Information Sheet for Candidates

You work as HMO in a suburban emergency

department. Your next patient is a 75 year old
man, Mr. Green, who presented with a history of
60 minutes of severe central chestpain radiating
into the jaw and the left arm. He told the triage
nurse that the pain was about 8 out of 10 and
started when he was splitting wood at home
which is heavy physical work.
Your tasks are to:
Take a brief history
Examine the patient and organize
appropriate investigations
Manage his condition

HOPC: Mr. Green was splitting wood for their pot belly stove in the house because
winter had set in and the fire has been going non stop over the last 3 weeks. It is quite
heavy work with a splitter and an axe.
He suddenly felt this incredible central chest pain, squeezing and radiating into his jaw
and towards the left arm. With the pain he a broke out in a sweat as well. He had to stop
working, sat down for a rest but the pain did not subside so he called his wife who
brought him to the hospital.
There were no other symptoms like nausea or vomiting, no SOB.
PHx: he has always been fit and healthy, no medical conditions, has had a few operations
like appendicectomy, vasectomy and cholecystectomy.
FHx: nothing unusual, his parents died of old age.
SHx: retired accountant, married, 3 children, no stress, lives on a little farm, they manage
quite well. Non smoker, no alcohol, no medication, NKA.
Examination: except for looking a bit sweaty and pale, no abnormal findings.
BP 110/75, P 76/min + reg., RR 18, T 37.0, SaO2 96% on RA
WHAT IS THE MOST LIKELY DIAGNOSIS?:

AMI!!!

Management and Investigations:

Oxygen
Aspirin
ECG and monitoring
iv line, bloods (FBE, U+Es, cardiac markers, others like cholesterol/ lipids,
glucoseTFT etc. can be done later)
consider beta blocker
PROGRESS: you take the bloods to send them off to pathology and when you return the
monitor shows the following picture:

What do you do now?

Check the conscious state and the pulse (pat. is unconscious, no pulse!)
Defibrillation with 200 joules (repeated x1 if necessary then up to 360!)
Progress: the patient regains consciousness and cardiac output, the monitor shows
marked ST elevation and a 12 lead ECG confirms an inferior infarction.
TREATMENT OPTIONS:
Thrombolysis

PTCA (percutanious transluminal coronary angioplasty) / stenting

Treatment Overview of Ventricular Arrythmias

Cardioversion either with drugs (class one agents such as lignocaine) or DC shock.
Once the arrhythmia has been cardioverted, prophylaxis should be instigated to prevent
recurrence (using agents such as beta-blockers). Patients whould also be placed on
continuous cardiac monitoring and arrangements made for assessment by a cardiologist.
Drugs used in the treatment of this disease:

Amiodarone hydrochloride
(Cardinorm)

Sotalol hydrochloride
(Cardol)
Flecainide acetate
(Flecatab)
Lignocaine hydrochloride
(Lignocaine Hydrochloride Injection)
Mexiletine hydrochloride
(Mexitil Capsules)