Clinical Pathology Conference May 21, 2018 Jody Manners, PGY4

Clinical History 50 year old female with history of EtOH abuse, NHL s/p R-CHOP 2005, headaches, transferred with AMS. LSW 6pm on 4/28, presented to OSH after found at 2pm on 4/29 “unresponsive” and with agonal breathing At OSH, emesis and aspiration and eventually intubated on arrival in Presby ED

Additional History PMH: EtOH abuse, NHL s/p R-CHOP 2005, headaches PSH: Hysterectomy Home meds: lorazepam, metoprolol ROS: per family, several days of severe HA

Exam OSH: At PUH: Hypothermic, reported fixed pupils HR 76, BP 162/100, RR 24, T 29.5 Intubated without sedation, 4/4 TOF Pupils 6mm fixed, symmetric. +R corneal, no cough, +gag Extension in all extremities

Labs Na 131, BUN/Cr 6/0.3, glucose 115 WBC 8, Hb 15, plt 251 Lactate 3.2 CPK 1029 Trop < 0.10 -> 0.37 EtOH 35

Imaging 4/29/18

Imaging Final Read Large R SDH, 1.8cm subfalcine herniation, brainstem duret hemorrhage + IVE in 4th, early/subacute R PCA infarct involving parietal/posterior mesial temporal and entrapment of R temporal horn and left lateral ventricle

Hospital Course NRSGY evaluation in the ED; no intervention and suspected poor prognosis. Admitted to 4G where expected progression to brain death would occur. Slowly rewarmed with monitoring of electrolytes, pressor support Family focus on comfort on 4/29-4/30 CTB 4/30

Autopsy Findings: Severe calcific atherosclerotic cardiovascular disease, up to 95% occlusion of proximal LAD, healed posterior LV infarct, cardiomegaly (440g) and LVH Bronchopneumonia Hepatomegaly with steatosis (suspected related to EtOH abuse) Horseshoe kidney joined at lower poles with focal cortical hemorrhage, with incidental focus of renal cell carcinoma (grade 2, clear cell type favored) No evidence of lymphoma

Gross Examination of Brain Expected Gross findings Suspected etiology?