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In Memoriam
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December 2016 Critical Care Case of the Month

Theodore Loftsgard APRN, ACNP

Department of Anesthesiology

Mayo Clinic Minnesota

Rochester, MN 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): Theodore Loftsgard APRN, ACNP.  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 62-year-old lady with primary biliary cirrhosis/autoimmune hepatitis listed for liver transplantation was admitted to the general medicine floor with progressive lethargy. She had progressive fatigue for about 10 days prior to admission. She had not been able to walk for the last few days; had anorexia; had not had a bowel movement for approximately one week; and had not taken her medicines for 4 days according to her daughter. Her family was concerned with her progressive lethargy; her darkening urine; and progressive jaundice.

She had been managed for several years on mycophenolate mofetil, budesonide, and ursodiol. She had increasing problems with ascites and had paracentesis performed about every 4 days despite taking Lasix and spironolactone. She had early encephalopathy manifested by increasing problems with word finding but had not received lactulose.

Past Medical History

She has a history of esophageal varices, recurrent cellulitis and obesity.

Physical Examination

Vital Signs: P 121 beats/min, BP 102/35 mm Hg, T 37.5 C, R 25 breaths/min

General: She was lethargic, somewhat confused but oriented to time, place and person.

Lungs: shallow respirations.

Heart: regular rhythm with a tachycardia.

Abdomen: distended with a fluid wave.


Portable chest and abdominal x-rays were performed (Figure 1).


Figure 1. Admission chest (A) and abdominal (B) radiographs.

Which of the following best describes the x-rays? (Click on the correct answer to proceed to the second of six pages)

  1. The abdominal x-ray shows diffuse, nonspecific gaseous distention
  2. The abdominal x-ray shows gastrointestinal perforation
  3. The chest x-ray shows bilateral atelectasis
  4. The chest x-ray shows bilateral pneumonia
  5. 1 and 3
  6. 2 and 4
  7. All of the above

Cite as: Loftsgard T. December 2016 critical care case of the month. Southwest J Pulm Crit Care. 2016;13(6):278-84. doi: PDF

Reader Comments (2)

Hi, you content on "Critical Care Case of the Month CME Information' is good and useful. Thank you for the information Provided in the content.

January 20, 2017 | Unregistered CommenterCritical Care Journal

Hi, you content on "Critical Care Case of the Month CME Information' is good and useful. Thank you for the information Provided in the content.

January 20, 2017 | Unregistered CommenterCritical Care Journal

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