Pulmonary embolus!

[yaah]

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First, note that pathology is not an easy residency. At michigan today we had 5 autopsies. Although one of them was brain only. I was responsible for 2. One was an operated congenital heart case and the other was a person with a low grade chronic illness who suffered a sudden death.

The sudden death had pulmonary emboli in each lung. Eureka! The first autopsy I have actually had that demonstrated a pulmonary embolus, despite the fact that 95% of cases that are sent down from upstairs where the clinical history has anything of the following: dyspnea, SOB, tachypnea, tachycardia, acid-base abnormalities, hypoxia, peripheral edema carries a statement "likely pulmonary embolus."

Do other people experience this? No one ever has a PE. This lady did, and ironically, they did not have it in their differential. She was a "likely aspiration followed by ventricular arrhythmia." (She had chronic interstitial lung disease and right heart failure).

A real pulmonary embolus. two of them. We took lots of pictures. If I get the photos back I will prove it to you.

 

[b&ierstiefel]

Holy crap...FIVE?!?

Were the pulmonary emboli big honker emboli?

Your story is a testament to how mental masturbation on the floors sometimes fails to reach proper diagnoses/courses of action...but one can turn to the trusty pathologist to make the right diagnosis for ya 🙂

Oh wait...this post belongs in the Anti-Medicine thread...

 

[yaah]

They were big. They were in the origin of lobar branches. One on each side. It may have been one large one that split after the initial hit, who knows.

Didn't find any aspiration though.

Ironically, she did not come into the hospital for that. She came in for hematuria and not feeling well for awhile, probably related to her chronic disease state. Must have done a lot of sitting around and clotting.

A nice way for the autopsy months to end. However, now I feel like I have to learn all of microbiology in the next 16 hours. 😱

 

[b&ierstiefel]

They were big. They were in the origin of lobar branches. One on each side. It may have been one large one that split after the initial hit, who knows.

Didn't find any aspiration though.

Ironically, she did not come into the hospital for that. She came in for hematuria and not feeling well for awhile, probably related to her chronic disease state. Must have done a lot of sitting around and clotting.

A nice way for the autopsy months to end. However, now I feel like I have to learn all of microbiology in the next 16 hours. 😱

That's interesting. Did she have some autoimmune disease that caused her to have a relatively pro-coagulant state. Like lupus or anti-PPL syndrome or something?

 

[yaah]

She had the old, "poorly defined connective tissue disease" syndrome. You know, PDCTD. It's a killer.

Intermittently positive ANA. Postive anti-Ro. They called it sjogrens with extra features or something like that. Plus she was subtherapeutic on her coumadin. Whoops.

 

[b&ierstiefel]

Uh yeah...whoops is right 🙂

 

[BeastNovot]

Yaah: I had a case recently of a pt with CABG x6, bilateral CEA, and h/o previous infarcts, who came into the hospital with ARF and then posted positive troponins and CK-MB's... I called the IM resident and asked him why they wanted an autopsy... guess what the answer was? OK, I know you can't guess, so here's a transcript:
Me: Greetings, good doctor. I see you wanted an autopsy on patient X. Are there any specific questions you would like answered when we perform the autopsy?
"I wondered why she died."
"Don't you think that's obvious?" I replied.
"Well, I thought she might have had a PE" says he.
"You don't say" says I as I hung up the phone. Needless to say: Cause of death was not a PE...

Although I actually have seen several PE's, at least two or three in the last 3 months of autopsy...

 

[edamame]

in the second autopsy of my PSF, a gigantic, textbook-quality saddle embolus practically leapt out of the pulmonary trunk when we opened it....wow!!!

 

[Matte Kudesai]

A real pulmonary embolus. two of them. We took lots of pictures. If I get the photos back I will prove it to you.

YAAH I know exactly how you feel. I had a perfect saddle thromboembolus a few weeks ago. Do you guys insufflate the lungs? By the way why not use a digital camera?

The most autopsies I have had in a day is three. What's cool is I am almost at 50 now only 3 months into my first year.

 

[yaah]

I guess they just haven't gotten around to getting a digital camera for the morgue yet. They have them, but not there.

We generally insufflate lungs, or perhaps inflate one and not the other. Looks so much better on histo.

But yeah, they always suspect it. We had a lady with clear cirrhosis and hepatic failure (with coagulopathy), sepsis, and obviously evolving and severe ARDS. Why do you think she died? I asked. What started her on this course?.

Well, we suspect PE, he said.

Get out of my morgue! I said.

 

[Doctor B.]

I've had a couple of cases of great PE's including one classic saddle embolus on our forensics service. I've also seen Robbin's-esque MI's. Forensics is good for textbook acute pathology b/c the clinicians haven't had a chance to futz all the findings up.

 

[Mindy]

I have seen quite a few PE's, just rarely of the size that acutely kills (i.e. saddle, etc.)

Mindy