December 2017 Critical Care Case of the Month

Michael B. Gotway, MD

Department of Radiology

Mayo Clinic Arizona

Scottsdale AZ USA

Clinical History: A 57-year-old man with no known previous medical history was brought to the emergency room via ambulance and admitted to the intensive care unit with a compliant of severe chest pain in the substernal region and epigastrium. The patient was awake and alert and did not complain of shortness of breath.

Physical examination was largely unremarkable and the patient’s oxygen saturation was 98% on room air. The patient’s vital signs revealed tachycardia (105 bpm) and his blood pressure was 108 mmHg / 60 mmHg.

Laboratory evaluation showed a slightly elevated white blood cell count (13 x 10⁹ cells/L), but his hemoglobin and hematocrit values were with within normal limits, as was his platelet count. 

Which of the following diagnoses are appropriate considerations for this patient’s condition? (Click on the correct answer to proceed to the second of nine pages)

1. Acute pericarditis
2. Aortic dissection
3. Community-acquired pneumonia
4. Myocardial infarction
5. All of the above

Cite as: Gotway MB. December 2017 critical care case of the month. Southwest J Pulm Crit Care. 2017;15(6):241-52. doi: https://doi.org/10.13175/swjpcc145-17 PDF 

November 2015 Critical Care Case of the Month

Samir Sultan, DO

Banner University Medical Center Phoenix

Phoenix, AZ

 History of Present Illness

A 39-year-old Caucasian woman was admitted to the ICU with worsening dyspnea and increasing oxygen requirements. Her lips turned blue with minimal activity. She was admitted to another hospital 5 months earlier with pneumonia. At discharge she was placed on oxygen. At follow-up with her pulmonologist, she was diagnosed with sleep apnea.

Past Medical History, Family History, Social History

• She has a history of an optic glioma at age 7 with resection followed by radiation therapy and development of panhypopituitarism.
• Liver cirrhosis diagnosed in 2014 with presentation of hematemesis.
• Type 2 diabetes mellitus
• Denies tobacco, ethanol, or illicit drug use.
• There is a family history of diabetes and liver cirrhosis

Physical Examination

• Vital signs:110 / 86, HR 97, RR 16, 88% on 6 liter O2
• General: obese female (BMI 35) in no apparent distress
• Chest: Clear to auscultation bilaterally
• Cardiovascular: regular rate without murmur or rub
• The remainder of the physical exam is normal  

Radiography

      A chest x-ray was interpreted as normal.

Laboratory

• CBC: hemoglobin 13.8 gm/dL, WBC 7 X 103 cells/microliter with a normal differential
• Basic metabolic panel: Na⁺ 132 mEq/L, K⁺ 4 mEq/L, Cl^- 100 mEq/L, HCO3^- 22 mEq/L, glucose 150 mg/dL.
• Arterial blood gases (ABGs): PaO₂ 35 mm Hg, PaCO₂ 37 mm Hg, pH 7.43

Which of the following is/are not possible cause(s) of hypoxemia in this patient? (Click on the correct answer to proceed to the second of six panels)

1. Decreased diffusion (alveolar capillary block)
2. Ventilation-perfusion mismatch
3. Hypoventilation
4. 1 and 3
5. All of the above

Cite as: Sultan S. November 2015 critical care case of the month. Southwest J Pulm Crit Care. 2015;11(5):209-15. doi: http://dx.doi.org/10.13175/swjpcc137-15 PDF

Ultrasound for Critical Care Physicians: Shortness of Breath

Matthew JK Douglas, MD

David Verbunker, MD

Jarrod Mosier, MD 

Department of Emergency Medicine

Banner University Medical Center Tucson

University of Arizona

Tucson, AZ

Figure 1. Video of the right thoracic ultrasound (coronal).

An 85 year old woman with a history of congestive heart failure and diabetes presented to the emergency department with progressive shortness of breath. She had recently been discharged from another hospital where she had been admitted for several days for community acquired pneumonia. The patient was in respiratory distress on arrival with tachypnea, increased work of breathing, and hypoxia despite supplemental oxygen with a non-rebreather mask and she was subsequently intubated. ED point-of-care ultrasound was performed of the right hemithorax.

What does Figure 1 demonstrate? (Click on the correct answer for the second of two panels and an explanation)

1. Intravascular volume depletion
2. Normal lung aeration
3. Numerous B-lines
4. Pleural effusion and consolidation
5. Pneumothorax

Cite as: Douglas MJK, Verbunker D, Mosier J. Ultrasound for critical care physicians: shortness of breath. Southwest J Pulm Crit Care. 2015;11(3):112-3. doi: http://dx.doi.org/10.13175/swjpcc116-15 PDF

December 2014 Critical Care Case of the Month: Weak for Weeks

Bhupinder Natt MD¹

Shadi Koleilat MD²

Janet Campion MD¹

¹Division of Pulmonary, Allergy, Critical care and Sleep Medicine

²Department of Neurology

University of Arizona Medical Center

Tucson, AZ

History of Present Illness

A 65 year old woman presents with weakness involving both upper and lower extremities that is intermittent over the last 3 months, but in the last 2 weeks she has also noticed increasing neck weakness, droopy eyelids and increased drooling. Prior to this she was able to walk without difficulty and ride a recumbent bike for 20 minutes, but now is having difficulty walking on her own. She denies fevers, weight loss, shortness of breath, chest pain, palpitations, LE edema, joint pain, rash, any recent or current GI/GU symptoms and no new medications.

