May 2025 Critical Care Case of the Month: Where’s the Rub?

Robert A. Raschke MD

Ethan Weisman

The University of Arizona College of Medicine – Phoenix

Phoenix, AZ USA

Chief Complaint: A 70-year-old woman with a 13-year history of Crohn’s disease presented with two days of severe generalized myalgias, progressive pleuritic chest pain and malaise, followed by the acute onset of  confusion and oxygen desaturation.

History of Present Illness: She had been admitted one week earlier with bloody diarrhea and cramping lower abdominal pain, presumptively diagnosed with a Crohn’s flair and treated with solumedrol 40mg Q12 hourly. An esophagogastroduodenoscopy (EGD) and colonoscopy were performed on the second hospital day, showing angiodysplastic gastric lesions with stigmata of recent bleeding, and severe inflammation with serpentine ulceration of the rectum through the cecum. The angiodysplastic lesions were treated with argon plasma coagulation and colonic biopsies were performed. The patient received 2 units of packed red blood cells. She was discharged the next day on prednisone 40mg and pantoprazole 40mg daily.

She was only home a few hours when she experienced onset of severe generalized myalgias, pleuritic chest pain and malaise, with no change in her resolving gastrointestinal symptoms. She denied fever, cough or dysuria. A home test for SARS-CoV-2 was positive.

The next day she reported to the emergency room (ER) with worsening symptoms described above. She was afebrile with normal vitals and SpO2 of 93% on room air. The physical examination recorded only mild abdominal tenderness. Her white blood cell count (WBCC) was 15.9 10⁹/L and Hb 12.7 g/dL. A chest x-ray (CXR) was clear and a CT angiogram of the chest showed no pulmonary embolism, but a few scattered nodules <1cm in diameter were noted throughout her lungs (Figures 1 and 2).

Figure 1. CXR from ER visit. To view Figure 1 in a separate, enlarged window click here.

Figure 2. Representative image from thoracic CT scan done during ER visit. To view Figure 2 in a separate, enlarged window click here.

The patient checked herself out of the ER against medical advice.

Two days later, the patient was returned to the hospital by her family, who reported she had become confused and had an SpO2 of 78% according to an oximeter they had purchased at a drug store.

Past Medical History: Her past medical history was significant for type-2 diabetes, hypertension and osteoporosis s/p bilateral hip arthroplasties. She was taking alendronate, empagliflozin, levothyroxine, losartan, metformin and a prednisone taper.

Physical Examination: Her temperature was 97.9o F., blood pressure 103/65 mmHg, heart rate 107 bpm, respiratory rate 26 bpm, and SpO2 92% on room air. She was described as ill-appearing and alert but disoriented. Her lungs were clear. Cardiac exam was normal except for tachycardia. Mild abdominal distention and tenderness were noted. The rest of the recorded examination was unremarkable.

What should be done next? (Click on the correct answer to be directed to the second of six pages)

1. Complete blood count
2. EKG
3. Repeat chest X-ray
4. 1 and 3
5. All of the above

Cite as: Raschke RA, Weisman E. May 2025 Critical Care Case of the Month: Where’s the Rub? Southwest J Pulm Crit Care Sleep. 2025;30(5):46-52. doi: https://doi.org/10.13175/swjpccs011-25 PDF

April 2025 Critical Care Case of the Month: Being Decisive During a Difficult Treatment Dilemma

Suanna G. VonEssen MD

University of Nebraska Medical Center

Omaha, NE USA

History of Present Illness

A 71-year-old woman was seen in the emergency department with acute onset of shortness of breath. The patient was well until 3 days prior to admission when she developed pain and swelling in her right calf and ankle. She self-treated with ibuprofen and elevation. She was improving until the afternoon of admission she developed fatigue, dyspnea on exertion, and shortness of breath and came to the emergency department.

Past Medical History

• Partial adrenal insufficiency after resection of pituitary tumor in 1992
• Growth hormone deficiency, treated with augmentation therapy
• Hypothyroidism due to history of pituitary tumor and Hashimoto’s thyroiditis
• Gastroesophageal reflux disease
• Prediabetic
• Hypertension
• Iron deficiency, treated with daily iron
• Colon polyps (adenomas)
• Gluteal tendinopathy, right hip
• COVID-19 a month prior to admission with minimal symptoms

Surgical History

• Appendectomy at age 16
• Resection of pituitary macroadenoma at age 38
• Operations for herniated lumbar disks at age 47, 49 and 52
• Resection of right tonsil for chronic infection at age 54

Family History

• There is a positive family history of deep venous thrombosis in the patient’s mother.

