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Submission: On September 09 via api from US — Scanned from DE
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Text Content
Toggle navigation * Qbank * Live Online * Live * Free Events * More * Free Practice * What Is the PANCE/PANRE? EASE INTO PREP WITH A PANCE® QUESTION A DAY Answer the question below and see how ready you are. We’ll explain the correct answer in detail so you understand the concept. A little daily practice goes a long way. A 57-year-old man with hypertension and hyperlipidemia comes to the emergency department complaining of crushing substernal chest pain, diaphoresis, and nausea for 3 hours. He denies palpitations or shortness of breath. He has no previous history of angina or myocardial infarction. His temperature is 37.0° C (98.6° F), blood pressure is 82/60 mm Hg, pulse is 103/min, and respirations are 20/min. Physical examination shows jugular venous distention, a tachycardic heart that is without murmurs, and clear lungs. An electrocardiogram is shown. A right-sided electrocardiogram is also performed that shows ST elevation in V3 and V4. Which of the following is the most appropriate medical intervention at this time? Dopamine Furosemide (Lasix) Intravenous fluids Metoprolol (Lopressor, Toprol XL) Nitroglycerin CORRECT INCORRECT The correct answer is C. This patient is having a right ventricular infarct. The triad of jugular venous distention, hypotension, and clear lungs should make you suspect the diagnosis. In addition, the electrocardiogram shows inferior ST-segment elevation (II, III, and aVF), which is consistent with RV infarct. Right-sided electrocardiogram can be used to support this diagnosis. The finding of elevations in lead V4 on a right-sided electrocardiogram is 100% specific for a right-sided infarct. The management of right ventricular infarct requires aggressive fluid resuscitation, as this type of myocardial infarction is fluid-dependent. The patients sustaining this type of infarction are now preload-dependent. They require aggressive intervention to keep the preload high. Aggressive intravenous fluids therefore should be started until the patient stabilizes or goes for cardiac catheterization. Intravenous fluids should be first-line in maintaining adequate blood pressure. Dopamine (choice A) also might be a useful adjunct if blood pressure cannot be maintained with intravenous fluids alone. Remember that cardiac pressors, although good at maintaining blood pressure, can increase cardiac ischemia, because they increase peripheral vascular resistance. Pressors are helpful at maintaining blood pressure in this setting at the expense of increasing myocardial oxygen demand. Furosemide (choice B) is potentially harmful to patients who have right ventricular infarction because of this type of infarct's dependence on preload. This patient has borderline blood pressure and clear lungs. Furosemide would decrease preload and therefore decrease cardiac output. Metoprolol (choice D) is used in most patients who have acute coronary syndrome, but it should not be used in patients who have bradycardia or hypotension. The patient's systolic blood pressure is only 82 mm Hg. Beta-blockers should not be used in a patient who has borderline blood pressure, because they will further lower the patient's blood pressure. Nitroglycerin (choice E) must be avoided in patients who have right ventricular infarcts. Nitroglycerin is a potent preload reducer. It will decrease right ventricular filling and therefore decrease cardiac output. PEARL: Right ventricular infarct should be considered in all patients who present with ST-segment elevation in the inferior leads, hypotension, and clear lungs. These patients should not receive any medications that will decrease preload (e.g., nitrates, diuretics). The treatment of choice is fluids to increase the preload. WANT ANOTHER PRACTICE QUESTION? Spacing out study makes it stick. Get practice questions emailed to you every day. Are you a permanent resident of Canada? Yes Canada Consent Please check this box if you’d like to receive commercial email messages from Kaplan regarding its educational programs and services. You may withdraw your consent at any time. Kaplan, Inc., Customer Care, 750 Third Avenue, New York, NY 10017. Phone at 1-800-KAP-TEST, or email customer.care@kaplan.com. By clicking "Sign Up", I agree to Kaplan's Terms and Conditions and Privacy Policy. READY FOR A HIGHER SCORE ON THE PANCE? No matter where you are on your journey, Kaplan's expert teachers can help you raise your score. Find the course that fits you best. Find Your Prep Kaplan | 750 Third Ave | New York, NY 10017 © Kaplan Inc. All Rights Reserved. Privacy Policy Terms and Conditions pan666 Sumo