May 2014 Critical Care Case of the Month: Second Wind

Kenneth K. Sakata, MD

Sudheer Penupolu, MD 

Robert W. Viggiano, MD

Department of Pulmonary Medicine

Mayo Clinic Arizona

Scottsdale, AZ

History of Present Illness

A 65 year old woman was admitted for gastrointestinal bleeding as evidence by hematochezia. At the time of admission she denied any respiratory symptoms other than mild dyspnea. However, she rapidly developed respiratory failure, was transferred to the ICU and required emergent intubation.

PMH, FH, SH

She has a history of rheumatoid arthritis with a cervical spine fusion. There is also a history of sarcoidosis and she was receiving prednisone 30 daily up until the time of admission. There is no significant family history. She does not smoke or drink.

Physical Examination

Afebrile. Pulse 78. BP 105/65 mm Hg. Respirations: 28. SpO2 96% while receiving an FiO2 of 60% at the time of transfer to the ICU.

Neck: No jugular venous distention.

Lungs: Scattered rales and rhonchi.

Cardiovascular: Regular rhythm. 

Abdomen: no hepatosplenomegaly.

Radiography

A portable chest x-ray taken after intubation is shown in figure 1.

Figure 1. Portable chest x-ray taken shortly after intubation.

Which of the following best describe the chest x-ray? (Click on the correct answer to move to the next panel)

1. Chronic interstitial disease
2. Diffuse consolidation
3. Endotracheal tube in the right mainstem bronchus
4. Small right pneumothorax
5. All of the above

Reference as: Sakata KK, Penupolu S, Viggiano RW. May 2014 critical care case of the month: second wind. Southwest J Pulm Crit Care. 2014;8(5):258-65. doi: http://dx.doi.org/10.13175/swjpcc033-14 PDF

February 2014 Critical Care Case of the Month: A Rush of Blood

Maja Udovcic MD

Sudheer Penupolu MD

Robert W. Viggiano MD

Lewis J. Wesselius MD

Department of Pulmonary Medicine

Mayo Clinic Arizona

Scottsdale, AZ

History of Present Illness

A 51 year old African-American woman was admitted from the emergency department with hemoptysis. She had blood tinged sputum earlier in the day followed by about ½ cup of hemoptysis which led her to seek care.

PMH, SH, FH

She is known to have stage IV sarcoidosis with bronchiectasis and cavitation. A right upper lobectomy was performed in 1996 and embolization of  

3 left bronchial arteries in 2011 for hemoptysis. She has a history of anaphylaxis with iodinated radiocontrast dye. However, no reaction occurred with premedication in 2011. She also has a history of asthma, but has been out of her medications for several days. Since this time she has noted increased cough. She is a nonsmoker and a Jehovah’s Witness. Her family history is noncontributory.

Medications

• Albuterol HFA
• Montelukast
• Fluticasone propionate nasal spray
• Loratidine

Physical Examination

VS:  36.9°C, 106 beats/min, 135/83 mm Hg, 26 breaths/min, SpO2 100% on room air

General: She is in no acute distress.  

Respiratory: coarse breath sounds with scattered wheezing, inspiratory crackles, and diminished air movement throughout

Which of the following laboratory tests should be ordered? (click on correct answer to move to next panel)

1. Blood urea nitrogen
2. Coagulation profile (PT, INR, APTT)
3. Complete blood count
4. 2 + 3
5. All of the above

Reference as: Udovcic M, Penupolu S, Viggiano RW, Wesselius LJ. February 2014 critical care case of teh month: a rush of blood. Southwest J Pulm Crit Care. 2014:8(2):79-87. doi: http://dx.doi.org/10.13175/swjpcc165-13 PDF