Michael Pham, MD
Karen Swanson, DO
Department of Pulmonary Medicine
Mayo Clinic Arizona
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.
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)
- Elevated right hemidiaphragm
- Right pleural effusion
- Volume loss in the right hemithorax
- 1 and 3
- All of the above