Part 1

Case 1: John Silver (a 67 year old man with dyspnea)

Mr. John Silver has been a patient on your inpatient service for the past two days — admitted with metastatic lung cancer. He was diagnosed several months ago and has received chemotherapy. The most recent round of chemotherapy was stopped, as he was unable to tolerate it ( due to increased nausea, and fatigue). He had expressed a wish for comfort care only and has elected to become a “no code” (do not resuscitate) patient.

Over the past two weeks he has experienced increasing dyspnea with three emergency room visits finally prompting this admission. An evaluation for reversible causes of dyspnea was not successful and the pulmonary consultant believes the dyspnea is irreversible, caused by the underlying lung disease.

Past Medical History

Mild hypertension.

Bronchial asthma.

Photo of Mr. Silver

Medications

Hydrochlorothiazide 12.5mg every day

Albuterol and ipratropium inhalers prn.

Examination

On admission his respiratory rate was 22-26 per minute, pulse was 100 beats per minute and pulse oximetry was 100% on room air. He complains of breathlessness. Exam reveals only scattered wheeze bilaterally.

What are some interventions that should be considered at this point?

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