Yesterday, a 70yo guy with diastolic CHF who had been hospitalized for exacerbation for 3 days earlier this month, came to see me for follow up (not my patient) after he was newly put on 2L O2 by urgent care 3 days ago for shortness of breath, spo2 85-88, told to increase his Lasix, given azithro which he kept forgetting to take. He was taking 60 bid PO lasix up from 40 bid for two days and had noticed his weight increase steadily from dry weight of 205 to 218 in my clinic yesterday. He kept telling me he felt slowly worsening SOB, and his wife said it was worse than earlier that month when they had been hospitalized, getting worse over the past few days. On my exam, he had very poor air movement so it was hard for me to tell if there were crackles or wheezing, but had 3+ putting edema to the calf (unclear what he was prior). I recommended he go to the ER for IV lasix which we don’t do in our clinic. He refused, so I had him sign an AMA paper and gave him strict ER precautions.
I checked on his chart this morning and saw that he went to the ER at 3 AM, at which point the ER doc documented wheezing and crackles, said in his note there was “some concern about his weight in clinic”, gave him IV lasix x1 and sent him home. My concern is that now this guy has no trust in us and will continue not to listen to our advice, plus I don’t think this was the right management. What do you do in this situation?
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