Hospital Discharge Summary

Mr. Robert Vance (DOB: 12/04/1958, MRN: 849-201-54) was admitted on 15/10/2023 at 14:20 CST with acute on chronic CHF exacerbation secondary to medication non-adherence. At admission, he presented with worsening SOB, orthopnoea, and 3+ bilateral pitting oedema. Initial vitals showed BP 158/94 mmHg, HR 98 bpm, and SpO2 89% on RA. CXR confirmed pulmonary oedema, and BNP was elevated at 1,450 pg/mL. He was placed on 2 L/min NC O2 and started on furosemide (Lasix®) 40 mg IV BID. Over 48 hours, he achieved a net negative fluid balance of 3.2 L, weaned off supplemental O2, and returned to his baseline weight of 84.5 kg. Renal function and electrolytes remained stable throughout diuresis. On 17/10/2023 at 09:00 CST, he was transitioned to furosemide (Lasix®) 40 mg PO daily and resumed lisinopril (Prinivil®) 20 mg PO daily and metoprolol succinate (Toprol-XL®) 50 mg PO daily. At discharge on 18/10/2023 at 11:15 CST, he was ambulating without dyspnoea, lungs were clear to auscultation, and trace pedal oedema remained.

Follow up with Family Medicine Clinic on 25/10/2023 at 10:30 CST for repeat BMP and volume status check. Patient educated on strict adherence to a low-sodium diet (< 2 g/day) and fluid restriction (1.5 L/day). Instructed to record daily morning weights and contact the clinic if weight increases by > 1 kg in 24 hours or > 2.5 kg in one week. Advised to present to the nearest ED immediately if experiencing worsening SOB, chest pain, or syncope.