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October 2013 Critical Care Case of the Month: Slow to Respond

Michael P. Mohning, MD


Pulmonary Sciences and Critical Care Medicine

University of Colorado Hospital

Denver, CO


History of Present Illness

A 66-year-old woman presents with confusion and lower extremity edema. She was brought to the emergency department by her family after 2-3 days of increasing confusion.  She has fatigue and a dry non-productive cough but denies shortness of breath, chest pain, fevers or chills. She had a decrease in oral intake and constipation for several days.


Five months ago, she was admitted to a hospital for community acquired pneumonia and hyponatremia. She is a never smoker, and doesn’t use alcohol.

There is no significant family history.


  • Omega 3 fatty acids
  • Multivitamins

Physical Examination

Temperature 36.1° C, blood pressure 106/61 mm Hg, heart rate 72 beats/min, respiratory rate 15 breaths/min, oxygen saturation 90% on room air.

She was confused, and oriented to self only.  She had facial edema.  Cardiac exam was normal. Pulmonary findings include rales at the lung bases. Her abdomen was non-tender, with active bowel sounds. She had 1+  lower extremity edema, no rashes, and delayed relaxation of reflexes.


She was anemic with hematocrit of 32%, hemoglobin 11 g/dL and WBC 5,000. Serum sodium is low at 118 meq/L, anion gap was normal at 9 and potassium and calcium levels were normal. Albumin is low at 3.2 g/dL. Remaining liver function, blood glucose and creatinine are normal. EKG shows no T wave inversions or ST segment elevation.


Chest x-ray is shown in figure 1.


Figure 1. Admission PA (Panel A) and lateral (Panel B) chest x-ray.

Which best describes the chest-x-ray?

  1. Bilateral interstitial infiltrates
  2. Enlarged cardiac silhouette
  3. Hyperexpanded lungs
  4. Poor inspiratory effort
  5. Pulmonary edema

Reference as: Mohning MP. October 2013 critical care case of the month: slow to respond. Southwest J Pulm Crit Care. 2013;7(4):214-20. doi: PDF

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