October 2013 Critical Care Case of the Month: Slow to Respond
Wednesday, October 2, 2013 at 8:00AM
Rick Robbins, M.D. in adrenal insufficiency, glucocorticoids, hypoadrenal, hypothyroid, myxedema, myxedema coma, panyhypopituitarism, poor inspiratory effort, thyroid stimulating hormone, thyroxine

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.


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: http://dx.doi.org/10.13175/swjpcc105-13 PDF

Article originally appeared on SOUTHWEST JOURNAL of PULMONARY & CRITICAL CARE (http://www.swjpcc.com/).
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