Critical Care
The Southwest Journal of Pulmonary and Critical Care publishes articles directed to those who treat patients in the ICU, CCU and SICU including chest physicians, surgeons, pediatricians, pharmacists/pharmacologists, anesthesiologists, critical care nurses, and other healthcare professionals. Manuscripts may be either basic or clinical original investigations or review articles. Potential authors of review articles are encouraged to contact the editors before submission, however, unsolicited review articles will be considered.
June 2017 Critical Care Case of the Month
Stephanie Fountain, MD
Pulmonary and Critical Care Medicine
Banner University Medical Center Phoenix
Phoenix, AZ USA
History of Present Illness
The patient is a 60-year-old woman who presented with a month long history of of odynophagia with retrosternal pain and occasional nausea and vomiting.
Past Medical History, Social History and Family History
She has a past medical history of mixed connective tissue disease with anti-phosopholipid antibody. There is also a history of leukocytoclastic vasculitis, chronic leg ulcers, and poor dentition. She also has a history of chronic obstructive lung disease (COPD) and is a current smoker having accumulated about 50 pack-years of cigarette smoking.
Current Medications
- Prednisone 20 mg daily
- Azathioprine 75 mg daily
- Plaquenil 400 mg daily
- Salmeterol/fluticasone BID
- Albuterol prn
Electrocardiographic, Radiologic and Laboratory Evaluation
Her electrocardiogram and chest x-ray were unremarkable. Complete blood count showed a white blood cell count of 10,500 cells per microliter (mcL), hemoglobin 10.3 grams/deciliter (dL), hematocrit 31%, and platelet count of 48,000 cells per mcL. Electrolytes were unremarkable and creatinine was 0.6 mg/dL.
What should be done next? (Click on the correct answer to proceed to the second of six pages)
- Bronchoscopy
- Gastroenterology consult
- Platelet and red blood cell (RBC) transfusion
- 1 and 3
- All of the above
Cite as: Fountain S. June 2017 critical care case of the month. Southwest J Pulm Crit Care. 2017;14(6):262-8. doi: https://doi.org/10.13175/swjpcc061-17 PDF
December 2016 Critical Care Case of the Month
Theodore Loftsgard APRN, ACNP
Department of Anesthesiology
Mayo Clinic Minnesota
Rochester, MN USA
Critical Care Case of the Month CME Information
Members of the Arizona, New Mexico, Colorado and California Thoracic Societies and the Mayo Clinic are able to receive 0.25 AMA PRA Category 1 Credits™ for each case they complete. Completion of an evaluation form is required to receive credit and a link is provided on the last panel of the activity.
0.25 AMA PRA Category 1 Credit(s)™
Estimated time to complete this activity: 0.25 hours
Lead Author(s): Theodore Loftsgard APRN, ACNP. All Faculty, CME Planning Committee Members, and the CME Office Reviewers have disclosed that they do not have any relevant financial relationships with commercial interests that would constitute a conflict of interest concerning this CME activity.
Learning Objectives:
As a result of this activity I will be better able to:
- Correctly interpret and identify clinical practices supported by the highest quality available evidence.
- Will be better able to establsh the optimal evaluation leading to a correct diagnosis for patients with pulmonary, critical care and sleep disorders.
- Will improve the translation of the most current clinical information into the delivery of high quality care for patients.
- Will integrate new treatment options in discussing available treatment alternatives for patients with pulmonary, critical care and sleep related disorders.
Learning Format: Case-based, interactive online course, including mandatory assessment questions (number of questions varies by case). Please also read the Technical Requirements.
CME Sponsor: University of Arizona College of Medicine
Current Approval Period: January 1, 2015-December 31, 2016
Financial Support Received: None
History of Present Illness
A 62-year-old lady with primary biliary cirrhosis/autoimmune hepatitis listed for liver transplantation was admitted to the general medicine floor with progressive lethargy. She had progressive fatigue for about 10 days prior to admission. She had not been able to walk for the last few days; had anorexia; had not had a bowel movement for approximately one week; and had not taken her medicines for 4 days according to her daughter. Her family was concerned with her progressive lethargy; her darkening urine; and progressive jaundice.
