CC: SOB, leg swelling.
HPI: 81F with HFpEF (EF 60% on echo 03/2026), T2DM, HLD, hypothyroidism, OSA on CPAP, obesity, presents with 1 week progressive DOE, 3-pillow orthopnea, PND x2 nights, and bilateral leg swelling. Reports 8 lb weight gain. Admits to dietary indiscretion at a family reunion. Compliant with furosemide 20 mg daily.
ROS: + DOE, orthopnea, LE edema. Denies CP, palpitations, syncope, fever, cough.
Vitals: T 36.7, HR 88, RR 22, BP 132/74, SpO2 92% RA -> 96% on 2L NC.
Exam: JVD to angle of jaw. Bibasilar crackles. Regular rhythm, no murmur. 2+ pitting edema to knees bilaterally.
Labs: BNP 1,240. Troponin 0.02 (flat on repeat). Na 128, K 4.0, Cl 94, CO2 27, BUN 24, Cr 1.0. Glucose 168. Hgb 12.1.
ECG: NSR 86, no acute ST changes.
CXR: cardiomegaly, vascular congestion, small bilateral effusions.
MDM: Acute on chronic HFpEF exacerbation, likely dietary. Furosemide 40 mg IV given. Admit.
HPI: 81F with chronic diastolic HF (EF 60%), T2DM, HLD, hypothyroidism, OSA, obesity, admitted with volume overload after high-salt intake. Up 8 lb from dry weight 196 lb.
PMH: HFpEF, T2DM, HLD, hypothyroidism, OSA on CPAP, obesity.
Meds: furosemide 20 mg daily, metformin 500 mg BID, atorvastatin 20 mg, levothyroxine 88 mcg, CPAP nightly.
Social: widowed, lives alone, former teacher, no tobacco or EtOH.
Exam: Wt 204 lb, Ht 5'5" (BMI 34.0). JVD +, bibasilar crackles, 2+ BLE edema.
Labs/imaging reviewed; see ED note. TSH 2.1. A1c 7.0.
Assessment/Plan:
1. Acute on chronic diastolic (HFpEF) heart failure - EF 60%. Furosemide 40 mg IV BID, strict I/O, daily weights, 2 g Na diet, 1.5 L fluid restriction, BMP daily. Wean O2 as tolerated.
2. T2DM - hold metformin, SSI.
3. HLD - continue atorvastatin.
4. Hypothyroidism - continue levothyroxine; TSH normal.
5. OSA - CPAP qHS.
6. Obesity, BMI 34 - outpatient counseling.
DVT ppx: heparin SQ. Code: Full.
S: Breathing easier, slept with 2 pillows. Net -1.9 L.
O: HR 80, BP 124/70, RR 18, SpO2 95% on 1L. Wt 201.6 lb. JVD improving. Crackles at bases. 2+ edema.
Labs: BMP reviewed. Cr 1.1, K 3.8.
A/P:
1. Acute on chronic HFpEF - good response, continue furosemide 40 IV BID, KCl 20 mEq daily.
2. T2DM - glucose 140-180 on SSI.
3. Hypothyroidism, HLD, OSA - stable on home regimen.
S: Feels close to baseline. Walked hallway without dyspnea. Net -5.2 L since admit.
O: HR 76, BP 118/68, SpO2 96% RA. Wt 197.2 lb. No JVD. Trace crackles. Trace edema.
Labs: BMP reviewed, Cr 1.1 stable. Mg 2.0.
A/P:
1. Acute on chronic diastolic HF - near euvolemic. Transition to PO furosemide 40 mg daily today, observe 24h.
2. T2DM - resume metformin at discharge.
3. Remaining chronic issues stable.
Basic metabolic panel trend (reference Na 135-145 mmol/L):
09/08 10:00 Na 128 L K 4.0 Cl 94 L CO2 27 BUN 24 Cr 1.0 Glu 168 H
09/09 05:00 Na 127 L K 3.8 Cl 93 L CO2 28 BUN 26 Cr 1.1 Glu 152 H
09/10 05:00 Na 129 L K 3.9 Cl 94 L CO2 29 BUN 27 Cr 1.1 Glu 148 H
09/11 05:00 Na 128 L K 4.1 Cl 93 L CO2 29 BUN 28 Cr 1.1 Glu 139 H
09/12 05:00 Na 129 L K 4.0 Cl 95 L CO2 28 BUN 27 Cr 1.0 Glu 131 H
Serum osmolality 09/09: 266 mOsm/kg (L). Urine sodium 09/09: 22 mmol/L.
Admit: 09/08/2026 Discharge: 09/12/2026
Discharge diagnoses:
1. Acute on chronic diastolic heart failure (HFpEF, EF 60%), precipitated by dietary sodium indiscretion
2. Type 2 diabetes mellitus
3. Hyperlipidemia
4. Hypothyroidism
5. Obstructive sleep apnea on CPAP
6. Obesity, BMI 34
Hospital course: Admitted with volume overload (BNP 1,240, JVD, edema, pulmonary congestion). Diuresed with IV furosemide, net -5.6 L, weight 204 -> 196.8 lb (dry weight). Weaned off O2 day 3. Transitioned to furosemide 40 mg PO daily with stable renal function. Diet and daily weight education completed.
Discharge meds: furosemide 40 mg daily (increased), KCl 20 mEq daily, metformin, atorvastatin, levothyroxine.
Follow-up: HF clinic 7 days with BMP; PCP 2 weeks.
Condition: stable, home with home health.