Chest Pain Test Questions and Answers Graded A+
f the following, which diagnosis is most likely literature supports its selection over thrombolytic
given the EKG shown in the Figure? therapy as primary intervention. In preparation for
[image] either thrombolytic therapy or PCI, you need to
A. posterior myocardial infarction control her pain, maximize O2 delivery, decrease
B. inferior myocardial infarction work of the heart and inhibit platelet function. O2,
C. anteroseptal myocardial infarction nitroglycerin and morphine will increase O2
D. anterior myocardial infarction - -The delivery to the heart. A beta blocker, which
answer is B. The EKG demonstrates classic should also be administered to AMI patients who
findings (ST-segment elevations in II, III, AVF) lack contraindications, will decrease the work of
associated with inferior myocardial infarction. the heart, and aspirin will inhibit platelets. A
glycoprotein IIb/IIIa-inhibitor should also be
administered - selections will depend on the
A 70 year old woman presents with chest pain exact treatment course chosen for the patient.
that began 2 hours ago. She describes it as Anticoagulation with low molecular weight
substernal radiating to her jaw and left shoulder; heparin or unfractionated heparin (dose being
there is no other area of pain or radiation. She dependent on exact treatment course for patient)
took an aspirin at home but the pain is not better. should be started if there are no patient historical
She also took 3 sublingual nitroglycerin tablets or chest X-ray findings suggestive of aortic
en route to the hospital. Her initial EKG shows dissection.
ST elevation in the anterior leads >2mm and ST
depression in the inferior leads. The nurse has
already administered oxygen, placed her on an A 72-year-old male presents with five hours of
EKG monitor, and attained IV access. You order substernal chest pain and pressure despite
beta-blockade and nitroglycerin for pain relief, taking three sublingual nitroglycerin. You order
and the supervising resident asks you which of an EKG. What findings on the EKG would
the following should be done next: indicate that this patient is potentially a candidate
A. Call her primary care physician. for thrombolytic therapy?
B. Send her to radiology for a good-quality chest A. Ventricular tachycardia
X-ray.
C. Give her a GI cocktail to check for pain relief B. ST-segment elevation of at least 1 mm in two
from this. or more contiguous leads
D. Call cardiology for a decision between C. ST-segment depression of at least 2mm in
thrombolytic and percutaneous coronary any precordial lead
intervention. D. Atrial fibrillation with a rapid ventricular
E. Call cardiology - -The answer is D. This response - -The answer is B. "Fibrinolytic
patient is having an acute myocardial infarction. therapy is indicated for patients with STEMI (as a
AMI is defined when two of the following three reperfusion option) if time to treatment is <6 to 12
findings are present: clinical history of chest pain hours from symptom onset, and the ECG has at
of at least 20 minutes duration, EKG changes least 1-mm ST-segment elevation in two or more
and/or positive myocardial enzyme testing. This contiguous leads."
patient has ST elevation with concomitant ST
depression in contiguous leads with chest pain.
She needs immediate thrombolytic therapy or A 58-year-old male previously in good health
cardiac catheterization; if percutaneous coronary presents with chest pain for two hours. Vital signs
intervention (PCI) can be achieved within 90-120 are BP 126/78, HR 80 (sinus rhythm), RR 14,
minutes of emergency department arrival, the oxygen saturation 99%, T 36.8. His EKG shows
1/6
, Chest Pain Test Questions and Answers Graded A+
ST segment elevation in leads II, III, aVF and V1.
ST-segment elevation is greater in lead III than in
lead II. What additional diagnostic test is A 71-year-old male presents after a syncopal
indicated prior to giving nitroglycerin? episode. He reports 12 hours of recurrent
A. d-dimer substernal chest pressure. A report from the
B. Echocardiogram patient's primary care physician's office states
C. EKG with right-sided leads that an EKG performed four days ago was
completely normal. Repeat EKG in the ED
D. CXR - -The answer is C. "Nitrate- reveals no ST-segment elevation, but you do
induced hypotension is also suggestive of right note a right bundle-branch block, and a left
ventricular infarction, and of tamponade. Initial anterior fascicle block. Troponin I is elevated
therapy for both would include volume loading above normal at 1.6. What intervention would be
and avoidance of vasodilators or other agents indicated to provide definitive management for
that may lower the blood pressure." the findings seen on EKG in this patient?