She had been managed for several years on mycophenolate mofetil, budesonide, and ursodiol. She had increasing problems with ascites and had paracentesis performed about every 4 days despite taking Lasix and spironolactone. She had early encephalopathy manifested by increasing problems with word finding but had not received lactulose.
Past Medical History
She has a history of esophageal varices, recurrent cellulitis and obesity.
Physical Examination
Vital Signs: P 121 beats/min, BP 102/35 mm Hg, T 37.5◦ C, R 25 breaths/min
General: She was lethargic, somewhat confused but oriented to time, place and person.
Lungs: shallow respirations.
Heart: regular rhythm with a tachycardia.
Abdomen: distended with a fluid wave.
Radiography
Portable chest and abdominal x-rays were performed (Figure 1).
Figure 1. Admission chest (A) and abdominal (B) radiographs.
Which of the following best describes the x-rays? (Click on the correct answer to proceed to the second of six pages)
- The abdominal x-ray shows diffuse, nonspecific gaseous distention
- The abdominal x-ray shows gastrointestinal perforation
- The chest x-ray shows bilateral atelectasis
- The chest x-ray shows bilateral pneumonia
- 1 and 3
- 2 and 4
- All of the above
Cite as: Loftsgard T. December 2016 critical care case of the month. Southwest J Pulm Crit Care. 2016;13(6):278-84. doi: https://doi.org/10.13175/swjpcc104-16 PDF
September 2016 Critical Care Case of the Month
Clement U. Singarajah, MD
Samir Sultan, DO
Phoenix VA Medical Center
Phoenix, AZ USA
Critical Care Case of the Month CME Information
Members of the Arizona, New Mexico, Colorado and California Thoracic Societies and the Mayo Clinic are able to receive 0.25 AMA PRA Category 1 Credits™ for each case they complete. Completion of an evaluation form is required to receive credit and a link is provided on the last panel of the activity.
0.25 AMA PRA Category 1 Credit(s)™
Estimated time to complete this activity: 0.25 hours
Lead Author(s): Clement U. Singarajah, MD. All Faculty, CME Planning Committee Members, and the CME Office Reviewers have disclosed that they do not have any relevant financial relationships with commercial interests that would constitute a conflict of interest concerning this CME activity.
Learning Objectives:
As a result of this activity I will be better able to:
- Correctly interpret and identify clinical practices supported by the highest quality available evidence.
- Will be better able to establsh the optimal evaluation leading to a correct diagnosis for patients with pulmonary, critical care and sleep disorders.
- Will improve the translation of the most current clinical information into the delivery of high quality care for patients.
- Will integrate new treatment options in discussing available treatment alternatives for patients with pulmonary, critical care and sleep related disorders.
Learning Format: Case-based, interactive online course, including mandatory assessment questions (number of questions varies by case). Please also read the Technical Requirements.
CME Sponsor: University of Arizona College of Medicine
Current Approval Period: January 1, 2015-December 31, 2016
Financial Support Received: None
Clinical History
A 66-year-old man was admitted to the ICU in complete heart block with borderline hypotension. After cardiology consultation, a decision was made to place an urgent transvenous pacer. The transvenous pacer was place without use fluoroscopy from an right internal jugular venous (IJV) approach using real time ultrasound by two very experienced operators. The ultrasound confirmed right IJV placement and the pacer was found to capture and pace appropriately without any complications. A post placement CXR was obtained (Figure 1).
Figure 1. Portable chest x-ray after RIJV transvenous pacer (TVP).
