Ismail Ayaan mukhtar abdi Mukhtar abdi ismail, Gure Maryama Abdullahi Bile

The case nr. 1

History
A 60-year-old man presented to the emergency department complaining of persistent right-
sided chest pain and cough. The chest pain was pleuritic in nature and had been present for
the last month. The associated cough was productive of yellow sputum without hemoptysis.
He had unintentionally lost approximately 30 pounds over the last 6 months and had nightly
sweats. He had denied fevers, chills, myalgias or vomiting. He also denied sick contacts or a
recent travel history. The patient smoked one pack of cigarettes daily for the past 50 years
and denied recreational drug use. He reported remote right-sided rib fractures and a wrist
fracture as a result of alcohol consumption.
Physical Exam
His blood pressure was 125/71 mm Hg, heart rate of 122/min, temperature 38 gr.C,
respiratory rate 33/min, and oxygen saturation 77% on room air and 92% on 40% venti-mask.
The heart exam revealed tachycardia but regular rhythm, a normal S1 and S2 and no
murmurs, gallops or rubs. On auscultation of the lung fields, breath sounds were diminished
on the right side in the upper zone without the presence of adventitious sounds. The abdomen
was benign without organomegaly. The patient’s extremities were normal with absence of
clubbing or edema. He was oriented only to person, and had an inability to pay attention or
remember immediate events. He was moving all four extremities with slightly brisk deep
tendon reflexes. Neck was supple and the pupils were brisk in reacting to light.
Lab
White blood cell count was 11,000/mm3 with 38% neutrophils, 8% lymphocytes, 18 %
monocytes and 35% bands, Hematocrit 33%, Platelet count was 187,000/mm3, Serum
sodium was 125 mmol/L, potassium 3 mmol/L, chloride 91 mmol/L, bicarbonate 21 mmol/L,
blood urea nitrogen 14 mg /dl, serum creatinine 0.6 mg/dl and anion gap of 14. Urine sodium
<10 mmol/L, urine osmolality 630 mosm/kg. Liver function tests revealed albumin 2.1 with
total protein 4.6, normal total bilirubin, aspartate transaminase (AST) 49, Alanine
transaminase (ALT) 19 and alkaline phosphatase 47.
2D transthoracic ECHO of the heart showed normal valves and an ejection fraction of 65%
with a normal left ventricular end-diastolic pressure and normal left atrial size. No
vegetations were noted.

Riam Safaa Nisaf Al-Amary, Cimen Zeynep Beyza Erol

The case nr. 2

A 73-year-old woman presents to the emergency department via emergency medical service,
with increasing shortness of breath and cough over the past day. She has a history of COPD,
CHF, hypertension, and hyperlipidemia. On arrival, she is breathing rapidly and is using all
her accessory muscles.
Physical Exam
Her blood pressure was 155/95 mm Hg, heart rate of 115/min, temperature 37.5, respiratory
rate 34/min, and oxygen saturation 70% on room air. The heart exam revealed tachycardia
but regular rhythm. On auscultation of the lung fields, breath sounds were diminished on the
right and left side in the inferior zones. The patient’s extremities were with edema.
Lab
White blood cell count was 10,000/mm3 with 60% neutrophils, 8% lymphocytes. Hematocrit
37%, Platelet count was 187,000/mm3, Serum sodium was 155 mmol/L, potassium 3
mmol/L, blood urea nitrogen 20 mg /dl, serum creatinine 5 mg/dl. Liver function tests
revealed albumin 2.0 with total protein 4.6, normal total bilirubin, aspartate transaminase
(AST) 42, Alanine transaminase (ALT) 10.
2D transthoracic ECHO of the heart showed abnormal valves and an ejection fraction of 35%
with an abnormal left ventricular end-diastolic pressure.
Aidid Nusaipa Mubarak, Ali-Heybe Hafsa Ahmed, Abdurahman Hafsa Warsame

