Cardiac Diagnosis for Acute Care The NP's and PA's Guide to
a Comprehensive History and Deciphering the Differential 1st
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To my friends and family . . . Without your love, support, and
encouragement this would not have been possible.
To the reader . . .
An inquisitive mind leads to limitless finds.
coNTeNTS
Foreword by Susan M. Salahshor, PhD, PA-C DFAAPA ix
Foreword by Joseph L. Blackshear, MD xi
Preface xv
Introduction: Assessment, Diagnosis, and Patient History in
Acute Cardiac Presentations xvii
Share Cardiac Diagnosis for Acute Care: The NP’s and PA’s Guide
to a Comprehensive History and Deciphering the Differential
PART I: COMMON PRESENTATIONS OF ACUTE
CARDIAC CONDITIONS
1. Chest Pain: A First Look 3
2. Chest Pain: Another Encounter 21
3. Shortness of Breath: A First Look 41
4. Shortness of Breath: Another Encounter 63
5. Syncope: A First Look 85
6. Syncope: Another Encounter 111
7. Elevated Troponin: A First Look 135
8. Elevated Troponin: Another Encounter 147
PART II: UNCOMMON PRESENTATIONS OF ACUTE
CARDIAC CONDITIONS
9. Fatigue 159
10. Cough 179
11. Abdominal Pain 201
PART III: SUMMARY AND USEFUL CLINICAL TOOLS
12. Conclusion 223
13. Bonus Section: The Write-Up 227
Index 243
vii
Foreword
As a physician assistant for more than 23 years who has worked in
geriatrics, internal medicine, minimally invasive surgery, women’s health,
bariatric surgery, and transplant surgery and medicine, I am honored to
write this Foreword for my colleague, Leslie Janik. When I request a con-
sultation from Leslie, she not only performs the consult, but also takes the
time to explain her decision-making techniques. When I call her, I know
I will come away with at least one nugget of knowledge to add to my
practitioner toolkit.
Leslie Janik is the ideal person to write this book because of her vast
experience in cardiology, her willingness to teach, and her commitment
to share her knowledge. My first thought in reviewing this book was, “It’s
about time someone wrote a practical, real-life book for advanced practice pro-
viders!” This book should have been written years ago, and I am excited
to share it with my students and physician assistant colleagues. With
Cardiac Diagnosis for Acute Care, providers now have a practical guide to
use when caring for patients who present in various settings with cardiac
complaints.
This book prepares new providers in acute care settings to ask the
right questions, ask questions early, immediately begin to form a differ-
ential diagnosis, and take the best care of the patient who presents with
chest pain, shortness of breath, and syncope. Leslie’s book is a must-read
for all physician assistants and nurse practitioners who need a handy tool
to meet the needs of their patients when they enter the acute care setting.
The case scenario format, contrasting the history obtained by an emer-
gency department provider from that of a cardiovascular provider, helps
readers identify critical findings simply and clearly. Leslie’s care in high-
lighting components of the history prepares the reader to begin to for-
mulate a differential diagnosis early, and with ease. The inclusion of key
features and the comparison and analysis of histories help readers to
improve their clinical acumen. Leslie does not stop there; she goes on to
explain each differential diagnosis. These features combine to make this
cardiology handbook an essential reference for providers in acute care
settings.
ix
x Foreword
Leslie’s process, in focusing on key features of the history, physical
exam, and other assessment findings, and the ability to put it all together,
is analogous to working out a problem—you cannot wait to get to the
answer to see if you are right. I was impressed by her case scenarios and
surprised by the uncommon presentations of acute cardiac conditions.
This is the only book for providers that breaks down troponins in a way
you will not forget! The lessons on fatigue, cough, and abdominal pain
are invaluable because of the Q&A method used. I am so excited to see
this book in print.
Leslie is right: History taking is an art. She not only gives us a practical
guide, but also a resource to share with students to help them provide
confident care during and after training. She provides a bonus section on
writing up complete history and physical examination findings, which is
a “must” for everyone, advanced practice student and provider alike. She
complements this with a complete consult write-up that gives students
and providers the opportunity to see the different lenses specialty provid-
ers use in their evaluations.
