pupils equal, round & reactive to light and accommodation), EOMI (extraocular muscles intact), hearing aids noted, poor dentition (may need teeth removed prior to valve surgery or intubation)
NECK - supple with thyromegaly, lymphadenopathy or bruits. Trachea midline. No JVD.
CHEST - slight pectus excavatum and kyphoscoliosis noted. No pain to palpation.
LUNGS - CTA w/o W/R/R (clear to auscultation without wheezes, rales, or rhonchi)
HEART - RRR (regular rate and rhythm) II/VI systolic murmur radiating to neck, no gallops or rubs
ABDOMEN - Sol, NT/ND (nontender, no distention), OHSM (no hepatosplenomegaly), no CVA tenderness (costovertebral angle)
VASCULAR - right groin cardiac catheterization puncture site (or radial, good to know how groins look if you have to do a cut down), pulses 2/4 throughout, no bruits, Negative Allen’s test in right arm (patient not able to have radial used as conduit from right arm)
LOWER EXTREMITIES - no varicosities, clubbing, edema or cyanosis
TUBES/LINES/WIRES- peripheral IV, central line, hemodialysis catheter, atrial/ventricular wires
INCISIONS- endoscopic vein site, sternotomy
Formulating the HPI is critical to painting a picture and telling a story. The sequence of events also plays an important role.
EXAMPLE: 64-year-old male with past medical history of hypertension, hyperlipidemia, and type 2 diabetes who initially presented to the emergency department with complaints of shortness of breath. Patient states the shortness of breath began yesterday evening, worse with activity and associated with lower extremity edema and orthopnea. He denies any chest pain, palpitations, PND, or nausea/vomiting. Initial significant findings were CXR with pulmonary edema and BNP 5000. TTE showed severe aortic stenosis with a mean PG of 50mmHg, AVA 0.9cm2, and mean velocity of 4.3 msec.