Ultrasound for Critical Care Physicians: Right Diagnosis, Wrong Place

The patient was a 76 year old man, with a history of a prosthetic aortic valve (aortic stenosis) and chronic myelogenous leukemia.  He presented with fever and cough, and was found to have pneumonia with Klebsiella pneumonia cultured from a BAL. However, he also had persistent Enterococcus faecalis bacteremia and a new 3/6 diastolic murmur. 

An ultrasound of the heart was performed (Figures 1 and 2).

Figure 1. Parasternal long axis view of the heart.

Figure 2. Four chamber view of the heart.

Which of the following is the likely diagnosis?

1. Aortic dissection
2. Aortic valve endocarditis
3. Displacement of the aortic valve
4. Mitral valve endocarditis
5. Tricuspid endocarditis

Reference as: Raschke RA. Ultrasound for critical care physicians: right diagnosis, wrong place. Southwest J Pulm Crit Care. 2013;7(4):232-5. doi: http://dx.doi.org/10.13175/swjpcc123-13 PDF

October 2013 Critical Care Case of the Month: Slow to Respond

Michael P. Mohning, MD

Pulmonary Sciences and Critical Care Medicine

University of Colorado Hospital

Denver, CO

History of Present Illness

A 66-year-old woman presents with confusion and lower extremity edema. She was brought to the emergency department by her family after 2-3 days of increasing confusion.  She has fatigue and a dry non-productive cough but denies shortness of breath, chest pain, fevers or chills. She had a decrease in oral intake and constipation for several days.

PMH, SH, FH

Five months ago, she was admitted to a hospital for community acquired pneumonia and hyponatremia. She is a never smoker, and doesn’t use alcohol.

There is no significant family history.

Medications

• Omega 3 fatty acids
• Multivitamins

Physical Examination

Temperature 36.1° C, blood pressure 106/61 mm Hg, heart rate 72 beats/min, respiratory rate 15 breaths/min, oxygen saturation 90% on room air.

She was confused, and oriented to self only.  She had facial edema.  Cardiac exam was normal. Pulmonary findings include rales at the lung bases. Her abdomen was non-tender, with active bowel sounds. She had 1+  lower extremity edema, no rashes, and delayed relaxation of reflexes.

Laboratory

She was anemic with hematocrit of 32%, hemoglobin 11 g/dL and WBC 5,000. Serum sodium is low at 118 meq/L, anion gap was normal at 9 and potassium and calcium levels were normal. Albumin is low at 3.2 g/dL. Remaining liver function, blood glucose and creatinine are normal. EKG shows no T wave inversions or ST segment elevation.

Radiography

Chest x-ray is shown in figure 1.

 

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

Which best describes the chest-x-ray?

1. Bilateral interstitial infiltrates
2. Enlarged cardiac silhouette
3. Hyperexpanded lungs
4. Poor inspiratory effort
5. Pulmonary edema

Reference as: Mohning MP. October 2013 critical care case of the month: slow to respond. Southwest J Pulm Crit Care. 2013;7(4):214-20. doi: http://dx.doi.org/10.13175/swjpcc105-13 PDF

Ultrasound for Critical Care Physicians: Connecting Disparate Symptoms

An 18-year-old woman was recently diagnosed with non-ACTH-Mediated Cushing syndrome, now with a complaint of mild shortness of breath.

Her cardiac exam showed normal sinus rhythm at 84 beats per minute and blood pressure of 130/80 mmHg. Her mitral first heart sound was slightly accentuated, but the pulmonic sound was normal. Grade-I diastolic murmur was heard over the mitral area. Opening snap was absent. Lungs were clear and chest radiograph showed slight cardiomegaly. She had multiple freckles on his face and trunk and along the vermillion border of the lips.

An ultrasound of the heart was performed (Figure 1).

Figure 1. Four chamber view of the heart.

Which of the following is the likely diagnosis?