This book breaks down each problem, supporting you, me, and any
provider who treats patients with acute cardiac complaints. This book is
exactly what we noncardiology providers need to make us more confi-
dent in how we assess a patient who presents with cardiac complaints.
I am excited to have been given the opportunity to read it and look for-
ward to promoting a book that is effective in getting the message across to
providers in a way that is helpful, practical, and not boring.
Thank you, Leslie.
Susan M. Salahshor, PhD, PA-C DFAAPA
Lead Physician Assistant, Abdominal Transplant
Mayo Clinic, Jacksonville, Florida
President, Florida Academy of Physician Assistants (2017–2018)
Foreword
In her conclusion to this book, Leslie Janik likens the acquisition of the
medical history to a work of art, in which multiple components must
come together to create a whole. I might enlarge on this notion by sug-
gesting likeness also to creating good music—the key to which is prac-
tice, practice, practice. As with a learned piece of music, a specific history,
heard once, is embedded in memory to be called up when heard again,
as the need arises. For clinicians early in their careers, it is essential not
only to learn which questions to ask, as is so brilliantly conveyed in this
book, but also how to interpret information volunteered after the initial
“How can I help you?” or similar opening. Finding the optimum mix-
ture of silence with listening and observation of body language, redirect-
ing and listening, double checking and listening, and then moving on to
complete the history efficiently but accurately are all behaviors that must
be learned. In this book, the author exposes key questions and lines of
questioning systematically for the most common complaints for which
hospital-based cardiologists are consulted—chest pain, acute dyspnea,
syncope, and troponin elevation, among others—and highlights and dis-
cusses both typical and atypical presentations of important conditions in
which an accurate history, exam, and subsequent action are key to the
best possible outcome for the patient.
Exposure to the acute care cardiac patient requires sacrifices: irreg-
ular schedules, time away from family, sleep disruption, and so on.
Since our practice added advanced care practitioners in 2005, Leslie
Janik has functioned in this role, the last several years as supervisor,
so her cumulative exposure to the sorts of histories presented is truly
massive. It has been my great fortune to watch her grow in her role
from mentee to supervisor and colleague. If history taking is similar
to playing a musical instrument, she is a virtuoso. Her case scenarios
are best read one at a time, ideally when evaluating patients with the
same type of complaint. The straightforward methodology of evalua-
tion and consideration of differential diagnoses are playbooks for eval-
uating patients, and thus a reference for everyday use for practitioners
on the frontline. I am reminded of reference materials used early in my
xi
xii Foreword
own career that I found similarly essential when seeing individual
patients—Degowin’s Diagnostic Examination, the Washington Manual of
Medical Therapeutics, and the Profiles chapters in Grossman and Bain’s
Cardiac Catheterization—all of which I also would recommend to the
contemporary cardiac practitioner.
The payoff from accurate assessment is, of course, the immense
satisfaction received by the practitioner in getting a good outcome for
the patient. Examples highlighted in the book are immediate relief of
dire symptoms with catheter drainage of cardiac tamponade, emer-
gency surgery for acute dissection of the ascending aorta, and throm-
bolytic therapy of submassive pulmonary embolism. Other examples
would include seeing stroke deficits melt away under the influence of
thrombolytic therapy, relief of cardiogenic shock by emergent percu-
taneous coronary angioplasty and stenting in ST-segment elevation
myocardial infarction, and relief of agonizing respiratory distress in
a patient with acute pulmonary edema with intravenous diuresis, to
name but a few.
For those of us later in our careers, this book provides a reminder that
history taking is a skill never quite perfected and in need of continuous
refreshment, requiring continuing education and an open mind. In my
late 50s, I first learned that one third of hypertrophic cardiomyopathy
(HCM) patients had a definite post-prandial exacerbation of symptoms,
and that 10% to 20% have an acquired bleeding history due to acquired
von Willebrand syndrome, which is discussed in this book in the Chapter 8
scenario detailing the patient with aortic endocarditis. So now I ask HCM
patients about nosebleeds, gastrointestinal bleeds, and transfusion. Only
this year I learned that patients who have had a Nissen fundoplication
cannot drink carbonated beverages because they cannot burp effectively.
