Introduction John Doe, a 46-year old male, was found dead slumped off his bed at his home on the morning of August 30th. Mr. Doe had a long medical history of malignant hypertension, end-stage renal disease secondary to nephrosclerosis (on peritoneal dialysis), and was a smoker. Mr Doe had also been in and out of the hospital over the past year with congestive heart failure and anasarca. His cardiac history also includes cardiomegaly and mitral insufficiency on the echocardiogram. On further investigation it was found that Mr. Doe weighed 240 pounds and was 70 inches tall. The decedent's family reported that he had not been feeling well and had complained of extreme fatigue, low blood pressure, and "puffiness" prior to his death. He had also recently injured his left arm while repairing a car. Upon external investigation of the decedent's body during the autopsy, it is evident that resuscitative efforts were made to revive Mr. Doe. An endotracheal tube and EKG pads were on the chest. A peritoneal dialysis catheter was also present in the lower abdomen. Generalized mild edema and rigor mortis are noted. Blood is obtained for toxicology, which shows normal acetominophen levels and no other drugs.

Outline of Learning Objectives I. What do you know? A. The decedent had a long medical history and was a smoker B. The decedent had been seen at the hospital with congestive heart failure and other cardiac problems in the recent past C. Symptoms noted by the decedent's family II. Nephrosclerosis A. What is it? B. How it affects a person III. End-Stage Renal Disease A. What is it? B. How it relates to BP C. Treatments D. Effects on other systems IV. Mitral Insufficiency A. What is it? B. How the ECG is affected by this C. Causes of mitral insufficiency D. Mitral insufficiency and cardiac output E. Mitral insufficiency and the decedent's other symptoms V. CHF and Anasarca A. What is it? B. Contributing factors C. How it affects his other symptoms VI. What happens to the body after death A. What happens to the blood? B. What happens to the cells? C. Rigor mortis D. Determining time of death

Questions to Consider 1) Define the following terms: a) malignant hypertension b) end stage renal disease secondary to nephrosclerosis c) congestive heart failure d) cardiomegaly and mitral insufficiency on the EKG 2) The patient had been complaining of fatigue and "puffiness," and he had a low BP. What causes these symptoms? How are each of these symptoms related? 3) What are the functions of the endotracheal tube and EKG pads that were used on the patient? 4) What is the function of the peritoneal dialysis catheters? 5) What is rigor mortis and what causes this phenomenon? 6) How does mitral insufficiency affect cardiac output?

Case Summary The patient was a 46-year old man who died of congestive heart failure. The heart failure caused the blood to pool in the veins and resulted in edema that was present in his extremities. The heart failure was caused by a mitral valve insufficiency that was detected during an echocardiogram. The mitral valve insufficiency caused the heart to work harder which could have caused atrophy of the ventricles of the heart. This would reduce the volume that could fill the ventricles and thus further decrease the volume that the heart could pump. The heart would have to work even harder to pump to maintain cardiac output. Because there is a smaller amount of blood that is pumped by the heart, the blood pools in the venous system which increases the pressure in this system. The increased pressure leads to decreased reabsorption in the capillaries. The extremities then accumulate fluid because the plasma is not being completely reabsorbed. The edema could have been worsened because the patient had damage to his kidneys which control the blood composition. The kidneys could not properly control the salt concentration of the body which results in water being retained in the body. This excess water then causes the blood pressure to be higher than normal and could have contributed to his hypertension. All of these factors seemed to have contributed this patient's death.

References Used to Develop Case: 1) www.webmd.com 2) Widmaier, Eric P., Hershel Raff, and Kevin T. Strang. Human Physiology: The Mechanisms of Body Function. New York, 2006. 3) http://www.deathonline.net/decomposition/ 4) http://www.americanheart.org/ The development of this case was also assisted by the Monroe County Coroner. Suggested References for Use: 1) Widmaier, Eric P., Hershel Raff, and Kevin T. Strang. Human Physiology: The Mechanisms of Body Function. New York, 2006. 2) http://folk.uio.no/mostarke/forens_ent/afterdeath.shtml 3) http://www.americanheart.org/