This is a 70 y/o Caucasian male who has had 4 admissions in the last 4 months for shortness of air, volume overload and gangrene of his right foot which he had a transmetatarsal amputation of. His current admission is for increased oxygen needs (up to 4-6L NC from 2L), SOA with talking and any activity and BLE edema.
He reported increased SOA when lying flat and that it has been worsening for the last two days as has his edema. Upon presentation he is noted to also have renal insufficiency (Crt now 3.7), anemia (Hgb 7.3), volume overload (BNP 20,692).
He presented with a wound vac on his right foot from his recent transmetatarsal amputation which was removed yesterday by vascular and rebandaged.
He reports chronic aching pain in his back and neuropathy in his feet, otherwise no new onsets of pain, numbness or tingling.
Met with patient and his children this afternoon at bedside regarding patient’s current status, prognosis and goals of care. He is seen resting in bed with his daughter and son at bedside.
He is wearing his nasal cannula initially but is obviously easily short of air and tiresome. He states this make him very anxious and he feels more comfortable wearing the Bipap which he asks to be place on him within a few minutes of me bring in the room. He states he is having chest heaviness, denies pain, and shortness of breath.
He is tearful at times during our conversation and states he feels broke and is tired of living this way.
Pt is frustrated about being stuck in bed and wats very badly to be able to return to his home.
We discussed the need to be stronger and that in his current state it is not safe for him or his children (who will be assisting with cares if this were to happen). He understands this but is tearful and clearly disappointed.
We discussed the possibility of needing an above the knee amputation as his RLE has severe vascular disease and his wounds are not healing on his foot, opening him up to additional infections.
He states “what’s the point” and that he is absolutely not interested in further amputation.
We went on to discuss the possible need for a pacemaker as he has become bradycardic, is not tolerating beta blockers, and has had pauses. We discussed the process of the procedure, healing time, risks and benefits and he feels that he would be okay with this if and when the cardiologist says it is necessary.
Palliative care and hospice are also discussed in detail and he understands these options as well.
He is not ready to make a decision regarding aggressive care with palliative support vs hospice and would like time to discuss these options with his family.
All questions were answered and the patient was encouraged to discuss the information with his children as well as continue to ask questions and accept support as needed.
Contact information was shared and we will follow up with him tomorrow for further questions and thoughts.
Contacted by attending physician later this evening.
She has had an additional conversation with the patient and family and they have decided to take the patient home on hospice care.
Current Medications:
Atorvastatin 40mg PO HS
Bumex 1mg PO BID
Hydralazine 50mg PO TID
Isosorbide Mononitrate 60mg PO Daily
Sodium Bicarbonate 650mg 1 tab PO Daily
Flomax 0.4mg PO HS
Lispro Insulin 5 units SQ ACHS
Glargine Insulin 5 units SQ qAM
Apixaban 2.5mg PO BID
Ferrous Sulfate 325mg PO BID
Trazadone 100mg PO HS
Furosemide 40mg IV BID
Ocean Spray 1 spray nasally Q2H PRN nasal dryness
Duoneb 0.5-3mg/3ml 3ml IH q2h PRN Shortness of breath
Norco 5/325mg 1 tablet PO Q4H PRN Pain 7-10/10
Acetaminophen 650mg PO q4h PRN Pain 2-6/10
Ondansetron 4mg IV q6h PRN N/V
Polyethylene Glycol 17GM PO Daily PRN Constipation
Glucose Tabs 3 tabs PO PRN BG <50
Allergies: NKA
PMHx: DM2, HTN, HLD, CAD, Diastolic HF (EF 40-45% with moderate hypokinesis 6/2020), Ischemic Cardiomyopathy CKD3, MI (2009), Peripheral Neuropathy, Gangrene, Osteomyelitis, Cellulitis, COPD, Chronic Wound, Atrial Fibrillation, Hyponatremia, BPH, Chronic Foley for Urinary Retention, Anxiety, Depression, Alcohol Abuse (last drink 3/2021), former smoker
Tetanus Vaccine 4/2021, Patient states he has had his pneumonia vaccine (unknown date) and had a flu shot last year (2020). He has not received his Covid vaccine.
