Part 3

The Case Continues…

The patient’s dyspnea is much palliated by oral Morphine Sulfate sustained release 15 mg every 12 hours and oxygen by nasal prongs at 3 L and hand-held inhalers.

The patient has previously expressed a wish for No Code status. You discharge Mr. Silver home with a follow-up appointment in your clinic. A home hospice referral is pending.

Three weeks after discharge, patient he returns to clinic. The home hospice has been managing his medications and currently his dyspnea is well palliated on oral Morphine Sulfate sustained release 30 mg every 12 hours and nasal prongs supplemental oxygen by a room air concentrator and hand-held inhalers. Today, Mr. Silver complains of frequent headaches for the past week, some swelling of his arms and one episode of lightheadedness.


Exam reveals mild facial and neck edema and distended neck and chest wall veins.

Neck: jugular venous distention; central venous pressure estimated at 12 cmH2O. Lymph nodes: normal.

Chest vesicular breath sounds with a few scattered rhonchi.

Cardiac: normal heart sounds; no gallops or murmurs.

Abdomen: unremarkable.

Extremities: bilateral upper extremity edema; no cyanosis or clubbing.

Laboratory Findings

HCT 35 percent.

WBC 9000/mm3 with a normal differential.

Electrolytes, renal indices, and liver function tests: normal.

What interventions should be considered with his changed state?


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