Past Medical History, Social History, and Family History

The patient has a past history of hypertension, hyperlipidemia, diabetes mellitus Type II, GERD, obstructive sleep apnea (compliant with BiPAP), atrial fibrillation and hypothyroidism. She has a 40 pack-year history of tobacco use. Family history is noncontributory.

Medications

• Dabigatran 75mg BID
• Esomeprazole 20 mg BID
• Furosemide 30 mg BID
• Insulin glargine 50 Units BID and Lispro per sliding scale
• Levothyroxine 88 mcg per day
• Losartan 50 mg QD,
• Pregabalin 75 mg BID
• Rosuvastatin 40 mg per day

Physical Examination

Vital signs: Afebrile. Pulse 86, respiratory rate 20, PaO2 92% on room air

General: Awake, fully oriented, dysarthric speech.

HEENT: Non-icteric, ears, nares, oropharynx unremarkable; there is no neck LAD, elevated JVP or thyromegaly.

Respiratory: Normal breath sounds, no wheeze or rhonchi.

CVS: Irregularly irregular rhythm, no murmurs. Peripheral vascular exam normal.

Abdomen: Obese, soft, non-tender with normal bowel sounds. No organomegaly appreciable.

Extremities: Trace pedal edema, normal muscle bulk and tone.

CN: Ptosis bilaterally, no nystagmus, reactive pupils, extra-ocular muscles intact, sensation intact, weak cheek puff, symmetric palate excursion, normal tongue protrusion.

Motor: Neck flexion and extension 4-/5, bilateral pronator drift, no focal lower extremity weakness, no muscle atrophy, no tremors or fasciculations.

Sensation: Intact to light touch hands and feet.

Reflexes: 2+ and symmetric throughout.

Gait: Wide-based and slow, can only walk short distances before experiencing bilateral leg weakness.

Laboratory: Normal electrolytes, complete blood count, and liver function tests. Creatinine mildly elevated at 2.1 mg/dL.

EKG

Atrial Fibrillation.

What is the most likely diagnosis? (Click on the correct answer to proceed to the next panel)

1. Guillain-Barré syndrome (GBS)
2. Hypothyroidism
3. Lambert-Eaton myasthenic  syndrome (LEMS)
4. Motor neuron disease (ALS)
5. Myasthenia gravis crisis

Reference as: Natt B, Koleilat S, Campion J. December 2014 critical care case of the month: weak for weeks. Southwest J Pulm Crit Care. 2014;9(6):302-8. doi: http://dx.doi.org/10.13175/swjpcc141-14 PDF

November 2014 Critical Care Case of the Month: I Be Gaining on My Addiction

Nathaniel R. Little, MD

Carolyn H. Welsh, MD

University of Colorado and the Eastern Colorado Veterans Affairs Medical Center

Department of Medicine

Division of Pulmonary Sciences and Critical Care Medicine

Denver, CO

History of Present Illness

A 33 year-old man came by ambulance to the Emergency Department for progressive altered mental status and bizarre behavior. Per history from his significant other, the patient had a long-standing history of heroin addiction and diazepam abuse. Despite multiple failed attempts at prior detoxification, he had recently resolved to “take matters into his own hands.”

The patient had informed his girlfriend that he quit heroin “cold turkey” 3 days prior to admission. On the first day after his last heroin use, he was communicative, energetic, and appeared normal. On the second day, he was increasingly introspective, somnolent, and mute. He spent the majority of the day in bed, and had tremors of all extremities. On the third day, he experienced increased arousal, with auditory and visual hallucinations. His speech was “very technical and scientific” with episodes of “waxing philosophic.” Given increasingly erratic behavior, worsening tremors, and inability to ambulate; emergency services were called for transport to the hospital.

Past Medical History, Social history and Family History:

The patient had a history of heroin and diazepam addiction, with failed attempts at cessation. He carried prior diagnoses of depression and anxiety, with a history of suicide attempts in his youth. He took no prescribed medications. He was employed as a software engineer. Aside from daily intravenous heroin use, he did not smoke nor drink alcohol. Family history was non-contributory.

