October 2017 Critical Care Case of the Month

Margaret Ragland, MD¹

Carolyn H. Welsh, MD^1,2

Pulmonary Sciences and Critical Care Medicine

¹University of Colorado Anschutz Medical Campus and ²VA Eastern Colorado Health Care System

Denver, Colorado USA

History of Present Illness

A 42-year-old man with a history of intravenous heroin abuse and chronic hepatitis C infection presents to the emergency department (ED) with recurrent abdominal pain. The pain was dull, epigastric, and did not radiate. The pain worsened after eating, but the timing after eating that it worsened was inconsistent. He had nausea but no vomiting. His bowel movements were normal without constipation, diarrhea, or melena.   

He had presented to another ED multiple times with this same pain over the past six weeks. He does not know what the work-ups revealed, but was discharged from the emergency department each time. He received supportive care including fluids and analgesics, but the pain would always recur a few hours after returning home.

He went to a third ED a few weeks ago with bilateral testicular pain after which he was discharged home with acetaminophen for pain.

Past Medical History, Family History, and Social History

His past medical history is notable for bipolar disorder. He takes no prescribed medications and does not know his family’s medical history. He is a current every day smoker, has no history of heavy alcohol use, and uses intravenous heroin but no other recreational drugs.

Current Medications

Acetaminophen a few times a day for abdominal pain.

Review of Systems

He notes subjective fevers, poor appetite, and an 8 pound unintentional weight loss over the past six weeks.

Physical Exam

Vital signs are notable for hypertension to 158/91 mm Hg. Other vitals are within normal limits.

On exam, he is an ill appearing middle aged man who appears very uncomfortable. His abdomen is nondistended. He has normal bowel sounds and epigastric tenderness with a tender, smooth liver edge palpable just under the costal margin. He has decreased sensation to light touch in his toes with no skin changes. Toes are warm with capillary refill less than two seconds.

Laboratory Evaluation

CBC reveals a leukocytosis to 23,600 cells/mcL with 80% neutrophils; eosinophils are normal. Hemoglobin and platelet counts are normal. Sodium is 128 mmol/L with a bicarbonate of 30 mmol/L and creatinine of 0.64 mmol/L. AST 155 U/L, ALT 137 U/L, with a total bilirubin 1.1 mmol/L. Albumin is 1.8 g/L. INR is 1.9. Urinalysis showed 1+ protein.

What additional laboratory evaluation is indicated at this time? (Click on the correct answer to proceed to the second of six pages)

1. Acetaminophen level
2. Hepatitis B viral (HBV) serologies
3. Lipase
4. 1 and 3
5. All of the above

Cite as: Ragland M, Welsh CH. October 2017 critical care case of the month. Southwest J Pulm Crit Care. 2017;15(4):131-7. doi: https://doi.org/10.13175/swjpcc113-17 PDF 

March 2014 Critical Care Case of the Month: Interstitial Lung Disease

Seongseok Yun, MD PhD

Konstantin Mazursky, DO

Kahroba Jahan, MD

Enas Al Zaghal, MD

Department of Medicine

University of Arizona

Tucson, AZ 85724

History of Present Illness

An 80 year-old man with a history of chronic obstructive pulmonary disease, asbestosis and interstitial lung disease, presented to the outpatient clinic with cough, sinus congestion and mild sputum. He was sent home with amoxicillin for the treatment of a sinus infection. However, he came back to emergency department with worsening respiratory symptoms including shortness of breath and persistent cough. He required 8-10 L/min of oxygen to maintain an oxygen saturation above 90 %.

PMH

• COPD
• Asbestosis
• Interstitial lung disease
• Diabetes mellitus,  type II
• Hypertension
• Aortic valve replacement

Medications

• Fluticasone-salmeterol 250-50 mcg inhaler
• Mometasone 50 mcg/actuation nasal spray
• Furosemide 40 mg PO daily
• Felodipine 5 mg PO BID
• Warfarin 3 mg PO daily
• Insulin aspart 5 units SC injection before meals
• Insulin glargine 15 units SC injection night time

Social History

• 50 pack-year prior smoking history
• No ethanol or recreational drugs
• No recent travel history      

Physical Examination

Vital signs: temperature 37.2 °C, pulse 116 beats/min, respiratory rate 32-34 breaths/min, blood pressure 179/77 mmHg, SpO2 90 % on 10 L/ min non-rebreathing mask (NRB).

