CASE 1

History:

A 27-year-old man was driving a truck & trailer rig northbound on an interstate roadway when he lost control of the vehicle, leaving the roadway. He rolled into an embankment, overturning the vehicle. Police and paramedics arrived on the scene soon after and extricated him from the cab. He was transported to a local hospital. Upon arrival, he was hypotensive and incoherent. Blood alcohol was 0.27 G/dl. He had fractures of the right humerus, right upper femur and lower left tibia. Peritoneal lavage revealed no evidence for abdominal hemorrhage. His condition was stabilized and he did well for 3 days, but then he became increasingly short of breath and died despite intubation and ventilatory support.

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Questions:

1. What is the diagnosis?
2. What is the pathogenesis?
3. What other conditions can produce this syndrome?
4. What is the legal limit for blood ethanol while driving?

CASE 2

History:

This 44-year-old woman was found down on the ground and was unarousable. She was transported to the hospital where it was noted that her pupils were of unequal size. There was a 5 cm laceration on the back of the scalp. Periorbital ecchymoses were present. The liver was palpated 10 cm below the costal margin. Blood pressure was 140/70, temperature 35.5, pulse 90, and respirations 25. Blood ethanol on admission was 0.17 gm%. A CT scan revealed bilateral subdural hemorrhages. She was evaluated by neurosurgery and then taken to surgery where subdural blood clots were evacuated. The ethanol level in the clots removed at surgery was 0.35 gm%. Her condition did not improve markedly, and two weeks later she became comatose and died.

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Questions:

1. What is the etiology for her liver disease?
2. What is the relationship of her liver disease with the trauma?
3. What is the CNS hemorrhage produced?
4. How do you explain the difference in ethanol level measured on admission and in the subdural blood clots?
5. How do you explain the injury pattern that relates a posterior scalp laceration to the orbital plate fractures?

CASE 3

History:

A 68-year-old man presented to his physician with increasing shortness of breath that he had experienced for several months. He had a 20 lb weight loss in the last month. He has a 100 pack/year history of smoking. He has lived all his life in the U.S. He has worked as a real estate agent for many years. Earlier in his career, he also spent time remodelling the homes he sold. His hobbies include gardening and woodworking. A chest x-ray showed diffuse interstitial disease along with left pleural thickening without an effusion. A pleural biopsy was performed. Two months after the biopsy, his respiratory status worsened and he died.

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Questions:

1. What is his disease process?
2. What is the name of the pleural lesion?
3. How does his history relate to this?

CASE 4

History:

Police were called to a house after neighbors reported windows being broken and screams being heard. Police officers arriving on the scene found that all windows were latched and all doors were locked. Upon entering the house, the officers found a 25-year-old man in the bathroom. The shower was running and water covered the floor. The man was combative and it took 5 officers to restrain him. He was delerious. There were injuries on his hands and forearms. He died on the way to the hospital. His mother and ex-wife are claiming that excessive force by the police led to his death.

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The postmortem toxicology findings are shown here.

Questions:

1. Why did the neighbors hear screaming and breaking glass?
2. Why was the shower running?
3. What is the significance of the toxicology findings?
4. How could you prove that the police did not cause this man's death?

CASE 5

History:

Police respond to a residence after receiving a report of "shots fired". Inside the unlocked house they find the body of an elderly man lying on the floor. Near the body is a large caliber pistol. There are gunshot wounds of the head and chest. No notes are found at the scene, but the decedent's important papers are laid out on a desk in the study. Further investigation with interview of family members reveals that the man had recently been diagnosed with prostate cancer. He had also recently argued with his son over financial matters and had threatened that he was going to change his will to make sure that his son got nothing.

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Questions:

1. Based upon the investigative and pathologic findings, what do you determine is the manner of death (accident, suicide, homicide)?
2. How do you interpret the wound on the back in relation to the wound on the chest. What is the direction of fire?
3. What is the range of fire of the two wounds?

