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STEMI (ACS)

Practice this case based on how you are assessed in your OSCEs, and use the relevant sections for general revision. 🤓

 

Doctor Instruction:


You are a doctor working in an emergency department. Your next patient is Marina Mason, a 45-year-old female coming in for chest pain. Please take a history and perform a relevant examination.



 

Patient History:


Your name is Marina Mason – but you would like to be called Mari instead. A 45-year-old female working as a product manager at Google.


An hour ago, you developed a central crushing, heavy chest pain as if someone was pressing or squeezing your chest. You have been experiencing much chest pain in the past – this time, it just felt a little different. The pain lasted longer for at least 20 minutes, and the pain radiates toward the left side of your jaw and shoulder. You rate the pain 8/10, and it happened really suddenly. At that time, you were watching television at home. You tried to take a spray your GP gave you (you can't remember the name), but it hasn't helped.


Other symptoms: You felt sweating, nauseous, breathless, the heart was racing – You thought you were about to die. You felt lightheaded.


Ideas, Concerns, Expectations:

  • You think this might be angina. You always have these almost at least once every month. You are worried because the pain doesn't just go away with your spray this time. You would like to find out what is going on.


Past Medical History:

  • Angina, Hypertension, Anxiety


Drug History:

  • A Spray (can’t remember the exact name), Ramipril. NKDA


Family History:

  • You remember your mother died of a heart condition at a young age, but you do not remember what exactly it was and when it was.

  • Your father has type 2 diabetes.


Social History:

  • Ex-smoker – smoked 20 cigarettes a day for 30 years

  • Drink around 1 glass of wine every night

  • Live alone

  • Work as a product manager at Google – noted been stressful lately


 

Examination Findings:

  • Observations: HR 123, bpm, Resp. rate of 29, BP 106/70 mmHg

  • The patient is clammy, agitated, breathing fast, and grasping his chest in pain. Heart sounds normal on auscultation, and lung fields are clear.


 

Differentials:

  1. STEMI / NSTEMI

  2. Unstable Angina


Other considerations:

  1. Pericarditis / Myocarditis

  2. GORD

  3. Costochondritis

  4. To rule out aortic dissection – tearing pain

  5. Anxiety or panic attack

  6. Respiratory causes: PE, pneumothorax, pneumonia


 

Investigations:

  1. Observations

  2. ECG – looking for any axis deviation, BBB, ST elevation/depression

  3. ABG – quick assessment + due to breathlessness + for oxygen if required

  4. Baseline bloods + specifics e.g. Troponin baseline + 6/12 hours after onset, FBC (anaemia), U&E (ACEi + electrolytes imbalance), LFTs (statins), Lipid profile, TFT, HbA1c/Glucose (risk factors for MIs), CRP (elevated in acute phase of MI)

  5. CXR – other causes of chest pain, signs of heart failure

  6. Echocardiography – assess functional damage

  7. CT coronary angiogram – coronary artery disease


 

Data Interpretation:


Please Interpret the ECG below:

Interpretation

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