CASE 1:

Clinical History:

A 34-year-old man works as an administrator in a nursing home. His job is not strenuous, but he comes to his physician complaining of shortness of breath on weekends when he is more active in sports with his family. Sleeping is becoming more difficult, and he reports a better night's sleep if he props himself up on a couple of pillows. He reports no chest pain. He has no history of alcohol or tobacco use. On physical examination he is found to have a pulse of 75, respirations 28, temperature 36° C, and blood pressure 115/75. Examination of the chest reveals bilateral lower lung field rales. The heart has a regular rate and rhythm, but there is a faint murmur suggesting tricuspid insufficiency. He also has lower extremity edema.

Image 1.1

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Image 1.4

Questions:

1. What is the diagnosis?
2. What is the etiology of this disease?
3. How do you explain the signs and symptoms manifested in this patient?
4. Explain the mechanism for increased comfort at night derived from using extra pillows.
5. Is this process in the lung more typical of right or of left-sided failure?
6. Where does the hemosiderin seen in the alveolar macrophages come from?
7. What are treatment options?

CASE 2:

Clinical History:

This is a 51-year-old executive for a shipping company. He has been feeling some chest pains over the last year, particularly after climbing up the stairs to the accounting office. He had cholesterol screening done, which showed a total cholesterol of 250 and HDL component of 25. His fasting glucose is 145 mg/dl. He smokes half a pack of cigarettes a day. He is overweight. He is admitted to hospital after onset of severe chest pain that was substernal and described as "crushing".

Image 2.1

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Image 2.9

Questions:

1. What is the diagnosis in this man?
2. What are the risk factors for his disease?
3. Explain the symptomatology.
4. What is the lesion in the coronary artery?
5. Describe and date the pathologic findings seen in images 2.3 to 2.8.
6. How would you use laboratory findings to help diagnose his condition?
7. How could his disease be treated?
8. What are possible complications?
9. What are etiologies for the complication seen in image 2.9?
10. What pharmacologic therapy would be useful in view of his total serum cholesterol?
11. What dysrhythmias would most likely be seen as a result of the anterior descending lesion? What mechanisms would underlie these arrhythmias?

CASE 3:

Clinical History:

A 44-year-old African-American man has a history of hypertension, but on arrival in the emergency room his blood pressure is recorded as 220/150 mg Hg.

Image 3.1

Questions:

1. What is the nature of the process seen in the renal artery shown here microscopically at high magnification?
2. What complications are likely to develop?
3. Describe two mechanisms by which renal artery ischemia produces hypertension.

Clinical History:

A 57-year-old woman is developing renal failure. Her BUN is currently 45 mg/dl and her creatinine 3.5 mg/dl.

Image 3.2

Questions:

1. Describe the changes seen in this high magnification microscopic view of a renal glomerulus.
2. What underlying disease process is probably present?

CASE 4:

Clinical History:

This 32-year-old man was found down in his apartment when a friend came to visit. The friend called 911. On arrival in the emergency room, the patient was febrile, with a temperature of 38.9 C. Physical examination revealed a palpable spleen tip, splinter hemorrhages, needle tracks in the left antecubital fossa, and a heart murmur. Echocardiography reveals nodular lesions up to 1 cm involving the aortic valve, which also shows valvular insufficiency.

Image 4.1

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Image 4.4

Questions:

1. What is the diagnosis?
2. Explain how this occurred.
3. Explain how the gross appearance of the mitral valve shown in image 4.3 relates to this same disease process.
4. Explain how the microscopic appearance in image 4.4 tells you something about complications of this disease as well as the site of involvement.
5. What is the treatment?
6. Name some other causes for these lesions on a cardiac valve.
7. What would the radial blood pressure curve look like in this disorder?
8. What arrhythmia would be seen most often in chronic mitral valve insufficiency?

CASE 5:

Clinical History:

A 30-year-old woman is 183 cm (6'2") tall and has dislocated ocular lenses and very long fingers. She has relatives with a similar body habitus. Shown below are some possible complications of her underlying disorder.

Image 5.1

Image 5.2

Image 5.3

Image 5.4

Image 5.5

Questions:

1. What is the complication shown in this gross photograph of the left heart opened to reveal the aortic valve?
2. What is demonstrated by this cross section of the aorta?
3. What histologic lesion is demonstrated in the media of the aorta with this mucin stain?
4. What complication is shown here involving the mitral valve?
5. What is her underlying disorder?
6. What other risk factors may lead to the complication seen in images 5.1 and 5.2?
7. Pulmonary hypertension is often found in this disorder. What effect would this have on auscultatory findings?
8. What are the issues regarding surgical intervention. When is surgery done, and by whom?

CASE 6:

Clinical History:

Here are some examples of congenital heart disease:

Image 6.1

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Image 6.3

Questions:

1. What is the abnormality seen here in image 6.1 and what is the natural history?
2. Name the lesion seen here in image 6.2. What is its natural history? Describe the auscultatory findings.
3. What is this lesion in image 6.3? What physical exam findings could clue you in to its presence?