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I think that Anna died from  a heart disease. In her family she has a history of early heart disease. Also she was experiencing signs of PVCs which only occurs only in patients with heart diseases. In addition, her medical history shows that she has high cholesterol. Her overall cholesterol was 389 mg/dL, and an ideal overall cholesterol level should be around 100, so she was way over. This is what may have lead to a heart attack which is what caused her to die.

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I believe that Anna may have died because of the blockage of her left coronary artery due to plaque build up. In her medical history it says that there was blockage and also recommended that an angioplasty be done and a potential stenting. Because there was no autopsy report or medical history documenting that this was ever done, I'm assuming that the artery blockage was never taken care of. Because of this, there may have been lack of blood flow going to and from the heart, which lead to a heart attack.

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https://docs.google.com/document/d/1d8QDqRXDJM8MwgnjvpU7J48OwWAOW_9DhQDENzGddQs/edit#heading=h.gjdgxs

Anna has a family history of early heart disease as well as uncontrolled hypertension. Her father had a heart attack when he was only 41 years old.

Patient was evaluated by physical exam, blood work, cardiac stress test with electrocardiogram (EKG), and an echocardiogram. Results later prompted an angiogram.

Laboratory Analysis

CBC results are normal – no abnormalities in red blood cells, white blood cells, or platelets.

Full cholesterol panel

Total Cholesterol – 389 mg/dL

LDL – 243 mg/dL

HDL – 60 mg/dL

Triglycerides – 145 mg/dL

Fasting blood sugar – 85 mg/dL

Hemoglobin A1c – 7.1%

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https://docs.google.com/document/d/1oH6R6Y0lYhJc2388OfaKcDETKT_X4nRWkEUWphRo6Ls/edit#

Physical Exam

Patient is tachycardic – average resting heart rate ranged from 90-105 over the course of the day.

Patient shows no signs of edema (swelling) in her feet or lower legs, although she does mention an occasional tingling sensation in her right calf.

Blood pressure values averaged 142/85 over the course of the work-up.

Slight heart murmur detected.

Waist Circumference – 33 inches

Cardiac Testing

Patient completed a treadmill stress test. The patient experienced drastic increases in blood pressure as well as a few premature ventricular contractions (PVCs) on EKG during the exam. One run of ventricular tachycardia was noted. Additional monitoring using a Holter monitor is suggested given these abnormalities and the noted mitral regurgitation (going back to the aorta) (see below). The patient was only able to walk for 8 minutes before the test was concluded – max speed 3.5 mph at an elevation of 2%, and max blood pressure of 190/110.

Due to EKG changes during the treadmill test and the patient complaint of chest pain, an angiogram was recommended to explore the cardiac vessels. Scans revealed a blockage in the left anterior descending coronary artery (not fully visible on the summary scan below). Angioplasty is recommended with the potential for stenting.

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https://docs.google.com/document/d/1QK5BtcjW9LBKKy8wxSQZ8_PkY8LaQMA4qYVBU0VrLng/edit

Laboratory Results:

Toxicology:

1.     Blood:

No evidence of alcohol.

Evidence of statins,(statins lower cholesterol levels) equivalent to 40mg/day. NOTE: A prescription bottle for Vasotec, an ACE inhibitor, was found at the scene, although there is no evidence of this drug in the blood. The decedent most likely had not taken this medication for at least 3-4 days.

Blood glucose level 280 mg/dL (normal range 70-125 mg/dL)

External Examination

The following X-ray image was obtained of the heart and lungs before internal examination. Lungs appear normal with no infiltrates.

Internal Examination

Cardiovascular System:

Examination of the heart revealed concentric left ventricular hypertrophy. There is also evidence of mild mitral valve prolapse (this means that the mitral valve does not close properly).

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https://docs.google.com/document/d/1tq3atmJdDj75JJsmF1S1yHTpZE1hjSughzjHqS2JkxQ/edit

Internal Examination

Gastrointestinal System:

The mucosa and wall of the esophagus are intact and gray-pink, without lesions or injuries. The gastric (stomach) mucosa is intact and pink without injury. The mucosa of the three parts of the small intestine, the duodenum, the jejunum, and the ileum, and the mucosa of the large intestine, the colon and rectum, appears normal. Approximately 125 ml of partially digested semisolid food is found in the stomach.

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https://docs.google.com/document/d/1l4TAl8GqoTkHNMKUoQDxP3SiJ8E_rRwH0L1Mlf9l0mQ/edit

Physical Exam

Patient’s pulse is normal.

Patient shows no signs of edema (swelling) in her feet or lower legs, although she does mention an occasional tingling sensation.