Soc and Substance Hx:
Patient is retired and widowed. He is a former smoker that quit in 2002 and a former alcoholic who quit in March of 2021. He denies illicit drug use.
Prior to his serial admissions, he lived at home alone and was able to complete all ADLs without assistance, did all his own shopping and had a group of friends he hung out with regularly.
He enjoys working in his yard and likes to brag it’s the best on the street.
His daughter, his son and his son’s family live nearby and he sees them often. Family is his passion. Prior to March of this year, he has a history of being very compliant with medications, doctor appointments and preventative care.
In March he drank heavily after being sober for 6 months and decided he was done with alcohol and medication.
Fam Hx:
Mother died from heart disease
Father died from throat and tongue cancer
1 Brother: alive with prostate cancer and heart disease
1 Sister: alive and healthy
2 children: alive and healthy
Surgical Hx:
Cardiac Stents 2009, CABG 2017, Right transmetatarsal amputation 2021, Aortagram with runoff and right femoral-tibial bypass 2021
Mental Hx: Anxiety and Depression, Denies suicidal or homicidal ideation.
Violence Hx: Pt with chronic debility, unsafe to be at home alone. Family unable provide 24/7 care.
Reproductive Hx: unknown if sexually active
ROS:
GENERAL: Weight gain of almost 50lbs since April, increasing weakness
HEENT: Eyes: No vision or hearing changes, denies congestion, sore throat, dry mouth
SKIN: Denies dry skin, itching
CARDIOVASCULAR: Constant chest pressure which he feels is related to his breathing. Reports swelling in his BLE. Denies palpitations and chest pain.
RESPIRATORY: Shortness of breath, dyspnea on exertion, Bipap dependent, denies cough.
GASTROINTESTINAL: Denies anorexia, nausea, vomiting, diarrhea, or abdominal pain.
GENITOURINARY: Chronic foley
NEUROLOGICAL: Persistent headache 5/10, Dizziness at times. BLE neuropathy. Denies syncope.
MUSCULOSKELETAL: Constant low back pain 5/10, describes as an ache and repositioning improves the pain while lying in one position too long aggravates it.
HEMATOLOGIC: Denies bleeding or abnormal bruising.
LYMPHATICS: No enlarged nodes.
PSYCHIATRIC: Reports depression in regards to his current state and health and anxiety in regards to his breathing and end of life.
ENDOCRINOLOGIC: Denies cold or heat intolerances, excessive thirst or dry mouth.
ALLERGIES: No history of asthma, hives, eczema, or rhinitis.
O.
VITAL SIGNS: 157/87, 98% on 35%FiO2, 65bpm, 23 RR, 35.6̊ C, 243lbs, BMI 32.1
GENERAL APPERANCE: alert, awake, oriented, pleasant, chronically ill appearing, respiratory support
HEENT: atraumatic, normocephalic, PERRLA, dry mucosal membranes
NECK: non-tender, no JVD
CARDIOVASCULAR: irregular rate and rhythm, normal capillary refill in upper extremities, delayed capillary refill in left lower extremity.
RESPIRATORY: DOE, shallow rapid breaths, decreased breath sounds and wheezes throughout, symmetric expansion, increased work of breathing noted with accessory muscle use.
ABDOMEN: non tender, soft, rounded, normal bowel sounds
GENITOURINARY: chronic foley with clear yellow urine
EXTREMITIES: 2+ BLE and BUE edema, Right toe amputation- covered with dressing, not inspected
MUSCULOSKELETAL: normal inspection, MAE
NEUROLOGICAL/CNS: A&Ox4, normal speech, CNII-XII intact
SKIN: Bandage to right foot- CDI
PSYCHIATRY: Depressed and anxious, not homicidal or suicidal, no hallucinations.
Diagnostic results:
Crt 3.7, GFR 17, BUN 76, BNP 20692, Albumin 2.2, RBC 2.54, Hgb 7.3, Hct 23.3
CXR: Pulmonary edema
A.
