Search Journal-type in search term and press enter
Social Media-Follow Southwest Journal of Pulmonary and Critical Care on Facebook and Twitter

April 2015 Pulmonary Case of the Month: Get Down

Michael Pham, MD

Karen Swanson, DO

Department of Pulmonary Medicine

Mayo Clinic Arizona

Scottsdale, AZ


History of Present Illness

A 59 year old woman was admitted with hypercapnic respiratory failure and an altered mental state. She had progressive “breathing issues” for the last year and was  increasingly error prone with decreased mental acuity at the end of her work shift for the last 6 months. She was on oxygen at 2 L by nasal cannula at home and has had several admissions over the last 3 months for hypercapnic respiratory failure.

Past Medical History

Obstructive sleep apnea with continuous positive airway pressure (CPAP) intolerance, type 2 diabetes mellitus, and fibromyalgia. She is a life-long nonsmoker.

Physical Examination

Vital signs: T 36.9º C, P 116 beats/min, R 42 breaths/min, BP 134/80 mm Hg, SpO2 93% on room air.

General: She appeared very short of breath.

Neck: No jugular venous distention.

Lungs: Clear anteriorly.

Heart: RR with a tachycardia. 

Abdomen: no organomegaly or masses.


  • +3-to-4 of 5 strength upper and lower extremities
  • Difficulty holding upright posture
  • Decreased sensation in lower extremities
  • R > L lower extremity gastrocnemial fasciculations
  • Hand asterixis/tremor bilaterally
  • Decreased DTRs diffusely


ABG's: pH 7.3 / CO2 82 / pO2 77. Following 4 hours CPAP: pH 7.4 / CO2 68 / pO2 80

Basic metabolic panel: Na+ 138 | Cl- 86 | Creatinine 0.4

                                         K+ 4.8 | TCO2 44 | BUN 13

                                         Ca++ 4.9 / PO4- 4.1 / Mg++ 1.9

Complete blood count: WBC 11.9 cells/mm3, Hemoglobin 10.8 g/dL

Liver function tests, ammonia and lactate were all normal.



Admission chest x-ray is shown in Figure 1.

Figure 1. Admission chest x-ray.

Which of the following is/are true regarding the chest x-ray? (Click on the correct answer to proceed to the second of four panels)

  1. Elevated right hemidiaphragm
  2. Right pleural effusion
  3. Volume loss in the right hemithorax
  4. 1 and 3
  5. All of the above

Reference as: Pham M, Swanson K. April 2015 pulmonary case of the month: get down. Southwest J Pulm Crit Care. 2015;10(4):152-8. doi: PDF

Reader Comments (1)

Great I am first time visit this website thank you so much for sharing this.Amazing post you are a great writer.very interesting article its really amazing. i like your article very much
pro kabaddi live streaming

July 5, 2015 | Unregistered Commenterankush

PostPost a New Comment

Enter your information below to add a new comment.

My response is on my own website »
Author Email (optional):
Author URL (optional):
Some HTML allowed: <a href="" title=""> <abbr title=""> <acronym title=""> <b> <blockquote cite=""> <code> <em> <i> <strike> <strong>