Hyperresonant lung sounds3/11/2024 In addition, his supplemental oxygen requirement has increased from 2 to 15 liters per minute via a nonrebreather mask. Two hours later, despite continued resuscitation and medical therapy, the patient becomes acutely hypotensive with a blood pressure of 65/35 mm Hg. Because of poor vascular access, a left-subclavian central venous catheter is placed (after several attempts) its position is verified by a portable chest radiograph. The patient is started on broad-spectrum antibiotics. Urinalysis is positive for nitrites and leukocyte esterase, shows 50 white cells per high-power field (0–2), and reveals gram-negative rods on Gram stain. Initial laboratory testing reveals a leukocyte count of 26,500 per mm 3 (reference range, 4500–11,000). His blood pressure is 104/64 mm Hg, his heart rate is 144 beats per minute, and his respiratory rate is 25 breaths per minute. The Case & QuestionĪn 83-year-old man with a history of hypertension and chronic renal insufficiency presents with a chief complaint of altered mental status and a temperature of 39.5☌. The case-based question requires several cognitive steps, including considering the possible adverse events that could happen after putting in a CVC, interpreting physical examination findings, and identifying the appropriate interventions for ICU emergencies. It asks the learner to select the best immediate response to a patient with a complication of central venous catheter (CVC) placement. One of our NEJM Knowledge+ Internal Medicine Board Review questions has generated a fair amount of discussion and uncertainty.
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