Date post: | 13-Dec-2015 |
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Case Discussion
Dr. Raid Jastania
• A 65-year-old man presented to the emergency room with a recent (4-hour) history of severe chest pain radiating to his left arm. He was suspected to have had a "heart attack." Coronary angiography revealed a complete occlusion of the left anterior descending branch about 2 cm from its origin.
• He was given a therapeutic dose of recombinant human tissue plasminogen activator (t-PA). This treatment restored coronary artery blood flow, and his chest pain improved. Simultaneously, he was started on one tablet of aspirin per day.
• What therapeutic agent can be used to lyse the clots in coronary vessels?
• Why was aspirin given? What stage of hemostasis is affected by aspirin?
• What are natural anticoagulants?
• What are the causes of arterial thrombosis?
• What is the thrombus made of? • What causes arterial thrombosis? ...venous
thrombosis• What are the various fates of thrombi? • Which of these fates is clinically most significant
in the arterial circulation vs. the venous circulation?
• Describe the morphology (microscopy) of myocardial infarction?
• What are the major similarities between a myocardial and a cerebral infarct?
• What are the major differences between a myocardial and a cerebral infarct?
• What is the mechanism of formation of hemorrhagic infarcts in brain? • What are the types of infarcts?
• Seven days later, he noted swelling of both legs and feet and was found to have pitting edema of the legs; his liver was somewhat enlarged; and his neck veins (jugular) appeared full. He was given diuretics and asked to consume a salt-restricted diet. Because of considerable weakness, he remained in bed most of the time.
• What caused enlargement of the liver, edema, and fullness of the neck veins in this patient?
• What is the pathogenesis of pulmonary edema? • How does this type of edema differ from that seen
in acute inflammation?
• Are the alveolar septa normal in thickness?
• What effect would such a histologic picture have on gaseous exchange in the lung?
• What might the symptoms be?
• A few days later, he developed sudden pain in the lower right part of his chest, which was aggravated by taking a deep breath. Physical examination revealed that his left leg had developed more swelling than the right. X-ray of his chest showed a faint shadow in the peripheral part of the lower lobe of the right lung. Intravenous heparin was started. Two days later, he became very breathless and died suddenly.
• Did this patient have clinical features suggestive of pulmonary thromboembolism?
• Why are some infarcts red and others pale? • What is the most common symptom of pulmonary embolism? • How and when does pulmonary thromboembolism cause
sudden death? • When does pulmonary thromboembolism result in infarction?
• What conditions predispose to venous thrombosis? • What is the most common source of clinically
significant pulmonary emboli (ie, thrombi from which vessels in the leg)?
• What is the most common symptom associated with such venous thrombi?