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:

1. Correctly interpret and identify clinical practices supported by the highest quality available evidence.
2. Will be better able to establsh the optimal evaluation leading to a correct diagnosis for patients with pulmonary, critical care and sleep disorders.
3. Will improve the translation of the most current clinical information into the delivery of high quality care for patients.
4. 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)

1. The abdominal x-ray shows diffuse, nonspecific gaseous distention
2. The abdominal x-ray shows gastrointestinal perforation
3. The chest x-ray shows bilateral atelectasis
4. The chest x-ray shows bilateral pneumonia
5. 1 and 3
6. 2 and 4
7. 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

August 2014 Critical Care Case of the Month: The Beans Are Done

Theodore Loftsgard RN, CNP

Zanele Manaka R.R.T., C.R.T.

Jocelyn Coy R.N.

Jared J. Jones, Pharm.D., R.Ph.

Division of Critical Care

Mayo Clinic

Rochester, Minnesota

Case Presentation

A 68-year-old woman was admitted to the ICU due to acute renal failure in setting of ovarian cancer recurrence.

She reports a two week history of abdominal pain with increased, loose ileostomy output, nausea, one episode of vomiting of food returns, and profound increasing generalized weakness. She states she has been voiding urine in normal frequency. She took her most recent dose of Xarelto 20mg the evening prior to presentation.

On ICU arrival, she was alert and oriented but pale and underweight with dry mucous membranes. She reported 2/10 generalized abdominal pain. Her blood pressure was stable. 

PMH

March 2013: Diagnosed with stage IIIC metastatic ovarian cancer.  She underwent extensive abdominal surgery including radical hysterectomy, diverting loop ileostomy and cholecystectomy.  Final pathology: grade 3 serous carcinoma involving omentum, descending colon, cecum and terminal ileum, both ovaries with implants on bilateral tubes and uterine serosa, right pelvic side wall, right diaphragm, 3 right paraaortic lymph nodes, and gallbladder. 

April 2013: She developed thrombus of the bilateral peroneal veins, left posterior tibial vein, and right soleal veins and was started on Lovenox She was recently transitioned to rivaroxaban (Xarelto).

February 2014: abdominal ultrasound showed numerous small, hypoechoic nodules and lesions throughout the liver which were worrisome for metastatic disease. She presented to the clinic today for a second opinion.

Current Medications

1. Fentanyl 100 mcg/hr patch 72 hour 1 patch transdermally every 3 days
2. Ibuprofen PRN
3. Oxycodone PRN
4. Rivaroxaban (Xarleto®) 20 mg daily
5. Sertraline (Zoloft®) 25 mg daily

Past Medical/Surgical History

    Past Medical History   

1. Craniocervical dystonia receives Botox injections.
2. Ovarian cancer

    Past Surgical History  

1. Appendectomy at 8 years old.
2. Tonsillectomy.
3. Laparoscopy in 1983 for infected Dalkon Shield.
4. L5 bulging disk surgery in the 1990s.
5. Total abdominal hysterectomy, bilateral salpingo-oophorectomies, cholecystectomy, lymphadenectomy, and tumor debulking for ovarian cancer March 2013.

Physical Exam

Vital signs: height 164.3 cm, weight 42.90 kg, BSA(G) 1.40 M², BMI 15.892 Kg/M², temperature 36.4 °C, respiratory rate 13 breaths/minute, blood pressure 148/77 mmHg.  pulse 64/minute.  SpO2 98% on room air.

Heart: S1, S2 with no murmur, click, rub. Sinus rhythm, rate 64, no ectopy.

Lungs: Respirations symmetrical and easy with bilateral breath sounds clear to auscultation.

Abdomen: Slightly firm, nondistended, mild tenderness to palpation, bowel sounds present. Ostomy pink with dark brown liquid output in bag.

Electrocardiogram

Figure 1. ICU admission electrocardiogram.

Ultrasonography

Figure 2. Panel A: Static image from abdominal ultrasound of inferior vena cava. Panel B: Static image from abdominal ultrasound showing longitudinal axis of left kidney. Panel C: Static image from abdominal ultrasound showing longitudinal axis of right kidney. Lower panel: movie of ultrasound of inferior vena cava.

Which of the following is (are) true? (Click on the correct answer to proceed to the next panel)

1. The electrocardiogram shows tall, peaked T waves
2. The inferior vena cava is collapsed suggesting volume depletion
3. There is hydronephrosis of the left kidney
4. There is hydronephrosis of the right kidney
5. All of the above

Reference as: Loftsgard TO, Manaka Z, Coy J, Jones JJ. August 2014 critical care case of the month: the beans are done. Southwest J Pulm Crit Care. 2014;9(2):72-82. doi: http://dx.doi.org/10.13175/swjpcc087-14 PDF