You are a staff nurse in a lake resort community hospital emergency department. It is a busy summer Friday night at 9:30 PM and the place is packed. The sole physician on duty is suturing an extensive dog bite wound when the triage nurse brings back a 62-year-old black male with chest pain and hands the patient off to you. Mr. Frederick transfers from the wheelchair to the stretcher. He appears to be in pain. He relates to you that he has had retrosternal chest pain, radiating into both arms, for 30min. As you are placing him on oxygen by nasal cannula at 6L and connecting him to the monitoring equipment, you note that his skin appears warm and dry, and that he does not appear to be in respiratory distress. The monitor shows normal sinus rhythm at a rate of 80. The non-invasive blood pressure module reads 134/82. His oxygen saturation is 100% on oxygen. You quickly listen to his lungs, and they are clear. You can see no jugular venous distension. His heart rhythm is regular and you can hear no gross murmurs or gallops. His abdomen is soft and nontender. There is no peripheral edema.
You prepare to start an IV. Further questioning during this task reveals that he has been having chest discomfort about once a week for about two years. The discomfort usually comes with exercise, such as taking out the trash, and goes away within 2-3 min when he takes a nitroglycerin tablet or sits and rests for 5 min. He is maintained on diltiazem 60 mg tid and sustained release propranolol 80 mg bid. Tonight's pain came on at rest while watching TV after dinner, and it has been unrelieved by one sublingual nitroglycerin. He has never had pain this long. He has had no nausea and vomiting, diaphoresis, or shortness of breath. He denies allergies to medications.
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. You have completed starting the IV and have drawn bloods in the process. Your next step is to:
a) administer 0.4mg nitroglycerin sublingually.
b) administer aspirin 325 mg PO.
c) perform a STAT 12-lead electrocardiogram.
d) start a second IV line.
e) order a STAT portable chest film.
Further questioning reveals no historical contraindications to thrombolytic therapy. A 12-lead ECG has been performed (Figure 14.6).
4. Upon completion of the ECG you quickly note that the patient's electrocardiogram shows:
a) a normal axis.
d) an indeterminate axis.
5. 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) ST depression compatible with ischemia.
f) LBBB simulating anterior myocardial infarction.
h) acute pericarditis.
i) normal ECG.
j) nonspecific ST changes.
6. After presenting a report to the physician, who is suturing the dog bite wound, and showing her the ECG, she is most likely to order you to:
a) begin the thrombolytic protocol.
b) start a nitroglycerin drip.
c) complete the cardiac workup with a chest film.
d) administer morphine sulfate 4mg IV
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