July 2014 Critical Care Case of the Month: There Is Still a Role for Physical Examination

Robert A. Raschke, MD 

Banner Good Samaritan Medical Center

Phoenix, AZ

History of Present Illness

A 90-year-old woman was the seatbelt-restrained driver in a low speed frontal motor vehicle collision with airbag deployment, after she accidentally hit the gas instead of the brake. In the emergency room, the patient’s main complaint was right shoulder pain. On ER physical exam, she had sternal ecchymosis consistent with “seatbelt sign”. Her right shoulder was said to be tender, but the mechanism of injury to the right shoulder was unclear since her drivers-side seatbelt would been in contact with her left rather than right shoulder. Her right upper extremity was said to be “weak secondary to pain”. Further neurological examination was noted to be difficult due to “patient crying out in pain and anxiety”, but it was noted that she could lift both legs off the bed. Her left knee was echymotic. Cardiac auscultation revealed irregularly irregular rhythm.

PMH

• Chronic atrial fibrillation
• Coronary artery disease
• Hypertension

Medications

• Warfarin
• Aspirin
• Clonidine
• Metoprolol

Labs performed in the emergency room showed an INR 1.9. Radiographs demonstrated a normal right shoulder and a left patellar fracture. CT scans of the cervical spine and chest showed no bony abnormalities. An incidental 4 cm thoracic aortic aneurysm was noted. CT of the brain showed periventricular white matter hyperlucencies consistent with small vessel disease. The patient became a bit drowsy after receiving narcotic analgesia in the emergency room and was transferred to the medical ICU for management of pain and delirium.

ICU Physical Examination

In the medical ICU the patient was alert, and seemed much younger than 90 years of age, with a sharp wit. She complained of 10/10 shoulder pain at rest which occasionally made her wince, cry out in pain and move her shoulder – however, she said there was no position in which her shoulder did not hurt. There were no ecchymosis of the shoulder, and it could be passively abducted and rotated without worsening the pain. The initial neurological examination was cursory and unrevealing because the patient was distracted by pain, and her left leg was immobilized.  A short time later the nurse reported that she felt the patient’s right leg was weak and the neurological exam was repeated. Strength in the patient’s right leg was 1/5, her left leg was immobilized, but ankle extension was 5/5. She could not cooperate well with strength testing of her painful right arm, but her right grip was 2/5 with a normal strength in her left arm and hand. Toes were down-going and reflexes were generally hypoactive. She was not aphasic. Neurology was consulted.

Which of the following is true in regards to this patient’s neurological findings? (Click on the correct answer to proceed to the next panel)

1. A cervical spinal cord injury could explain these findings
2. A seat belt injury of the left carotid artery could have resulted in traumatic dissection and subsequent stroke
3. Right hemiparesis without aphasia could represent a lacunar stroke
4. They might represent a cardio-embolic stroke related to her history of atrial fibrillation
5. All of the above

Reference as: Raschke RA. July 2014 critical care case of the month: there is still a role for physicial examination. Southwest J Pulm Crit Care. 2014;9(1):8-14. doi: http://dx.doi.org/10.13175/swjpcc086-14 PDF

Ultrasound For Critical Care Physicians: Neutropenic Patient With Fever and Shortness of Breath

Erik Kraai MD

Michel Boivin MD

Division of Pulmonary / Critical Care and Sleep

University of New Mexico

Albuquerque, NM

A 63 year old female with a history of acute myelogenous leukemia presents with shortness of breath, fever and hypotension to the ICU. She is in septic shock on norepinephrine, and has been treated on the oncology unit with vancomycin, cefepime, acyclovir and voriconazole. She has been neutropenic for 1 month. The patient develops a progressive right lower chest opacity. This opacity has progressed in spite of antibiotics and antifungals. The portable AP chest radiograph is presented below (Figure 1). 

Figure 1. Portable AP of chest.

An ultrasound of the right chest was performed for further evaluation of the opacity (figure 2). 

