February 2014 Critical Care Case of the Month: A Rush of Blood

Maja Udovcic MD

Sudheer Penupolu MD

Robert W. Viggiano MD

Lewis J. Wesselius MD

Department of Pulmonary Medicine

Mayo Clinic Arizona

Scottsdale, AZ

History of Present Illness

A 51 year old African-American woman was admitted from the emergency department with hemoptysis. She had blood tinged sputum earlier in the day followed by about ½ cup of hemoptysis which led her to seek care.

PMH, SH, FH

She is known to have stage IV sarcoidosis with bronchiectasis and cavitation. A right upper lobectomy was performed in 1996 and embolization of  

3 left bronchial arteries in 2011 for hemoptysis. She has a history of anaphylaxis with iodinated radiocontrast dye. However, no reaction occurred with premedication in 2011. She also has a history of asthma, but has been out of her medications for several days. Since this time she has noted increased cough. She is a nonsmoker and a Jehovah’s Witness. Her family history is noncontributory.

Medications

• Albuterol HFA
• Montelukast
• Fluticasone propionate nasal spray
• Loratidine

Physical Examination

VS:  36.9°C, 106 beats/min, 135/83 mm Hg, 26 breaths/min, SpO2 100% on room air

General: She is in no acute distress.  

Respiratory: coarse breath sounds with scattered wheezing, inspiratory crackles, and diminished air movement throughout

Which of the following laboratory tests should be ordered? (click on correct answer to move to next panel)

1. Blood urea nitrogen
2. Coagulation profile (PT, INR, APTT)
3. Complete blood count
4. 2 + 3
5. All of the above

Reference as: Udovcic M, Penupolu S, Viggiano RW, Wesselius LJ. February 2014 critical care case of teh month: a rush of blood. Southwest J Pulm Crit Care. 2014:8(2):79-87. doi: http://dx.doi.org/10.13175/swjpcc165-13 PDF

Ultrasound for Critical Care Physicians: Hypotension

A 68 year old man is transferred to the intensive care unit because of hypotension. An ultrasound of the heart and inferior vena cava (IVC) were performed (Figure 1).

Figure 1. Upper panel: subxiphoid view of heart. Lower panel: inferior vena cava.

What is the cause of the hypotension? (Click on the correct answer)

1. Cardiogenic shock secondary to cardiomyopathy
2. Intracardiac thrombus
3. Intravascular volume depletion
4. Massive pulmonary embolism
5. Pericardial effusion

Reference as: Mosier JM. Ultrasound for critical care physicians: hypotension. Southwest J Pulm Crit Care. 2013;8(1):41-3. doi: http://dx.doi.org/10.13175/swjpcc176-13 PDF

January Critical Care Case of the Month: Bad Cough

Bhupinder Natt MD

Linda Snyder MD

Janet Campion MD

University of Arizona Medical Center

Tucson, AZ

History of Present Illness

A 41 year-old man was admitted with a five-day history of cough, shortness of breath, and fever to 102° F. He was recently diagnosed with a high-grade astrocytoma of the brain and had undergone resection followed by chemotherapy with temozomide (an alkylating agent) and radiation therapy. 

PMH

• Renal transplantation (1993)
• Glioblastoma (astrocytoma grade 4)
• Crohn’s disease treated with budesonide and meselamine

Medications

• Dexamethasone 2 mg PO BID
• Keppra 500 mg PO BID
• Tacrolimus 1.5 mg PO AM and 1mg PO PM
• Mycophenolate 750 mg PO BID
• Budesonide 3 mg PO daily
• Meselamine 1600 mg PO TID
• Sulfamethoxazole/trimethoprim DS PO on Mon/Wed/Fri
• Temozolomide 75 mg IM with radiotherapy

Social History

Nonsmoker, no ethanol or recreational drugs, no recent travel, and no occupational exposures.

Physical Examination

T 38.6°C, P 112 beats/min, RR 32-40 breaths/min, BP 119/76 mm Hg, SpO2 100% on NRB

General: Fatigued, ill appearing and dyspneic.

Skin: No rash or lesions, well-healed craniotomy scar

HEENT: Dry oral mucosa, pupils and extra-ocular muscles normal

Respiratory: Reduced breath sounds, fine crackles throughout all lung fields, no wheezing

CVS: Hyperdynamic precordium, tachycardia without murmur, no elevation of jugular venous pressure (JVP), peripheral vascular exam normal.

Abdomen: Soft, non-distended, no hepato-splenomegaly, normal bowel sounds.

Lymph: No cervical lymphadenopathy

Extremities: No edema, normal muscle bulk and tone.

Laboratory

WBC 11 X 10³/µL, Hemoglobin 9.8 g/dL, Hematocrit 30%, Platelets 264,000/ µL

Na⁺ 135 meq/L, K⁺ 4.2 meq/L, Cl⁻ 111 meq/L, CO2 14 mmol/L, blood urea nitrogen (BUN) 46 mg/dL, creatinine 1.7 mg/dL, glucose 132 mg/dL, calcium 10.5 mg/dL, albumin 1.5 g/dL, liver function tests-within normal limits

Prothrombin time (PT) 15 sec, international normalized ratio (INR) 1.2, partial thromboplastin time (PTT) 29.9 sec

Chest X-ray

Figure 1. Admission PA (Panel A) and lateral (Panel B) chest x-ray.

