Answer each question below. Use complete sentences when providing short answer responses.
- You are the AGACNP in the emergency room. A 55-year-old Caucasian male with a past medical history of HTN, thyroid cancer, and diverticulitis presents with crushing chest pain. His chest pain developed one hour ago after eating a large steak and potato dinner. He states the pain is 10 out of 10 and is not relieved by antacids. He is also diaphoretic and anxious. You review his 12 lead EKG, as per below.
Using the EKG strip, answer questions A-D.
- What part of the area of the heart is showing an evolving infarct?
- Which leads show ST elevation?
- II, III, AVL
- II, III, AVF
- II, III, AVR
- Where would you expect to find reciprocal changes?
- Reciprocal changes in at least AVL
- Reciprocal changes in lead III
- Reciprocal changes in lead IV and V
- There are No reciprocal changes.
- What coronary artery is the likely cause?
- The Right Coronary artery in most cases as it is usually dominant, however in some patients the left circumflex is dominant and thus the culprit for an inferior MI.
- The left anterior descending
- The septal artery
- none of the above
- A 67-year-old female is your established cardiology patient. She is following up with you regarding her uncomplicated mitral valve stenosis. During the visit, she happens to mention that she has suffered 9 hours of chest pain and sweating, which takes you by surprise. Your patient further describes the pain as both gnawing and intermittent. She thought she was experiencing heartburn, but admits that she has never experienced heartburn before, so she is not sure. You perform a 12-lead EKG immediately and call 911.
Interpret the EKG recording below.
What area of the heart is involved, what is your diagnosis, and which coronary artery is affected?
- Anterior part of the heart; this is an ST elevation myocardial infarction (STEMI); and the Left anterior descending is affected
- Inferior; this is a Non ST elevation MI (NSTEMI), and the right coronary artery is affected
- Posterior; this is not an MI but does show ischemia, and the circumflex is involved
- This simply pericarditis and thus the affected coronary arteries are not affected, the heart strain distribution is diffuse and global
- What qualifies for “significant” ST elevation or depression in a 12 lead EKG- in the limb leads_(i)._____________? What is significant for the or the precordial leads_(ii)._____? These changes must be present in at least_(iii)___________consecutive leads in order to be considered diagnostic of myocardial pathology.
- (i))1mm in a limb lead, (ii)1mm in precordial lead, (iii)and must be present 3 consecutive leads
- (i)1mm in a limb lead, (ii)2mm in precordial lead, (iii)and must be present 2 consecutive leads
- (i) 2mm in a limb lead; (ii)) 2 mm in a precordial lead, (iii) must be present in 3 consecutive leads
- (i) 3 mm in a limb lead, (ii) 3 mm in a precordial lead, (iii) must be present in 2 consecutive leads
Instructor Notes: An ST segment elevation or depression is considered significant if there is at least 1 mm or 1 small square in a limb lead or 2 mm or 2 small squares in a precordial leads. These significant changes must be present in at least two consecutive leads.
- A 27-year-old African-American female is admitted to the hospital with severe sepsis related to a cellulitis infection in the groin. The patient was treated appropriately with antibiotics, and then transferred out of the intensive care unit to the medical/surgical unit. On post-admission Day 4, she complains of feeling anxious, short of breath, and chest pain that is worse with deep inspiration. The resident provider on call orders a 12-lead EKG and asks you to interpret it for her. You assess the patient, then review the 12-lead EKG. What is your interpretation?
- Left bundle branch block
- Right bundle branch block
- Normal EKG
- First degree heart block
- Your 52-year-old Asian female patient with a past medical history of smoking and maybe “some sort of bronchitis” presents to your cardiology clinic. She states she has been having palpitations, light-headedness, and a feeling as if her heart is beating irregularly. The symptoms are not constant, and she is currently not having any symptoms. You obtain a 12-lead EKG in the clinic. What is your interpretation of her 12 Lead EKG, as shown below?
