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History of Present Illness

Quote:

A 63 year-old male presents to the emergency department after resolution of a 20-minute episode of chest pain, which began while he was raking leaves. The pain was described as a "pressure" sensation. The pain radiated down his arms and into his jaw and was associated with palpitations and dyspnea. The pain resolved shortly after resting. The patient had 3 prior episodes of similar pain today, lasting approximately 10 minutes each, and all with activity. He denies nausea, vomiting, diaphoresis, cough or any other associated complaints, nor is there change in the pain with inspiration or movement. He has had no recent illnesses. His past medical history is significant for diet controlled diabetes and hypertension. He hasn't smoked in "many years" and denies drug use. He presently takes HCTZ and states that he is compliant. Family history is significant for a sister who had an acute MI at age 55. He has no known allergies.

Physical exam

Quote:

On physical examination he is an anxious, thin male who looks appropriate for age. His vitals are as follows: BP 150/85, pulse is 80, respirations 24/min, room air oxygen saturation 94%, and temperature 37.3. His external jugular veins are not distended. He has basilar crackles ¼ up bilaterally and his chest is nontender to palpation. Cardiovascular exam reveals no murmurs, gallops or rubs. His abdomen is soft and non-tender. His skin is dry and pink. He has equal bounding pulses in all four extremities. The rest of his examination is unremarkable. View the ECG: Click on attachment to view While in the emergency department he says that his pain is returning.

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Question 1


What is your differential diagnosis at this time?


This question has more than one answer that could be correct.

Answer & Explanation



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Attached Images

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History of Present Illness

Quote:

A 63 year-old male presents to the emergency department after resolution of a 20-minute episode of chest pain, which began while he was raking leaves. The pain was described as a "pressure" sensation. The pain radiated down his arms and into his jaw and was associated with palpitations and dyspnea. The pain resolved shortly after resting. The patient had 3 prior episodes of similar pain today, lasting approximately 10 minutes each, and all with activity. He denies nausea, vomiting, diaphoresis, cough or any other associated complaints, nor is there change in the pain with inspiration or movement. He has had no recent illnesses. His past medical history is significant for diet controlled diabetes and hypertension. He hasn't smoked in "many years" and denies drug use. He presently takes HCTZ and states that he is compliant. Family history is significant for a sister who had an acute MI at age 55. He has no known allergies.

Physical exam

Quote:

On physical examination he is an anxious, thin male who looks appropriate for age. His vitals are as follows: BP 150/85, pulse is 80, respirations 24/min, room air oxygen saturation 94%, and temperature 37.3. His external jugular veins are not distended. He has basilar crackles ¼ up bilaterally and his chest is nontender to palpation. Cardiovascular exam reveals no murmurs, gallops or rubs. His abdomen is soft and non-tender. His skin is dry and pink. He has equal bounding pulses in all four extremities. The rest of his examination is unremarkable. View the ECG: Click on attachment to view While in the emergency department he says that his pain is returning.

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Question 2



Which of the following are high-risk indicators in patients with Acute Coronary Syndromes?




This question has more than one answer that could be correct.

Answer & Explanation



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History of Present Illness

Quote:

A 63 year-old male presents to the emergency department after resolution of a 20-minute episode of chest pain, which began while he was raking leaves. The pain was described as a "pressure" sensation. The pain radiated down his arms and into his jaw and was associated with palpitations and dyspnea. The pain resolved shortly after resting. The patient had 3 prior episodes of similar pain today, lasting approximately 10 minutes each, and all with activity. He denies nausea, vomiting, diaphoresis, cough or any other associated complaints, nor is there change in the pain with inspiration or movement. He has had no recent illnesses. His past medical history is significant for diet controlled diabetes and hypertension. He hasn't smoked in "many years" and denies drug use. He presently takes HCTZ and states that he is compliant. Family history is significant for a sister who had an acute MI at age 55. He has no known allergies.