The case nr. 3

A 35-year-old woman with a history of mid-trimester miscarriage at 15 weeks was
seen in the antenatal clinic at 16 weeks’ gestation in her second pregnancy. She had a
booking body mass index of 24 and was a non-smoker. Her medical history included
treatment for symptomatic anaemia. She was not on any medications and had no allergies.
During this pregnancy, she was admitted at 24 weeks’ gestation with a history of abdominal
pain with backache and incidentally found to be in threatened preterm labour. She was given
antenatal corticosteroids for fetal lung maturity and magnesium sulfate for fetal
neuroprotection, but was not given any other tocolytics. The woman was allowed to drink and
encouraged to keep well hydrated and intravenous fluids were not necessary, 18 h later she
delivered a live infant vaginally. Within 30 min of delivery, she ‘felt wheezy’ and was found
to be profoundly hypoxic. On further questioning she denied any other symptoms, and on
examination she was alert and orientated, without fever, tachycardic with a pulse rate of 120 
bpm, urine dipstick negative, blood pressure of 120/70 mm Hg, tachypnoeic at 24
breaths/minute.
Investigations
The arterial blood gas analysis was suggestive of hypoxia (saturations of 88% on room air
with a partial pressure of oxygen of 6.8 kPa). A chest X-ray showed increased pulmonary
vasculature and an ECG showed a sinus tachycardia. Blood tests were requested (including
full blood count, urea and electrolytes, C reactive protein, liver function test and clotting
profile), which were all normal.
Întuneric Simina Adrian, Mohamed Faahiye Salad Mohamed Filsan Mahamed,
The case nr. 4
A 68-year-old man with a past medical history of hypertension, hemorrhagic stroke,
and tobacco use and a family history of coronary artery disease, living at an adult family
when he was noted to develop acute dyspnea. On arrival at his residence, the paramedics
found the patient moaning, with a Glasgow Coma Scale score of 8 and increased work of
breathing. On arrival at the emergency department, his temperature was 36.28C; heart rate 47
beats/minute; blood pressure, 97/56 mm Hg; respiratory rate 36 breaths/minute; and he had
an oxygen saturation of 70% while he breathed oxygen via a nonrebreather mask.
Lab
pH 6.9, PCO2 47 mmHg, PO2 49 mmHg, HCO3 10 mEq/L. Peripheral blood cells WBC
16.9 103cells/ml Hgb 10.0 mg/dl. Blood studies Na 139 mEq/L K 6.2 mEq/L. Lactate 11.0
mmol/L, Anion gap 21, Troponin-I 10.82 ng/ml
Ultrasonography was performed and revealed a severely dilated right ventricle with
flattening of the interventricular septum.

Mohamed ismail Shucayb Ismail shucayb, Gure Hajara Abdullahi Bile,

Mohamed Ismail Hafsa Mohamed Ismail
The case nr. 5
A 57-year-old man was admitted to the medical intensive care unit (ICU). The patient
had been well until 21 days before this admission, when myalgias, arthralgias, chills, fever
(with a temperature of 39.2°C), and upper respiratory symptoms occurred. Two days later,
the patient called his physician because of persistent symptoms: cough with blood-tinged
sputum and pleuritic chest pain that prevented him from sleeping. On examination, he had
dyspnea. The blood pressure was 148/71 mm Hg, the pulse between 88 and 120 beats per
minute, the respiratory rate 24 breaths per minute, and the oxygen saturation 94% while he
was breathing ambient air at rest. There were crackles at the left lung base and left axillary
region. A chest radiograph revealed a dense infiltrate on the left side.

QUESTIONS (for all cases)

What type of respiratory failure?
How are the etiologies of respiratory failure categorized?
Which metabolic disorders of the central nervous system (CNS) lead to respiratory failure?
What are common causes of type I (hypoxemic) respiratory failure?
What are common causes of type II (hypercapnic) respiratory failure?
How is respiratory failure diagnosed?
What are the signs and symptoms of acute respiratory failure?
Which physical findings are characteristic of type I and type II respiratory failure?
Which nervous system findings suggest respiratory failure?
What are the diagnostic criteria for acute respiratory distress syndrome (ARDS)?
When is early intubation indicated for respiratory failure?
What causes of hypercapnic respiratory failure (type II)?
What are the differential diagnoses for Respiratory Failure?
What is the role of arterial blood gas measurement in the diagnosis of respiratory failure?
What is the role of imaging in the diagnosis of respiratory failure?
How is the clinical diagnosis of respiratory failure confirmed?
What is the role of a CBC count in the diagnosis of respiratory failure?
What is the role of a chemistry panel in the evaluation of respiratory failure?
How is myocardial infarction excluded in the evaluation of respiratory failure?
What is the role of chest radiography in the diagnosis of respiratory failure?
What is the role of echocardiography in the diagnosis of respiratory failure?
What is the role of the pulmonary capillary wedge pressure in the diagnosis of respiratory
failure?
What are the risks of oxygen therapy for respiratory failure?
What is the first objective for treatment of respiratory failure?
What is the role of endotracheal intubation in the treatment of respiratory failure?
What are the benefits of mechanical ventilation in the treatment of respiratory failure?
What is positive end-expiratory pressure (PEEP) ventilation for respiratory failure?
How is positive end-expiratory pressure (PEEP) used for treatment of respiratory failure?
What is the role of positive end-expiratory pressure (PEEP) in the treatment of respiratory
failure?
What is the traditional ventilation strategy for acute respiratory distress syndrome (ARDS)?
Why is the prone position beneficial in the treatment of acute respiratory distress syndrome
(ARDS)?
When should patients with respiratory failure be considered for discontinuance of mechanical
ventilation?
Which medications are used in the treatment of respiratory failure?