November 2015 Critical Care Case of the Month

Monday, November 2, 2015 at 8:00AM
Rick Robbins, M.D. in differential diagnosis, garlic, hepatopulmonary syndrome, hypoxemia, liver transplantation, prognosis, right to left shunt, shunt fraction, shunting, treatment

Samir Sultan, DO

Banner University Medical Center Phoenix

Phoenix, AZ

 History of Present Illness

A 39-year-old Caucasian woman was admitted to the ICU with worsening dyspnea and increasing oxygen requirements. Her lips turned blue with minimal activity. She was admitted to another hospital 5 months earlier with pneumonia. At discharge she was placed on oxygen. At follow-up with her pulmonologist, she was diagnosed with sleep apnea.

Past Medical History, Family History, Social History

• She has a history of an optic glioma at age 7 with resection followed by radiation therapy and development of panhypopituitarism.
• Liver cirrhosis diagnosed in 2014 with presentation of hematemesis.
• Type 2 diabetes mellitus
• Denies tobacco, ethanol, or illicit drug use.
• There is a family history of diabetes and liver cirrhosis

Physical Examination

• Vital signs:110 / 86, HR 97, RR 16, 88% on 6 liter O2
• General: obese female (BMI 35) in no apparent distress
• Chest: Clear to auscultation bilaterally
• Cardiovascular: regular rate without murmur or rub
• The remainder of the physical exam is normal  

Radiography

      A chest x-ray was interpreted as normal.

Laboratory

• CBC: hemoglobin 13.8 gm/dL, WBC 7 X 103 cells/microliter with a normal differential
• Basic metabolic panel: Na⁺ 132 mEq/L, K⁺ 4 mEq/L, Cl^- 100 mEq/L, HCO3^- 22 mEq/L, glucose 150 mg/dL.
• Arterial blood gases (ABGs): PaO₂ 35 mm Hg, PaCO₂ 37 mm Hg, pH 7.43

Which of the following is/are not possible cause(s) of hypoxemia in this patient? (Click on the correct answer to proceed to the second of six panels)

1. Decreased diffusion (alveolar capillary block)
2. Ventilation-perfusion mismatch
3. Hypoventilation
4. 1 and 3
5. All of the above

Cite as: Sultan S. November 2015 critical care case of the month. Southwest J Pulm Crit Care. 2015;11(5):209-15. doi: http://dx.doi.org/10.13175/swjpcc137-15 PDF

Article originally appeared on Southwest Journal of Pulmonary, Critical Care and Sleep (https://www.swjpcc.com/).