Social History

• She is a physician.
• She does not smoke or drink alcohol.

Physical Examination

• Vital Signs: Normotensive with a regular tachycardia of 106 beats/min. Respiratory rate 22 breaths/minute. SpO2 92% on room air. 
• Lungs: Clear
• CVS: regular rhythm without murmur
• Abdomen: soft without organomegaly masses or tenderness.
• Extremities: Tender right calf with edema

What should be done next? (Click on the correct answer to be directed to the second of six pages)

1. X-rays of the right lower leg and ankle
2. D-dimer
3. Chest x-ray
4. 1 and 3
5. All of the above

Cite as: VonEssen SG. April 2025 Critical Care Case of the Month: Being Decisive During a Difficult Treatment Dilemma. Southwest J Pulm Crit Care Sleep. 2025;30(4):37-39. doi: https://doi.org/10.13175/swjpccs007-25 PDF

January 2025 Critical Care Case of the Month: A 35-Year-Old Admitted After a Fall

Susanna G. Von Essen MD

University of Nebraska Medical Center

Omaha, NE USA

History of Present Illness

A 35-year-old was injured at work earlier that day. He fell approximately 10 feet while power washing a hog confinement pen from inside the bucket of a skid loader. He complained of pain in his left foot. He had struck his head but denied loss of consciousness. He was admitted to an outside hospital ICU for observation.

PMH, SH, and FH

• He has no chronic medical conditions and has never been hospitalized.
• He has never smoked and only drinks socially. He is single.
• His mother died at 55 of heart disease. His father and 6 brothers and sisters are all healthy.

Physical Examination

He is 5’5” and weighs 193 pounds. There is a head laceration and he has tenderness in his left foot. Otherwise, his physical examination is normal.

Radiology

A foot x-ray reveals fractures of the left second and third metatarsals. Head CT was interpreted as normal.

His chest x-ray is shown in Figure 1.

Figure 1. Chest x-ray on the day of injury. To view Figure 1 in a separate enlarged window click here.

Which of the following are true? (Click on the correct answer to be directed to the first of seven pages

1. His chest x-ray is normal.
2. He has fractures of the 9^th and 10^th right ribs.
3. He can be discharged from the hospital
4. 1 and 3
5. None of the above

Cite as: VonEssen SG. January 2025 Critical Care Case of the Month: A 35-Year-Old Admitted After a Fall. Southwest J Pulm Crit Care Sleep. 2024;30(1):1-4. doi: https://doi.org/10.13175/swjpccs036-24 PDF

October 2024 Critical Care Case of the Month: Respiratory Failure in a Patient with Ulcerative Colitis

Lewis J. Wesselius MD

Pulmonary Department

Mayo Clinic Arizona

Scottsdale, AZ USA

History of Present Illness

The patient is a 57-year-old woman with a history of ulcerative colitis (UC) complicated by toxic megacolon with subsequent colectomy. She presented to the emergency department with cough, shortness of breath and hypoxemia (87% on RA).

PMH, SH

• UC with history of toxic megacolon (4 years prior) with a total colectomy.
• History of a prior episode of respiratory failure a year earlier thought possibly medication-induced (ustekinumab, Stelara®) which she was taking for her UC. She was treated with steroids with a good response.
• Pyoderma gangrenosum of both ankles (attributed to UC).
• Anemia of chronic disease.
• She is a lifelong non-smoker.
• No exposures to toxic dusts, birds, down, humidifiers, mold or other antigens associated with hypersensitivity pneumonitis.

Physical Exam

• Afebrile, Oxygen saturation 94% on 2 lpm supplemental oxygen.
• Chest: crackles noted at left base.
• CV regular rhythm, no murmur.
• Ext: scarring and erythema on both ankles consistent with resolving pyoderma gangrenosum.

