Information Sheet for Candidates

You are working a night shift in the emergency department of a rural hospital about 100 kilometers from a major city. A 55 year old man presents at 04: 0 because he woke up with crushing chest pain and his wife decided to dri!e him to the hospital.

What is your management?

Information Sheet for Candidates

You are working a night shift in the emergency department of a rural hospital about 100 kilometers from a major city. A 55 year old man presents at 04: 0 because he woke up with crushing chest pain and his wife decided to dri!e him to the hospital.

What is your management?

Information Sheet for Candidates

You are working a night shift in the emergency department of a rural hospital about 100 kilometers from a major city. A 55 year old man presents at 04: 0 because he woke up with crushing chest pain and his wife decided to dri!e him to the hospital.

What is your management?

Acute Inferior Myocradial Infarction HISTORY:

"he patient had a normal day and e!ening. #ent to bed at about $ :00 and was awoken at about 0 :15 by a central% hea!y and crushing chest pain behind the breast bone which lasted for about 0 minutes. &e felt nauseated and sweaty all the time and his wife decided to take him to hospital.

H!":
'o significant medical or surgical (&). *moked for about $5 years% 1 pack per day% has gi!en up just months ago because of increasing *+,. -rinks .socially/.

#H!:
0other still ali!e and well. 1ather died at age 20 following a stroke 34high ,(5. 1 older sister has angina and older brother had an A06 at age 5$.

SH!":
(at. is married with children% no problems at home. &as been a successful accountant for 0 years% working long hours% recently stressed because of financial losses caused by a partners resignation. 'o allergies

$%AMI&ATIO&:
0ildly o!erweight% pale and sweaty. ,( 110785% pulse rate 8$ 3*95% temp. 8 o :elsius% 99 1;. 'o abnormal findings on (.<.

I&'$STI(ATIO&:
<:= 3&and out copy after discussion of other in!estigations>>>5 :?9 :ardiac en@ymes 3 changes o!er time: 0A9A<9 <A9B6<*" 96*< 3hrs5 (<AA 3hrs5 '+90AB6*<* 3days5 :A 2C; $4C 0 C4 :AC0, C4 1;C$4 $ B1$C$4 4;CD2 8C10 "n6% "nt C2 1;C$4 14 0Y+=B+,6' 2C1$ $

)!": Acute Inferior Myocardial Infarction* R!":

+$ Aspirin "&9+0,+BY*6* ="' 0orphine 3E7C metoclopramide 10 mg i.!.5 ,etablockers

SC$&ARIO: The $C( changes do not normali+e, ST ele-ation does not come do.n / WHAT )O YO0 )O &$%T??? Frgent transfer for acute angioplasty 7 stenting What are the contraindications for throm1olysis? A,*+BF"<: 1. aortic dissection $. acute pericarditis . acti!e bleeding 4. known intracranial !ascular malformation 5. pre!ious e)posure to streptokinase 7 streptococcal infections 2. haemorrhagic stroke within last year 345

9<ABA"6G<: 1. &ypertension $. :(9 . *urgery: major surgery in pre!ious 1078% :'* surgery in pre!ious $71$ 4. :GA in pre!ious $71$ 5. gastrointestinal haemorrhage in pre!ious 1078 2. malignancy 8. anticoagulation with 6'9 $C ;. pregnancy

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Question:

63 year-old woman admitted to the Emergency Department with a complaint of chest pain. All of the findings are present EXCEPT? * * * Difficulty rating a) b) c) AV Wenckebach Low limb lead voltage Acute ST elevation, inferior-posterolateral myocardial infarction (MI)

d) e)

Sinusrhythmwith atrial prematurebeats Sinus tachycardia

The rhythm is sinus tachycardia with 3:2 AV Wenckebach (sinus rate about 110 bpm, ventricular rate about 70 bpm) with 3:2 conduction. (See also Cases # 148 and 244 for comparison.) Acute ST elevations and Q waves are present in leads, II, III, and aVF with reciprocal ST depressions in leads I, aVL and VI-V3, consistent with an acute inferior-posterolateral infarction. Cardiac catheterization revealed two vessel disease with a 100% occlusion of the mid-right coronary artery with a left ventricular ejection fraction of 30%. Percutaneous transluminal coronary angioplasty (PCTA) was attempted without success.
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Answer:

Case Author(s): Diane L. Perry, CCT and Ary L. Goldberger, MD

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