April 2014 Critical Care Case of the Month: Too Much, Too Fast

Kenneth Sakata, MD

Richard A. Helmers, MD

Department of Pulmonary Medicine

Mayo Clinic Arizona

Scottsdale, AZ

History of Present Illness

A 69 year old man was admitted to the intensive care unit with shortness of breath and atrial fibrillation with a rapid ventricular response.

PMH, FH, SH

He has a history of peripheral vascular disease, end-stage renal disease and is receiving chronic hemodialysis.

Physical Examination

Afebrile. Pulse 135 and irregular. BP 105/65 mm Hg. SpO2 96% while receiving oxygen at 2L/min by nasal cannula.

HEENT: Unremarkable.

Neck: Jugular venous distention to the angle of the jaw while the head is elevated at 45 degrees.

Lungs: Decreased breath sounds at the right base.

Cardiovascular: Irregularly, irregular rhythm. 2-3+ pretibial edema.

Abdomen: no hepatosplenomegaly.

Radiography

The admission chest x-ray is shown in figure 1.

Figure 1. Admission portable chest x-ray.

Which of the following is the best interpretation of the chest x-ray given the clinical situation? (Click on the correct answer to move to the next panel)

1. Hepatomegaly elevating the right diaphragm
2. Large right pleural effusion
3. Paralyzed right diaphragm
4. Right lower lobe pneumonia
5. Right middle lobe pneumonia

Reference as: Sakata K, Helmers RA. April 2014 critical care case of the month: too much, too fast. Southwest J Pulm Crit Care. 2014;8(4):205-12. doi: http://dx.doi.org/10.13175/swjpcc031-14 PDF