CASE 6

History:

The body of a young woman is found in her bedroom. Investigation reveals that the victim's roommate came home to find the apartment door open with the furniture overturned and broken. There were blood stains throughout the dwelling. The victim had recently broken up with her boyfriend after a stormy on again/off again relationship. A knife covered in blood was found in a dumpster behind the apartment building. Analysis of this weapon confirmed that two different types of human blood were present. Fingerprints were also present on the weapon, but they could not be classified because of smudging.

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Questions:

1. What does the number and the distribution of the wounds indicate?
(What is the manner of death and the nature of this situation?)
2. What is the significance of the injuries of the wrist and hand? (How did these injuries occur?)
3. What can you tell about the weapon from the stab wounds?
4. Why were two types of blood found on the weapon? What further analysis could be performed to help solve this case?

CASE 7

History:

A 24-year-old woman was found on the floor of her apartment by her mother. Next to her was a bottle labelled "Tylenol, extra strength" and "100 tablets" which was empty. The mother called paramedics who took her daughter to a local hospital. Laboratory data indicated increasing ALT and AST. She was started on dialysis. Despite therapy, she died a week later. Further history from the mother revealed that her daughter had recently gone through a divorce in which she had lost custody of her two children.

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Questions:

1. What is the diagnosis?
2. What is the manner of death?

CASE 8

History:

A 19-year-old man was involved in a high-speed chase. He was driving a stolen vehicle and was pursued by highway patrol officers. After 10 kilometers, he lost control of his vehicle, striking another vehicle nearly head-on. Paramedics arrived on the scene and had to extricate him from the vehicle. He had no blood pressure and a barely palpable pulse. He died at the scene despite resuscitative measures. The driver of the car he struck (who was wearing a seat belt and whose auto had an airbag) was taken to a local hospital and was in stable condition with only minor contusions.

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The postmortem toxicology findings are shown here.

Questions:

1. What is the name of the process shown in image 8.3?
2. If more than one person were in the car in a fatal collision, how can the medical examiner determine which one was the driver?
3. What public policy measures can affect death rates from vehicular accidents?

CASE 9

History:

In the early afternoon an emergency call is received requesting assistance for an unresponsive 13 month old child, and paramedics are dispatched. The child was in good health and had been behaving and reacting normally when last seen by her parents at approximately 9 am. During the day, she was in the sole custody of a 17-year-old in-home caretaker, who had been living with the child's family for the past 10 months.

The child was apneic and unresponsive when the paramedics first arrived but was resuscitated and taken to a local hospital. At the hospital, a head CT scan reveals a subdural hematoma with cerebral edema. Funduscopic examination reveals bilateral retinal hemorrhages. A body radiograph reveals a fracture of the upper right humerus. The child died two days after admission.

Upon questioning, the caretaker reported that she was changing the child's diaper on a table when the child suddenly arched her back and fell off the table, landing on her head. Investigation of the scene reveals that the surface of the table is 74 centimeters above the floor. The floor is concrete but covered with carpeting and an underlying carpet pad.

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Questions:

1. How do you explain these injuries?
2. What is the manner (mode) of death?
3. What issues need to be addressed in this case?

CASE 10

History:

A 39-year-old gravida 7 para 5 ab 2 woman had delivered a term baby who was 3500 gm. The baby's Apgar scores had been 8 and 10 at birth. Both mother and baby had been sent home on postpartum day 2. The baby had been doing well, with only a minor respiratory infection noted at age 3 months. Mother and father left the baby with a babysitter one Saturday evening while they attended a symphony orchestra concert. Upon returning home, they found paramedics in the house who related to them that their child was dead. The babysitter said that she had noticed nothing wrong with the baby, and put the baby in the crib at about 10:00 pm. She went to check on the baby at 10:30 and noted that the baby was prone and was not breathing, at which time she called the paramedics.

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Autopsy was performed and revealed no gross pathologic findings. There was no evidence for injury except for a bruise on the right forehead. Radiography revealed no fractures.

Questions:

1. What is your diagnosis?
2. What possibilities have to be ruled out?