Michael Pham, MD
Karen Swanson, DO
Department of Pulmonary Medicine
Mayo Clinic Arizona
Pulmonary 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): Michael Pham, 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.
As a result of this activity I will be better able to:
- Correctly interpret and identify clinical practices supported by the highest quality available evidence.
- Will be better able to establsh the optimal evaluation leading to a correct diagnosis for patients with pulmonary, critical care and sleep disorders.
- Will improve the translation of the most current clinical information into the delivery of high quality care for patients.
- 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.
Current Approval Period: January 1, 2015- December 31, 2016
Financial Support Received: None
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