1. Brugada syndrome
2. Carney syndrome
3. Gotway syndrome
4. Jervell and Lange-Nielsen syndrome
5. Peutz-Jeghers syndrome

Reference as: Gotway MB. Ultrasound for critical care physicians: connecting disparate symptoms. Southwest J Pulm Crit Care. 2013;7(3):176-8. doi: http://dx.doi.org/10.13175/swjpcc122-13 PDF

September 2013 Critical Care Case of the Month: Revenge of the Pharaohs

Robert A. Raschke, MD

Elijah Poulos, MD

Banner Good Samaritan Regional Medical Center

Phoenix, AZ

History of Present Illness

The patient was a 68 year-old man, admitted to our ICU through the emergency room (ER) in July 2013 with suspected urinary tract origin sepsis.

The patient was evaluated in ER by the ICU team. He was in his usual state of general good health until he visited his primary care physician for what he felt was a left inguinal hernia, and underwent a prostate examination, four days previously. The patient associated this prostate examination with the onset of fevers and chills that began the next morning. He was seen in an urgent care center where he was told his urinalysis was normal, and antibiotics were not prescribed. Over the intervening 3 days, he suffered recurrent fevers, had vomited three times, and had one diarrheal bowel movement. Earlier on the day of presentation, he had been mowing his lawn (in >100° F environment) and had become a little dizzy. His wife, a retired nurse, finally convinced him to report to the ER.

He denied dysuria, urinary frequency or urgency, headache, sore throat, cough, or abdominal pain.

PMH, SH, FH

He had a prior history of hypertension, gastroesophageal reflux, gout and hypercholesterolemia. He drank alcohol about twice a month and did not smoke.

There was no family history of illnesses.

Medications

• Atorvastatin
• Allopurinol
• Hydrochlorothiazide
• Lisinopril
• Temazepam

Physical Exam

On ER triage, his temperature was 41.2° C, but vitals at the time of our initial examination were temp 38.2° C, HR 93 beats/min, BP 103/48 mm Hg, and respiratory rate 20 breaths/min. He was awake and alert, but made a few errors while relating his history – for instance, he initially answered yes when asked if he had a headache, then corrected himself and said no – he meant he had a fever. He was actively rigoring. HEENT exam was unrevealing. He had no lymphadenopathy. His lungs were clear. His abdomen was soft and nontender. He had a sliding left inguinal hernia that was not tender. None of his joints were acutely inflamed. His prostate was not enlarged or tender to palpation. He had no focal neurological deficits.

Laboratory

Pertinent laboratory values in the ER:

• WBC: 7.7 x10⁹/L
• Hematocrit: 38.4%
• Sodium: 131 me/L
• Potassium: 3.1 me/L
• BUN:28 g/dL
• Creatinine: 1.3 mg/dL
• Lactate: 2.1 mMol/L.

The rest of his admission labs and urinalysis were unremarkable.

Chest Radiography

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

Figure 1. Initial portable chest x-ray.

Which of the following is the likely cause of his fever?

1. Prostatitis exacerbated by digital rectal exam
2. Right middle lobe pneumonia
3. Urinary tract infection
4. All of the above
5. None of the above

Reference as: Raschke RA, Poulos E. September 2013 critical care case of the month: revenge of the pharaohs. Southwest J Pulm Crit Care. 2013;7(3):142-50. doi: http://dx.doi.org/10.13175/swjpcc104-13 PDF

Ultrasound for Critical Care Physicians: Sickle Cell Crisis

A 32 year old man was admitted a week earlier with sickle cell pain crisis. He had developed increasing dyspnea, oxygen desaturation and bilateral pulmonary infiltrates.  He had a pulseless electric activity code blue and an ultrasound of the heart was obtained (Figure 1).

Figure 1. Subxiphoid view ultrasound of the heart.

What does the ultrasound show?

1. Aortic dissection
2. Aortic stenosis
3. Enlarged left ventricle
4. Enlarged right ventricle
5. Pericardial effusion

Reference as: Raschke RA. Ultrasound for critical care physicians: sickle cell crisis. Southwest J Pulm Crit Care. 2013:7(2):110-1. doi: http://dx.doi.org/10.13175/swjpcc113-13 PDF