"ST segment elevation in lead V1 in the setting of
inferior MI (i.e., ST segment elevation in leads II, A. Urgent placement of a cardiac pacemaker
III, and aVF rather than in the setting of B. Radiofrequency ablation
concomitant ST segment elevation in all anterior C. Emergent revascularization with thrombolytics
precordial leads) is suggestive of right ventricular or percutaneous coronary intervention (PCI)
infarction." D. Continuous cardiac monitoring for 24-48
"ST segment elevation is usually greater in lead hours - -The answer is A. "In the face of an
III than in lead II when right ventricular infarction AMI, the risks of complete heart block are much
coexists with inferior AMI." greater when new or preexisting bi- or
"Application of "right-sided" precordial leads is trifascicular conduction blocks are present. In this
the best means to diagnose right ventricular setting, prophylactic placement of a ventricular
infarction with the ECG. These leads, as a mirror demand pacemaker is indicated."
image of the left precordial leads, demonstrate
ST segment elevation with right ventricular
infarction in leads V3R to V6R, with V4R having Which coronary vessel is usually the cause of the
the highest sensitivity." myocardial infarction in a patient with ST
elevation in V1, V2, and V3?
A patient with nontraumatic chest pain is A. right coronary artery (RCA)
administered nitroglycerin in the field and has B. left anterior descending (LAD)
subsequent drop in blood pressure. An EKG C. right ventricular branch of the right coronary
reveals ST-segment elevation in lead V4R. What artery
is the diagnosis? D. left circumflex artery
A. unstable angina E. posterior descending branch of the right
coronary artery - -The answer is B. This
B. anteroseptal MI EKG pattern is consistent with that of anterior
C. right-ventricular MI wall myocardial infarction (MI). The LAD supplies
D. pericarditis the anterior wall of the myocardium. The left
E. pulmonary embolism - -The answer is circumflex artery, the LAD, or a branch of the
C. The ST-segment elevation in the right-sided RCA supplies the lateral wall of the left ventricle.
lead V4R is strongly suggestive of right- Proximal occlusion of the LAD will give ST
ventricular MI. elevation in leads V1-6, aVL and I (an
2/6
f the following, which diagnosis is most likely literature supports its selection over thrombolytic
given the EKG shown in the Figure? therapy as primary intervention. In preparation for
[image] either thrombolytic therapy or PCI, you need to
A. posterior myocardial infarction control her pain, maximize O2 delivery, decrease
B. inferior myocardial infarction work of the heart and inhibit platelet function. O2,
C. anteroseptal myocardial infarction nitroglycerin and morphine will increase O2
D. anterior myocardial infarction - -The delivery to the heart. A beta blocker, which
answer is B. The EKG demonstrates classic should also be administered to AMI patients who
findings (ST-segment elevations in II, III, AVF) lack contraindications, will decrease the work of
associated with inferior myocardial infarction. the heart, and aspirin will inhibit platelets. A
glycoprotein IIb/IIIa-inhibitor should also be
administered - selections will depend on the
A 70 year old woman presents with chest pain exact treatment course chosen for the patient.
that began 2 hours ago. She describes it as Anticoagulation with low molecular weight
substernal radiating to her jaw and left shoulder; heparin or unfractionated heparin (dose being
there is no other area of pain or radiation. She dependent on exact treatment course for patient)
took an aspirin at home but the pain is not better. should be started if there are no patient historical
She also took 3 sublingual nitroglycerin tablets or chest X-ray findings suggestive of aortic
en route to the hospital. Her initial EKG shows dissection.
ST elevation in the anterior leads >2mm and ST
depression in the inferior leads. The nurse has
already administered oxygen, placed her on an A 72-year-old male presents with five hours of
EKG monitor, and attained IV access. You order substernal chest pain and pressure despite
beta-blockade and nitroglycerin for pain relief, taking three sublingual nitroglycerin. You order
and the supervising resident asks you which of an EKG. What findings on the EKG would
the following should be done next: indicate that this patient is potentially a candidate
A. Call her primary care physician. for thrombolytic therapy?
B. Send her to radiology for a good-quality chest A. Ventricular tachycardia
X-ray.
