November 2015 Critical Care Case of the Month

Samir Sultan, DO

Banner University Medical Center Phoenix

Phoenix, AZ

 History of Present Illness

A 39-year-old Caucasian woman was admitted to the ICU with worsening dyspnea and increasing oxygen requirements. Her lips turned blue with minimal activity. She was admitted to another hospital 5 months earlier with pneumonia. At discharge she was placed on oxygen. At follow-up with her pulmonologist, she was diagnosed with sleep apnea.

Past Medical History, Family History, Social History

• She has a history of an optic glioma at age 7 with resection followed by radiation therapy and development of panhypopituitarism.
• Liver cirrhosis diagnosed in 2014 with presentation of hematemesis.
• Type 2 diabetes mellitus
• Denies tobacco, ethanol, or illicit drug use.
• There is a family history of diabetes and liver cirrhosis

Physical Examination

• Vital signs:110 / 86, HR 97, RR 16, 88% on 6 liter O2
• General: obese female (BMI 35) in no apparent distress
• Chest: Clear to auscultation bilaterally
• Cardiovascular: regular rate without murmur or rub
• The remainder of the physical exam is normal  

Radiography

      A chest x-ray was interpreted as normal.

Laboratory

• CBC: hemoglobin 13.8 gm/dL, WBC 7 X 103 cells/microliter with a normal differential
• Basic metabolic panel: Na⁺ 132 mEq/L, K⁺ 4 mEq/L, Cl^- 100 mEq/L, HCO3^- 22 mEq/L, glucose 150 mg/dL.
• Arterial blood gases (ABGs): PaO₂ 35 mm Hg, PaCO₂ 37 mm Hg, pH 7.43

Which of the following is/are not possible cause(s) of hypoxemia in this patient? (Click on the correct answer to proceed to the second of six panels)

1. Decreased diffusion (alveolar capillary block)
2. Ventilation-perfusion mismatch
3. Hypoventilation
4. 1 and 3
5. All of the above

Cite as: Sultan S. November 2015 critical care case of the month. Southwest J Pulm Crit Care. 2015;11(5):209-15. doi: http://dx.doi.org/10.13175/swjpcc137-15 PDF

Ultrasound for Critical Care Physicians: The Martian

Jawad Abukhalaf, MD

Michel Boivin, MD

Division of Pulmonary, Critical care and Sleep Medicine,

University of New Mexico School of Medicine

Albuquerque, NM USA

A 54 year old male with a past medical history significant for granulomatosis with polyangiitis (formerly known as Wegener’s granulomatosis) and chronic kidney disease presented with hemoptysis and chest pain.

On presentation, he was found to have a 10 cm right middle lobe cavitary lesion and was subsequently treated with high dose steroids, antibiotics and antifungals based on bronchoalveolar lavage results. On day 9 of his hospital stay the patient was found to have bilateral lower extremity deep venous thromboses that were treated with intravenous heparin. On day 11 of his stay, the patient started experiencing lower abdominal pain and hypotension. The patient was resuscitated with saline. Bedside ultrasonography was performed.

Figure 1. Transverse lower abdominal ultrasound in the pelvis.

What does the transverse view of the lower abdomen (just above the symphysis pubis) demonstrate? (Click on the correct answer for an explanation)

1. Abdominal wall hematoma
2. Distended bladder
3. Horseshoe kidney
4. Psoas hematoma

Cite as: Abukhalaf J, Boivin M. Ultrasound for critical care physicians: the martian. Southwest J Pulm Crit Care. 2015;11(4):186-8. doi: http://dx.doi.org/10.13175/swjpcc135-15 PDF 

October 2015 Critical Care Case of the Month: A Moldy But Gooey

Jennifer M. Hall, DO

Banner University Medical Center Phoenix

Phoenix, AZ

History of Present Illness

A 45-year-old man with a history of a kidney transplant in 2011 was admitted with subjective fevers, nausea, abdominal pain, chest pain and recurrent renal failure. Cardiac workup was negative for ischemia and intermittent hemodialysis was initiated. CT of chest and abdomen was significant for a new cavitary pulmonary lesion. Leading up to this admission, he had been on immunosuppressive agents including tacrolimus, mycophenolate and prednisone, and the day of presentation had been doing quite well, actually was bear hunting in the mountains near Flagstaff, Arizona.

Past Medical History

• Donor kidney transplant in 1999, which failed in 2011, prompting a second kidney transplant
• Failed pancreas transplant
• Coronary artery disease, with percutaneous cardiac intervention in 2001
• Diabetes mellitus type I
• Chronic anemia
• History of total parathyroidectomy
• History of C5-C7 cervical fixation

Physical Examination

• Vital signs stable
• Appeared to be pale, no apparent distress
• Cardiac exam unremarkable
• Chest exam with fine crackles in left base / otherwise clear
• Abdomen slightly tender in left lower quadrant, but without guarding, rebound or peritoneal signs; small dime-sized area of ecchymosis, where lovenox injections had been administered
• No peripheral edema or clubbing

Laboratory Evaluation

• WBC 17,900 cells/mcL with 96% segmented neutrophils, hemoglobin 8.9 g/dL(after transfused 2 units prior to transfer), PLT 232,000 cells/mcL,
• INR 1.3
• Blood urea nitrogen (BUN) 74 mg/dL, serum creatinine 2.32 mg/dL, electrolytes within normal limits, albumin 3.2 g/dL, aspartate aminotransferase (AST) 24 IU/L, alanine transaminase (ALT)81 IU/L.
• NT-proBNP 6841 pg/ml (normal < 300 pg/ml)
• Hemoglobin A1C 7.2%
• Lactate 0.7 mmol/L

Imaging

A thoracic CT scan was performed (Figure 1).