General: Alert and oriented but appearing distressed, tachypneic and dyspneic

Skin: Diaphoretic, no rash or lesions noted.

HEENT: Unremarkable.

Respiratory: Diffuse rales but no wheezing or stridor.

CVS: Tachycardic, regular rhythm, soft systolic murmur.

Abdomen: Soft, non-tender, no tenderness, no guarding, no hepato-splenomegaly

Lymph: No cervical lymphadenopathy

Extremities: No peripheral edema, normal tone, normal range of movement  

Laboratory

CBC: WBC 20.2 X 10³ /μL, hemoglobin 9.3 g/dL, hematocrit 29.8 %, platelets 272,000/μL.

Chemistries: Na⁺ 134 meq/L, K⁺ 4.8 meq/L, Cl^- 108 meq/L, CO₂ 19 mmol/L, blood urea nitrogen (BUN) 58 mg/dL, creatinine 1.7 mg/dL, glucose 272 mg/dL, calcium 9.7 mg/dL, albumin 2.2 g/dL, liver function test-within normal limits.

Prothrombin time (PT) 28.0 sec, international normalized ratio (INR) 2.5, partial thromboplastin time (PTT) 44.5 sec

An old chest x-ray and CT scan were reviewed (Figure 1).     

Figure 1. Old PA (panel A) and lateral (Panel B) and representative image from an old CT scan (panel C).

Which of the followings are the findings of asbestos related disease on chest x-ray? (click on correct answer to move to next panel)  

1. Reticular or patchy opacity
2. Calcified pleural plaque
3. Bilateral consolidation
4. Pulmonary edema
5. 1 + 2
6. 3 + 4

Reference as: Yun S, Mazursky K, Jahan K, Al Zaghal E. March 2014 ciritcal care case of the month: interstitial lung disease. Southwest J Pulm Crit Care. 2014;8(3):152-60. doi: http://dx.doi.org/10.13175/swjpcc013-14 PDF

October 2013 Critical Care Case of the Month: Slow to Respond

Michael P. Mohning, MD

Pulmonary Sciences and Critical Care Medicine

University of Colorado Hospital

Denver, CO

History of Present Illness

A 66-year-old woman presents with confusion and lower extremity edema. She was brought to the emergency department by her family after 2-3 days of increasing confusion.  She has fatigue and a dry non-productive cough but denies shortness of breath, chest pain, fevers or chills. She had a decrease in oral intake and constipation for several days.

PMH, SH, FH

Five months ago, she was admitted to a hospital for community acquired pneumonia and hyponatremia. She is a never smoker, and doesn’t use alcohol.

There is no significant family history.

Medications

• Omega 3 fatty acids
• Multivitamins

Physical Examination

Temperature 36.1° C, blood pressure 106/61 mm Hg, heart rate 72 beats/min, respiratory rate 15 breaths/min, oxygen saturation 90% on room air.

She was confused, and oriented to self only.  She had facial edema.  Cardiac exam was normal. Pulmonary findings include rales at the lung bases. Her abdomen was non-tender, with active bowel sounds. She had 1+  lower extremity edema, no rashes, and delayed relaxation of reflexes.

Laboratory

She was anemic with hematocrit of 32%, hemoglobin 11 g/dL and WBC 5,000. Serum sodium is low at 118 meq/L, anion gap was normal at 9 and potassium and calcium levels were normal. Albumin is low at 3.2 g/dL. Remaining liver function, blood glucose and creatinine are normal. EKG shows no T wave inversions or ST segment elevation.

Radiography

Chest x-ray is shown in figure 1.

 

Figure 1. Admission PA (Panel A) and lateral (Panel B) chest x-ray.

Which best describes the chest-x-ray?

1. Bilateral interstitial infiltrates
2. Enlarged cardiac silhouette
3. Hyperexpanded lungs
4. Poor inspiratory effort
5. Pulmonary edema

Reference as: Mohning MP. October 2013 critical care case of the month: slow to respond. Southwest J Pulm Crit Care. 2013;7(4):214-20. doi: http://dx.doi.org/10.13175/swjpcc105-13 PDF