Physical exam

Quote:

On physical examination he is an anxious, thin male who looks appropriate for age. His vitals are as follows: BP 150/85, pulse is 80, respirations 24/min, room air oxygen saturation 94%, and temperature 37.3. His external jugular veins are not distended. He has basilar crackles ¼ up bilaterally and his chest is nontender to palpation. Cardiovascular exam reveals no murmurs, gallops or rubs. His abdomen is soft and non-tender. His skin is dry and pink. He has equal bounding pulses in all four extremities. The rest of his examination is unremarkable. View the ECG: Click on attachment to view While in the emergency department he says that his pain is returning.

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Question 3


Which of the following cardiac markers levels are indicated at this time?



This question has more than one answer that could be correct.

Answers & Explanation


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History of Present Illness

Quote:

A 63 year-old male presents to the emergency department after resolution of a 20-minute episode of chest pain, which began while he was raking leaves. The pain was described as a "pressure" sensation. The pain radiated down his arms and into his jaw and was associated with palpitations and dyspnea. The pain resolved shortly after resting. The patient had 3 prior episodes of similar pain today, lasting approximately 10 minutes each, and all with activity. He denies nausea, vomiting, diaphoresis, cough or any other associated complaints, nor is there change in the pain with inspiration or movement. He has had no recent illnesses. His past medical history is significant for diet controlled diabetes and hypertension. He hasn't smoked in "many years" and denies drug use. He presently takes HCTZ and states that he is compliant. Family history is significant for a sister who had an acute MI at age 55. He has no known allergies.

Physical exam

Quote:

On physical examination he is an anxious, thin male who looks appropriate for age. His vitals are as follows: BP 150/85, pulse is 80, respirations 24/min, room air oxygen saturation 94%, and temperature 37.3. His external jugular veins are not distended. He has basilar crackles ¼ up bilaterally and his chest is nontender to palpation. Cardiovascular exam reveals no murmurs, gallops or rubs. His abdomen is soft and non-tender. His skin is dry and pink. He has equal bounding pulses in all four extremities. The rest of his examination is unremarkable. View the ECG: Click on attachment to view While in the emergency department he says that his pain is returning.

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Question 4



Which of the following tests should be performed initially on this patient?




This question has more than one answer that could be correct.

Answers & Explanation


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3.


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History of Present Illness

Quote:

A 63 year-old male presents to the emergency department after resolution of a 20-minute episode of chest pain, which began while he was raking leaves. The pain was described as a "pressure" sensation. The pain radiated down his arms and into his jaw and was associated with palpitations and dyspnea. The pain resolved shortly after resting. The patient had 3 prior episodes of similar pain today, lasting approximately 10 minutes each, and all with activity. He denies nausea, vomiting, diaphoresis, cough or any other associated complaints, nor is there change in the pain with inspiration or movement. He has had no recent illnesses. His past medical history is significant for diet controlled diabetes and hypertension. He hasn't smoked in "many years" and denies drug use. He presently takes HCTZ and states that he is compliant. Family history is significant for a sister who had an acute MI at age 55. He has no known allergies.

Physical exam

Quote:

On physical examination he is an anxious, thin male who looks appropriate for age. His vitals are as follows: BP 150/85, pulse is 80, respirations 24/min, room air oxygen saturation 94%, and temperature 37.3. His external jugular veins are not distended. He has basilar crackles ¼ up bilaterally and his chest is nontender to palpation. Cardiovascular exam reveals no murmurs, gallops or rubs. His abdomen is soft and non-tender. His skin is dry and pink. He has equal bounding pulses in all four extremities. The rest of his examination is unremarkable. View the ECG: Click on attachment to view While in the emergency department he says that his pain is returning.

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Question 5


Which pharmacotherapies are indicated at this time?



This question has more than one answer that could be correct.