What does the chest x-ray show? (Click on the correct answer to proceed to the second of five panels)
Cite as: Singarjah CU, Sultan S. September 2016 critical care case of the month. Southwest J Pulm Crit Care. 2016;13(3):108-13. doi: http://dx.doi.org/10.13175/swjpcc079-16 PDF
August 2016 Critical Care Case of the Month
Jillian L. Deangelis, APRN, CNP
Theodore Loftsgard APRN, ACNP
Department of Anesthesiology
Mayo Clinic Minnesota
Rochester, MN USA
Critical Care Case of the Month CME Information
Members of the Arizona, New Mexico, Colorado and California Thoracic Societies and the Mayo Clinic are able to receive 0.25 AMA PRA Category 1 Credits™ for each case they complete. Completion of an evaluation form is required to receive credit and a link is provided on the last panel of the activity.
0.25 AMA PRA Category 1 Credit(s)™
Estimated time to complete this activity: 0.25 hours
Lead Author(s): Jillian L. Deangelis, MS, APRN, CNP. All Faculty, CME Planning Committee Members, and the CME Office Reviewers have disclosed that they do not have any relevant financial relationships with commercial interests that would constitute a conflict of interest concerning this CME activity.
Learning Objectives:
As a result of this activity I will be better able to:
- Correctly interpret and identify clinical practices supported by the highest quality available evidence.
- Will be better able to establsh the optimal evaluation leading to a correct diagnosis for patients with pulmonary, critical care and sleep disorders.
- Will improve the translation of the most current clinical information into the delivery of high quality care for patients.
- Will integrate new treatment options in discussing available treatment alternatives for patients with pulmonary, critical care and sleep related disorders.
Learning Format: Case-based, interactive online course, including mandatory assessment questions (number of questions varies by case). Please also read the Technical Requirements.
CME Sponsor: University of Arizona College of Medicine
Current Approval Period: January 1, 2015-December 31, 2016
Financial Support Received: None
History of Present Illness
The patient is a previously healthy, albeit anxious, 15-year-old girl seen by her primary care physician. She has had several months of general malaise and ongoing fatigue and an increased frequency in night terrors over the past few weeks. Her family attributes this to stress of school and her new job. She was noted to have lost 3 kg in the previous nine weeks.
PMH, SH, and FH
Her PMH was unremarkable. She is a student and denies smoking, drinking or drug abuse. Her family history is noncontributory.
Physical Examination
- Vital signs: BP 100/60 mm Hg, P 90 beats/min and regular, R 16 breaths/min, T 100.8 ºF, BMI 15.
- Diffuse, non-tender lymphadenopathy through the submandibular and upper anterior cervical chains.
- Lungs: clear
- Heart: regular rhythm without murmur.
- Abdomen: slightly rounded and firm.
Which of the following are diagnostic considerations at this time? (Click on the correct answer to proceed to the second of seven panels)
Cite as: Deangelis JL, Loftsgard T. August 2016 critical care case of the month. Southwest J Pulm Crit Care. 2016;13(2):46-53. doi: http://dx.doi.org/10.13175/swjpcc056-16 PDF
April 2016 Critical Care Case of the Month
Samir Sultan, DO
Banner University Medical Center Phoenix
Phoenix, AZ
Critical Care Case of the Month CME Information
Members of the Arizona, New Mexico, Colorado and California Thoracic Societies and the Mayo Clinic are able to receive 0.25 AMA PRA Category 1 Credits™ for each case they complete. Completion of an evaluation form is required to receive credit and a link is provided on the last panel of the activity.
0.25 AMA PRA Category 1 Credit(s)™
Estimated time to complete this activity: 0.25 hours
Lead Author(s): Samir Sultan, DO. All Faculty, CME Planning Committee Members, and the CME Office Reviewers have disclosed that they do not have any relevant financial relationships with commercial interests that would constitute a conflict of interest concerning this CME activity.
Learning Objectives:
As a result of this activity I will be better able to:
- Correctly interpret and identify clinical practices supported by the highest quality available evidence.