C. Give her a GI cocktail to check for pain relief B. ST-segment elevation of at least 1 mm in two
from this. or more contiguous leads
D. Call cardiology for a decision between C. ST-segment depression of at least 2mm in
thrombolytic and percutaneous coronary any precordial lead
intervention. D. Atrial fibrillation with a rapid ventricular
E. Call cardiology - -The answer is D. This response - -The answer is B. "Fibrinolytic
patient is having an acute myocardial infarction. therapy is indicated for patients with STEMI (as a
AMI is defined when two of the following three reperfusion option) if time to treatment is <6 to 12
findings are present: clinical history of chest pain hours from symptom onset, and the ECG has at
of at least 20 minutes duration, EKG changes least 1-mm ST-segment elevation in two or more
and/or positive myocardial enzyme testing. This contiguous leads."
patient has ST elevation with concomitant ST
depression in contiguous leads with chest pain.
She needs immediate thrombolytic therapy or A 58-year-old male previously in good health
cardiac catheterization; if percutaneous coronary presents with chest pain for two hours. Vital signs
intervention (PCI) can be achieved within 90-120 are BP 126/78, HR 80 (sinus rhythm), RR 14,
minutes of emergency department arrival, the oxygen saturation 99%, T 36.8. His EKG shows
1/6
, Chest Pain Test Questions and Answers Graded A+
ST segment elevation in leads II, III, aVF and V1.
ST-segment elevation is greater in lead III than in
lead II. What additional diagnostic test is A 71-year-old male presents after a syncopal
indicated prior to giving nitroglycerin? episode. He reports 12 hours of recurrent
A. d-dimer substernal chest pressure. A report from the
B. Echocardiogram patient's primary care physician's office states
C. EKG with right-sided leads that an EKG performed four days ago was
completely normal. Repeat EKG in the ED
D. CXR - -The answer is C. "Nitrate- reveals no ST-segment elevation, but you do
induced hypotension is also suggestive of right note a right bundle-branch block, and a left
ventricular infarction, and of tamponade. Initial anterior fascicle block. Troponin I is elevated
therapy for both would include volume loading above normal at 1.6. What intervention would be
and avoidance of vasodilators or other agents indicated to provide definitive management for
that may lower the blood pressure." the findings seen on EKG in this patient?
"ST segment elevation in lead V1 in the setting of
inferior MI (i.e., ST segment elevation in leads II, A. Urgent placement of a cardiac pacemaker
III, and aVF rather than in the setting of B. Radiofrequency ablation
concomitant ST segment elevation in all anterior C. Emergent revascularization with thrombolytics
precordial leads) is suggestive of right ventricular or percutaneous coronary intervention (PCI)
infarction." D. Continuous cardiac monitoring for 24-48
"ST segment elevation is usually greater in lead hours - -The answer is A. "In the face of an
III than in lead II when right ventricular infarction AMI, the risks of complete heart block are much
coexists with inferior AMI." greater when new or preexisting bi- or
"Application of "right-sided" precordial leads is trifascicular conduction blocks are present. In this
the best means to diagnose right ventricular setting, prophylactic placement of a ventricular
infarction with the ECG. These leads, as a mirror demand pacemaker is indicated."
image of the left precordial leads, demonstrate
ST segment elevation with right ventricular
infarction in leads V3R to V6R, with V4R having Which coronary vessel is usually the cause of the
the highest sensitivity." myocardial infarction in a patient with ST
elevation in V1, V2, and V3?
A patient with nontraumatic chest pain is A. right coronary artery (RCA)
administered nitroglycerin in the field and has B. left anterior descending (LAD)
subsequent drop in blood pressure. An EKG C. right ventricular branch of the right coronary
reveals ST-segment elevation in lead V4R. What artery
is the diagnosis? D. left circumflex artery
A. unstable angina E. posterior descending branch of the right
coronary artery - -The answer is B. This
B. anteroseptal MI EKG pattern is consistent with that of anterior
C. right-ventricular MI wall myocardial infarction (MI). The LAD supplies
D. pericarditis the anterior wall of the myocardium. The left
E. pulmonary embolism - -The answer is circumflex artery, the LAD, or a branch of the
C. The ST-segment elevation in the right-sided RCA supplies the lateral wall of the left ventricle.
lead V4R is strongly suggestive of right- Proximal occlusion of the LAD will give ST
ventricular MI. elevation in leads V1-6, aVL and I (an
2/6