So, never stop listening, reading, learning.
There has been a trend in professional continuing medical educa-
tion (CME) offerings in recent years away from didactic presentations
to case-based learning. While history and exam findings are featured,
they tend to be given a back seat to imaging and cutting-edge technol-
ogy. Upstream of these dazzling and expensive imaging techniques, we
have the clinical evaluation, which is increasingly performed by nurse
practitioners or physician assistants, supervised by hospitalists or oth-
ers. Inasmuch as the imaging modalities are widely disseminated, the
Foreword xiii
excellence of any institution might best be defined by the consistency
with which frontline physician extenders and physicians make proper
initial assessments. This book represents an important “how-to” guide
to foster excellence in those assessments.
Joseph L. Blackshear, MD
Consultant in Cardiovascular Diseases
Professor of Medicine
Mayo Clinic, Jacksonville, Florida
PreFace
Anyone who has been in practice for any length of time has experienced
a situation in which a patient tells one provider one thing and a second
provider something else. This happens even when the patient is asked
the same question by both. These variables can be hard to account for
when trying to evaluate a patient. While we may not be able to control
the patient’s responses, we can control how we ask the questions in order
to elicit a clear and consistent response. That concept is a particular focus of
this book.
Many books and other resources focus on the differential diagnosis,
various disease processes, and the appropriate treatment plan for such.
However, very little of what has been published discusses the history of
a present illness in any great detail, or how important this history is in
determining the correct diagnosis.
In the acute care setting, cardiovascular clinicians are asked to eval-
uate many patients with symptoms that might suggest an acute car-
diac diagnosis. We can take into account that patients may change their
answers, but often the information presented to us by the first point of
contact can be misleading. We are told the patient’s presentation and any
relevant data along with a suspected diagnosis, about which we are asked
to render an opinion. I have learned in my own practice that there is usually a
lot more information we can gather about the complaint by asking more compre-
hensive questions in a manner that is clear for the patient to understand.
To get every bit of information about the patient’s symptoms, the line
of questioning has to be very specific and detailed—dissecting the symp-
toms down to their core. When this is done effectively, a diagnosis can
often be made just by utilizing the history alone. This, in turn, can lead to
an accelerated evaluation and treatment and, ultimately, a positive out-
come for the patient.
In this book, clinical scenarios are presented that involve various chief
complaints and reasons for consults that typically confront cardiovascu-
lar clinicians in an acute care setting. These scenarios will challenge you
to look beyond what seems obvious and to think of atypical presentations
xv
xvi Preface
of acute cardiac issues. The history that is obtained by two providers is
compared and broken down to demonstrate the differences in question-
ing, and how such differences contribute to differing diagnoses.
The objective is to help the novice and experienced clinician alike—
particularly those evaluating patients with potential cardiac prob-
lems—identify and extract key features of the chief complaint in order to
formulate an accurate diagnosis. By the end of this book you will become
proficient in using a streamlined approach when questioning the patient,
allowing you to obtain data and formulate a concise, detailed, and thor-
ough history of the present illness.
Leslie E. Janik
INTrodUcTIoN
Assessment,
Diagnosis, and Patient
History in Acute
Cardiac Presentations
Healthcare providers working in the field of cardiology often encounter
patients with critical issues that require prompt evaluation and diagno-
sis. If an accurate diagnosis is delayed or inadequate information is gath-
ered, it can mean the difference between life and death for the patient.
Becoming an expert in this field requires the ability to take a thorough
history in a timely fashion, interpret all data, and identify what may be
relevant to the chief complaint.
Often, patients present with classic symptoms of a diagnosis, and it is
simple to draw a conclusion and initiate treatment. At other times, how-
ever, the presentation may not be what it seems. When this happens, a
patient may be misdiagnosed, undergoing unnecessary evaluation with-
out any relief of symptoms. It is the responsibility of every provider to avoid
making assumptions. Rather, he or she must dissect the chief complaint to avoid
delay and potentially costly workups that may not be indicated.
