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

Thursday, July 2, 2015 at 8:00AM
Rick Robbins, M.D. in CT scan, MRI, brain abcess, bronchoscopy, coccidioidomycosis, endobronchial lesion, endobronchial ultrasound, histology, mediastinal lymphadenopathy, valley fever

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

Article originally appeared on Southwest Journal of Pulmonary, Critical Care and Sleep (https://www.swjpcc.com/).