HPI: 84F with ischemic cardiomyopathy (EF 25% on TTE 05/2026), CAD s/p DES to RCA 2019, T2DM, HLD, hypothyroidism, presents from home with 10 days of worsening DOE, orthopnea, abdominal bloating and leg swelling. Weight up 12 lb. Has been largely chair-bound for the past week due to fatigue.
PMH: ischemic cardiomyopathy/HFrEF, CAD s/p PCI, T2DM, HLD, hypothyroidism.
Meds: sacubitril/valsartan 24/26 mg BID, carvedilol 6.25 mg BID, spironolactone 12.5 mg, furosemide 40 mg daily, empagliflozin 10 mg, aspirin 81 mg, atorvastatin 40 mg, levothyroxine 50 mcg.
Exam: HR 96 regular, BP 108/64, RR 22, SpO2 91% RA -> 95% 2L. JVD to ear, bibasilar crackles, S3, 3+ pitting edema to thighs, sacral edema. Skin: no breakdown noted.
Labs: BNP 3,880. Troponin 0.04 flat. Na 136, K 4.4, Cr 1.1 (baseline 1.0). A1c 7.1.
CXR: cardiomegaly, pulmonary edema, bilateral small effusions.
Assessment/Plan:
1. Acute on chronic systolic heart failure (HFrEF, EF 25%) due to ischemic cardiomyopathy - furosemide 80 mg IV BID, strict I/O, daily weights, continue carvedilol; hold sacubitril/valsartan for soft BP, resume as tolerated.
2. Ischemic cardiomyopathy / CAD s/p PCI - no ACS, flat troponin. Aspirin, statin.
3. T2DM - hold empagliflozin, SSI.
4. HLD - atorvastatin.
5. Hypothyroidism - levothyroxine.
6. Mobility - PT/OT eval; turning schedule q2h, pressure-redistribution mattress.
Code: Full (discussed with patient and son).
Admission nursing assessment. Braden score 15 (at risk). Skin assessment head-to-toe with second RN: skin intact; no breakdown noted to sacrum, coccyx, buttocks, heels, or elbows. Sacral area with edema, blanchable. Pressure-redistribution mattress in place, heels floated, q2h turns initiated. Foley not placed. Patient on 2L NC, 3+ BLE edema.
S: Breathing better, lying flatter. Net -3.4 L.
O: HR 88, BP 104/62, SpO2 94% on 1L. Crackles at bases. 2+ edema. Cr 1.2.
A/P:
1. Acute on chronic systolic HF - diuresing well. Continue IV furosemide; resume sacubitril/valsartan low dose when SBP > 105.
2. CAD/ischemic CM - aspirin, statin, carvedilol.
3. T2DM - SSI, glucose 150s.
4. HLD, hypothyroidism - stable.
5. Mobility - PT working with her; spending much of day in bed due to fatigue.
Consulted by bedside RN for new sacral skin breakdown found on AM turn.
Location: sacrum, midline.
Assessment: Full-thickness skin loss, 3.0 x 2.5 x 0.3 cm. Wound bed 80% red granulation, 20% yellow slough. Subcutaneous fat visible; no bone, tendon or muscle visible. No tunneling or undermining. Small serous drainage. Periwound macerated, no erythema or induration. No odor.
Stage: Stage 3 pressure injury, sacrum. Not present on admission per admission skin assessment 09/02 (skin intact).
Plan: Cleanse with NS, apply calcium alginate + silicone foam border, change q2 days and PRN. Low-air-loss mattress ordered. Turn q2h, limit HOB to 30 degrees except meals. Dietitian consult for protein. Wound care to follow twice weekly.
S: Breathing near baseline. Notes some discomfort at tailbone.
O: HR 82, BP 112/66, SpO2 95% RA. Trace crackles. 1+ edema. Wt down 9 lb. Cr 1.2. Sacral dressing c/d/i.
A/P:
1. Acute on chronic systolic HF - near euvolemia. Transition to PO torsemide 20 mg tomorrow; resumed sacubitril/valsartan 24/26 BID.
2. Sacral pressure ulcer, stage 3, hospital-acquired, wound care following - low-air-loss mattress, offloading, protein supplementation.
3. CAD/ischemic CM, T2DM, HLD, hypothyroidism - stable.
4. Mobility - PT recommends SNF for strengthening.
Admit: 09/02/2026 Discharge: 09/09/2026
Discharge diagnoses:
1. Acute on chronic systolic heart failure (HFrEF, EF 25%)
2. Ischemic cardiomyopathy
3. Coronary artery disease s/p PCI
4. Pressure ulcer of sacrum, stage 3
5. Type 2 diabetes mellitus
6. Hyperlipidemia
7. Hypothyroidism
Hospital course: Admitted with volume overload, diuresed 11 lb with IV furosemide, transitioned to PO torsemide. GDMT resumed. During admission developed a sacral pressure ulcer (see wound care notes), managed with alginate/foam dressings and low-air-loss mattress. Discharged to SNF for rehab per PT.
Discharge meds: torsemide 20 mg daily, sacubitril/valsartan 24/26 BID, carvedilol, spironolactone, empagliflozin, aspirin, atorvastatin, levothyroxine. Wound care: calcium alginate + foam q2 days.
Follow-up: HF clinic 1 week; wound care at SNF.