- Will be better able to establsh the optimal evaluation leading to a correct diagnosis for patients with pulmonary, critical care and sleep disorders.
- Will improve the translation of the most current clinical information into the delivery of high quality care for patients.
- Will integrate new treatment options in discussing available treatment alternatives for patients with pulmonary, critical care and sleep related disorders.
Learning Format: Case-based, interactive online course, including mandatory assessment questions (number of questions varies by case). Please also read the Technical Requirements.
CME Sponsor: University of Arizona College of Medicine
Current Approval Period: January 1, 2015-December 31, 2016
Financial Support Received: None
History of Present Illness
The patient is a 22-year-old African-American man who was initially seen following a rapid response team called to the neonatal intensive care unit for a seizure. He was visiting his newborn child. The nurses described the seizure as tonic-clonic which resolved spontaneously without treatment before the rapid response team arrived.
Past Medical History, Family History and Social History
The patient has a past medical history of a brain aneurysm treated by coil embolization 2 years earlier. He had no complications of the embolization including seizures. Family history is unremarkable. He smokes 1-2 cigars per day but does not drink alcohol.
Physical Examination
He was drowsy when initially seen but the drowsiness resolved in about 5 minutes. The physical examination was unremarkable and there were no focal neurologic signs.
What should be next? (Click on the correct answer to proceed to the second of seven panels)
- CT scan of the head
- Phenytoin administration
- Metabolic screening (BUN, glucose and electrolytes)
- 1 and 3
- All of the above
Cite as: Sultan S. April 2016 critical care case of the month. Southwest J Pulm Crit Care. 2016 Apr;12(4): . doi: http://dx.doi.org/10.13175/swjpcc033-16 PDF
Ultrasound for Critical Care Physicians: The Martian
Jawad Abukhalaf, MD
Michel Boivin, MD
Division of Pulmonary, Critical care and Sleep Medicine,
University of New Mexico School of Medicine
Albuquerque, NM USA
A 54 year old male with a past medical history significant for granulomatosis with polyangiitis (formerly known as Wegener’s granulomatosis) and chronic kidney disease presented with hemoptysis and chest pain.
On presentation, he was found to have a 10 cm right middle lobe cavitary lesion and was subsequently treated with high dose steroids, antibiotics and antifungals based on bronchoalveolar lavage results. On day 9 of his hospital stay the patient was found to have bilateral lower extremity deep venous thromboses that were treated with intravenous heparin. On day 11 of his stay, the patient started experiencing lower abdominal pain and hypotension. The patient was resuscitated with saline. Bedside ultrasonography was performed.
Figure 1. Transverse lower abdominal ultrasound in the pelvis.
What does the transverse view of the lower abdomen (just above the symphysis pubis) demonstrate? (Click on the correct answer for an explanation)
Cite as: Abukhalaf J, Boivin M. Ultrasound for critical care physicians: the martian. Southwest J Pulm Crit Care. 2015;11(4):186-8. doi: http://dx.doi.org/10.13175/swjpcc135-15 PDF
September 2015 Critical Care Case of the Month: If You Don't Look, You Won't Find
Robert A. Raschke, MD
Banner University Medical Center
Phoenix, AZ
History of Present Illness
A 55-year-old woman was transferred from Mexico emergently for acute cardiomyopathy. On the day of admission, she went for a 45-min “exercise” walk and cleaned her house. While taking a shower, she suffered an acute onset of dyspnea with nausea and vomiting and possibly a small amount of hematemesis. She appeared seriously ill to her husband, who took her blood pressure (198/?) and pulse (90) and rushed her to a local medical facility. There, she was found to have severe pulmonary edema, and a troponin of 11. Her echo showed inferior wall motion abnormality with an ejection fraction of 35%. However, coronary catheterization showed normal coronaries. She was treated with oxygen, furosemide, labetolol and enoxaparin and transferred emergently to Banner-University Medical Center.
