Okay...my turn...
62yo male...as you guessed, a run I had recently...
CC: Shortness of Breath...
Hx: HTN; Recently underwent treatment for mild bronchitis.
HOPI: Pt relates waking up in the morning feeling just a little SOB, coughed, felt better and went about his day. Sitting down for dinner, he noticed that SOB had returned and had been getting progressively worse over the last 45-60 minutes. He denies any CP; but relates feeling "tight" across his chest.
Initial assessment/impressions: 62yo white male without hx of lung disease or cardiac hx outside his HTN. Pt is sitting upright on kitchen chair in a tripod position. His skin is pale, cool, and slightly diaphoretic. Sternocleidomastoid retractions noted. Pt is in severe respiratory distress. Central Cyanosis noted. Vitals: BP 182/106; HR 122 and regular; RR 28bpm and labored; SpO2 83% RA. Blood Glucose 152; Sinus Tach on monitor without ectopy or ST changes. Pt is normothermic. Lung sounds are markedly diminished to mid-lobe bilaterally. Very tight wheezes noted on inspiration/expiration. No pedal edema or JVD noted; Pt sleeps on two pillows a night normally for personal comfort.
Tx: 100% O2 via NRB; IVx2 (18g/20g in ACs); Cardiac Monitoring (6-lead EKG obtained) Continuous MedNeb (Albuterol x2 UD); 125mg SIVP Solu-Medrol. VS q5 minutes during emergent transport to ER. Calm reassurance as pt was very anxious.
Reassessment: BP 178/100; HR 118; RR 24...labored but cyanosis reduced significantly. SpO2 94% on 15lpm NRB. Lung sounds reveal widespread wheezes with rhonchi noted in the bases ant/post auscultation. Pt relates feeling somewhat better, but still feels "tight" in his chest. Pt begins to develop strong, cough productive of thick yellow/green/brownish sputum. Air movement in lungs improved.
Field "diagnosis": Acute Respiratory distress secondary to pneumonia.
Now, on this run, the ER asked me why I gave Solu-Medrol when she clearly believed he was in CHF. I explained that he had no history of CHF or any pulmonary disease, just a recent bout of bronchitis which he got ATBs for. He had no pedal edema, JVD, or any other signs of CHF that you would expect. Last I checked, CHF is a secondary condition, rarely primary unless it is congenital. I really wanted to ask her why she believed it to be CHF. Did she draw a BNP level, get a CXR, or even listen to what I told her in my verbal report? But, I kept me yap shut and went about my merry way. 2 weeks later, I get pulled into the Chief's office concerning this run. That same RN wrote me up for giving the Solu-Medrol (and I did follow my protocol for acute respiratory distress). I explained to the chief my reasoning behind it and he agreed I did what protocol dictated for this pt and that it was appropriate.
Please share any insight you may have concerning the use of Solu-Medrol in a CHF pt vs Pneumonia pt. My medical director reviewed that run and said that even if he was in CHF, the Solu-Medrol would not have hurt him. (BTW...he did have pneumonia, not CHF and was given Lasix anyway at the ER).