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 markvo 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.