werner@aecom.UUCP (Craig Werner) (12/11/85)
<>
[OK, this is your chance to play doctor.]
The following case history and eight questions is what I consider to be
the best section of the best formulated exam we have had to date in Medical
School. Even if you know little medicine, it is still amusing and informative.
I have posted the answers in a separate file, which propagation allowing,
should come immediately after this file.
In going through the case and questions, you also can get a glimpse of
what has to be on the doctor's mind.
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A 55 year old moderately obese male with a 40 pack year history of cigarette
smoking but no significant medical disease was quietly sitting on his porch
attempting to complete the Sunday NY Times crossword puzzle in ink. While
pondering over a definition for an "oxymoronic large crustacean", he suddenly
experienced anterior chest pressure, shortness of breath, and diaphoresis
which lasted 10 minutes and then spontaneously dissapeared.
Q1: The most likely cause of this man's acute symproms is (choose the best
answer):
A. Acute coronary artery thrombosis with total luminal occlusion [ie, a "heart
attack"]
B. Transient coronary artery spasm superimposed on moderately severe (50-70%)
coronary artery atherosclerosis.
C. Moderately severe coronary artery atherosclerosis
D. Dissecting aneurysm of the thoracic aorta
E. Acute allergic reaction to jumbo shrimp
Q2: If he died at this time and an autopsy was performed, the grossly visible
changes observed in the heart would most likely include (best answer):
A. Acute transmural myocardial infarction
B. Acute subendocardial myocardial infarcation
C. No grossly visible observable changes
D. Hemorrhagic necrosis of the AV node
E. Assymetric Septal Hypertrophy
Case Continued:
One hour later, the original symptoms recurred after he threw the uncompleted
crossword puzzle down in disgust. Severe chest pain persisted until he
arrived at the hospital 4 hours after the second onset of symptoms. He was
immediately rushed to the CCU and stabilized. EKG revealed acute ischemic
changes in the anterolateral leads, and the CPK level was elevated to 200 IU
(normal 110) with an MB fraction of 7.0% Within 2 hours he was taken to the
cardiac catheterization suite. Catherization revealed total occlusion of the
proximal LAD [Left Anterior Descending] coronary artery and hypokinesia of the
anterior left ventricle.
Q3: The most likely causes of the coronary occlusion include all but one of
the following lesions (Choose the incorrect answer):
A. Acute thrombosis superimposed on an atherosclerotic plaque
B. Ruptured atherosclerotic Plaque and acute thrombosis.
C. Coronary spasm with subsequent acute thrombosis.
D. Rapidly expanding atherosclerotic plaque due to plaque hemmorhage.
E. Embolization from the descending aorta mural thrombus.
Case Continued:
Following the coronary angiogram, the cardiologist perfused the affected
vessel with streptokinase, and performed an angioplasty by placing a balloon
catheter across the lesion and dilating the vessel. Good flow was
reestablished and the patient was returned to the CCU.
Q4: If the heart was observed 24 hours from this point it is likely that one
of the following changes would be noted (choose the best):
A. Hemorrhagic, transmural anterior wall infarction.
B. Ischemic (pale) subendocardial myocardial infarction
C. Hemorrhagic infarction of the anterolateral papillary muscle
D. Ischemic transural myocardial infarction
E. No visible changes would be seen.
Case Continued:
On the day following the coronary angiogram, the patient developed new chest
pain different in character from the previous precordial pain. The pain was
relieved when the patient sat up. A friction rub was heard to the left of the
sternum.
Q5: The friction rub is most likely due to (choose the bext):
A. Fibrinous pericarditis associated with a subendocardial myocardial
infarction.
B. The post-myocardial infarction syndrome (Dressler's syndrome)
C. Fibrinous pleuritis associated with bronchopneumonia
D. Acute pericardial tamponade
E. Fibrinous pericarditis associated with transmural myocardial infarction.
Case continued:
6 days later the patient was clinically improved and was transferred from the
CCU to a private bed. While watching Dwight Gooden pitch out of a 9th inning
bases loaded jam, he suddenly clutched his chest and expired with ever finding
out if the Mets won the game. An autopsy was performed.
Q6: The most likely cause(s) of death include all but one of the following
(choose the incorrect):
A: Acute massive emboli to left and right pulmonary arteries.
