American College of Physicians: Internal Medicine — Doctors for Adults ®

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The MKSAP Challenge

From the April ACP Observer, copyright 2004 by the American College of Physicians.

Clinical scenario

A 56-year-old postmenopausal woman is brought to the emergency department by ambulance because of the onset of severe substernal burning pain and progressive dyspnea beginning 3 hours ago. She has taken four sublingual nitroglycerin tablets belonging to her husband, and continues to have severe chest pain.

On physical examination, her respiration rate is 30/min, her pulse rate is 108/min, her blood pressure is 80/60 mm Hg, and her oxygen saturation is 90% on an oxygen face mask. She appears anxious. Her jugular venous pressure is 15 mm Hg. She has inspiratory crackles three-quarters up both lung fields. She has an S3 gallop with no murmur.

Her electrocardiogram shows sinus tachycardia with 3-mm ST-segment elevation in leads V2-6. She is given a chewable aspirin and intravenous heparin, and is started on dopamine.

What is the most appropriate management for this patient?

A. Urgent coronary angiography and possible coronary revascularization
B. Immediate thrombolysis
C. Placement of an intra-aortic balloon pump
D. Intravenous nitroglycerin
E. Intravenous beta-blocker

Answer

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