Answers & Explanation


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History of Present Illness

Quote:

A 63 year-old male presents to the emergency department after resolution of a 20-minute episode of chest pain, which began while he was raking leaves. The pain was described as a "pressure" sensation. The pain radiated down his arms and into his jaw and was associated with palpitations and dyspnea. The pain resolved shortly after resting. The patient had 3 prior episodes of similar pain today, lasting approximately 10 minutes each, and all with activity. He denies nausea, vomiting, diaphoresis, cough or any other associated complaints, nor is there change in the pain with inspiration or movement. He has had no recent illnesses. His past medical history is significant for diet controlled diabetes and hypertension. He hasn't smoked in "many years" and denies drug use. He presently takes HCTZ and states that he is compliant. Family history is significant for a sister who had an acute MI at age 55. He has no known allergies.

Physical exam

Quote:

On physical examination he is an anxious, thin male who looks appropriate for age. His vitals are as follows: BP 150/85, pulse is 80, respirations 24/min, room air oxygen saturation 94%, and temperature 37.3. His external jugular veins are not distended. He has basilar crackles ¼ up bilaterally and his chest is nontender to palpation. Cardiovascular exam reveals no murmurs, gallops or rubs. His abdomen is soft and non-tender. His skin is dry and pink. He has equal bounding pulses in all four extremities. The rest of his examination is unremarkable. View the ECG: Click on attachment to view While in the emergency department he says that his pain is returning.

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Question 6



Which of the following are used in patients with acute unstable angina?



This question has more than one answer that could be correct.

Answers & Explanation


1.

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2.



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History of Present Illness

Quote:

A 63 year-old male presents to the emergency department after resolution of a 20-minute episode of chest pain, which began while he was raking leaves. The pain was described as a "pressure" sensation. The pain radiated down his arms and into his jaw and was associated with palpitations and dyspnea. The pain resolved shortly after resting. The patient had 3 prior episodes of similar pain today, lasting approximately 10 minutes each, and all with activity. He denies nausea, vomiting, diaphoresis, cough or any other associated complaints, nor is there change in the pain with inspiration or movement. He has had no recent illnesses. His past medical history is significant for diet controlled diabetes and hypertension. He hasn't smoked in "many years" and denies drug use. He presently takes HCTZ and states that he is compliant. Family history is significant for a sister who had an acute MI at age 55. He has no known allergies.

Physical exam

Quote:

On physical examination he is an anxious, thin male who looks appropriate for age. His vitals are as follows: BP 150/85, pulse is 80, respirations 24/min, room air oxygen saturation 94%, and temperature 37.3. His external jugular veins are not distended. He has basilar crackles ¼ up bilaterally and his chest is nontender to palpation. Cardiovascular exam reveals no murmurs, gallops or rubs. His abdomen is soft and non-tender. His skin is dry and pink. He has equal bounding pulses in all four extremities. The rest of his examination is unremarkable. View the ECG: Click on attachment to view While in the emergency department he says that his pain is returning.

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Question 7



Which of the following is the mechanism of action of LMWH?





Answer


1.

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History of Present Illness

Quote:

A 63 year-old male presents to the emergency department after resolution of a 20-minute episode of chest pain, which began while he was raking leaves. The pain was described as a "pressure" sensation. The pain radiated down his arms and into his jaw and was associated with palpitations and dyspnea. The pain resolved shortly after resting. The patient had 3 prior episodes of similar pain today, lasting approximately 10 minutes each, and all with activity. He denies nausea, vomiting, diaphoresis, cough or any other associated complaints, nor is there change in the pain with inspiration or movement. He has had no recent illnesses. His past medical history is significant for diet controlled diabetes and hypertension. He hasn't smoked in "many years" and denies drug use. He presently takes HCTZ and states that he is compliant. Family history is significant for a sister who had an acute MI at age 55. He has no known allergies.

