Monday, December 11, 2006

A week in the life....Tuesday

This week Tuesday was Cecil’s autopsy day. There were three cases – two for him and one for the registrar. All were coroner’s cases because the causes of death were unknown. His first case was a 57 year old man who was found dead at home and came with the usual scanty coroner’s office information via a police report.

“Found dead at home, collapsed in kitchen. Last seen at midday the day before by his son. House secure, no suspicious circumstances. Medical history: high blood pressure. Medication: losartan, ibuprofen.”

On external examination Cecil saw tar staining on the fingers of the patient’s right hand, a sign of smoking, and an old appendicectomy scar. Internally he found widespread atheroma throughout most of the arterial system. In the heart there was thrombosis over an atheromatous plaque in the left anterior descending coronary artery.
Blood clot can be seen in the sections of coronary artery in this picture.

This would have cut off the blood supply to part of the heart and caused a heart attack. There was left ventricular hypertrophy, one of the consequences of high blood pressure. The thickened wall of the left ventricle can be seen in this picture of transverse slices of a heart (the right ventricle is the irregular slit-like space on the right of the slices).

The lungs were filled with frothy fluid, suggesting that the patient had been in heart failure at the time of death. There was an incidental simple cyst in the left kidney. Cecil gave the cause of death as:
Ia Coronary thrombosis
Ib Coronary artery atheroma
II Hypertension

The second case was a 74 year old man who had been admitted to the hospital on Friday with a two week history of back pain, lethargy and loss of appetite. When he had been seen on Friday he was noted to be thin, and have some tenderness in his upper abdomen but there was nothing else found on examination. His blood results showed a microcytic anaemia, a slightly raised urea, and slightly raised bilirubin and liver enzymes. He had been stable on the ward over the weekend while waiting for more tests, but collapsed on Sunday and could not be resuscitated. His hospital notes said that he had had an uncomplicated hernia repair 8 years previously.

During the autopsy Cecil found a large ulcerated tumour on the back wall of the stomach. It had invaded through the stomach wall and into the pancreas. There were metastases in the liver (the paler lesions in this picture) and a single metastasis in the brain.

There was a rib fracture, probably due to the resuscitation attempts, and the patient also had gallstones and diverticular disease. The local coroner did not allow the pathologists to take any histology unless they could not identify a cause of death without it, so Cecil could not sample the tumour to prove that it was an adenocarcinoma, although that was the most likely type. He gave the cause of death as:
Ia Metastatic gastric carcinoma

Then he went over the registrar’s autopsy, dictated his autopsy report and faxed the causes of death to the coroner’s office.

After lunch it was time for more reporting, including some reporting on the double headed microscope with one of the registrars. Some of the specimens he cut up yesterday had come through. The slides from the uterus and ovaries showed a benign leiomyoma in the uterus and a benign serous papillary cystadenoma in the ovary. The breast specimen contained a grade 2 ductal carcinoma. Cecil had to measure the size of the tumour and distance to the resection margins. When he’d gone through all 23 lymph nodes that came with the specimen he filled in a minimum dataset with all the information about the tumour on it.
Then it was time for the department slide meeting. All the pathologists got together round the multi-headed microscope with interesting or difficult cases to discuss. One of the other pathologists had brought some slides from a soft tissue tumour from a patient’s thigh. Everybody seemed to come up with a different idea about what it was and the registrars just looked a bit blank. They decided on a selection of immunohistochemical stains which should help.
Pathology pictures are all from the Pathology Education Instructional Resource.


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