July 2017 Critical Care Case of the Month

Robert A. Raschke, MD

Banner University Medical Center Phoenix

Phoenix, AZ USA

History of Present Illness

A 62-year-old man was brought to the Emergency Department with an altered mental status after a neighbor found him unresponsive. Medications the paramedics found in his home were cyclobenzaprine, duloxetine, gabapentin, levothyroxine, ibuprofen, and tramadol.

Past Medical History, Social History and Family History

He had a past medical history of neck and back pain and hypothyroidism. He lived alone. There was a history of a C3-4 anterior cervical discectomy in 2010. Other history including family history was unobtainable.

Physical Examination

• Vital Signs: HR 61 beats/min, BP 86/50 mm Hg, RR 8 breaths/min, T 32.2º C
• General: arousable but did not answer questions. He had multiple tattoos. No needle track marks are identified.
• HEENT: pupils were small but reacted to light.
• Lungs: clear to auscultation.
• Heart: regular rhythm without murmur.
• Abdomen: soft without organomegaly or masses.
• Neurology: he moved all 4 extremities but minimally. Plantar reflexes were downgoing.

Which of the following should be done immediately? (Click on the correct answer to proceed to the second of six pages)

1. Administer naloxone
2. CT scan of the head
3. Obtain a blood glucose
4. 1 and 3
5. All of the above

Cite as: Raschke RA. July 2017 critical care case of the month. Southwest J Pulm Crit Care. 2017;15(1):7-14. doi: https://doi.org/10.13175/swjpcc081-17 PDF

November 2016 Critical Care Case of the Month

Richard A. Robbins, MD

Phoenix Pulmonary and Critical Care Research and Education Foundation

Gilbert, AZ USA

History of Present Illness

A 45-year-old Iraqi War Veteran was seen in the outpatient clinic after referral for COPD based on abnormal blood gases. He denies any dyspnea or cough.

PMH, SH and FH

He has a history of a lower back injury and uses a motorized wheelchair. His pain is managed with morphine sulfate ER 60 mg daily and morphine sulfate 10 mg every 4 hours as needed for breakthrough pain.

He does not smoke cigarettes but does use marijuana for pain. He denies alcohol abuse.

Physical Examination

Physical examination shows a lethargic man in a wheelchair who intermittently falls asleep during questioning and examination. When aroused he is oriented to time, place and person and frequently mentions that his pain is a 10. His vital signs are normal expect his SpO2 is 75% on room air. His lungs were clear and his heart had a regular rhythm without murmur. His pupil size is approximately 2 mm bilaterally and muscle strength is difficult to determine due to his inability to remain alert or fully cooperate.

Radiography

A chest x-ray had been performed about a week previously (Figure 1).

Figure 1. Initial chest x-ray.

Spirometry had been performed earlier in the day (Figure 2).

Figure 2. Spirometry.

Which of the following are indicated at this time? (Click on the correct answer to proceed to the second of four pages)

1. Arterial blood gases (ABGs)
2. Immediate intubation
3. Intensive care unit (ICU) admission
4. 1 and 3
5. All of the above

Cite as: Robbins Ra. November 2016 critical care case of the month. Southwest J Pulm Crit Care. 2016;13(5):196-201. doi: http://dx.doi.org/10.13175/swjpcc103-16 PDF