What is the best description of the chest x-ray? (click on correct answer to move to next panel)

1. Bibasilar consolidation
2. Bilateral diffuse nodules
3. Pneumomediastinum with subcutaneous emphysema
4. Pulmonary edema with evidence of pulmonary hypertension
5. Subdiaphragmatic free air

Reference as: Natt B, Snyder L, Campion J. January critical care case of the month: bad cough. Southwest J Pulm Crit Care. 2014;8(1):20-6. doi: http://dx.doi.org/10.13175/swjpcc161-13 PDF

Ultrasound for Critical Care Physicians: Unique

A 22-year-old man is seen for shortness of breath. Cardiac ultrasound / echocardiography is performed (Figure 1).

Figure 1. Cardiac ultrasound.

Which of the following best describes the ultrasound? (click on correct answer to move to next panel)

1. Enlarged left atrium
2. Enlarged left ventricle
3. Enlarged right atrium
4. Enlarged right ventricle
5. Normal

Reference as: Gotway MB. Ultrasound for critical care physicians: unique. Southwest J Pulm Crit Care. 2013;7(6):336-7. doi: http://dx.doi.org/10.13175/swjpcc148-13 PDF

December 2013 Critical Care Case of the Month: I Don’t Have a Drinking Problem

Robert Raschke MD

Elijah Poulos MD

Adam Bosak MD

Critical Care Medicine

Banner Good Samaritan Medical Center

Phoenix, AZ

History of Present Illness

A 69-year-old male retired diabetic police officer was admitted to the ICU with intractable vomiting, severe abdominal pain and acute blindness. About a week prior, he suffered urinary frequency and was prescribed ciprofloxacin at urgent care with a presumptive diagnosis of urinary tract infection.  Over the course of the week his urinary frequency resolved and he became anuric, he developed progressively worsening nausea and eventually vomiting to the point that he was unable to keep anything down, and severe bilateral lower abdominal and pelvic pain.    His wife and son actually forced him into the ER when he became blind the day of admission. He denied fever, dysuria, cough and headache.   In our emergency room he was noted to be in moderate distress with tachycardia, tachypnea, hyperpnoea and completely blind in both eyes unable to discern even simple shadows.

PMH, SH, FH

The patient is a retired police officer with a past medical history of diabetes mellitus and benign prostatic hypertrophy.  The patient denied alcohol, tobacco, or illicit drug use. He works out at a local gym almost daily since being diagnosed with diabetes a couple of years ago.

Medications

• Glipizide
• Metformin
• Tamsulosin

Physical Exam

Blood pressure160/95 mmHg with a heart rate of 110, respiratory rate 35, SpO2 99% on 2 lpm nasal cannula, and temp 36.0° C.  He appeared uncomfortable and moderately distressed, lethargic but arousable with GCS 13. He was able to briefly answer simple questions. His eyes were conjugate, but did not track nor fix on objects placed in front of his eyes, and he could vaguely discern the light of a bright flashlight shined into both eyes. His pupils were 3-4 mm and fixed, with no light reflex elicitable, even with magnified examination of the pupil using an ophthalmoscope.  On fundoscopic exam his discs were flat, and there were no hemorrhages or other lesions seen.  He was tachycardic but regular with normal heart tones, and a bedside echocardiogram showed good left ventricular function.  He had Kussmaul breathing with an odor of ketones and clear lungs. The lower abdomen was distended and tender, and a Foley catheter insertion returned 2 liters of yellow urine which resolved his abdominal pains.  He had no peripheral edema and his hands were cool.  The rest of his physical examination was unremarkable.

Laboratory Evaluation

Initial laboratory evaluation included a white blood count 24.3 K/mm3 with 79% segmented neutrophils and no bands, hemoglobin 14.7 g/dL; sodium 138 mmol/L;  potassium 5.1 mmol/L; chloride 92 mmol/L; and CO₂ 4 mmol/L, yielding an anion gap of 44 when corrected.  His BUN was 116 mg/dL; creatinine of 7.7 mg/dL.  A venous blood gas showed a pH 6.77 pCO₂ 17 mmHg; pO₂ 73 mmHg; bicarbonate of 3 mmol/L. Urinalysis showed negative leukocyte esterase, 1-5 leukocytes per HPF, glycosuria and ketonuria.

Radiology Evaluation

Admission chest x-ray is in Figure 1. 

Figure 1. Admitting chest radiograph.

Computerized tomography of the abdomen showed no urinary tract obstruction (was performed after the Foley catheter was placed) and no other significant findings. Piperacillin/tazobactam and gentamicin were started for possible urinary tract infection with sepsis.

Which of the following is the best fits the clinical presentation explaining both his metabolic abnormalities and blindness? (click on correct answer to move to next panel)

1. Acute renal failure
2. Alcoholic ketoacidosis
3. Diabetic ketoacidosis
4. Ethylene glycol ingestion
5. Methanol ingestion

Reference as: Raschke RA, Poulos E, Bosak A. December 2013 critical care case of the month: I don't have a drinking problem. Southwest J Pulm Crit Care. 2013;7(6):328-35. doi: http://dx.doi.org/10.13175/swjpcc141-13 PDF