Figure 1. Panels A-D: representative static views from the CT scan in lung windows. Note the cavitary lesion in the right lung (red arrow), the right pleural effusion (blue arrow) and the left lower lobe consolidation (yellow arrow) with a pleural effusion. Lower panel: video of the thoracic CT scan in lung windows.

Which diagnosis is least likely in this patient’s differential diagnosis for the cavitary pulmonary lesion? (Click on the correct answer to proceed to the second of five panels)

1. Aspergillosis
2. Coccidioidomycosis
3. Invasive mucormycosis
4. Metastatic malignancy
5. Nocardiosis
6. Pulmonary Infarct

Cite as: Hall JM. October 2015 critical care case of the month: a moldy but gooey. Southwest J Pulm Crit Care. 2015;11(4):136-43. doi: http://dx.doi.org/10.13175/swjpcc130-15 PDF

Ultrasound for Critical Care Physicians: Shortness of Breath

Matthew JK Douglas, MD

David Verbunker, MD

Jarrod Mosier, MD 

Department of Emergency Medicine

Banner University Medical Center Tucson

University of Arizona

Tucson, AZ

Figure 1. Video of the right thoracic ultrasound (coronal).

An 85 year old woman with a history of congestive heart failure and diabetes presented to the emergency department with progressive shortness of breath. She had recently been discharged from another hospital where she had been admitted for several days for community acquired pneumonia. The patient was in respiratory distress on arrival with tachypnea, increased work of breathing, and hypoxia despite supplemental oxygen with a non-rebreather mask and she was subsequently intubated. ED point-of-care ultrasound was performed of the right hemithorax.

What does Figure 1 demonstrate? (Click on the correct answer for the second of two panels and an explanation)

1. Intravascular volume depletion
2. Normal lung aeration
3. Numerous B-lines
4. Pleural effusion and consolidation
5. Pneumothorax

Cite as: Douglas MJK, Verbunker D, Mosier J. Ultrasound for critical care physicians: shortness of breath. Southwest J Pulm Crit Care. 2015;11(3):112-3. doi: http://dx.doi.org/10.13175/swjpcc116-15 PDF

September 2015 Critical Care Case of the Month: If You Don't Look, You Won't Find

Robert A. Raschke, MD

Banner University Medical Center

Phoenix, AZ

 History of Present Illness

A 55-year-old woman was transferred from Mexico emergently for acute cardiomyopathy. On the day of admission, she went for a 45-min “exercise” walk and cleaned her house. While taking a shower, she suffered an acute onset of dyspnea with nausea and vomiting and possibly a small amount of hematemesis. She appeared seriously ill to her husband, who took her blood pressure (198/?) and pulse (90) and rushed her to a local medical facility.  There, she was found to have severe pulmonary edema, and a troponin of 11.  Her echo showed inferior wall motion abnormality with an ejection fraction of 35%.  However, coronary catheterization showed normal coronaries.  She was treated with oxygen, furosemide, labetolol and enoxaparin and transferred emergently to Banner-University Medical Center. 

Past Medical History, Family History and Social History

The patient reported intermittent "spells" since May. These typically occurred upon  lying down in bed and were characterized by her as a feeling of “numbness” or tingling  which ascends from her chest to her head associated with palpitations and a feeling of  “desperation”, typically relieved after a few minutes upon getting up out of bed.

She had a history of hypertension and had been on losartan but this was discontinued a few months previously because of the onset of orthostatic dizziness. She also has a history of hypothyroidism and is taking synthroid. She was treated three times in the last 6 month for amoebiasis. She is a medical missionary to La Paz, Mexico and has recently traveled to Bolivia and Guatemala.

Review of Systems

She has had some night sweats, coughing with deep inspiration, and some slight hemoptysis. She did have a headache one month previously at 7000 ft elevation while in Guatemala.

Physical Examination

• She appears in moderate distress. Her vital signs are normal other than a mild tachycardia.  
• She does have rales on auscultation of her lungs.
• The remainder of the physical examination was unremarkable.

Radiography

A portable chest radiograph is performed (Figure 1).

Figure 1. Admission portable chest radiograph.

Laboratory evaluation

Her CBC shows a normal hemoglobin and hematocrit but with an elevated white blood cell count of 26,500 cells/mcL with a left shift. Admission electrolytes and blood sugar are within normal limits.

What additional procedures/testing are indicated? (Click on the correct answer to proceed to the second of four panels)

1. Blood cultures
2. Echocardiogram
3. Electrocardiogram
4. NT-pro-brain natriuretic peptide (NT-pro-BNP)
5. All of the above

Reference as: Raschke RA. September 2015 critical care case of the month: if you don't look, you won't find. Southwest J Pulm Crit Care. 2015;11(3):97-102. doi: http://dx.doi.org/10.13175/swjpcc113-15 PDF