Critical Care
The Southwest Journal of Pulmonary and Critical Care publishes articles directed to those who treat patients in the ICU, CCU and SICU including chest physicians, surgeons, pediatricians, pharmacists/pharmacologists, anesthesiologists, critical care nurses, and other healthcare professionals. Manuscripts may be either basic or clinical original investigations or review articles. Potential authors of review articles are encouraged to contact the editors before submission, however, unsolicited review articles will be considered.
October 2017 Critical Care Case of the Month
Margaret Ragland, MD1
Carolyn H. Welsh, MD1,2
Pulmonary Sciences and Critical Care Medicine
1University of Colorado Anschutz Medical Campus and 2VA Eastern Colorado Health Care System
Denver, Colorado USA
History of Present Illness
A 42-year-old man with a history of intravenous heroin abuse and chronic hepatitis C infection presents to the emergency department (ED) with recurrent abdominal pain. The pain was dull, epigastric, and did not radiate. The pain worsened after eating, but the timing after eating that it worsened was inconsistent. He had nausea but no vomiting. His bowel movements were normal without constipation, diarrhea, or melena.
He had presented to another ED multiple times with this same pain over the past six weeks. He does not know what the work-ups revealed, but was discharged from the emergency department each time. He received supportive care including fluids and analgesics, but the pain would always recur a few hours after returning home.
He went to a third ED a few weeks ago with bilateral testicular pain after which he was discharged home with acetaminophen for pain.
Past Medical History, Family History, and Social History
His past medical history is notable for bipolar disorder. He takes no prescribed medications and does not know his family’s medical history. He is a current every day smoker, has no history of heavy alcohol use, and uses intravenous heroin but no other recreational drugs.
Current Medications
Acetaminophen a few times a day for abdominal pain.
Review of Systems
He notes subjective fevers, poor appetite, and an 8 pound unintentional weight loss over the past six weeks.
Physical Exam
Vital signs are notable for hypertension to 158/91 mm Hg. Other vitals are within normal limits.
On exam, he is an ill appearing middle aged man who appears very uncomfortable. His abdomen is nondistended. He has normal bowel sounds and epigastric tenderness with a tender, smooth liver edge palpable just under the costal margin. He has decreased sensation to light touch in his toes with no skin changes. Toes are warm with capillary refill less than two seconds.
Laboratory Evaluation
CBC reveals a leukocytosis to 23,600 cells/mcL with 80% neutrophils; eosinophils are normal. Hemoglobin and platelet counts are normal. Sodium is 128 mmol/L with a bicarbonate of 30 mmol/L and creatinine of 0.64 mmol/L. AST 155 U/L, ALT 137 U/L, with a total bilirubin 1.1 mmol/L. Albumin is 1.8 g/L. INR is 1.9. Urinalysis showed 1+ protein.
What additional laboratory evaluation is indicated at this time? (Click on the correct answer to proceed to the second of six pages)
Cite as: Ragland M, Welsh CH. October 2017 critical care case of the month. Southwest J Pulm Crit Care. 2017;15(4):131-7. doi: https://doi.org/10.13175/swjpcc113-17 PDF
April 2013 Critical Care Case of the Month: Too Many Diagnoses
Elijah Poulos, MD
David M. Baratz, MD
Banner Good Samaritan Regional Medical Center
Phoenix, AZ
History of Present Illness
A 71 year old diabetic woman was admitted for 6-8 weeks of progressive dyspnea, non-productive cough, orthopnea, generalized edema and intermittent fevers. She has a history of living-related donor renal transplant from her husband in 1999 and was diagnosed with locally advanced pancreatic adenocarcinoma in October 2012. She was treated with insulin for diabetes; the immunosuppressants tacrolimus, mycophenolate and low-dose prednisone for her renal transplant; and weekly gemcitabine beginning in 11/2012 for her pancreatic cancer. Her course was complicated by left lower extremity deep venous thrombosis in January 2013 and she was treated with full dose enoxaparin at 1 mg/kg BID. She was tolerating her chemotherapy poorly with a myriad of complaints including fatigue, skin ulcerations, poor appetite, weakness, dysphagia, malaise, nausea and intermittent chest pains. Her most recent chemotherapy was held because of pancytopenia. She was admitted to our hospital in early March 2013 with the above symptoms.
Physical Examination
Vital signs: Temp 98.8°F, BP 125/65 mm Hg, HR 84 beats/min, RR 18/min, O2 saturation 85% on room air.
General: She was an obese woman in no distress but with conversational dyspnea
Neck: Jugular venous distention could not be appreciated secondary to obesity.
Lungs: Bibasilar rales
Heart: regular rhythm with distant heart sounds, but no murmur or gallop.
Lungs: Bibasilar rales
Abdomen: Soft and non-tender without palpable organomegaly or masses.
Ext: 2+ bilateral lower extremity pitting edema to above the knees.
Radiography
Her chest x-ray was interpreted as showing cardiomegaly with radiographic sequelae of pulmonary venous hypertension (Figure 1).
Figure 1. Admission PA (Panel A) and lateral (Panel B) chest radiography.
A thoracic CT scan was performed and was interpreted as showing vague diffuse bilateral groundglass opacities (Figure 2).
Figure 2. Movies of axial thoracic CT (upper panel) and coronal thoracic CT (lower panel).
Which of the following is a cause of ground glass opacities?
Reference as: Poulos E, Baratz DM. April 2013 critical care case of the month: too many diagnoses. Southwest J Pulm Crit Care. 2013;6(4):161-7. PDF