Patient Presentation
Chief Complaint
“My chest hurts, I can't catch my breath, and this cough is getting
worse.”
HPI
Justin Case is a 60-year-old man with a past medical history
significant for myocardial infarction who was admitted to the
hospital 5 days ago to undergo a scheduled surgical procedure
following a recent diagnosis of colorectal adenocarcinoma with
metastatic lesions to the liver. The patient was taken to the
operating room (OR) on hospital day 2 and underwent an
exploratory laparotomy, diverting ileostomy, and Hickman port
placement in preparation for chemotherapy. Postoperatively, the
patient was transferred to the progressive intensive care unit
(PICU) for his recovery without complication. The patient had no
new complaints until hospital day 5 when he complained of
retrosternal crushing chest pain radiating to the left shoulder and
left jaw, shortness of breath, and a worsening cough with sputum
production. The patient was noted to be in respiratory distress
with a RR of 43, HR 153, BP 162/103, and O2 saturation of 87%.
The patient was then transferred to the medical ICU and
underwent endotracheal intubation due to worsening respiratory
status. Cardiac markers were obtained, given the patient's
symptoms and history of MI. Blood and sputum cultures were
obtained after patient transfer.
PMH
Coronary artery disease, S/P MI 3 years ago for which he did not
undergo any surgical intervention
SH
Lives with his wife
Smokes one ppd × 40 years
Denies alcohol or illicit drug use
Meds
Patient states that he did not take any medications at home.
Hospital medications include (ICU medication list):
Aspirin 325 mg po daily
Enoxaparin 70 mg subcutaneously every 12 hours
Esomeprazole 40 mg po daily
Fentanyl 25 mcg/h IV continuous infusion
Lorazepam 2 mg/h IV continuous infusion
Metoprolol 25 mg po every 12 hours
Morphine 1–2 mg IV every 1–2 hours as needed for
chest pain
Nicotine patch 21 mg per day applied daily
All
NKDA
ROS
Patient is experiencing significant chest pain, shortness of breath,
and a cough with sputum production. He denies nausea, vomiting,
or difficulty urinating. He complains of mild abdominal pain near
his ostomy and incision sites.
Physical Examination
Gen
WDWN Caucasian man, initially anxious, ill-appearing, and in
moderate respiratory distress; now, S/P endotracheal intubation
and in NAD
VS
BP 162/103, P 147, RR 42, T 38.5°C; Wt 70 kg, Ht 5′6″
Skin
Warm; no rash; no skin breakdown
HEENT
PERRLA; moist mucous membranes
Neck/Lymph Nodes
Supple; no lymphadenopathy
Lungs/Thorax
Scattered rhonchi with expiratory wheezing; diffuse bilateral
crackles; decreased breath sounds in bilateral bases; right IJ port-acath intact without erythema
CV
Tachycardic with regular rhythm; no MRG
Abd
Soft; mildly distended; hypoactive BS; large liver palpated in RUQ;
ileostomy in RLQ is pink and functioning; surgical incision is C/D/I.
Genit/Rect
Deferred
MS/Ext
1+ pitting edema; 2+ pulses bilaterally; good peripheral perfusion
Neuro
Prior to intubation, A & O × 3; CN II–XII intact; patient is now
intubated and sedated.
Labs
Lab Parameter
Admission
Hospital Day 5
Na (mEq/L)
130
141
K (mEq/L)
4.1
5.1
Cl (mEq/L)
92
110
CO2 (mEq/L)
24
19
BUN (mg/dL)
22
34
SCr (mg/dL
1
1.1
Glu (mg/dL
113
148
Ca (mg/dL
9.4
9.2
WBC (mm− 3)
9.5 × 103
17 × 103
Neutros (%)
89
88
Bands (%)
0
5
Lymphs (%)
5
4
Monos (%)
6
3
Eos (%)
0
0
11.9
12.4
Hgb (g/dL)
Hct (%)
35
37
Plts (mm− 3)
448 × 103
584 × 103
Cardiac Markers
CK 871 IU/L, troponin-I 1.23 ng/mL
ABG
pH 7.39; PaCO2 30; PaO2 51 with 87% O2 saturation on room air
(preintubation)
pH 7.44; PaCO2 29; PaO2 89 with 100% O2 saturation on 40%
inspired oxygen (postintubation)
Chest X-Ray
New bilateral opacities are noted in the left upper lobe and right
middle lobe; likely infectious process. Some increased alveolar
infiltrates in the perihilar location and involving the lower lobes.
Chest CT Scan with IV Contrast
No evidence of pulmonary embolism. The heart size is normal.
There are small mediastinal and axillary lymph nodes; none are
pathologically enlarged. There are small bilateral pleural effusions
with adjacent atelectasis. There are pleural-based airspace opacities
within the left upper lobe and right middle lobe; this is most
consistent with an acute infectious process.
EKG
Sinus tachycardia, low voltage QRS, septal infarct (age
undetermined); ST- and T-wave abnormality; consider inferior
ischemia. Inverted T waves noted in the inferior leads.
Sputum Gram Stain
>25 WBC/hpf, <10 epithelial cells/hpf, 1+ (few) gram-positive
cocci, 3+ (many) gram-negative rods
Sputum Culture
Pending
Blood Cultures × Two Sets
Pending
Assessment
Presumed bilobar HAP involving the LUL and RML
Postoperative NSTEMI