April 2021 Critical Care Case of the Month: Abnormal Acid-Base Balance in a Post-Partum Woman

Mohammad Abdelaziz Mahmoud, MD, DO

Andrea N. Pruett, BS

Emanuel Medical Center

Turlock, CA 95382

History of Present Illness

A 29-year-old healthy woman, who is 8 weeks postpartum, presented to the emergency department with severe shortness of breath, fast shallow breathing, nausea, several episodes of nonbloody nonbilious emesis, abdominal pain and malaise for 1 week. The patient delivered a healthy boy at full-term by spontaneous vaginal delivery. Her pregnancy was uneventful. She denied smoking or use of alcohol.

Physical Exam

On presentation to the emergency department her blood pressure was found to be 121/71, temperature 36.8°C, pulse 110 beats per minute, respiratory rate 20 breaths per minute and SpO2 saturation of 99% while breathing ambient air. Physical exam was remarkable except for dry mucous membranes, sinus tachycardia, and tachypnea with mild epigastric tenderness with light palpation.

Which of the following should be done? (Click on the correct answer to be directed to the second of five pages)

1. Complete blood count (CBC)
2. Metabolic panel
3. Chest x-ray
4. Arterial blood gases (ABGs)
5. All of the above

Cite as: Mahmoud MA, Pruett AN. April 2021 Critical Care Case of the Month: Abnormal Acid-Base Balance in a Post-Partum Woman. Southwest J Pulm Crit Care. 2021;22(4):81-85. doi: https://doi.org/10.13175/swjpcc007-21 PDF.

April 2019 Critical Care Case of the Month: A Severe Drinking Problem

Francisco J. Marquez II MD

Department of Pulmonary and Critical Care Medicine

Banner University Medical Center/University of Arizona – Phoenix

Phoenix, AZ USA

History of Present Illness

A 55-year-old Caucasian man, presented to an outside hospital with altered mental status.

Past Medical/Social History

• Severe alcohol and intermittent fentanyl abuse
• Homelessness

Physical Exam

• Hypothermic and hypertensive.
• Patient encephalopathic without any acute deficits
• Pupils are normal sized and react to light

Which of the following should be obtained or done in his initial evaluation? (Click on the correct answer to proceed to the second of six pages)

1. CBC
2. Electrolytes
3. Give naloxone (Narcan®) and glucose
4. 1 and 3
5. All of the above

Cite as: Marquez FJ II. April 2019 critical care case of the month: A severe drinking problem. Southwest J Pulm Crit Care. 2019;18(4):67-73. doi: https://doi.org/10.13175/swjpcc003-19 PDF 

September 2017 Critical Care Case of the Month

James T. Dean III, MD

Tyler R. Shackelford, DO

Michel Boivin, MD

Division of Pulmonary, Critical Care and Sleep Medicine

University of New Mexico School of Medicine

Albuquerque, NM 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): James T. Dean III, MD.  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 completing this activity, participants will be better able to:

1. Interpret and identify clinical practices supported by the highest quality available evidence.
2. Establish the optimal evaluation leading to a correct diagnosis for patients with pulmonary, critical care and sleep disorders.
3. Translate the most current clinical information into the delivery of high quality care for patients.
4. Integrate new treatment options 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, 2017-December 31, 2018

Financial Support Received: None

A 73-year-old man presented with a three-day history of diffuse abdominal pain, decreased urine output, nausea and vomiting. His past medical history included diabetes, coronary artery disease, hypertension and chronic back pain. The patient reported being started on hydrochlorothiazide, furosemide, pregabalin and diclofenac within the last week in addition to his long-standing metformin prescription.

Initial vitals were significant for tachypnea, tachycardia to 120 bpm, hypothermia to 35ºC and hypotension with a blood pressure of 70/40 mm Hg. Physical exam was remarkable for bilateral lung wheezing and significant respiratory distress. Laboratory examination was concerning for a pH of 6.85, pCO2 of < 5mmHg, serum lactate of 27mmol/l, WBC of 15.6 x10⁶ cells/cc and a serum creatinine of 8.36 mg/dl. A chest X-ray showed evidence of mild pulmonary edema and a CT of the abdomen did not show any acute pathology.

