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