Osca station.
A 67 year old man presents to Emergency department with 20min of
severe chest pain.
i. What is the most important differential diagnosis that may
be causing hia chest pain?
Aortic dissection
2 marks
21. What aspects of the nistory would suggest tne pain to pe
isohaemic in nature?
Exacerbated by exertion
Central in location
Classical radiation
crushing in nature
+/~ Relief by rest
Associated nausea,
vomiting,
sweating,
apprehension,
dyspnoea,
palpitations,
syncope
Risk factors: Family History
Smoking
Diabetes.
Hypertension.
Hyperlipidaemia
iii. Assuming this man's history was
2 e290090900000
& BELUneausaue
6 marks
ishaemio in nature what
inveekigations would you say are must appiupsiate?
ECG
coun
Cardiac enzymes.
U+E + serum Mg.
FRE.
ESR.
Glucose.
Lipids.
4marks
iv. The ECG shows ST elevation of 2mm in V,,, what is the likely
diagnesio.
Anterior infarct
Antere coptal infarct
Possibility of vasospasm
1 markvo Coneidering yau taak the cardiac enzymes sppeosimately 1
hour after the onset of ohest pain what abnormalities are likely
to be present in myocardial infarction?
Troponin I Possibly both elevated 2 marks.
Troponin T
Too early for remainder of cardiac enzymes to be elevated.
vi. Considering the site of the lesion (anteroseptal), which
major coronary vessle is occluded.
Left anterior descending 2 marks
How please outline in a sequential, stepwise fashion, how you
would further manage this patient who has an otherwise
haemodynamically stable anteroseptal infarct.
Admit to CCU, continuous monitoring
Reassure
I.V line for emergency arrhythmia treatment
Oxygen
Mild sedation
Pain relief: 1.V morphine
GTN +/- infusion.
i Nifedipine if hypertensive and contin. pain
Anticoagulation: Aspirin
Low dose heparin
Limitation of infarct size TPA
Streptokinase
(note if give tPA need heparinization).
Acute angioplasty
Beta blockers.
ACE inhibitors. 7 marks
What signa indicate re-perfusion?
Relief of chest pain.
Kesoiution of ST elevation.
Early peak in cardiac enzymes.
New onset arrhythmia.
2 marks
What axrhythmia do you get indicating re-perfusion?
Runs of VT 1 mark
On the eocend day he develops an abnormal ECO with bevad abnormal
QRS complexes (ventricular in origin) a rate of 70 bpm and a
regular rhythm, what is the diagnosis?
Accelerated idioventricular rhythm 2 marks.
What in tha treatment?
Nothing unless hypotensive, in which case give atropine
T mark.
total 30.