What is the most likely etiology of the patient’s severe acidosis? (Click on the correct answer to proceed to the second of four pages)

1. Diabetic ketoacidosis
2. Ethylene glycol poisoning
3. Metformin-associated lactic acidosis
4. Septic shock

Cite as: Dean JT III, Shackelford TR, Boivin M. September 2017 critical care case of the month. Southwest J Pulm Crit Care. 2017;15(3):100-3. doi: https://doi.org/10.13175/swjpcc101-17 PDF

January Critical Care Case of the Month: Bad Cough

Bhupinder Natt MD

Linda Snyder MD

Janet Campion MD

University of Arizona Medical Center

Tucson, AZ

History of Present Illness

A 41 year-old man was admitted with a five-day history of cough, shortness of breath, and fever to 102° F. He was recently diagnosed with a high-grade astrocytoma of the brain and had undergone resection followed by chemotherapy with temozomide (an alkylating agent) and radiation therapy. 

PMH

• Renal transplantation (1993)
• Glioblastoma (astrocytoma grade 4)
• Crohn’s disease treated with budesonide and meselamine

Medications

• Dexamethasone 2 mg PO BID
• Keppra 500 mg PO BID
• Tacrolimus 1.5 mg PO AM and 1mg PO PM
• Mycophenolate 750 mg PO BID
• Budesonide 3 mg PO daily
• Meselamine 1600 mg PO TID
• Sulfamethoxazole/trimethoprim DS PO on Mon/Wed/Fri
• Temozolomide 75 mg IM with radiotherapy

Social History

Nonsmoker, no ethanol or recreational drugs, no recent travel, and no occupational exposures.

Physical Examination

T 38.6°C, P 112 beats/min, RR 32-40 breaths/min, BP 119/76 mm Hg, SpO2 100% on NRB

General: Fatigued, ill appearing and dyspneic.

Skin: No rash or lesions, well-healed craniotomy scar

HEENT: Dry oral mucosa, pupils and extra-ocular muscles normal

Respiratory: Reduced breath sounds, fine crackles throughout all lung fields, no wheezing

CVS: Hyperdynamic precordium, tachycardia without murmur, no elevation of jugular venous pressure (JVP), peripheral vascular exam normal.

Abdomen: Soft, non-distended, no hepato-splenomegaly, normal bowel sounds.

Lymph: No cervical lymphadenopathy

Extremities: No edema, normal muscle bulk and tone.

Laboratory

WBC 11 X 10³/µL, Hemoglobin 9.8 g/dL, Hematocrit 30%, Platelets 264,000/ µL

Na⁺ 135 meq/L, K⁺ 4.2 meq/L, Cl⁻ 111 meq/L, CO2 14 mmol/L, blood urea nitrogen (BUN) 46 mg/dL, creatinine 1.7 mg/dL, glucose 132 mg/dL, calcium 10.5 mg/dL, albumin 1.5 g/dL, liver function tests-within normal limits

Prothrombin time (PT) 15 sec, international normalized ratio (INR) 1.2, partial thromboplastin time (PTT) 29.9 sec

Chest X-ray

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

What is the best description of the chest x-ray? (click on correct answer to move to next panel)

1. Bibasilar consolidation
2. Bilateral diffuse nodules
3. Pneumomediastinum with subcutaneous emphysema
4. Pulmonary edema with evidence of pulmonary hypertension
5. Subdiaphragmatic free air

Reference as: Natt B, Snyder L, Campion J. January critical care case of the month: bad cough. Southwest J Pulm Crit Care. 2014;8(1):20-6. doi: http://dx.doi.org/10.13175/swjpcc161-13 PDF

