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Human Case Study for a Female Diagnosed with Chest Pain Updated Study Guide 2024 -2025.
Questions with Answers.
A 70 year old woman presents with chest pain that began 2 hours ago. She describes it as substernal radiating to her jaw and left shoulder; there is no other area of pain or radiation. She took an aspirin at home but the pain is not better. She also took 3 sublingual nitroglycerin tablets en route to the hospital.Her initial EKG shows ST elevation in the anterior leads >2mm and ST depression in the inferior leads.The nurse has already administered oxygen, placed her on an EKG monitor, and attained IV access. You order beta-blockade and nitroglycerin for pain relief, and the supervising resident asks you which of the
following should be done next:
- Call her primary care physician.
- Send her to radiology for a good-quality chest X-ray.
- Give her a GI cocktail to check for pain relief from this.
- Call cardiology for a decision between thrombolytic and percutaneous coronary intervention.
- Call cardiology - ANSWER - The answer is D. This patient is having an acute myocardial infarction. AMI
is defined when two of the following three findings are present: clinical history of chest pain of at least 20 minutes duration, EKG changes and/or positive myocardial enzyme testing. This patient has ST elevation with concomitant ST depression in contiguous leads with chest pain. She needs immediate thrombolytic therapy or cardiac catheterization; if percutaneous coronary intervention (PCI) can be achieved within 90-120 minutes of emergency department arrival, the literature supports its selection over thrombolytic therapy as primary intervention. In preparation for either thrombolytic therapy or PCI, you need to control her pain, maximize O2 delivery, decrease work of the heart and inhibit platelet function. O2, nitroglycerin and morphine will increase O2 delivery to the heart. A beta blocker, which should also be administered to AMI patients who lack contraindications, will decrease the work of the heart, and aspirin will inhibit platelets. A glycoprotein IIb/IIIa-inhibitor should also be administered - selections will depend on the exact treatment course chosen for the patient. Anticoagulation with low molecular weight heparin or unfractionated heparin (dose being dependent on exact treatment course for patient) should be started if there are no patient historical or chest X-ray findings suggestive of aortic dissection. 1 / 2
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A 72-year-old male presents with five hours of substernal chest pain and pressure despite taking three sublingual nitroglycerin. You order an EKG. What findings on the EKG would indicate that this patient is potentially a candidate for thrombolytic therapy?
- Ventricular tachycardia
- ST-segment elevation of at least 1 mm in two or more contiguous leads
- ST-segment depression of at least 2mm in any precordial lead
- Atrial fibrillation with a rapid ventricular response - ANSWER - The answer is B. "Fibrinolytic therapy is
indicated for patients with STEMI (as a reperfusion option) if time to treatment is <6 to 12 hours from symptom onset, and the ECG has at least 1-mm ST-segment elevation in two or more contiguous leads."
A 58-year-old male previously in good health presents with chest pain for two hours. Vital signs are BP 126/78, HR 80 (sinus rhythm), RR 14, oxygen saturation 99%, T 36.8. His EKG shows ST segment elevation in leads II, III, aVF and V1. ST-segment elevation is greater in lead III than in lead II. What additional diagnostic test is indicated prior to giving nitroglycerin?
- d-dimer
- Echocardiogram
- EKG with right-sided leads
- CXR - ANSWER - The answer is C. "Nitrate-induced hypotension is also suggestive of right ventricular
infarction, and of tamponade. Initial therapy for both would include volume loading and avoidance of vasodilators or other agents that may lower the blood pressure." "ST segment elevation in lead V1 in the setting of inferior MI (i.e., ST segment elevation in leads II, III, and aVF rather than in the setting of concomitant ST segment elevation in all anterior precordial leads) is suggestive of right ventricular infarction." "ST segment elevation is usually greater in lead III than in lead II when right ventricular infarction coexists with inferior AMI." "Application of "right-sided" precordial leads is the best means to diagnose right ventricular infarction with the ECG. These leads, as a mirror image of the left precordial leads, demonstrate ST segment elevation with right ventricular infarction in leads V3R to V6R, with V4R having the highest sensitivity."
A patient with nontraumatic chest pain is administered nitroglycerin in the field and has subsequent drop in blood pressure. An EKG reveals ST-segment elevation in lead V4R. What is the diagnosis? A.unstable angina
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