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