Past Medical History, Family History and Social History
The patient reported intermittent "spells" since May. These typically occurred upon lying down in bed and were characterized by her as a feeling of “numbness” or tingling which ascends from her chest to her head associated with palpitations and a feeling of “desperation”, typically relieved after a few minutes upon getting up out of bed.
She had a history of hypertension and had been on losartan but this was discontinued a few months previously because of the onset of orthostatic dizziness. She also has a history of hypothyroidism and is taking synthroid. She was treated three times in the last 6 month for amoebiasis. She is a medical missionary to La Paz, Mexico and has recently traveled to Bolivia and Guatemala.
Review of Systems
She has had some night sweats, coughing with deep inspiration, and some slight hemoptysis. She did have a headache one month previously at 7000 ft elevation while in Guatemala.
Physical Examination
- She appears in moderate distress. Her vital signs are normal other than a mild tachycardia.
- She does have rales on auscultation of her lungs.
- The remainder of the physical examination was unremarkable.
Radiography
A portable chest radiograph is performed (Figure 1).
Figure 1. Admission portable chest radiograph.
Laboratory evaluation
Her CBC shows a normal hemoglobin and hematocrit but with an elevated white blood cell count of 26,500 cells/mcL with a left shift. Admission electrolytes and blood sugar are within normal limits.
What additional procedures/testing are indicated? (Click on the correct answer to proceed to the second of four panels)
- Blood cultures
- Echocardiogram
- Electrocardiogram
- NT-pro-brain natriuretic peptide (NT-pro-BNP)
- All of the above
Reference as: Raschke RA. September 2015 critical care case of the month: if you don't look, you won't find. Southwest J Pulm Crit Care. 2015;11(3):97-102. doi: http://dx.doi.org/10.13175/swjpcc113-15 PDF
August 2015 Critical Care Case of the Month: A Diagnostic Branch of Medicine
William T. Love, MD
Karen L. Swanson, DO
Department of Pulmonary Medicine
Mayo Clinic Arizona
Scottsdale, AZ
History of Present Illness
A 66-year-old man had undergone an orthotopic heart transplantation on March 28th, 2015 due to end-stage cardiomyopathy. During a recent hospitalization from 6/26-7/2 a transbronchial lung biopsy was suggestive of subacute rejection. He was treated with:
- Plasmapheresis x 3
- Intravenous immunoglobulin (IVIG)
- 500 mg Solu-Medrol daily
- Tacrolimus held as supra-therapeutic level of 16.2
- Mycophenolate decreased to 500mg BID
- Prednisone at 10mg BID on discharge
On July 3rd he began having cough productive of clear sputum, nausea, vomiting, and headache. Subsequently he had body aches, subjective fever, chills, night sweats, and a poor appetite with a 4 kg weight loss over the last week. There was also a history of several falls after “losing his balance".
Past Medical History
There was also a history of type 2 diabetes mellitus, chronic kidney disease, coronary artery disease with coronary artery bypass grafting in 2000.
Physical Examination
- Vital signs: T-37.1, HR-100, BP-130/88, RR-22, 96% RA
- Heart: regular rate & rhythm. 2/6 Systolic Murmur
- Lungs: clear to auscultation bilaterally
Laboratory
- Hemoglobin 9.7, WBC 6.3, creatinine 2.2, mildly elevated AST/ALT
- Lumbar Puncture– Protein 58 mg/dL, Glucose 46 mg/dL, 47 Nucleated cells
Radiography
A chest x-ray was performed (Figure 1).
Figure 1. Admission PA of the chest.