Differential Diagnoses:
- Acute on Chronic Respiratory Failure
When airways are unable to get a sufficient amount of air to the lungs resulting in less oxygen and more carbon dioxide build up due to narrowing or damage due to an ongoing condition, this is chronic respiratory failure (Marcin, 2018a). In this patient’s situation, his respiratory failure is due to his COPD and smoking history.
His acute exacerbation in related to volume overload for this admission. Supportive findings include his increased need for pressure support oxygen, increase from baseline oxygen needs, CXR results and abnormal lung sounds.
- Chronic Kidney Disease (CKD) IV
Moderately to severely damaged kidneys with a glomerular filtration rate (GFR) between 15 and 30 is labeled as Stage 4. RM’s GFR is 17 and he is consistent with the symptoms of swelling and back pain as well as additional complications that often accompany CKD: anemia and hypertension (American Kidney, 2021).
- Diastolic Heart Failure
The heart is responsible for pumping the blood through the body to provide oxygen rich blood to tissues and return blood to the lungs to reoxygenate it and send it back out to the body.
When the left ventricle is unable to relax as it should, the amount of blood sent out to the body is less than it should be and there is congestion as the blood that was not sent out backs up waiting to exit the heart (American Heart, 2017). Heart failure diagnosis is supported by extremity edema, pulmonary edema and BNP of >20K.
- Anemia
Anemia is the most common blood disorder and happens when there is a decline in the amount of red blood cells in the body. RBCs carry hemoglobin which is necessary to transport oxygen to around the body.
This patient is at an exceptionally high risk due to his CKD and HF as well as advanced age (American Society, 2021). Supporting documentation for this patient include Hgb 7.3, Hct 23.3 and RBC 2.54.
- Non-Healing Right Foot Wound r/t PVD
Peripheral Vascular Disease (PVD) is caused by blood vessels of the body, with the exception of the heart and brain, narrowing or becoming blocked due to arteriosclerosis, spasms and clots.
It often leads to organ damage and digit amputation at the least. Risk factors of PVD associated with this patient include age over 50, overweight, HLD, HTN, HF, CAD, DM, smoking and kidney disease (Marcin, 2018b).
This patient has a non healing wound which is very typical for patients with PVD as the blood flow is not strong enough to perfuse the area with oxygenated blood to promote healing.
P.
Case Management and RN notified of patient’s decision, please provide choice letter for hospice company to patient/ family.
May discontinue all medications except Norco
Ativan 1mg PO TID
Ativan 0.5mg PO q2h prn anxiety
May D/C Home with Hospice once arrangements are made
Please call for concerns or needs, will follow along until patient can transfer.
REFLECTION: This is a complex case that I have had the opportunity to participate in on both the internal medicine side in my previous clinical rotation as well as on the palliative care side in this clinical rotation. This patient has glowed since day one when his family visited.
He told stories of gardening and working in his yard regularly. Amputation was difficult for him to digest but knowing he could still potentially get around made it worth it to him.
Unfortunately, his organs had other thoughts and were too tired to get him back to an acceptable quality of life.
He slowly shared his frustration and depression regarding his situation throughout the course of his four hospitalizations.
Medically he understands that he is not curable with COPD, CKDIV and HF diagnoses. He understands his diseases are manageable with assistance but that he will continue to slowly decline regardless of interventions provided making aggressive care futile.
Being quite active and independent was a huge change for this patient and put him at a higher risk of depression. He had support in his children, however, they both work full time jobs and could not be at his side as consistently as he would have liked.
I agree with offering this patient the options of aggressive care with palliative support versus hospice care.
Looking at this case as a whole from the internal medicine stance as well as the palliative stance, I would educate this patient earlier on regarding the fight he had in front of him and the importance of early mobilization and discuss his acceptable quality of life and care goals.
I also would have started him on an antidepressant and offered more mental and emotional support options.
This case taught me to evaluate the mental and emotional health of my patients early on in the disease process and to closely follow them for changes and needs.
Giving patients the attention and support they need either independently or through resources, is essential to their long-term success fighting a major health challenge.
What additional treatment options and/or orders would you recommend for this patient?