Physical Examination:

On admission , he was hypothermic (35.8 C), hypotensive (BP = 81/48), and bradycardic (HR =41). Respiratory rate and oxygen saturations were normal. He was pale, diaphoretic, altered, and responsive only to internal stimuli. Additional findings included nystagmus, with oral exam showing dry mucus membranes. Per cardiovascular exam, he had profound bradycardia, with diminished radial and dorsalis pedis pulses. His extremities were cool to the touch. Pulmonary and abdominal exams were normal. On neurologic evaluation, the patient demonstrated a Glasgow Coma Score of 9, opened eyes only to command, demonstrated mumbled speech, and had tongue fasiculations. He was able to move all extremities, but with severe ataxia. Deep tendon reflexes were normal.

Laboratory Studies:

Complete Blood Count: White blood cell count (WBC) 9.0 x 1000 cells/µL, hemoglobin 14.5 g/dL, hematocrit 43.0, platelets 220,000 cells/µL

Chemistry: Sodium 150 meq/L, potassium 3.6 meq/L, chloride 113 meq/L, bicarbonate (CO2) 25 meq/L, blood urea nitrogen (BUN) 31 mg/dL, creatinine 1.14 mg/dL, glucose 114 mg/dL, magnesium 1.6 meq/L, phosphorus 4.1 mg/dL, creatinine kinase 33.

Toxicology Screen: Urine drug screen positive only for benzodiazepines, negative for opiates.

Urine: trace ketones, otherwise unremarkable.

Imaging:

Figure 1. Admission AP of chest.

The patient’s clinical presentation thus far is most consistent with what type of shock: (click on the correct answer to proceed to the next panel)

1. Cardiogenic
2. Distributive
3. Hypovolemic
4. Neurogenic
5. Obstructive
6. Both 1 and 3
7. All of the above

Reference as: Little NR, Welsh CH. November 2014 critical care case of the month: I be gaining on my addiction. Southwest J Pulm Crit Care. 2014:9(5):257-63. doi: http://dx.doi.org/10.13175/swjpcc146-14 PDF

September 2013 Critical Care Case of the Month: Revenge of the Pharaohs

Robert A. Raschke, MD

Elijah Poulos, MD

Banner Good Samaritan Regional Medical Center

Phoenix, AZ

History of Present Illness

The patient was a 68 year-old man, admitted to our ICU through the emergency room (ER) in July 2013 with suspected urinary tract origin sepsis.

The patient was evaluated in ER by the ICU team. He was in his usual state of general good health until he visited his primary care physician for what he felt was a left inguinal hernia, and underwent a prostate examination, four days previously. The patient associated this prostate examination with the onset of fevers and chills that began the next morning. He was seen in an urgent care center where he was told his urinalysis was normal, and antibiotics were not prescribed. Over the intervening 3 days, he suffered recurrent fevers, had vomited three times, and had one diarrheal bowel movement. Earlier on the day of presentation, he had been mowing his lawn (in >100° F environment) and had become a little dizzy. His wife, a retired nurse, finally convinced him to report to the ER.

He denied dysuria, urinary frequency or urgency, headache, sore throat, cough, or abdominal pain.

PMH, SH, FH

He had a prior history of hypertension, gastroesophageal reflux, gout and hypercholesterolemia. He drank alcohol about twice a month and did not smoke.

There was no family history of illnesses.

Medications

• Atorvastatin
• Allopurinol
• Hydrochlorothiazide
• Lisinopril
• Temazepam

Physical Exam

On ER triage, his temperature was 41.2° C, but vitals at the time of our initial examination were temp 38.2° C, HR 93 beats/min, BP 103/48 mm Hg, and respiratory rate 20 breaths/min. He was awake and alert, but made a few errors while relating his history – for instance, he initially answered yes when asked if he had a headache, then corrected himself and said no – he meant he had a fever. He was actively rigoring. HEENT exam was unrevealing. He had no lymphadenopathy. His lungs were clear. His abdomen was soft and nontender. He had a sliding left inguinal hernia that was not tender. None of his joints were acutely inflamed. His prostate was not enlarged or tender to palpation. He had no focal neurological deficits.

Laboratory

Pertinent laboratory values in the ER:

• WBC: 7.7 x10⁹/L
• Hematocrit: 38.4%
• Sodium: 131 me/L
• Potassium: 3.1 me/L
• BUN:28 g/dL
• Creatinine: 1.3 mg/dL
• Lactate: 2.1 mMol/L.

The rest of his admission labs and urinalysis were unremarkable.

Chest Radiography

His initial portable chest x-ray is shown in Figure 1.

Figure 1. Initial portable chest x-ray.

Which of the following is the likely cause of his fever?

1. Prostatitis exacerbated by digital rectal exam
2. Right middle lobe pneumonia
3. Urinary tract infection
4. All of the above
5. None of the above

Reference as: Raschke RA, Poulos E. September 2013 critical care case of the month: revenge of the pharaohs. Southwest J Pulm Crit Care. 2013;7(3):142-50. doi: http://dx.doi.org/10.13175/swjpcc104-13 PDF