Based on the chest x-ray and lumbar puncture, which of the following are true? (Click on the correct answer to proceed to the second of four panels)
- The chest x-ray and lumbar puncture findings in this clinical situation suggest cancer metastatic to the lung and brain
- The chest x-ray and lumbar puncture findings in this clinical setting suggest an infection involving the lung and brain
- The clinical findings suggest granulomatosis with polyangiitis (formerly known as Wegener's granulomatosis)
- The clinical findings are suggestive of acute rejection
- The clinical findings are suggestive of tuberculosis
Reference as: Love WT, Swanson KL. August 2015 critical care case of the month: a diagnostic branch of medicine. Southwest J Pulm Crit Care. 2015;11(2):59-65. doi: http://dx.doi.org/10.13175/swjpcc100-15 PDF
July 2015 Critical Care Case of the Month: An Unusual Presentation
Allon Kahn, MD
Lewis J. Wesselius, MD
Department of Pulmonary Medicine
Mayo Clinic Arizona
Scottsdale, AZ
History of Present Illness
A 79 year old man was admitted because of a possible seizure. His wife found him unresponsive, displaying tonic-clonic motions with a right facial droop and right-sided weakness. He returned to consciousness, but was confused. A similar episode occurred 2 weeks prior to the present episode. He has additional symptoms of dysphagia with solid food for 6-8 months, a somewhat intentional 20 pound weight loss, night sweats for 4-5 months and fatigue for 1 year.
Past Medical History
- Coronary artery disease with a percutaneous transluminal coronary angioplasty in 1990, placement of 2 drug eluting stents in 2012.
- Idiopathic pulmonary fibrosis on 2-4 L/min home O2
- Myelofibrosis on ruxolitinib, a monoclonal antibody against JAK receptors
- Hypertension
- A remote history of DVT/PE related to surgery with an IVC filter placed
- Splenectomy due to trauma
Social and Family History
- He has a 15 pack-year smoking history, quitting in 1985.
- One brother with lung cancer, another with bladder cancer.
Medications
- Aspirin 81 mg daily
- Plavix 75 mg daily
- HCTZ 25 mg daily
- Metoprolol XL 50 mg daily
- Niacin 500 mg daily
- Protonix 40 mg daily
- Acetaminophen with hydrocodone
- Fish oil
Physical Examination
- Dysarthric
- No facial droop
- Some dysmetria
Which of the following should be done at this time? (Click on the correct answer to proceed to the second of five panels)
- A CT scan of the brain
- Begin tissue plasminogen activator (TPA)
- Chest x-ray
- 1 and 3
- All of the above
Reference as: Kahn A, Wesselius LJ. July 2015 critical care case of the month: an unusual presentation. Southwest J Pulm Crit Care. 2015;11(1):11-18. doi: http://dx.doi.org/10.13175/swjpcc086-15 PDF
June 2015 Critical Care Case of the Month: Just Ask the Nurse
Robert A. Raschke, MD
Banner University Medical Center
Phoenix, AZ
History of Present Illness
A 61-year-old police officer had just finished delivering a speech at a law enforcement conference in Phoenix when he briefly complained of chest pain or chest tingling before lapsing into a mute state. He became diaphoretic cyanotic, and vomited. Emergency medical services was called. They noted a blood pressure of 80/50 mm Hg, a pulse of 45, temperature of 95º F, a respiratory rate of 12, and widely dilated pupils. He was transported to the emergency room.
PMH, SH, FH, Medications
Unknown.
Physical Examination
Vital signs: blood pressure 120/75 mm Hg by oscillometric thigh cuff, pulse 43 and irregular, temperature 96º F, respiratory rate 10, SpO2 96% on O2 @ 5L/min by nasal cannula
Neck: No JVD.
Lungs: Poor inspiratory effort
Heart: Irregular rhythm without a murmur
Neurological:
- Delirious – mute – won’t obey commands or track with his eyes
- Pupils 3 mm reactive
- Withdrew 3 extremities to nail bed pressure – he will defend his left arm with his right arm
He suddenly became asystolic and cardiopulmonary resuscitation was begun. After about a minute a femoral pulse could be felt.
