April 2016 Critical Care Case of the Month

Samir Sultan, DO

Banner University Medical Center Phoenix

Phoenix, AZ

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): Samir Sultan, DO.  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

The patient is a 22-year-old African-American man who was initially seen following a rapid response team called to the neonatal intensive care unit for a seizure. He was visiting his newborn child. The nurses described the seizure as tonic-clonic which resolved spontaneously without treatment before the rapid response team arrived.

Past Medical History, Family History and Social History

The patient has a past medical history of a brain aneurysm treated by coil embolization 2 years earlier. He had no complications of the embolization including seizures. Family history is unremarkable. He smokes 1-2 cigars per day but does not drink alcohol.

Physical Examination

He was drowsy when initially seen but the drowsiness resolved in about 5 minutes. The physical examination was unremarkable and there were no focal neurologic signs.

What should be next? (Click on the correct answer to proceed to the second of seven panels)

1. CT scan of the head
2. Phenytoin administration
3. Metabolic screening (BUN, glucose and electrolytes)
4. 1 and 3
5. All of the above

Cite as: Sultan S. April 2016 critical care case of the month. Southwest J Pulm Crit Care. 2016 Apr;12(4): . doi: http://dx.doi.org/10.13175/swjpcc033-16 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