- Right atrial hypertrophy
- Left ventricular hypertrophy
- Complete heart block
- Atrial fibrillation
- A 77-year-old female with a history of dyslipidemia, hyperthyroidism, and colon cancer presents to the emergency room with chest pain that radiates to her left arm. She has a blood pressure of 70/43, is diaphoretic, and extremely nauseous. Her symptoms occurred after she left a nearby casino, where she had spent several hours. You attend to her in the emergency room and order a 12-lead EKG, stat.
- You are suspicious of a posterior myocardial infarction. What kind of 12 lead EKG would best capture the ST changes of a posterior MI and how is this type of EKG performed?
- Right sided EKG and move left sided anterior leads V4, V5, and V6, to the right anterior chest in a V7, V8, V9 configuration, also change setting on EKG machine to “right sided EKG.”
- There is no such technique available, you simply have to infer that depression in atypical leads and multiple leads could indeed be indicative of a posterior MI.
- Place all leads on the posterior left torso, thus mirroring the usual placement on anterior torso.
- Obtain serial troponins and recheck the EKG in four hours.
Instructor Notes: ST segment depression (not elevation) in the septal and anterior precordial leads (V1 to V4), in other words ECG leads will “see” the MI backwards (since the leads are placed anteriorly, but the myocardial injury is posterior. A right sided EKG can be performed to better visualize these changes, in doing this you must remove V4, V5, and V6 on the left side of the anterior chest and instead place these leads as V7-V9 directly opposite on the right side of the anterior chest. The presence or absence of ST elevation in the posterior leads V7-9 will more clearly differentiate a posterior MI.
- What findings would you expect to see in the leads that visualize an acute posterior wall myocardial infarction on your patient’s 12-lead EKG?
- ST segment depression in Septal and anterior leads (V1-V4) in a normal EKG, and ST elevation in V7-V9 in a right sided EKG
- ST segment depression in the Inferior leads and V2-V4, ST elevation in V7-V9.
- ST elevation in Septal and anterior leads, and ST depression in V7-V9
- ST elevation in all leads and depression in V7-V9
- What symptoms are common in an posterior myocardial infarction?
- Hypotension, nausea and vomiting, extreme weakness/ fatigue, any type of chest pain or pressure this is pretty individual.
- No pain and nausea, vomiting, diaphoresis and diarrhea.
- Neck pain, back pain, some euphoria.
- Nausea, vomiting, and fever with abdominal pain
- An 87-year-old female with long standing uncontrolled HTN presents to the emergency room after experiencing symptoms and signs of a stroke. You order an EKG as part of the standard procedures. What is your impression of the 12-lead EKG below?
- Left ventricular hypertrophy is common with uncontrolled hypertension, and likewise hypertension, not well controlled is a risk factor for stroke.
- Atrial hypertrophy and patient likely has also congestive heart failure
- Right ventricular hypertrophy
- Normal EKG
- You are the hospitalist AGACNP on call, and you complete a follow-up assessment on a 72-year-old female who was admitted for syncope yesterday. You hear a loud first heart sound and mid-diastolic murmur, which was not documented by the attending provider in the admission note from yesterday. Today’s EKG is below. What is your interpretation of the murmur and the results on the 12-lead EKG?
- This is atrial fibrillation with a rapid ventricular response and the heart murmur is not diagnostic with this EKG.
- This is a new murmur and along with the EKG the diagnosis is a Non ST Elevation MI.
- This is sinus tachycardia and it would be very difficult to auscultate a murmur at this rate
- There is a new murmur and thus systolic dysfunction is the diagnosis and the EKG is atrial flutter.
9. Using the EKG profile below, identify the AXIS.
- You are an AGACNP in a busy emergency department. A 78-year-old male comes in with chief complaint of left sided chest pressure, dizziness, nausea, and vomiting. He is diaphoretic with a blood pressure of 78/50. You are handed an EKG and respond to the nursing staff , “No further interpretation on this one. What is the troponin?” On what types of EKG’s are you unable to interpret ST elevation or depression?
- Paced rhythms and left bundle branch blocks
- Atrial fibrillation at rapid rates
- Right bundle branch blocks
- Any patient with a prior ablation procedure