Hospitalist H&P

Chief Complaint: Worsening shortness of breath and bilateral lower extremity edema.

History of Presenting Illness: 72-year-old male with a history of HFrEF (EF 35%), HTN, CAD s/p PCI, and T2DM presents with a 4-day history of progressively worsening DOE, orthopnea (requiring 3 pillows), PND, and bilateral LE swelling. Symptoms began after eating large, high-sodium meals over the weekend and missing two doses of his home loop diuretic. He reports a 3.5 kg weight gain over the past week. Denies chest pain, palpitations, syncope, fever, or productive cough.

In the ED, the patient was found to be tachypneic and hypoxic with SpO2 87% on room air, improving to 95% on 3 L/min nasal cannula. BP was 164/92 mmHg. Exam showed JVD, bibasilar crackles, and 3+ pitting edema to the knees bilaterally. Labs were notable for BNP 1,450 pg/mL, creatinine 1.5 mg/dL (baseline 1.1 mg/dL), and potassium 4.1 mmol/L. Troponin I was normal at 0.02 ng/mL. CXR demonstrated cardiomegaly, pulmonary vascular congestion, and small bilateral pleural effusions. ECG showed normal sinus rhythm with known LBBB, unchanged from prior. He was given furosemide (Lasix®) 40 mg IV once with 600 mL urine output over 2 hours. Hospitalist team requested to admit for further IV diuresis and management of acute decompensated heart failure.

Past Medical History: Heart failure with reduced ejection fraction (35% on echo 14/08/2024), hypertension, coronary artery disease (s/p DES to LAD in 2019), type 2 diabetes mellitus, stage 3a chronic kidney disease, hyperlipidemia.

Home Medications:

• furosemide (Lasix®) 40 mg PO daily
• sacubitril/valsartan (Entresto®) 49 mg/51 mg PO BID
• metoprolol succinate (Toprol-XL®) 50 mg PO daily
• empagliflozin (Jardiance®) 10 mg PO daily
• atorvastatin (Lipitor®) 40 mg PO daily
• acetylsalicylic acid (aspirin, Ecotrin®) 81 mg PO daily
• metformin (Glucophage®) 500 mg PO BID

Allergies: Lisinopril (angioedema).

Social History: Former smoker (30 pack-years, quit 2015). Denies alcohol or illicit drug use. Retired accountant. Lives at home with his wife in a single-story house. No pets.

Family History: Father died of myocardial infarction at age 68. Mother had hypertension and type 2 diabetes mellitus.

Review of Systems

• Constitutional symptoms: Positive for fatigue and 3.5 kg weight gain. Negative for fever, chills, or night sweats.
• Eyes: Negative for vision changes, pain, or redness.
• Ears, Nose, Mouth, Throat: Negative for hearing changes, nasal congestion, or sore throat.
• Cardiovascular: Positive for SOB, PND, DOE, orthopnea, and bilateral LE edema. Negative for chest pain or palpitations.
• Respiratory: Positive for dyspnea and dry cough when lying flat. Negative for sputum production or wheezing.
• Gastrointestinal: Negative for nausea, vomiting, diarrhea, constipation, or abdominal pain.
• Genitourinary: Negative for dysuria, hematuria, or urgency.
• Musculoskeletal: Negative for arthralgias, myalgias, or back pain.
• Integumentary (Skin): Negative for rashes, lesions, or pruritus.
• Neurological: Negative for dizziness, syncope, weakness, or numbness.
• Psychiatric: Negative for anxiety, depression, or insomnia.
• Endocrine: Negative for polyuria, polydipsia, or temperature intolerance.
• Hematologic/Lymphatic: Negative for easy bruising or bleeding.
• Allergic/Immunologic: Negative for seasonal allergies or autoimmune disorders.

Physical Exam

• Temp 36.8 °C, HR 88 bpm, BP 152/86 mmHg, RR 22 breaths/min, SpO2 95% on 3 L/min NC. Weight 89.5 kg.
• General: Alert, oriented x3, mild respiratory distress with speaking in full sentences. HEENT: Normocephalic, atraumatic, moist mucous membranes, JVD present at 10 cm H2O. Cardiovascular: Regular rate and rhythm, normal S1/S2, S3 gallop present, no murmurs. Respiratory: Bibasilar crackles halfway up lung fields, no wheezes. Abdomen: Soft, non-tender, non-distended, normal bowel sounds, no hepatosplenomegaly. Extremities: Warm, 3+ pitting edema bilaterally to the knees. Neurological: Cranial nerves II-XII intact, motor strength 5/5 throughout.

Lab Results

• Results of CBC, BMP, and cardiac biomarkers (24/03/2025 14:30 America/Chicago): WBC 7.8 x10^3/µL, Hgb 13.2 g/dL, Plt 210 x10^3/µL. Na 136 mmol/L, K 4.1 mmol/L, Cl 101 mmol/L, HCO3 25 mmol/L, BUN 32 mg/dL, Cr 1.5 mg/dL (baseline 1.1 mg/dL), Glucose 168 mg/dL. BNP 1,450 pg/mL. Troponin I 0.02 ng/mL.

Imaging Results

• CXR (24/03/2025 14:15 America/Chicago): Moderate cardiomegaly, cephalization of pulmonary vessels, interstitial pulmonary edema, and small bilateral pleural effusions. No focal consolidation or pneumothorax.
• ECG (24/03/2025 13:50 America/Chicago): Normal sinus rhythm, rate 88 bpm, LBBB (unchanged from prior ECG dated 10/11/2024).

Assessment/Plan

• 1. Acute on chronic systolic heart failure
  • Acute decompensated heart failure
  • Differential diagnosis: Pneumonia, pulmonary embolism, acute coronary syndrome.
  • Telemetry monitoring, daily BMP, strict I&Os, daily weights, repeat TTE to assess current LVEF.
  • Administer furosemide (Lasix®) 40 mg IV BID; titrate to goal net negative 1.5 L to 2 L daily. Continue home metoprolol succinate (Toprol-XL®) 50 mg PO daily and sacubitril/valsartan (Entresto®) 49 mg/51 mg PO BID. Hold empagliflozin (Jardiance®) temporarily given acute kidney injury. Supplemental O2 via NC to maintain SpO2 > 92%. Fluid restriction 1.5 L/day and 2 g sodium diet.
  • Consult Cardiology for co-management and GDMT optimization.
• 2. Acute kidney injury
  • Cardiorenal syndrome type 1
  • Differential diagnosis: Pre-renal azotemia, acute tubular necrosis.
  • Monitor daily BUN and creatinine.
  • Gentle IV diuresis to relieve renal venous congestion. Hold home metformin (Glucophage®) and empagliflozin (Jardiance®) until renal function returns to baseline. Avoid nephrotoxic agents.
  • Defer Nephrology referral unless renal function worsens despite diuresis.
• 3. Type 2 diabetes mellitus
  • Hyperglycemia
  • Differential diagnosis: Stress-induced hyperglycemia, medication non-adherence.
  • Point-of-care blood glucose monitoring AC and HS. Check HbA1c.
  • Hold home metformin (Glucophage®) and empagliflozin (Jardiance®). Initiate insulin lispro (Humalog®) sliding scale SC AC and HS. Diabetic diet.
  • Inpatient diabetes educator consult prior to discharge.

Two Midnight Documentation

The patient's hospitalization will probably extend beyond 2 midnights because of the severity of the illness.

Time Spent

45 minutes