Patient said she has no ear pain or a sore throat. Upon inspection, her ears, nose, and throat all look normal.

Patient’s glands are not swollen.

Patient’s speech, hearing, and vision appear normal.

Laboratory Analysis

CBC results are normal – no abnormalities in red blood cell, white blood cell, or platelet count.

Cultures for strep are negative.

Routine urinalysis shows glucose in the urine.

Given Anna’s family history of cardiovascular disease and her stated symptoms, Anna will be sent for glucose tolerance testing to rule out diabetes.

Follow-up/Diagnosis

Anna has been diagnosed with diabetes. After testing her glucose levels, they spiked up and didn’t go back to normal. She is a Type 1 diabetic because her insulin levels stayed low at a consistent rate.

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https://docs.google.com/document/d/1gdGWbPzNjp1BVM4sr6Bb6dMvPlk_uV_WSV7z_sX4SoA/edit#heading=h.gjdgxs

Tests Performed:

CBC

Hematocrit

Blood oxygen

CT scan

Sickle cell test

Results:

CBC

Red Blood Cell Count reduced levels

White Blood Cell Count increased levels

Hematocrit

Lower than normal hematocrit - 20%

Blood oxygen

Lower than normal levels

CT scan

Abnormal spleen, indicative of splenic sequestration

Sickle cell test

Positive for sickle cell anemia

Diagnosis:

Sickle cell anemia

Severe anemia

Splenic sequestration (sickling in the splenic vein resulting in a collection of a large amount of blood in the spleen, causing the spleen to be enlarged).

Treatment:

Intravenous hydration

Administration of pain medication

Red blood cell transfusion

Administration of antibiotics to prevent infection

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https://docs.google.com/document/d/1FFCLwSEFG3hiZa3m-UxSLqVQZVk9Vw2XD_pZRxE2-cE/edit#

Toxicology:

1. Blood:

Hydroxyurea, trace amounts – used to treat Sickle Cell Anemia

Hematocrit: 24.24%

Low hematocrit, this means that she is anemic

Microscopic analysis of blood:

Abnormalities found: Anna’s red blood cells are sickle shaped.

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https://docs.google.com/document/d/1PUiwEAgPeQWlKJUXWyLF81T2fdQAYmwnLgRA4MqT5EQ/edit

- Diagnosis: Anna is diagnosed with urinary tract infection.

- The results of the bacteria identification test indicate that the bacterial infection Anna has been diagnosed with is serratia marcescens.

- The results of the gram stain test indicate:

Gram Stain = negative

Morphology = bacillus

- The results of the gross examination of colony morphology test indicate that bacteria is Serratia marcescens that caused Anna’s infection. The colors, elevation, and margin matched.

- The results of the urinalysis test indicate positive for bacterial infection. Further tests need to be performed to identify the type of bacteria.

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When tested, Anna's glucose levels were 280 mg/dL (normal rrange 70-125 mg/dL)

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We used gel electrophorosis and did all the people of interests' blood, and compared it to the blood found at the crime scene. When compared the crime scene blood matched Anna Garcia's blood type

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-  I think that Anna died because of a complication due to her sickle cell anemia. As shown in her Autopsy Report 3.1.1. Anna was a low hematocrit which means that she was anemic causing her red blood cells to become sickle shaped. The red blood cells carry oxygen to the body. When the cells become sickled they get stuck in blood vessels and they are unable to transfer oxygen to parts f the body. Because this happened to Anna's blood, it caused her to become oxygen deprived which caused fatigue causing her to die. In addition in her 3.1.2. Medical History, it shows that her oxygen levels were lower than normal oxygen levels, which proves my theory.
- Another theory is that Anna died due to her splenic sequestration as mentioned in her Medical history. This is due to her sickle cell disease. Because of the enlargement of her spleen, it made her more susceptible to infections that are life threatening. This includes her getting a UTI with the bacteria Serratia marcescens. -

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- Hot, 92 degrees F summer morning
- Police and the EMT arrived at the scene at 9:56 a.m.
- Neighbor spoke to her the previous morning
- Neighbor tried to call Anna, but no one answered
- Neighbor tried ringing doorbell, but no one answered
- Door had to be broken down
- Anna was lying faced down in the entry hallway
- Comfortable 73 degrees F inside the house

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- Tag #1: Blood Splatter
- Tag #2: Syringe
- Tag #3: Spilled Drink
- Tag #4: Vomit
- Tag #5: Strands of Black Hair
- Tag #6: Footprint
- Tag #7: Fingerprint
- Tag #8: 2 White Pills

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Determined to be dropped from 50-55 cm

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7:00 a.m.

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Anna Garcia