All providers learn the basic skills of assessment and diagnosis in
their various training programs. It is not until working in a specialty role
that we learn the nuances of the assessment and physical exam that are
specific to the diagnoses we see most often. As cardiovascular clinicians,
xvii
xviii INTRODUCTION
we should be well versed in evaluating a patient with chest pain and other
chief complaints that we see frequently in our practices. With experience,
we learn to dig deeper into the patient’s complaint and ask questions other
providers might not have thought to ask in order to identify whether the
patient is having an acute cardiac issue such as an aortic dissection, acute
coronary syndrome, or even a life-threatening arrhythmia. In an acute care
setting, cardiovascular clinicians are often called upon to determine the
appropriate course of action and treatment with this knowledge in mind.
Diagnosing acute cardiac conditions is challenging but rewarding. Each
patient can be viewed as a mystery to be solved, and each piece of informa-
tion we obtain as a clue to help solve the mystery. As specialists in this role,
our focus should be to uncover all the information the patient can provide
about the chief complaint. This includes everything about the character of
the complaint, the timing, what the patient was feeling before, and whatever
else is associated with it. The assessment should include the following:
• The past medical history as well as the other histories need to be
carefully reviewed with the patient and any concerns clarified,
as much as possible.
• The patient’s medications need to be reviewed for compliance
and accuracy.
• A thorough cardiovascular exam should include careful
auscultation of the lungs and heart, palpation of the chest,
assessment of the pulses, and evaluation for any bruits.
• Evaluating the abdomen and extremities is also necessary.
A limited amount of objective data is usually available at the time
cardiovascular clinicians initially evaluate these patients. The electrocar-
diogram (ECG), any labs, and imaging data obtained can be crucial in
helping to solidify the working diagnosis developed during the encoun-
ter. These elements should come together in such a way that the cardio-
vascular clinician can make a prompt and accurate diagnosis.
In the current environment of rising healthcare costs and demands
placed on providers, we are often required to see more patients and have
less time and fewer resources in which to do so. The availability of elec-
tronic medical records enables providers to gather a lot of information
about past medical history, procedures, and medications when seeing
a patient who has previously received care at a particular institution.
INTRODUCTION xix
These details are often referenced in the admission or consult note to
fulfill necessary requirements so staff can move on to the next patient.
This information can be very helpful, especially when patients are not
able to give an accurate history or provide details about prior procedures.
The existence of this previously archived data can, however, foster
complacency. Providers may assume that prior histories and lists of med-
ications are still accurate, which can lead to inappropriate drug therapy or
failure to capture an important piece of data that is critical to the patient’s
plan of care.
Medicolegal aspects must also be considered in the acute care setting.
Practice has been geared toward the utilization of costly imaging and
testing as well as hospitalization to ensure that a critical diagnosis is
not missed, particularly in the emergency department setting. One
study examined how medicolegal concerns impacted admission rates of
patients presenting with possible acute coronary syndrome. The research-
ers found that emergency physicians would not have admitted 30% of the
cases if there had been a hypothetical medicolegal risk of zero, or a 1% to
2% acceptable miss rate (Booker et al., 2015). A perception of zero medi-
colegal risk would likely reduce admission rates and expensive testing.
Not every patient with chest pain needs a stress test, CT scan of the
chest, or coronary angiography, but providers may fear that without them,
a patient may slip through a gap in the diagnostic process and suffer an
unwanted outcome. As cardiovascular clinicians, we can aid in determin-
ing which patients require this type of testing by utilizing a comprehen-
sive history and objective data collection process.
The field of cardiology encompasses many conditions, both chronic
and acute. In the acute care setting, cardiovascular clinicians have an obli-
gation to identify a diagnosis and treatment plan promptly in order to
provide the patient with the best possible outcome. Other specialists, as
well as emergency department physicians, rely on the expertise we can
provide to assist in the best management plan for these patients.
I think many clinicians would agree that the most important piece of
information obtained when evaluating the patient is the history. The his-
tory is what gives us the story so we can understand why patients sought
or were brought for care, how they were feeling, and how we are going
to best treat them. A comprehensive history can guide us to a diagnosis
before any other data are gathered.
