August 2013 Critical Care Case of the Month: My, That’s a Big One

Andrew Waas, M.D.

Pulmonary Sciences and Critical Care Medicine

University of Colorado Hospital

Denver, Co

History of Present Illness

A 75 year old male presented to the emergency department with complaints of three days of increasing nausea, generalized weakness, and dyspnea on exertion.  He had undergone a radical prostatectomy 13 days prior to presentation from which he was recovering well until the onset of these symptoms. There was no associated chest pain, cough, fevers, chills or weight loss.

PMH, SH, FH

He had a history of hypertension and prostate cancer for which he underwent a recent prostatectomy.

He was born in Colorado and had not traveled recently.  There was no history of tobacco use, he drank ethanol on rare occasions, and did not use any illicit drugs. 

There was no family history of illnesses of which he was aware.

Medications

• Dutasteride 0.5 mg daily
• Telmisartan 40 mg daily

Physical Exam

Blood pressure 142/85, heart rate 108, temperature 36.7 C, respiratory rate 25, saturating 95% on 2L oxygen. 

Generally, he was in no distress, but was slightly tachypneic.  Lungs were clear to auscultation bilaterally and he was tachycardic but regular.  Otherwise, his exam was normal. 

Laboratory

Laboratory evaluation revealed a mild leukocytosis at 13 x 10⁶ cells/mcL with 72% neutrophils and 20% lymphocytes.  His basic metabolic panel (including creatinine) was normal; his liver function tests were likewise normal. 

Chest Radiography

His initial portable chest x-ray is shown in Figure 1.

Figure 1. Initial portable chest x-ray

Which of the following best describes the chest x-ray?

1. Cardiomegaly
2. Cavitating lung mass
3. Multifocal infiltrates
4. All of the above
5. None of the above

Reference as: Waas A. August 2013 critical care case of the month: my, that's a big one. Southwest J Pulm Crit Care. 2013;7(2):66-74. doi: http://dx.doi.org/10.13175/swjpcc096-13 PDF