Chapter 58 Coronary Revascularization (Case 40)
PATIENT CARE
Clinical Thinking
• Patient 1: In the setting of acute chest pain, an EKG is key for evaluating ST segment elevation as well as localization of the lesion and determination of associated arrhythmia.
• In the acute setting, cardiac catheterization is indicated in order to demonstrate the location of the lesion and other areas of stenosis, open the diseased artery, and prevent irreversible cardiac damage.
History
• Determine duration and character of the symptoms: location, radiation, and characteristic of pain; associated nausea and vomiting; diaphoresis; and palpitations.
• What worsens the pain? Consider exercise and stress. What alleviates the symptoms? Consider rest, nitroglycerin, and anxiolytics.
• Determine if there is a previous hx of coronary artery disease, peripheral vascular disease, renal insufficiency, and cerebrovascular disease.
Physical Examination
• Cardiac examination should be focused on whether the rate and rhythm are regular; determine presence of murmurs, rubs, or gallops.
• Particular attention should be paid to the Allen’s test on both arms as the radial artery is a potential conduit for bypass. The Allen’s test involves occluding both the radial and ulnar arteries while the patient is making a fist and then releasing the ulnar artery to see if it is adequate as the only blood supply to the hand.