Which of the following are indicated at this time? (Click on the correct answer to proceed to the second of five panels)
Reference as: Raschke RA. June 2015 critical care case of the month: just ask the nurse. Southwest J Pulm Crit Care. 2015;10(6):323-9. doi: http://dx.doi.org/10.13175/swjpcc077-15 PDF
Ultrasound for Critical Care Physicians: Tiny Bubbles
Kashif Aslam, MD
Michel Boivin, MD
Division of Pulmonary, Critical care and Sleep Medicine
University of New Mexico School of Medicine
Albuquerque, NM
A 59 year old woman with a past medical history significant for stage IV MALT lymphoma (after chemotherapy and in remission) presented from a long term care facility for respiratory distress and altered mental status. The patient was in hypercarbic respiratory failure with a severe lactic acidosis. Her blood pressure deteriorated, she was begun on vasopressors and intubated. Pertinent labs demonstrated a white blood cell count of 0.9 X106 /ml, a hemoglobin of 7.1 g/dl, and a platelet count 66 X106 /ml. The patient was started on Cefepime and Linezolid presumptively for septic shock. Ultrasounds of her thorax were performed (Videos 1 & 2).
Video 1. Ultrasound of the right thorax in the mid-axillary line.
Video 2. Ultrasound of the right thorax in the mid-axillary line (slightly more caudad).
What is the best explanation for the ultrasound findings shown above? (Click on the correct answer for an explanation)
Reference as: Aslam K, Boivin M. Ultrasound for critical care physicians: tiny bubbles. Southwest J Pulm Crit Care. 2015;10(5):216-9. doi: http://dx.doi.org/10.13175/swjpcc067-15 PDF
February 2015 Critical Care Case of the Month: A Bloody Mess
Mily Sheth, MD
Carmen Luraschi, MD
Matthew P. Schreiber, MD, MHS
University of Nevada School of Medicine: Las Vegas
Department of Internal Medicine
Division of Pulmonary/Critical Care
Las Vegas, NV
History of Presenting Illness:
A 23-year-old Ethiopian woman with a known history of systemic lupus erythematosus (SLE) but of unknown duration presented with the chief complains of cough and generalised weakness for 1 week. She had a recent history of travelling to Ethiopia 3 months ago for 3 weeks. She complained of subjective fevers and one episode of blood tinged sputum. She also complained of fatigue and an episode of syncope which prompted her hospitalization.
PMH, SH and FH:
The patient has a past medical history of SLE diagnosed in Ethiopia of which no records were available. She is a student and denied alcohol, smoking or drug abuse. She denied any family history of autoimmune disorders. She did not take any medications at home.
Physical Examination:
Initial admission vital signs were temperature of 100.5 F, heart rate of 130, respiratory rate of 30 and blood pressure of 92/48. Oxygen saturation was 96% on 2 L/min via nasal cannula.
She appeared to be in moderate distress but was speaking in full sentences. Skin examination revealed a malar rash on her face. Her upper and lower extremities had excoriated plaques. Her anterior chest had flat non blanchable, macular rash. CVS examination revealed tachycardia without any murmurs. Respiratory exam was positive for bilaterally diffuse bronchial breath sounds. The remainder of her exam was within normal limits.
Laboratory and Radiology:
CBC: WBC 6.7 million cells/mcL, hemoglobin 7.1 g/dL, hematocrit 20.9, platelet 160,000 cells/mcL
Renal panel: within normal limits.
Troponin 0.01, creatine kinase 457 U/L, lactic acid 1.1 mm/L, HIV non-reactive
Liver function tests: AST 288 U/L, ALT 93 U/L alkaline phosphatase 136 IU/L, total bilirubin 0.9 mg/dL
Radiography:
Her initial chest x-ray is shown in figure 1. It was interpreted as showing diffuse pulmonary infiltrates, right lung greater than left. No pleural effusions. No pneumothorax.
Figure 1. Initial chest x-ray.
