May 2016 Critical Care Case of the Month

Layth Al-Jashaami, MD

Yousef Usta, MD

Negin N. Blattman, MD

Rakesh Nanda, MD 

Phoenix VA Health Care System

650 E Indian School Road

Phoenix, Arizona, 85012 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): Layth Al-Jashaami, 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 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

A 50-year-old African American woman presented with weakness, altered mental status and constipation of 12 days duration. She was complaining of abdominal distension with diffuse pain and bloating. She denied melena, hematochezia or hematemesis. She had a history weight loss, anorexia and fatigue which had evolved over the past few months leading to recent severe weakness and inability to get out of bed.

Past Medical History, Social History and Family History

Her past medical history included HIV infection with AIDS and noncompliance with her antiretroviral medications. Her most recent CD4 count was <20 cells/uL and viral load of 554,483 copies/mL.

Physical Examination

Vital signs: Blood pressure, 120/80 mmHg, heart rate, 105/min, temperature, 98.6° and respiratory rate, 20/min.

General: Physical examination showed a lethargic female who was poorly responsive to questioning.

Abdomen: Distended, tympanic abdomen with hypoactive bowel sounds and diffuse tenderness.

Radiography

Plain x-ray examination of the abdomen on admission is shown in Figure 1.

Figure 1. Admission x-ray of the abdomen.

Which of the following are possible causes of the patient's complaints, physical findings and abdominal x-ray findings? (Click on the correct answer to proceed to the second of six panels)

1. Electrolyte disturbances
2. Use of anticholinergic drugs
3. Use of narcotics
4. 1 and 3
5. All of the above

Cite as: Al-Jashaami L, Usta Y, Blattman NN, Nanda R. May 2016 critical care case of the month. Southwest J Pulm Crit Care. 2016 May;12(5):171-9. doi: http://dx.doi.org/10.13175/swjpcc038-16 PDF

July 2015 Critical Care Case of the Month: An Unusual Presentation

Allon Kahn, MD 

Lewis J. Wesselius, MD
 

Department of Pulmonary Medicine

Mayo Clinic Arizona

Scottsdale, AZ

History of Present Illness

A 79 year old man was admitted because of a possible seizure. His wife found him unresponsive, displaying tonic-clonic motions with a right facial droop and right-sided weakness. He returned to consciousness, but was confused. A similar episode occurred 2 weeks prior to the present episode. He has additional symptoms of dysphagia with solid food for 6-8 months, a somewhat intentional 20 pound weight loss, night sweats for 4-5 months and fatigue for 1 year.

Past Medical History

• Coronary artery disease with a percutaneous transluminal coronary angioplasty in 1990, placement of 2 drug eluting stents in 2012.
• Idiopathic pulmonary fibrosis on 2-4 L/min home O2
• Myelofibrosis on ruxolitinib, a monoclonal antibody against JAK receptors
• Hypertension
• A remote history of DVT/PE related to surgery with an IVC filter placed
• Splenectomy due to trauma

Social and Family History

• He has a 15 pack-year smoking history, quitting in 1985.
• One brother with lung cancer, another with bladder cancer.

Medications

• Aspirin 81 mg daily
• Plavix 75 mg daily
• HCTZ 25 mg daily
• Metoprolol XL 50 mg daily
• Niacin 500 mg daily
• Protonix 40 mg daily
• Acetaminophen with hydrocodone
• Fish oil

Physical Examination

• Dysarthric
• No facial droop
• Some dysmetria

Which of the following should be done at this time? (Click on the correct answer to proceed to the second of five panels)

1. A CT scan of the brain
2. Begin tissue plasminogen activator (TPA)
3. Chest x-ray
4. 1 and 3
5. All of the above

Reference as: Kahn A, Wesselius LJ. July 2015 critical care case of the month: an unusual presentation. Southwest J Pulm Crit Care. 2015;11(1):11-18. doi: http://dx.doi.org/10.13175/swjpcc086-15 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