Ultrasound for Critical Care Physicians: An Unexpected Target Lesion

Jantsen Smith, MD

Department of Internal Medicine

University of New Mexico Hospital

Albuquerque, NM USA

A 39-year-old woman was admitted to the hospital for shortness of breath. Her medical history was significant for human immunodeficiency virus infection (not on anti-retroviral therapy), superior vena cava (SVC) syndrome with history of SVC stenting, cerebrovascular accident complicated by seizure disorder and swallowing difficulties, moderate pulmonary hypertension, end-stage renal disease on hemodialysis with past episodes of acute hypoxic respiratory failure related to fluid overload. Shortly after admission, the patient experienced a cardiac arrest due to hypoxia and necessitated emergent intubation. This was presumed to be due to fluid overload. Nephrology was consulted for emergent dialysis (the patient had a right upper extremity fistula for dialysis access). Dialysis was initiated through a right arm fistula. On day three of admission, the patient was noted to have worsening right upper extremity and breast swelling and pain. Physical exam revealed indurated edema of the skin of the breast. Point of care ultrasound was performed of the patient’s right neck, and the following ultrasound was obtained approximately 4cm above the clavicle in the right lateral neck.

Video 1. Ultrasound image of the right neck in the transverse plane.

What is the most likely cause of this patient’s right upper extremity and breast swelling? (Click on the correct answer for an explanation).

1. Right breast cellulitis
2. Ascending SVC thrombus
3. Lymphatic blockage of right axillary nodes
4. Fluid overload complicated by third spacing in the R upper extremity

Cite as: Smith J. Ultrasound for critical care physicians: An unexpected target lesion. Southwest J Pulm Crit Care. 2019;18(3):63-4. doi: https://doi.org/10.13175/swjpcc011-19 PDF

October 2018 Critical Care Case of the Month: A Pain in the Neck

Robert A. Raschke, MD

Critical Care Medicine

HonorHealth Scottsdale Osborn Medical Center

Scottsdale, AZ USA

History of Present Illness

A 54-year-old man was admitted after he had a decline in mental status. He complained of neck and back pain for one week prior to admission for which he took acetaminophen. He was seen in the emergency department two days prior to admission and diagnosed with “arthritis” and prescribed oxycodone/acetaminophen and cyclobenzaprine. On the day of admission be became unresponsive and was transported by ambulance to the emergency department where he was intubated for airway protection.

Past Medical History, Social History, Family History

• Alcoholism
• Hepatitis C
• Esophageal varices
• Family history is noncontributory

Physical Examination

• Vitals: T 102° F, BP 150/60 mm Hg, P 114 beats/min, 20 breaths/min
• Unresponsive
• Dupuytren’s contractures, spider angiomata
• 3/6 systolic murmur
• Deep tendon reflexes 3+  
• Bilateral Babinski’s sign (toes upgoing)

Which of the following are diagnostic considerations at this time? (Click on the correct answer to be directed to the second of six pages)

1. Bacterial endocarditis
2. Hypoglycemia
3. Liver failure
4. 1 and 3
5. All of the above

Cite as: Raschke RA. October 2018 critical care case of the month: a pain in the neck. Southwest J Pulm Crit Care. 2018;17(4):108-13. doi: https://doi.org/10.13175/swjpcc098-18 PDF

July 2014 Critical Care Case of the Month: There Is Still a Role for Physical Examination

Robert A. Raschke, MD 

Banner Good Samaritan Medical Center

Phoenix, AZ

History of Present Illness

A 90-year-old woman was the seatbelt-restrained driver in a low speed frontal motor vehicle collision with airbag deployment, after she accidentally hit the gas instead of the brake. In the emergency room, the patient’s main complaint was right shoulder pain. On ER physical exam, she had sternal ecchymosis consistent with “seatbelt sign”. Her right shoulder was said to be tender, but the mechanism of injury to the right shoulder was unclear since her drivers-side seatbelt would been in contact with her left rather than right shoulder. Her right upper extremity was said to be “weak secondary to pain”. Further neurological examination was noted to be difficult due to “patient crying out in pain and anxiety”, but it was noted that she could lift both legs off the bed. Her left knee was echymotic. Cardiac auscultation revealed irregularly irregular rhythm.

PMH

• Chronic atrial fibrillation
• Coronary artery disease
• Hypertension

Medications

• Warfarin
• Aspirin
• Clonidine
• Metoprolol

Labs performed in the emergency room showed an INR 1.9. Radiographs demonstrated a normal right shoulder and a left patellar fracture. CT scans of the cervical spine and chest showed no bony abnormalities. An incidental 4 cm thoracic aortic aneurysm was noted. CT of the brain showed periventricular white matter hyperlucencies consistent with small vessel disease. The patient became a bit drowsy after receiving narcotic analgesia in the emergency room and was transferred to the medical ICU for management of pain and delirium.

ICU Physical Examination

In the medical ICU the patient was alert, and seemed much younger than 90 years of age, with a sharp wit. She complained of 10/10 shoulder pain at rest which occasionally made her wince, cry out in pain and move her shoulder – however, she said there was no position in which her shoulder did not hurt. There were no ecchymosis of the shoulder, and it could be passively abducted and rotated without worsening the pain. The initial neurological examination was cursory and unrevealing because the patient was distracted by pain, and her left leg was immobilized.  A short time later the nurse reported that she felt the patient’s right leg was weak and the neurological exam was repeated. Strength in the patient’s right leg was 1/5, her left leg was immobilized, but ankle extension was 5/5. She could not cooperate well with strength testing of her painful right arm, but her right grip was 2/5 with a normal strength in her left arm and hand. Toes were down-going and reflexes were generally hypoactive. She was not aphasic. Neurology was consulted.

Which of the following is true in regards to this patient’s neurological findings? (Click on the correct answer to proceed to the next panel)

1. A cervical spinal cord injury could explain these findings
2. A seat belt injury of the left carotid artery could have resulted in traumatic dissection and subsequent stroke
3. Right hemiparesis without aphasia could represent a lacunar stroke
4. They might represent a cardio-embolic stroke related to her history of atrial fibrillation
5. All of the above

Reference as: Raschke RA. July 2014 critical care case of the month: there is still a role for physicial examination. Southwest J Pulm Crit Care. 2014;9(1):8-14. doi: http://dx.doi.org/10.13175/swjpcc086-14 PDF