You are an independent primary health care provider working in a rural clinic in a western state. You are seventy 70 miles from the nearest hospital, so your clinic also functions as the region's only emergency facility. You therefore have access to all ACLS equipment and drugs, including thrombolytics. It is two o'clock in the afternoon.
Your receptionist has inserted a walk-in patient in your busy afternoon schedule because the patient is complaining of chest pain. You enter the room designated for emergencies and find a 54-year-old white female who appears anxious, but in no immediate distress. Your assistant has placed her on oxygen and has connected her to the cardiac monitor. You quickly note that the patient is in normal sinus rhythm.
Mrs. Anderson is a cook in your town's only restaurant. She is known county-wide for her chicken-fried steak. Her presence reminds you that you missed lunch and you are starving. You recall that you have been treating her with hydrochlorothiazide for mild hypertension for 3 years. She relates to you that she has had gradually increasing pain above her left breast and in her left shoulder and upper arm since approximately 10 AM today. She was unable to lift a frying pan with her left arm during the lunch rush today because of pain and weakness and had to use her right arm. There is no history of a previous similar pain. She denies nausea, vomiting, diaphoresis, or shortness of breath.
You glance at the patient chart and note the vital signs that have been recorded by your assistant: pulse 73, respirations 18, blood pressure 168/92. Mrs. Anderson is moderately obese. Her face is ruddy, but her skin is dry. There is no jugular venous distension. Her lungs are clear. Cardiac rhythm is regular without obvious gallops or murmurs. She is exquisitely tender to palpation over the head of her left biceps tendon. The abdomen is soft and nontender. There is no peripheral edema.
1. With regard to the pain, on the basis of currently available information you conclude that:
a) the history is adequate to be compatible with AMI.
b) the history is not compatible with AMI.
2. With regard to the physical examination, you conclude that:
a) the physical exam lends support to the diagnosis of AMI.
b) the physical exam neither confirms nor denies the possibility of AMI.
3. Your first procedural step would be to:
a) start an IV of normal saline.
b) administer nitroglycerin 0.4mg sublingually.
c) perform a 12-lead electrocardiogram.
A review of Mrs. Anderson's chart while the chosen procedure is being performed reveals only the past medical history of hypertension, and a hospitalization for a cystocele repair in 1984. Her parents are both still living. There is no history of bleeding, tumors, trauma, cerebrovascular accident, or recent surgery. She has no known allergies.
4. On the basis of currently available information, you conclude that throm-bolytic agents, if they were to be needed, would be:
a) absolutely contraindicated.
b) relatively contraindicated.
c) not contraindicated.
5. With regard to contraindications to aspirin, should it be necessary, you conclude that:
a) contraindications exist.
b) no contraindications exist.
An ECG has been performed and is now available to you. It is reproduced in Figure 14.5A.
6. Upon completion of the ECG, you quickly note that the patient's electrocardiogram shows:
a) a normal axis.
d) an indeterminate axis.
7. Upon further examination of the ECG, you conclude that it shows:
a) acute inferior STEMI.
b) acute anterior STEMI.
c) inferior myocardial infarction that may be old.
d) anterior myocardial infarction that may be old.
e) benign early repolarization changes.
f) LBBB simulating anterior myocardial infarction.
h) acute pericarditis.
i) normal ECG.
j) nonspecific ST changes.
8. Your next procedural step would be to:
a) administer a therapeutic trial of nitroglycerin 0.4mg sublingually.
b) administer morphine sulfate 4mg IV
c) compare the current ECG to an old one on the chart.
An ECG taken two years previously is shown in Figure 14.5B.
9. With regard to thrombolytic therapy, you conclude that:
a) sufficient evidence of STEMI exists to initiate thrombolytic therapy and transport by helicopter to the nearest hospital.
b) sufficient evidence of STEMI exists to initiate thrombolytic therapy if a therapeutic trial of sublingual nitroglycerin does not resolve ST segment elevation.
c) evidence of STEMI exists, but absolute contraindications prohibit thrombolytic therapy.
I II III aVRaVLaVF V1V2 V3 V4V5V6
I II III aVRaVLaVF V1V2 V3 V4V5V6
d) evidence of STEMI exists, but relative contraindications rule out thrombolytic therapy.
e) insufficient evidence of STEMI exists to initiate thrombolytic therapy.
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Your heart pumps blood throughout your body using a network of tubing called arteries and capillaries which return the blood back to your heart via your veins. Blood pressure is the force of the blood pushing against the walls of your arteries as your heart beats.Learn more...