Figure 2. Ultrasound of right hemithorax.

Question: What pathology does the ultrasound reveal in the right hemithorax? (Click on the correct answer to proceed to the next panel)

1. Air filled cavity
2. Chest wall abscess
3. Fractured ribs
4. Pleural effusion and suspected empyema
5. Simple consolidation

Refernece as: Kraai E, Boivin M. Ultrasound for critical care physicians: neutropenic patient with fever snd shortness of breath. Southwest J Pulm Crit Care. 2014;8(6):330-3. doi: http://dx.doi.org/10.13175/swjpcc073-14 PDF

June 2014 Critical Care Case of the Month: Acute Exacerbation in Cystic Fibrosis

Seongseok Yun, MD PhD¹ 

Juhyung Sun, BS²

Laura Howe, MD¹

Roberto Bernardo, MD¹

Sepehr Daheshpour, MD¹

Department of Medicine¹

College of Medicine²

University of Arizona

Tucson, AZ 85724

History of Present Illness

A 28 year-old woman with a history of cystic fibrosis, presented with worsening shortness of breath and cough associated with productive secretions. She was diagnosed with cystic fibrosis when she was 14 months old, and has a history of multiple inpatient admissions for acute pulmonary exacerbation of cystic fibrosis. Her most recent hospitalization was a month prior to this admission, and sputum culture demonstrated methicillin-resistant Staphylococcus aureus, multidrug-resistant Pseudomonas aeruginosa, and Achromobacter xylosoxidans. She was treated with linezolide, meropenum, colistin, and azithromycin with significant symptom improvement, then, discharged home with ciprofloxacin, linezolide and zosyn. However, she developed worsening respiratory distress again and came back to hospital. In the emergency department she required 10 L/min of oxygen to maintain an SpO₂ above 90 %.

PMH

• Cystic fibrosis
• Seizure
• Kidney stone
• Portacath placement
• Gastrostomy tube placement

Medications

• Azithromycin 500 mg 3 times a day
• Dornase alpha 1 mg/ml nebulizer twice a day     
• Fluticasone-salmeterol 500-50 mcg/dose inhaler twice a day
• Lipase-protease-amylase 21,000-37,000-61,000 unit 4 caps a day
• Cholecalciferol  2,000 unit capsule daily
• Ferrous sulfate 325 mg PO twice a day
• Ascorbic acid 250 mg PO twice a day
• Oxycodone-acetaminophen  10-325 mg 4 times a day as needed

Social History

• No smoking
• No alcohol use
• No recreational drug use

Physical Examination

Vital signs: Temperature 37.3 °C, heart rate 114 beats/min, respiratory rate 20-24 breaths/min, blood pressure 99/69mmHg, SpO2 88-90 % on 10 L NC

General: Alert and oriented X 3, acutely distressed, tachypneic and dyspneic

Skin: Diaphoretic. No rash or lesions.

HEENT: Unremarkable.

Respiratory: Diffuse rales in all lung fields, no wheezing, no stridor

CVS: Tachycardic, regular rhythm, no murmur.

Abdomen: Soft, non-tender, no tenderness, no guarding, no hepato-splenomegaly, PEG tube placed

Lymphatics: No cervical or axillary lymphadenopathy

Extremities: No clubbing, no cyanosis, no peripheral edema, normal tone, normal range of movement

Neurological: Normal speech, no focal neurologic deficit, CN exam within normal range

Laboratory

CBC: WBC 11.9X 10³ /μL, Hb 9.8 g/dL, Hct 30.7%, Platelets 356,000 /μL.

Chemistries: Na⁺ 137 meq/L, K⁺ 4.1 meq/L, Cl^- 107 meq/L, CO₂ 22 mmol/L, blood urea nitrogen (BUN) 13 mg/dL, creatinine 0.7 mg/dL, glucose 106 mg/dL, calcium 8.0 mg/dL, albumin 2.6 g/dL, liver function tests within normal limits.

