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Cardiovascular Laboratory 5

(Slides will be presented during class)

Unknown Case 1

A 65-year-old woman who had recently undergone a right total hip replacement developed breathlessness and sharp pains localized to her right ribs. Her physical exam revealed tachypnea and tachycardia. Her right lower leg was warm to the touch when compared to the left lower leg. Cardiac auscultation disclosed an accentuated second heart sound. The patient appeared anxious. A chest radiograph manifested only normal findings. An EKG indicated right ventricular strain. Three days later, a right ventricular S3 gallop was heard by the medical student. Shortly thereafter, the patient died from circulatory collapse.

  1. Please discuss the pathologic findings and offer a diagnosis.

  2. What blood test may have aided in the diagnosis of this disorder?

  3. What imaging studies may have been diagnostically useful?

  4. Why did circulatory collapse occur?

  5. What risk factors are associated with this disorder?

Unknown Case 2

A 65-year-old man presented to the E.R. complaining of epistaxis and blurring of his vision. Physical examination manifested a variety of abnormal findings (please study the fundoscopic image). His subsequent laboratory evaluation revealed biochemical evidence of mild renal failure and an elevated serum LDL cholesterol level. Following his evaluation and diagnosis, the patient was followed in an outpatient clinic. Approximately one month after his initial evaluation, the patient died from a stroke.

  1. Please describe the pathologic findings and form a diagnosis.

  2. What abnormal physical findings might have been found during the patient’s examination?

Unknown Case 3

A 43-year-old man was admitted to the hospital because of fever and rapid deterioration of vision in his left eye. The patient had been well until 6 weeks earlier, when fevers, sweats, myalgias, and right-sided pleuritic chest pain had developed. Three days after the onset of his illness, a chest radiograph showed pneumonia in the right upper lobe. The patient received antibiotic treatment that brought clinical improvement. However, one day after the treatment ended, the patient felt worse. Antibiotic treatment was restarted, but, 5 days after the treatment ended, he again had fevers, dyspnea, orthopnea, and he became unable to work. Two days before admission, he observed a “brown spot” in the left visual field and noted mild pain in his left eye. The spot enlarged over the next 6 hours, until he could see only hand motion with that eye. The patient’s medical history included only diabetes mellitus, Type 2. He did not smoke and drank little alcohol.

At the time of admission, the patient was febrile and manifested tachycardia and tachypnea. He was overweight and he had clammy skin. The left eye was injected. There was dullness with diminished breath sounds over the right upper chest. Ausculatation of the heart disclosed a high-pitched, blowing, diastolic murmur that was heard best along the left sternal border. Mild peripheral edema was present. An electrocardiogram showed nonspecific ST segment and T-wave abnormalities. A chest radiograph manifested opacities in the right upper lobe and a right-sided pleural effusion; the left lung was clear.

Blood chemical values were unremarkable, including the troponin T level. A complete blood count revealed a leukocytosis with a neutrophilic left shift. The erythrocyte sedimentation rate was increased.

An urgent ophthalmologic evaluation revealed endogenous endophthalmitis. Blood cultures obtained at the time of admission were reported as positive for Streptococcus pneumoniae, highly sensitive to penicillin. At almost the same time the cultures were being reported, the patient became hypotensive and his heart rate fell to 35. He became cyanotic with increasing dyspnea. The patient was placed on pressor support and sent for emergency cardiac surgery. After surgery, the patient required continued pressor support.

He developed an acute abdomen the next day that led to an exploratory laparotomy. The small and large intestines were entirely necrotic. He died later that day.

This patient has had a catastrophic illness that appeared to begin with a pneumonia that responded only transiently to antibiotic treatment. It was complicated by acute endogenous endophthalmitis, a major cardiac abnormality, and systemic inflammation.

  1. Please describe the pathologic findings and form a pathologic diagnosis.

Unknown Case 4

A 53-year-old man was admitted to the hospital because of chest discomfort, described as “a heaviness.” He had been well until three months earlier, when he began having increasingly severe exertional shortness of breath. On the day of admission, he had been changing a flat tire when he noticed that his chest began to feel “tight.” He did not notice actual chest pain. He had hypertension and hyperlipidemia and took medicines for both conditions. There was no history of diabetes mellitus or heart disease. He did not have a family history of coronary artery disease. The patient had a 40-pack-per-year history of smoking.

His physical exam manifested a slight fever (38.3 degrees C), a pulse of 85, and a blood pressure of 115/80 mm Hg. The cardiac exam was unremarkable as was the remainder of the physical exam. The patient appeared anxious. An EKG showed elevated ST segments in the anterior chest leads V2 - V5. His blood chemical values included normal hepatic transaminase levels, a cholesterol of 239, an HDL of 43, and an LDL of 181.

Over the course of the second hospital day, the patient became dyspneic at rest and rales were heard. The hepatic transaminases became markedly elevated. The patient died on the third hospital day after developing ventricular fibrillation. An autopsy was performed.

  1. Please describe the pathologic findings.

  2. How do the pathologic findings explain the clinical course and the clinical and laboratory findings?

  3. Please discuss or explain the clinical course and physical findings.

  4. What additional pathologic feature(s) might have been found in the heart if the patient had died on the 12th hospital day?

  5. Chest discomfort is one of the most common challenges for clinicians in the office or emergency department. What are some of the major causes of acute chest discomfort?

Unknown Case 5

A 36-year-old man was admitted to the hospital for evaluation of vague malaise and focal muscle tenderness. On examination, the patient was afebrile, his pulse was 95, and respirations were 20. His blood pressure was 185/110 mm Hg. A neurologic examination was normal. Laboratory testing revealed 3+ proteinuria and rare hyaline casts. A test for hepatitis B surface antigen was positive, a test for hepatitis B surface antibody was negative. Serum creatinine and urea nitrogen levels were abnormally elevated.

The patient worked as a cashier at a retail outlet. He had noticed the recent onset of myalgias and leg weakness. A skeletal muscle biopsy sample was obtained.

  1. Based on the pathologic features manifested in the sample, please offer a differential diagnosis.

  2. Based on the pathologic and clinical features, please offer a diagnosis.

  3. What is the relationship between this patient’s disorder and hepatitis B infection?

  4. What other clinical signs and symptoms have been associated with the patient’s disorder?


The answers to the path lab questions will be posted approximately 48-72 hours after the lab sessions. These are abbreviated answers, not a full discussion of the topics. You can find them in the M2 CTools site resources. In the folder for each sequence the will be a folder called 'Path Lab Resources'


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