Internal Medicine Hospital Discharge Summary

Date Of Admission: 12/05/2026

Date Of Discharge: 17/05/2026

Most Responsible Diagnosis

ACUTE DECOMPENSATED HEART FAILURE: Symptom onset occurred on 09/05/2026 with progressive orthopnea, paroxysmal nocturnal dyspnea, and bilateral lower extremity edema. The diagnosis was confirmed on 12/05/2026 via clinical presentation, elevated NT-proBNP of 4,200 ng/L, and chest imaging, complicated by mild cardiorenal syndrome during diuresis.

Relevant Pre-Admission Diagnoses/Conditions

1. Heart failure with reduced ejection fraction (HFrEF): Diagnosed on 14/03/2022 with baseline LVEF of 35% on prior echocardiogram; previously managed on sub-maximal guideline-directed medical therapy due to borderline hypotension.
2. Chronic kidney disease stage 3b: Diagnosed on 10/11/2021 with a baseline serum creatinine of 145 umol/L and eGFR of 42 mL/min/1.73m2; complicated by acute-on-chronic renal injury at admission (creatinine 198 umol/L), managed with careful titration of loop diuretics.
3. Type 2 diabetes mellitus: Diagnosed on 05/06/2015 with a recent HbA1c of 7.8% on 02/02/2026; complicated by mild background retinopathy and managed in hospital with basal-bolus insulin while holding oral hypoglycemics.

Past Medical History

• Essential hypertension
• Dyslipidemia
• Osteoarthritis of the bilateral knees
• Laparoscopic cholecystectomy (2014)

Operative And Other Interventions In Hospital

1. 12/05/2026: Chest X-ray demonstrated cardiomegaly, bilateral moderate pleural effusions, and prominent pulmonary vascular congestion.
2. 13/05/2026: Transthoracic echocardiogram showed global left ventricular hypokinesis with an estimated LVEF of 30%, moderate functional mitral regurgitation, and a dilated inferior vena cava.
3. 14/05/2026: Renal ultrasound demonstrated normal-sized kidneys bilaterally with slightly increased cortical echogenicity and no hydronephrosis.

Course In Hospital And Condition On Discharge

HEART FAILURE: The patient presented with significant volume overload and hypoxia requiring 3 L/min of supplemental oxygen via nasal prongs. Intravenous furosemide (Lasix®) 40 mg IV BID was initiated, achieving a net negative fluid balance of 4.5 L over 4 days. Cardiology, Dr. A. Patel, was consulted on 13/05/2026 and recommended transitioning to oral diuretics once euvolemic and initiating an SGLT2 inhibitor prior to discharge. At discharge, the patient was ambulating without dyspnea on room air and was clinically euvolemic at a dry weight of 78.5 kg.

ACUTE KIDNEY INJURY: Admission creatinine was elevated at 198 umol/L from a baseline of 145 umol/L, attributed to type 1 cardiorenal syndrome. Nephrotoxic medications were held on admission, and renal function improved steadily Alongside venous decongestion. By 17/05/2026, serum creatinine had returned to baseline at 148 umol/L with normal serum electrolytes.

Additional discharge instructions are provided below.

Documentation generated with an AI scribe. Content was reviewed by myself. The patient was not recorded in the information provided. I comply with IHA AI Scribe policy.

Medications

Changed

1. furosemide (Lasix®) 40 mg PO daily (increased from 20 mg PO daily to maintain euvolemia following acute decompensation).
2. bisoprolol (Monocor®) 5 mg PO daily (increased from 2.5 mg PO daily per Cardiology recommendation for HFrEF optimization).

Continued

1. ramipril (Altace®) 5 mg PO daily.
2. atorvastatin (Lipitor®) 40 mg PO QHS.
3. metformin (Glucophage®) 500 mg PO BID (held during admission, resumed at discharge).

Stopped

1. naproxen (Naprosyn®) 250 mg PO BID PRN (discontinued permanently due to chronic kidney disease and heart failure exacerbation risk).

New Started

1. dapagliflozin (Forxiga®) 10 mg PO daily (initiated for HFrEF and CKD optimization).
2. paracetamol (acetaminophen, Tylenol®) 650 mg PO QID PRN (started as a safer alternative for osteoarthritis knee pain).

Discharge Location

Home with referral for home support services.

Discharge Instructions And Advice

• Follow up with family physician within 7 days of discharge for clinical volume assessment and blood pressure check.
• Complete outpatient laboratory testing (renal panel, electrolytes) on 21/05/2026; requisition provided to patient.
• Monitor daily morning weights; contact family physician if weight increases by more than 1.5 kg in 2 days or 2.5 kg in 1 week.
• Restrict total daily fluid intake to 1.5 L/day and maintain a low-sodium diet (< 2,000 mg/day).
• Outpatient referral sent to the Heart Function Clinic for ongoing titration of guideline-directed medical therapy.

Patient was transferred from 100 Mile House District General Hospital on 12/05/2026 with a peripheral intravenous line in situ; the patient did not have a peripherally inserted central catheter, central line, or mechanical ventilation.

MOST status changed during hospitalisation from M3 to M2 on 13/05/2026 following goals of care discussion with the patient and family.

Allergies: Penicillin (maculopapular rash), sulfa antibiotics (hives).

Other Forms Completed: MOST form, Heart Function Clinic referral form, outpatient laboratory requisition.