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SAQ 1

A 64 year old male presents to your rural ED with 30 minutes of right arm pain. He is a smoker, has HTN and DM, but denies high cholesterol. His ECG is shown.

1. List two abnormalities on the ECG and give your diagnosis. (3 marks)
2. In which coronary artery is the culprit lesion? (1 mark)
3. You decide to thrombolyse. State the drug, dose, route, and rate of administration. (3 marks)
4. List 6 absolute contraindications to thrombolysis. (6 marks)
5. Ninety minutes after thrombolysis, the patient is still in 8/10 pain with persistent ST elevation on his ECG. What is your next step? Justify your choice. (2 marks)

SAQ 2 (follows on from SAQ 1

Whilst preparing the patient for transfer, the nurse repeats the ECG (shown).

1. What is the rhythm shown? (1 mark)
2. The patient remains haemodynamically stable. What actions do you take given the ECG changes? Justify your answer. (2 marks)
3. Two years after being treated for his MI, the patient presents with three angina attacks at rest over the pat 24 hours. He is now on aspirin, metoprolol, and a statin. His ECG and troponin are normal. What is his TIMI score? (2 marks)
4. States his disposition and justify your reasoning. (2 marks)

SAQ 3

A 46 year old female presents to ED with chest pain for 24 hours. She is a smoker and has hypothyroidism. The pain is described as sharp chest pain, radiating to the left arm and neck, and is associated with dyspnoea. Her sats are 94% on RA. Her ECG is shown.

1. State the likely diagnosis, giving two features of the ECG that support your diagnosis. (3 marks)
2. List four likely causes of this diagnosis in THIS patient. (4 marks)
3. How can the ST/T ratio be used to differentiate between pericarditis and benign early repolarisation?
4. The patient remains in pain despite analgesia. Her troponin is 46. A CXR is ordered (shown below). What is the likely diagnosis, and how does this change disposition? (2 marks)

SAQ 4

1. Based on current guidelines, what is the recommended timeframe for each of the following interventions? (3 marks)

i.	Time to first ECG in suspected STEM
ii.	Time from patient arrival to PCI
iii.	Time to thrombolysis

2. For each of the following patients, indicate whether PCI, thrombolysis, or both are appropriate if said patient presents with an acute STEMI. Use a tick to indicate appropriate, a cross to indicate not appropriate.
   (9 marks)

	PCI	Thrombolysis
Postpartum 2/52 after LSCS
BP 160/90
On warfarin, INR 2.5
36/40 pregnant
Under CPR for <10 mins
Previous thrombolysis with streptokinase
Dressler’s syndrome
THR 2/52 ago
86 year old with GORD

3. For a patient with acute STEMI and no heart failure or contraindications, list five medications that are given acutely with a brief description of their mechanism of action. (5 marks)

SAQ 5

A 56 year old male presents with right arm pain for two hours. He complains of nausea and dizziness. His BP is 100/60 and his pulse rate 40bpm. His ECG is shown.

1. State two abnormalities on his ECG and give the likely diagnosis. (2 marks)
2. State two possible causes of his bradycardia. (2 marks)
3. List a pharmacological and a non-pharmacological treatment for his bradycardia. Give doses where appropriate. (2 marks)
4. The medication for bradycardia fails to have a meaningful result. Briefly outline how you would perform pacing in this patient. (6 marks)