Physical exam

Quote:

On physical examination he is an anxious, thin male who looks appropriate for age. His vitals are as follows: BP 150/85, pulse is 80, respirations 24/min, room air oxygen saturation 94%, and temperature 37.3. His external jugular veins are not distended. He has basilar crackles ¼ up bilaterally and his chest is nontender to palpation. Cardiovascular exam reveals no murmurs, gallops or rubs. His abdomen is soft and non-tender. His skin is dry and pink. He has equal bounding pulses in all four extremities. The rest of his examination is unremarkable. View the ECG: Click on attachment to view While in the emergency department he says that his pain is returning.

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Question 8



Which of the following are true regarding the use of IIb/IIIa inhibitors in this patient?



This question has more than one answer that could be correct.

Answers & Explanation


1.

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History of Present Illness

Quote:

A 63 year-old male presents to the emergency department after resolution of a 20-minute episode of chest pain, which began while he was raking leaves. The pain was described as a "pressure" sensation. The pain radiated down his arms and into his jaw and was associated with palpitations and dyspnea. The pain resolved shortly after resting. The patient had 3 prior episodes of similar pain today, lasting approximately 10 minutes each, and all with activity. He denies nausea, vomiting, diaphoresis, cough or any other associated complaints, nor is there change in the pain with inspiration or movement. He has had no recent illnesses. His past medical history is significant for diet controlled diabetes and hypertension. He hasn't smoked in "many years" and denies drug use. He presently takes HCTZ and states that he is compliant. Family history is significant for a sister who had an acute MI at age 55. He has no known allergies.

Physical exam

Quote:

On physical examination he is an anxious, thin male who looks appropriate for age. His vitals are as follows: BP 150/85, pulse is 80, respirations 24/min, room air oxygen saturation 94%, and temperature 37.3. His external jugular veins are not distended. He has basilar crackles ¼ up bilaterally and his chest is nontender to palpation. Cardiovascular exam reveals no murmurs, gallops or rubs. His abdomen is soft and non-tender. His skin is dry and pink. He has equal bounding pulses in all four extremities. The rest of his examination is unremarkable. View the ECG: Click on attachment to view While in the emergency department he says that his pain is returning.

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Question 9


What is/are the possible disposition/s of this patient?


This question has more than one answer that could be correct.

Answers & Explanation

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History of Present Illness

Quote:

A 63 year-old male presents to the emergency department after resolution of a 20-minute episode of chest pain, which began while he was raking leaves. The pain was described as a "pressure" sensation. The pain radiated down his arms and into his jaw and was associated with palpitations and dyspnea. The pain resolved shortly after resting. The patient had 3 prior episodes of similar pain today, lasting approximately 10 minutes each, and all with activity. He denies nausea, vomiting, diaphoresis, cough or any other associated complaints, nor is there change in the pain with inspiration or movement. He has had no recent illnesses. His past medical history is significant for diet controlled diabetes and hypertension. He hasn't smoked in "many years" and denies drug use. He presently takes HCTZ and states that he is compliant. Family history is significant for a sister who had an acute MI at age 55. He has no known allergies.

Physical exam

Quote:

On physical examination he is an anxious, thin male who looks appropriate for age. His vitals are as follows: BP 150/85, pulse is 80, respirations 24/min, room air oxygen saturation 94%, and temperature 37.3. His external jugular veins are not distended. He has basilar crackles ¼ up bilaterally and his chest is nontender to palpation. Cardiovascular exam reveals no murmurs, gallops or rubs. His abdomen is soft and non-tender. His skin is dry and pink. He has equal bounding pulses in all four extremities. The rest of his examination is unremarkable. View the ECG: Click on attachment to view While in the emergency department he says that his pain is returning.

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Question 10


Prior to transfer to the CCU, the patient notes worsening chest pain radiating down his arms. A repeat ECG is performed and reveals ST segment elevation consistent with acute MI. If thrombolytics are now considered, which of the following are contraindications or cautions?


This question has more than one answer that could be correct.

Answers & Explanation

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