CCS: Acute Coronary Syndrome - USMLE Forums
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Old 06-25-2011
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Heart CCS: Acute Coronary Syndrome

Emergency room: Patient with h/o DM, HTN, Hypercholesterolemia came with chest pain and shortness
of breath since this morning.
• Vitals: tachycardia, blood pressure may be high or low
• First take care of ABC: O2 inhalation, continuous; Pulse ox; cardiac monitor; IV access, EKG 12 leads,
• Aspirin, oral, one time
• Nitroglycerine, sublingual (contraindicated if in the history patient has taken sildenafil (Viagra),
vardenafil (Levitra), or tadalafil (Cialis), in the last 24 hours (36 hours with tadalafil) because it can
cause severe hypotension.
• Morphine, IV, one time; CBC, CHEM 8, PT, PTT, Cardiac enzymes every 8 hour, Liver function test,
• Check pulse ox, if O2 saturation 120
Order: Nitroglycerine, IV, continuous (Don’t use it if EKG has ST elevation in lead II, III, aVF which suggest
inferior wall ischemia
Order: Cardiac angiography
Move the clock to get angiogram report. If needed they would stent automatically. You will get all the lab result
same time. (Know that we don’t need to have cardiac enzyme result to order angiogram or thrombolytics)
Change location: Intensive care unit
Order:
Aspirin, oral, continous
Clopidrogel, oral, continuous
Metoprolol, oral, continuous
Fosinopril, oral, continuous (If renal function is normal and patient is not hypotensive)
Lipid profile, Liver function test, Homocysteine level (These labs could have been ordered initially)
Move the clock for next day round
End of the case
In case you come in : start Simvastatin if needed, order echocardiogram, then move the clock for next day
Diagnosis: MI with ST elevation
2. No ST elevation, T inversion, suspect ischemia/unstable angina from history (Acute coronary syndrome)
Order:
Metoprolol, IV, one time
Heparin, IV, continuous
Clopidrogel, oral, one time
Abciximab, IV, continuous
Interval history: If still has chest pain, get vital, if systolic blood pressure is >120
Order: Nitroglycerine, IV, continuous (Don’t use it if EKG has ST elevation in lead II, III, aVF which suggest
inferior wall
Move the clock to get cardiac enzyme report:
A. Cardiac enzyme positive: Order cardiac angiogram and manage same as above.
Diagnosis: MI without ST elevation
B. Cardiac enzyme negative:
Change location: Intensive care unit
Order:
Aspirin, oral, continous
Clopidrogel, oral, continuous
Metoprolol, oral, continuous
Lipid profile, Liver function test, Homocysteine level (These labs could have been ordered initially)
Move the clock for next day round, all 3 cardiac enzyme results will come, if any one came positive, you can
stop the clock and order cardiac angiogram.
Next day if patient is asymptomatic order: EKG 12 leads, Echocardiogram and stress test. (If continue to feel
chest pain or still has evidence of ischemia in EKG can refer for cardiac angiogram.)
End of the case
Diagnosis: Acute coronary syndrome
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The above post was thanked by:
hionlyf (07-31-2012)



  #2  
Old 06-29-2011
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Default

wow!! this was really helpful...thanks for the upload!!!

if you have more of these on other topics do share!! thanks again!!
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