September 2017 Critical Care Case of the Month

James T. Dean III, MD

Tyler R. Shackelford, DO

Michel Boivin, MD

Division of Pulmonary, Critical Care and Sleep Medicine

University of New Mexico School of Medicine

Albuquerque, NM 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): James T. Dean III, MD.  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 completing this activity, participants will be better able to:

1. Interpret and identify clinical practices supported by the highest quality available evidence.
2. Establish the optimal evaluation leading to a correct diagnosis for patients with pulmonary, critical care and sleep disorders.
3. Translate the most current clinical information into the delivery of high quality care for patients.
4. Integrate new treatment options 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, 2017-December 31, 2018

Financial Support Received: None

A 73-year-old man presented with a three-day history of diffuse abdominal pain, decreased urine output, nausea and vomiting. His past medical history included diabetes, coronary artery disease, hypertension and chronic back pain. The patient reported being started on hydrochlorothiazide, furosemide, pregabalin and diclofenac within the last week in addition to his long-standing metformin prescription.

Initial vitals were significant for tachypnea, tachycardia to 120 bpm, hypothermia to 35ºC and hypotension with a blood pressure of 70/40 mm Hg. Physical exam was remarkable for bilateral lung wheezing and significant respiratory distress. Laboratory examination was concerning for a pH of 6.85, pCO2 of < 5mmHg, serum lactate of 27mmol/l, WBC of 15.6 x10⁶ cells/cc and a serum creatinine of 8.36 mg/dl. A chest X-ray showed evidence of mild pulmonary edema and a CT of the abdomen did not show any acute pathology.

What is the most likely etiology of the patient’s severe acidosis? (Click on the correct answer to proceed to the second of four pages)

1. Diabetic ketoacidosis
2. Ethylene glycol poisoning
3. Metformin-associated lactic acidosis
4. Septic shock

Cite as: Dean JT III, Shackelford TR, Boivin M. September 2017 critical care case of the month. Southwest J Pulm Crit Care. 2017;15(3):100-3. doi: https://doi.org/10.13175/swjpcc101-17 PDF