B. Acute reocclusion of the LAD coronary artery.
C. Fibrinous pericarditis and pericardial tamponade.
D. Fibrinous pericarditis of the anterior left ventricular infarction
E. Sudden acute ventricular fibrillation.
Unexpectedly, the autopsy revealed that a small branch of the left middle
cerebral artery was occluded by a recent embolus, and that the right kidney
and spleen had several small, acute infarctions.
Q7: THe most likely cause of these lesions is (choose the best):
A. Endocardial thrombus overlying the acute infarction leading to systemic
emboli
B. The same problem which caused the origianl coronary artery occlusion.
C. Thrombophlebitis of the leg veins
D. Paradoxical embolization through a patent foramen ovale
E. Acute left ventricular failure (cardiogenic shock)
Q8: The gross and histologic appearance of the left ventricular wall is likely
to reveal (choose the best):
A. No gross or microscopic changes
B. Transmural myocardial necrosis surrounded by early granulation tissue
C. A fibrotic ventricular aneurysm with mural endocardial thrombus
D. A healing subendocardial myocardial infarction
E. Compensatory hypertropy of the uninvolved left ventricular wall.
--
Craig Werner
!philabs!aecom!werner
"It's hard to argue with someone who knows what he's talking about."wmartin@brl-tgr.ARPA (Will Martin ) (12/11/85)
In article <2130@aecom.UUCP> werner@aecom.UUCP (Craig Werner) writes: >pondering over a definition for an "oxymoronic large crustacean" "jumbo shrimp" The rest of this was beyond me... :-) Will
mmm@weitek.UUCP (Mark Thorson) (12/12/85)
> A 55 year old moderately obese male with a 40 pack year history of cigarette > smoking but no significant medical disease was quietly sitting on his porch > attempting to complete the Sunday NY Times crossword puzzle in ink. While > pondering over a definition for an "oxymoronic large crustacean", he suddenly > experienced anterior chest pressure, shortness of breath, and diaphoresis > which lasted 10 minutes and then spontaneously dissapeared. Reject patient's self-diagnosis. Prescribe spoonful of bicarbonate of soda. > One hour later, the original symptoms recurred after he threw the uncompleted > crossword puzzle down in disgust. Severe chest pain persisted until he > arrived at the hospital 4 hours after the second onset of symptoms. He was > immediately rushed to the CCU and stabilized. EKG revealed acute ischemic > changes in the anterolateral leads, and the CPK level was elevated to 200 IU > (normal 110) with an MB fraction of 7.0% Within 2 hours he was taken to the > cardiac catheterization suite. Catherization revealed total occlusion of the > proximal LAD coronary artery and hypokinesia of the anterior left ventricle. This guy's really trying to look sick. If he whines again, put him on a respirator. Check his medical coverage. > Following the coronary angiogram, the cardiologist perfused the affected > vessel with streptokinase, and performed an angioplasty by placing a balloon > catheter across the lesion and dilating the vessel. Good flow was > reestablished and the patient was returned to the CCU. No insurance. Good thing he's okay for now. Prepare to transfer him to County Med. Tell them he's got indigestion. > On the day following the coronary angiogram, the patient developed new chest > pain different in character from the previous precordial pain. The pain was > relieved when the patient sat up. A rub was heard to the left of the sternum. Got him over there just in time! Nobody buys the farm on my shift. > 6 days later the patient was clinically improved and was transferred from the > CCU to a private bed. While watching Dwight Gooden pitch out of a 9th inning > bases loaded, he suddenly clutched his chest and expired with ever finding > out if the Mets won the game. An autopsy was performed. Oh shi*, those losers at County are saying my diagnosis was faulty. Call on my department head to back me up. > Unexpectedly, the autopsy revealed that a small branch of the left middle > cerebral artery was occluded by a recent embolus, and that the right kidney > and spleen had several small, acute infarctions. Department head testifies that patient couldn't describe symptoms due to stroke to speech areas of brain. A certain nurse is quietly told in no uncertain terms to keep her own speech centers shut up. My a** is covered. Whew! > Craig Werner > !philabs!aecom!werner > "It's hard to argue with someone who knows what he's talking about." Mark Thorson (...!cae780!weitek!mmm) "It's even harder to argue with someone who's right!"