OSCE

Ryan Abduljawad
07-April-2015

You have 5 minutes for this

station
1 Interpret patients ECG.
2 What is your next step?
3 Write your final diagnosis with
the TIMI score.
4 What medications should be
avoided in this patient?
Good luck!

 A 50 year old gentleman

Diabetic presenting to the ER
with typical retrosternal
chest pain for 3 hours. HR
100/min, Blood Pressure:
90/50 mmHg. Troponin is
positive.
His ECG:

 1 Interpret this patients ECG.

Interpretation
Sinus rhythm
Rate 100/min
Normal axis
ST elevation in II, III, and aVF with
reciprocal ST depression in aVL
and lead I.
ST elevation in V1 and V2

 2 What do you ask for next?

Right sided leads

& Posterior leads

Right sided leads

 ST elevation in V4R electrode

position is consistent with RV
infarction.

Hints in the 1 ECG

st

Hint about RV extension

ST elevation in V1 - the only standard ECG
lead that looks directly at the right ventricle.
ST elevation in lead III > lead II because
lead III is more rightward facing than lead II
and hence more sensitive to the injury current
produced by the right ventricle. (Proximal RCA
thrombosis)

NB. The combination of ST elevation in

V1 and ST depression in V2 is highly
specific for right ventricular MI.

 What is your TIMI score?

TIMI score
Thrombolysis in Myocardial
Infarction score for ST
elevation acute myocardial
infarction.
Predicts 30 Day Mortality After
an MI.
Total of 14 points.
Entry criteria:
Chest pain for > 30 minutes,
ST elevation, symptom onset <
6 hours, fibrinolytic eligible.

Age ( 75 or more: 3 points,

65-74: 2 points, < 65: 0).
DM, HTN, h/o angina (1
point).
Systolic BP < 100 mm
Hg (3 points).
Heart rate > 100/min (2
points).
Weight < 67 kg. (more
S.E)
Anterior ST elevation or
LBBB (1 point).
Time to treat > 4 hours.

 3 Write your final diagnosis with

the TIMI score.

Diagnosis
Inferoseptal STEMI with RV
extension
TIMI score of 4 points.

 4 What medications should be

used with caution in this
particular patient?

 In this patient, it is advisable to be

cautious with any preload decreasing
medications as Nitrates, beta
blockers, and Morphine because the
patient is already hypotensive and is
prone to develop a hypotension
induced preload ischemia.
You should augment his stroke
volume with IVF.

2 more slides..

Statisitcs
40% of STEMIs are inferior STEMIs.
40% of inferior STEMIs are associated with
RV infarction, in which nitrates might result
in severe hypotension.
20% of inferior STEMI patients will develop
bradycardia due to 2nd or 3rd degree AV
block.
20% is the in-hospital mortality rate in AV
block patients.
Inferior infarction may also be associated
with posterior infarction.

Wait for the bell to ring

For next OSCE station..

Good Luck!