1. Develop a limited differential diagnosis (given the data in this case-causes of chest pain with higher probability than others).  Answer

2. What is your diagnosis? Why?  List and explain specific data from the history and physical exam which support this diagnosis. Explain why other diagnoses are less probable. Can the patient have two diseases, (i.e. AMI and GERD) simultaneously?  Answer

3. we are satisfied that he has history of ischemic type discomfort. Let us see whether he has Cardiac markers of injury. What enzymes, if any, would you order to assist in making the diagnosis? Compare and contrast the enzyme patterns if the pathologic process was of 3 hours duration, or 24 hours duration, or 72 hours duration? You should be able to explain the various enzymes which might be elevated during the course of the infarction.   Answer

4. Next we need to determine whether he has EKG evidence for Myocardial injury/infarction. Two electrocardiograms are attached. (A) was performed when Mr. Solomon applied for an insurance policy at age 42. (B) was performed in Loyola's emergency room. Determine the rate, rhythm and axis for both ECG's. Identify any abnormality, correlating any changes with the mechanism and location of the pathologic process.  Answer

5. What are the EKG changes of acute myocardial infarction and explain the genesis of each.  Answer

6. Correlate the site of infarction to coronary circulation  Answer

7. Describe the natural evolution of ECG changes following acute myocardial infarction.   Answer

8.  Correlate conduction system defects with coronary circulation  Answer

9. Based on the catheterization, explain the probable mechanisms for Mr. Solomon's chest pain during the admission and three months ago when he was seen in the office.  Answer

11. Describe the evolution of myocardial changes that occur following acute myocardial infarction.   Answer

12. Describe the evolution of clot/thrombus over time.  Answer

13 What are the clinical consequences of acute myocardial infarction?  Answer

14. What should be your strategy when you suspect that the patient may have Myocardial infarction in the Emergency room ?  Answer

15. Mr. Solomon was treated with oxygen by nasal cannula, IV morphine, IV nitroglycerine and IV metropolol upon admission from the emergency room to improve oxygen supply/demand ratio to myocardium. What effect would each treatment have on the oxygen supply/demand ratio of the myocardium?  Answer

16. What is the role, if any, for aspirin and/or heparin in Mr. Solomon’s treatment?  Answer

17. What are the options to re-establish coronary perfusion?  Is it indicated for every patient? How do you select the option?  Answer

18 Let us now address Thrombolytic therapy. What is the rationale, if any, for the use of intravenous t-PA in treating Mr. Solomon. How would you gauge the clinical effectiveness of t-PA?  Answer

19. How would the latency from the onset of symptoms to the start of t-PA therapy influence the effectiveness of therapy?  Answer

20. List and describe the current thrombolytic agents used to treat patients like Mr. Solomon.  Answer

21. What are the major risk factors associated with the use of thrombolytic therapy?  Answer

22. If Mr. Solomon presented with a holosytolic murmur heard best at the apex and radiating into the axilla, what would be a likely pathogenesis for this problem? What type of murmur this is, based on the characteristics given in the question. Correlate the physical finding with the pathologic process.   Answer

23. List complications of myocardial infarction and principles of management of each.   Answer