Prothrombin time (PT) 14.0 sec, international normalized ratio (INR)1.1, partial thromboplastin time (PTT) 37.2sec

Pulmonary Function Test

FVC 48 % (1.95 L), FEV₁ 36 % (1.25 L), FEF_25-75 14 % (0.55 L/sec)

Radiography

An old chest x-ray and thoracic CT scan were reviewed (Figure 1).

Figure 1. Previous PA (Panel A), lateral (Panel B) chest x-ray and representative image from the thoracic CT scan (Panel C).

Which of the following are findings of cystic fibrosis on chest x-ray? (Click on the correct answer to move to the next panel)

1. Bronchiectasis
2. Hyperinflation
3. Lobar collapse
4. Prominent pulmonary arteries
5. All of the Above

Reference as: Yun S, Sun J, Howe L, Bernardo R, Daheshpour S. June 2014 critical care case of the month: acute exacerbation in cystic fibrosis. Southwest J Pulm Crit Care. 2014;8(6):305-19. doi: http://dx.doi.org/10.13175/swjpcc047-14 PDF

Ultrasound for Critical Care Physicians: Really, At Her Age?

A 71 year old woman presented with dyspnea since late 2013 and denies a prior history of dyspnea. She had a cardiac pacemaker placed in 2008 for sick sinus syndrome. Her physical exam was unremarkable and her SpO2 was 96% on room air. However,  it decreased to 84% with exercise. Chest x-ray and pulmonary function testing were unremarkable (a DLco was unable to be performed). A transthoracic echocardiogram was performed (Figure 1).

Figure 1. Movie with Doppler flow of transthoracic echocardiogram. 

Which of the following best explains the patient's dyspnea and hypoxia? (Click on the correct answer to proceed to the next panel)

1. Cardiac tamponade
2. Decreased cardiac contractility
3. Intracardiac shunt
4. Mitral insufficiency
5. Ventilation perfusion mismatch from COPD

Reference as: Wesselius LJ. Ultrasound for critical care physicians: really, at her age? Southwest J Pulm Crit Care. 2014;8(5):278-9. doi: http://dx.doi.org/10.13175/swjpcc061-14 PDF

May 2014 Critical Care Case of the Month: Second Wind

Kenneth K. Sakata, MD

Sudheer Penupolu, MD 

Robert W. Viggiano, MD

Department of Pulmonary Medicine

Mayo Clinic Arizona

Scottsdale, AZ

History of Present Illness

A 65 year old woman was admitted for gastrointestinal bleeding as evidence by hematochezia. At the time of admission she denied any respiratory symptoms other than mild dyspnea. However, she rapidly developed respiratory failure, was transferred to the ICU and required emergent intubation.

PMH, FH, SH

She has a history of rheumatoid arthritis with a cervical spine fusion. There is also a history of sarcoidosis and she was receiving prednisone 30 daily up until the time of admission. There is no significant family history. She does not smoke or drink.

Physical Examination

Afebrile. Pulse 78. BP 105/65 mm Hg. Respirations: 28. SpO2 96% while receiving an FiO2 of 60% at the time of transfer to the ICU.

Neck: No jugular venous distention.

Lungs: Scattered rales and rhonchi.

Cardiovascular: Regular rhythm. 

Abdomen: no hepatosplenomegaly.

Radiography

A portable chest x-ray taken after intubation is shown in figure 1.

Figure 1. Portable chest x-ray taken shortly after intubation.

Which of the following best describe the chest x-ray? (Click on the correct answer to move to the next panel)

1. Chronic interstitial disease
2. Diffuse consolidation
3. Endotracheal tube in the right mainstem bronchus
4. Small right pneumothorax
5. All of the above

Reference as: Sakata KK, Penupolu S, Viggiano RW. May 2014 critical care case of the month: second wind. Southwest J Pulm Crit Care. 2014;8(5):258-65. doi: http://dx.doi.org/10.13175/swjpcc033-14 PDF