December 2013 Critical Care Case of the Month: I Don’t Have a Drinking Problem

Robert Raschke MD

Elijah Poulos MD

Adam Bosak MD

Critical Care Medicine

Banner Good Samaritan Medical Center

Phoenix, AZ

History of Present Illness

A 69-year-old male retired diabetic police officer was admitted to the ICU with intractable vomiting, severe abdominal pain and acute blindness. About a week prior, he suffered urinary frequency and was prescribed ciprofloxacin at urgent care with a presumptive diagnosis of urinary tract infection.  Over the course of the week his urinary frequency resolved and he became anuric, he developed progressively worsening nausea and eventually vomiting to the point that he was unable to keep anything down, and severe bilateral lower abdominal and pelvic pain.    His wife and son actually forced him into the ER when he became blind the day of admission. He denied fever, dysuria, cough and headache.   In our emergency room he was noted to be in moderate distress with tachycardia, tachypnea, hyperpnoea and completely blind in both eyes unable to discern even simple shadows.

PMH, SH, FH

The patient is a retired police officer with a past medical history of diabetes mellitus and benign prostatic hypertrophy.  The patient denied alcohol, tobacco, or illicit drug use. He works out at a local gym almost daily since being diagnosed with diabetes a couple of years ago.

Medications

• Glipizide
• Metformin
• Tamsulosin

Physical Exam

Blood pressure160/95 mmHg with a heart rate of 110, respiratory rate 35, SpO2 99% on 2 lpm nasal cannula, and temp 36.0° C.  He appeared uncomfortable and moderately distressed, lethargic but arousable with GCS 13. He was able to briefly answer simple questions. His eyes were conjugate, but did not track nor fix on objects placed in front of his eyes, and he could vaguely discern the light of a bright flashlight shined into both eyes. His pupils were 3-4 mm and fixed, with no light reflex elicitable, even with magnified examination of the pupil using an ophthalmoscope.  On fundoscopic exam his discs were flat, and there were no hemorrhages or other lesions seen.  He was tachycardic but regular with normal heart tones, and a bedside echocardiogram showed good left ventricular function.  He had Kussmaul breathing with an odor of ketones and clear lungs. The lower abdomen was distended and tender, and a Foley catheter insertion returned 2 liters of yellow urine which resolved his abdominal pains.  He had no peripheral edema and his hands were cool.  The rest of his physical examination was unremarkable.

Laboratory Evaluation

Initial laboratory evaluation included a white blood count 24.3 K/mm3 with 79% segmented neutrophils and no bands, hemoglobin 14.7 g/dL; sodium 138 mmol/L;  potassium 5.1 mmol/L; chloride 92 mmol/L; and CO₂ 4 mmol/L, yielding an anion gap of 44 when corrected.  His BUN was 116 mg/dL; creatinine of 7.7 mg/dL.  A venous blood gas showed a pH 6.77 pCO₂ 17 mmHg; pO₂ 73 mmHg; bicarbonate of 3 mmol/L. Urinalysis showed negative leukocyte esterase, 1-5 leukocytes per HPF, glycosuria and ketonuria.

Radiology Evaluation

Admission chest x-ray is in Figure 1. 

Figure 1. Admitting chest radiograph.

Computerized tomography of the abdomen showed no urinary tract obstruction (was performed after the Foley catheter was placed) and no other significant findings. Piperacillin/tazobactam and gentamicin were started for possible urinary tract infection with sepsis.

Which of the following is the best fits the clinical presentation explaining both his metabolic abnormalities and blindness? (click on correct answer to move to next panel)

1. Acute renal failure
2. Alcoholic ketoacidosis
3. Diabetic ketoacidosis
4. Ethylene glycol ingestion
5. Methanol ingestion

Reference as: Raschke RA, Poulos E, Bosak A. December 2013 critical care case of the month: I don't have a drinking problem. Southwest J Pulm Crit Care. 2013;7(6):328-35. doi: http://dx.doi.org/10.13175/swjpcc141-13 PDF