CC: Shortness of breath.
HPI: 66M with HFrEF (EF 25%), CKD 3b, HTN, insulin-treated T2DM and OSA presents with 1 week of progressive DOE, now SOB walking to the mailbox, 3-pillow orthopnea, PND and leg swelling. Home scale up 10 lb (4.5 kg). Reports taking all meds; no clear dietary change. No chest pain, fever or cough.
Vitals: T 36.8, HR 96, BP 152/88, RR 24, SpO2 93% RA -> 96% on 2 L NC.
Exam: Uncomfortable, speaking in short sentences. JVD to angle of jaw. Bibasilar crackles halfway up. S3. 3+ pitting edema to knees.
Labs: BNP 2,900. Troponin <0.01 x2. Na 137, K 4.6, BUN 38, Cr 1.6, Glu 214. Hgb 13.4.
ECG: sinus rhythm 94, no acute ST changes. CXR: cardiomegaly, pulmonary vascular congestion, small bilateral effusions.
Assessment/Plan:
1. CHF exacerbation - furosemide 80 mg IV now, O2, upright positioning.
Dispo: Admit to hospital medicine, telemetry.
HISTORY AND PHYSICAL
HPI: 66M admitted with 1 week of worsening dyspnea, orthopnea and edema; see ED note. Diuresed ~900 mL after first IV furosemide dose.
PMH: HFrEF, EF 25% (TTE 03/2026). CKD stage 3b (baseline Cr 1.5-1.7, eGFR ~40), attributed to diabetes and hypertension. T2DM with diabetic CKD, on insulin (A1c 7.9% 08/2026). HTN. Hyperlipidemia. OSA on CPAP.
Meds: torsemide 40 mg daily, sacubitril/valsartan 24/26 mg BID, carvedilol 12.5 mg BID, spironolactone 12.5 mg daily, empagliflozin 10 mg daily, insulin glargine 24 units qHS, atorvastatin 40 mg daily.
Social: Retired bus mechanic, lives with wife. Never smoker. No EtOH.
Exam: HR 90, BP 144/84, RR 20, SpO2 96% 2 L. Weight 97.3 kg (dry weight ~92 kg). JVP 14 cm. Crackles bilateral bases. 3+ edema to knees.
Assessment/Plan:
1. CHF exacerbation - no clear precipitant. Furosemide 80 mg IV BID, strict I/O, daily weights, 2 g Na diet, 1.5 L fluid restriction. Continue carvedilol and sacubitril/valsartan. Cardiology consult.
2. CKD stage 3b - Cr 1.6, at baseline. Daily BMP while diuresing.
3. T2DM with diabetic CKD - glargine 20 units + correction scale. Hold empagliflozin while inpatient, resume at discharge.
4. HTN - on GDMT as above.
5. Hyperlipidemia - atorvastatin.
6. OSA - CPAP qHS, home settings.
VTE ppx: heparin 5,000 units SC q8h. Code: Full.
CARDIOLOGY CONSULTATION
Requested by: Dr. P. Sandoval. Reason: heart failure management.
HPI: 66M with known HFrEF followed in our HF clinic, admitted with volume overload. Last clinic visit 06/2026 euvolemic at 92 kg, NYHA II. Now NYHA III-IV symptoms for 1 week.
Data: TTE 03/2026: LVEF 25%, global hypokinesis, LV dilated, normal RV function. BNP 2,900 on admission. Net -2.4 L in first 24 h. Cr 1.9 today (1.6 on admission).
Exam: JVP 12 cm, crackles at bases, 2+ edema.
IMPRESSION:
1. Acute on chronic systolic heart failure (HFrEF), EF 25%, NYHA class III, volume overloaded ~5 kg above dry weight.
2. CKD stage 3b.
3. Hypertension.
RECOMMENDATIONS:
- Continue furosemide 80 mg IV BID; goal net negative 1.5-2 L/day.
- Continue carvedilol 12.5 mg BID and sacubitril/valsartan; continue spironolactone if K <5.0.
- Resume empagliflozin at discharge.
- Transition to torsemide 40 mg BID when near dry weight.
- HF clinic follow-up within 7 days; repeat TTE in 3 months after GDMT optimization.
HOSPITAL DAY 3
S: Breathing much better, slept with 1 pillow. No dizziness.
O: HR 82, BP 112/68, RR 16, SpO2 96% RA. Weight 94.1 kg. Net -4.6 L since admission. JVP 9 cm, trace edema.
Labs: Cr 2.5 (1.9 yesterday, 1.6 on admission), BUN 58, K 4.9, Na 136.
Assessment/Plan:
1. CHF exacerbation - diuresing well, near euvolemic. Hold furosemide and spironolactone today; hold sacubitril/valsartan x24 h. Recheck BMP in AM.
2. CKD stage 3b - see above. Monitor BMP, avoid nephrotoxins.
3. T2DM - BG 140-190 on glargine + correction.
4. HTN - controlled.
5. OSA - CPAP.
RENAL FUNCTION TREND
Date Cr (mg/dL) BUN K eGFR
06/12/2026 1.6 30 4.4 46 (outpatient)
09/20/2026 1.6 38 4.6 46
09/21/2026 1.9 45 4.7 38
09/22/2026 2.5 58 4.9 28
09/23/2026 2.1 52 4.6 34
09/24/2026 1.8 44 4.4 40
BNP: 09/20 2,900 pg/mL; 09/23 1,180 pg/mL
Hemoglobin A1c (08/2026): 7.9%
DISCHARGE SUMMARY
Admit: 09/20/2026 Discharge: 09/24/2026 Disposition: Home
DISCHARGE DIAGNOSES:
1. CHF exacerbation
2. CKD stage 3b
3. Type 2 diabetes mellitus with diabetic CKD, on insulin
4. Hypertension
5. Hyperlipidemia
6. Obstructive sleep apnea
HOSPITAL COURSE:
66M with HFrEF (EF 25%) admitted with volume overload. Diuresed with IV furosemide, net -5.8 L, weight 97.3 -> 92.6 kg. Cardiology followed and agreed with plan. Creatinine rose to 2.5 on HD3 with diuresis; furosemide, spironolactone and sacubitril/valsartan were held for 24 h and creatinine improved to 1.8 by discharge. Transitioned to torsemide 40 mg BID. Off O2 since HD2.
DISCHARGE MEDICATIONS: torsemide 40 mg BID (increased), sacubitril/valsartan 24/26 mg BID, carvedilol 12.5 mg BID, spironolactone 12.5 mg daily, empagliflozin 10 mg daily (resume), insulin glargine 24 units qHS, atorvastatin 40 mg daily.
FOLLOW-UP: HF clinic (Dr. Abernathy) in 7 days. BMP in 3 days. Daily weights; call for gain >2 lb/day or 5 lb/week.