In a patient with these characteristics, which other test(s) would you order? (Click on the correct answer to proceed to the second of five panels)
- Arterial blood gases and lactic acid
- Cardiac angiogram
- Computed tomography (CT) of the chest without contrast
- VATS lung biopsy
- All of the above
Reference as: Sheth M, Luraschi C, Schreiber MP. February 2015 critical care case of the month: a blood mess. Southwest J Pulm Crit Care. 2015;10(2):63-9. doi: http://dx.doi.org/10.13175/swjpcc148-14 PDF
September 2014 Critical Care Case of the Month: Bad Case of Colic
Sherry Andrews MD
Eyad Almasri MD
Pulmonary and Critical Care
UCSF Fresno
Fresno, CA
History of Present Illness:
A 70 year old man with a past medical history of chronic kidney disease, bipolar disorder, benign prostatic hypertrophy, hypertension and diabetes presented to the emergency department with constipation associated with bloating for 15 days. He denies flatus. He tried over the counter laxatives (polyethylene glycol) with no relief. He has no recent history of colonoscopy or recent antibiotic use. He denies chills, diarrhea, dysuria, fever, hematochezia, hematuria, melena, nausea or vomiting. In the emergency department, he is tachypneic with a grossly distended abdomen.
Past Medical History:
- Diabetes
- Hypertension
- Chronic kidney disease
- Bipolar disorder
- Benign prostatic hypertrophy
- Hyperlipidemia
Past Surgical History:
- Cholecystectomy 2012
Medications:
- Aspirin 81 mg daily
- Furosemide 20 mg daily
- Quetiapine 300 daily
- Doxazosin- 4 mg daily
- Clonazepam 1 mg – twice daily as needed
- Simvastatin 20 mg – daily
- Pioglitazone 15 mg daily
Social History:
He is a retired farm laborer and worked in a cannery. He is married and has two adult children.
He was a former smoker and quit in 2010 He denies any alcohol or illicit drug use
Physical Exam:
- Vital signs – Temperature 37.2 °C, heart rate 84 beats/min, respiratory rate 18-24 breaths/min, blood pressure 121/83 mmHg, SpO2 94 % on 4 L NC
- General – Average build, well-nourished, in mild distress
- HEENT – Unremarkable
- Neck - Supple, no jugular venous distention
- Chest – Decreased breath sounds right base more than left base
- Heart - Regular rate, normal S1/S2, no murmur
- Abdomen – hypoactive bowel sounds, soft, distended, non-tender to palpation but diffusely tympanic.
- Neurological - Appropriately moves all 4 extremities, CN II-XII grossly intact
- Extremities - No edema
- Skin - No rash or palpable nodules
Laboratory:
- CBC: WBC 6.4 X 103 /μL, hemoglobin 15.3 g/dL, hematocrit 45%, Platelets 121,000 /μL.
- Chemistries: Na+ 141 mmol/L, K+ 4.5 mmol /L, Cl- 105 mmol /L, CO2 25 mmol /L, blood urea nitrogen (BUN) 24 mg/dL, creatinine 1.2 mg/dL, glucose 95 mg/dL, calcium 9.9 mg/dL, albumin 4.2 g/dL, liver function tests within normal limits. hemoglobin A1C 5.1%. lactic acid 1.8 mmol/L
- Coagulation: Prothrombin time (PT) 16.6 sec, international normalized ratio (INR) 1.3
Radiography:
A CT scan abdomen and pelvis was done and a representative coronal view is shown in Figure 1.
Panel 1. Coronal cut of computed Tomography (CT) of the abdomen and pelvis on admission.
Which of the following are characteristics of acute colonic pseudo-obstruction (Ogilvie’s syndrome)? (Click on the correct answer to proceed to the next panel)
Reference as: Andrews S, Almasri E. September 2014 critical care case of the month: bad case of colic. Southwest J Pulm Crit Care. 2014;9(3):151-9. doi: http://dx.doi.org/10.13175/swjpcc094-14 PDF