Current Medications

• Clonazepam 1.0 mg daily at bedtime
• Gabapentin 300 mg TID
• Pantoprazole 40 mg BID
• Prednisone 5 mg daily

Laboratory

• Hgb 9.7, WBC 16.9
• Swabs for Influenza A/B and Covid were negative
• Cocci serology negative

A chest radiograph was performed (Figure 1).

Figure 1. Portable chest X-ray performed in the emergency department. (To view Figure 1 in a separate, enlarged window click here).

Which of the following is/are true regarding the chest X-ray?

1. There is a left lower lobe consolidation.
2. The portable chest X-ray may be normal.
3. A chest CT scan is required to definitely view any consolidation.
4. There is a right upper lobe consolidation.
5. All of the above.

Cite as: Wesselius LJ. October 2024 Critical Care Case of the Month: Respiratory Failure in a Patient with Ulcerative Colitis. Southwest J Pulm Crit Care Sleep. 2024;29(4):30-33. doi: https://doi.org/10.13175/swjpcc2046-24 PDF

July 2024 Critical Care Case of the Month: Community-Acquired Meningitis

Robert A. Raschke MD

The University of Arizona College of Medicine – Phoenix

Phoenix, AZ USA

History of Present Illness

A 59-year-old man was brought to our emergency department at 0300 with a possible stroke. He was last known well at 2230 the previous evening, when he complained of severe headache and took some acetaminophen before going to bed. His wife (who provided all history) noted that the patient awoke about midnight, vomited and took some naproxen. The wife next heard the patient awake at 0230, and found him back in the bathroom vomiting again, slow to respond, “mumbling” and confused. The wife was able to get the patient into their car with some difficulty and drove him to the ER.

Past Medical History, Social History, Family History

Only minimal past medical history was elicited. There was no known trauma, no fever and no recent illnesses. The patient took no prescription medications. He did not have any history of neurological disease or of substance abuse.

Physical Examination

Vitals from the ER at 0300 included: BP 157/130 mmHg, HR 101 bpm, RR 16 bpm, temperature 97.7°F.

The patient was described as “non-toxic appearing.” His eyes were open, but he was mute and didn’t obey commands. His Glascow Coma Scale was E4, V1, M5. Formal strength testing wasn’t performed, but he was observed to spontaneously move his arms. No facial asymmetry was noted.

Hospital Course

A “Stroke alert” was called based on the clinical presentation. The laboratory evaluation was significant for: WBCC 14.9x10⁹/L, hemoglobin 13.2 g/L, platelets 181x10⁹/L; Na 135 mmol/L, K 4.0 mmol/L, Cl 100 mmol/L, CO2 23 mmol/L, BUN 14 mg/dL, creatinine 0.7 mg/dL, glucose 349 mg/dL and INR 1.0. A procalcitonin was elevated at 0.8 ng/mL. Urinalysis showed >500 mg/dL glucose, moderate leukocyte esterase, WBCC 19/hpf, and no bacteria. A urine drugs of abuse screen was negative. CT head, CTA head/neck and brain perfusion scans were all negative for acute abnormalities. A virtual stroke neurologist recommended against lytics and/or thrombectomy, due to the lack of radiographic evidence of a large vessel occlusion.

The patient was admitted to the family medicine service. Ceftriaxone 1gm was administered for a presumed urinary tract infection. His temperature was retaken at 0630, at which time it had risen to 102.7°F. At 0730 the patient became agitated, diaphoretic and his SpO₂ fell to 79%. His BP was 223/139 mmHg, HR 115 bpm, and RR 53 bpm and he was emergently intubated and transferred to the ICU.

Which of the following is false regarding the clinical findings of community-acquired bacterial meningitis? (Click on the correct answer to be directed to the second of 5 pages)

1. Fifty percent of patients present within 24 hours of symptom onset.
2. The majority of patients have the classic triad of fever, stiff neck and altered mental status.
3. Ninety-five percent of patients have at least two of four findings: (headache, fever, stiff neck and altered mental status).
4. Patients may less commonly present with community-acquired hemiplegia, aphasia, seizure, and cranial nerve deficits.
5. All are true.

Cite as: Raschke RA.  2024 Critical Care Case of the Month: Community-Acquired Meningitis. Southwest J Pulm Crit Care Sleep. 2024;29(1):1-5. doi: https://doi.org/10.13175/swjpccs027-24 PDF