15.A 59-year-old man presents to the ED with left-sided chest pain and
shortness of breath that began 2 hours prior to arrival. He states the pain is
pressure-like and radiates down his left arm. He is diaphoretic. His BP is
160/80 mm Hg, HR 86 beats per minute, and RR 15 breaths per minute.
ECG reveals 2-mm ST-segment elevation in leads I, aVL, V 3 to V 6. Which of
the following is an absolute contraindication to receiving thrombolytic
therapy?
a. Systolic BP greater than 180 mm Hg
b. Patient on Coumadin and aspirin
c. Total hip replacement 3 months ago
d. Peptic ulcer disease
e. Previous hemorrhagic stroke
16.A 67-year-old woman is brought to the ED by paramedics complain-
ing of dyspnea, fatigue, and palpitations. Her BP is 80/50 mm Hg, heart is
139 beats per minute, and RR is 20 breaths per minute. Her skin is cool
and she is diaphoretic. Her lung examination reveals bilateral crackles and
she is beginning to have chest pain. Her ECG shows a narrow complex
irregular rhythm with a rate in the 140s. Which of the following is the most
appropriate immediate treatment for this patient?
a. Diltiazem
b. Metoprolol
c. Digoxin
d. Coumadin
e. Synchronized cardioversion
17.A 61-year-old woman with a history of congestive heart failure (CHF)
is at a family picnic when she starts complaining of shortness of breath. Her
daughter brings her to the ED where she is found to have an oxygen satu-
ration of 85% on room air with rales halfway up both of her lung fields.
Her BP is 185/90 mm Hg and pulse rate is 101 beats per minute. On exam-
ination, her jugular venous pressure (JVP) is 6 cm above the sternal angle.
There is lower extremity pitting edema. Which of the following is the most
appropriate first-line medication to lower cardiac preload?
a. Metoprolol
b. Morphine sulfate
c. Nitroprusside
d. Nitroglycerin
e. Oxygen
10 Emergency Medicine