Short of breath

February 27, 2020

I spent this week following an elderly man who was recently discharged from the GIM ward for an upper gastrointestinal bleed due to an duodenal ulcer. He was referred to us for management of his shortness of breath.

Given that his shortness of breath only recently began within the past month, I attributed this to secondary to his anemia from his UGIB. However, we had to rule out other causes including CHF exacerbation and potentially COPD due to his smoking history. As such, we had ordered a chest x-ray and BNP which were negative. We also arranged for him to have a PFT. I also spent some time thinking about how I would best manage his symptomatic anemia. His most recent Hb was 86. Looking at the guidelines, a transfusion would be warranted to achieve a target Hb of >70, but a target Hb > 80 can be aimed for if he has coronary artery disease. At this time, it does not seem like he qualifies for a transfusion. There were also logistical things that would need to be arranged if he needed an outpatient transfusion. In order to get a transfusion, we would have to put in a referral to Women's College Hospital for this to be done as an outpatient. Fortunately, it seems this his SOB appears to be improving as his Hb is recovering.

This was a memorable case for me because I had the opportunity to follow him longitudinally over the past 2 weeks. I think longitudinal exposure to a patient's course of illness really allows the learning to settle in as you have can have the time to reflect on your medical decision making and see how it directly impacts your patient's outcomes.

This encounter also made me reflect on what it is like to care for patients with limited English proficiency. Although my patient did not speak English, I was fortunate to be able to communicate with him in my native language. Dr. Rawal recently had a talk during rounds about this topic as their is significant health disparities between patients who can speak English and those who cannot. Someone shared the experience of how a non-English speaking patient was diagnosed with COPD exacerbation and unfortunately the patient actually was having a NSTEMI but nobody had taken the time to communicate with this patient because of the "language barrier."

-JT-

Reference(s):

Barkun, A. N., Bardou, M., Kuipers, E. J., Sung, J., Hunt, R. H., Martel, M., & Sinclair, P. (2010). International consensus recommendations on the management of patients with nonvariceal upper gastrointestinal bleeding. Annals of internal medicine, 152(2), 101-113.

Villanueva, C., Colomo, A., Bosch, A., Concepción, M., Hernandez-Gea, V., Aracil, C., ... & Guarner-Argente, C. (2013). Transfusion strategies for acute upper gastrointestinal bleeding. New England Journal of Medicine, 368(1), 11-21.