CHF Patient

Progress Note / Report

Patient: 81 y.o. male

Code Status: FC
PMHx: Hypertension, hyperlipidemia, T2DM, CAD, NSTEMI with multiple PCI, CKD stage 4, pulmonary hypertension, HFpEF, prostate cancer, duodenal ulcer

Code Status: Full Code

O2: 2L NC (SpO₂ 96%)

Mobility: OOB x1 assist

Interval Events / Subjective:

• Re-presenting with weakness and back pain after leaving AMA from prior admission where RHC was planned.

• Wife reports back pain occurs when patient is volume overloaded.

• No focal, sharp, or radiating pain.

Objective:

Vitals: Stable, BP 108–113/60–70s
Exam: Diffuse, non-tender back discomfort; no focal tenderness.
Labs:

• WBC: 15.7 → 13.8

• Cr: 1.86 (baseline 1.8–2)

• Hgb: 10 (baseline ~10)

• BNP: 35,000 (↑ from prior month)

• K: 3.5 → repleted

• Troponins flat

• Procalcitonin low

• COVID/Flu/RSV negative

Imaging:

• Echo 9/17: EF 59%, severely increased RV size, RVSP 72 mmHg, RV systolic function moderately ↓, RA severely dilated, mild MR, moderate PR, mild TR (improved from moderate).

• ECG: RBBB, ST depressions anterolateral leads (unchanged).

• VQ scan 9/16: Low probability PE.

• CXR: No acute process.

• CT Chest: Pulmonary HTN, GGO upper lobes.

Assessment / Plan

# Weakness / SOB – Pulmonary HTN

• Likely i/s/o pulmonary hypertension.

• Appreciate cardiology consult → awaiting recommendations.

• On 2L NC, stable saturations.

• Continue IV Bumex 2 mg daily (home dose 2 mg PO daily).

• Consider dose adjustment per cardiology.

• Strict I&Os, daily weights.

• Possible RHC depending on cardiology recs.

Back Pain

• Nonspecific, likely related to volume overload.

• Similar pain during prior admission.

• Non-tender, diffuse; imaging not indicated at this time.

• Continue acetaminophen; one-time oxycodone PRN.

• Avoid NSAIDs given CKD.

Leukocytosis

• Improving WBC trend.

• Infectious workup negative (UA, CXR, viral panel, procal).

• Monitor.

# Cardiovascular (HTN, HLD, CAD, NSTEMI/PCI, HFpEF)

• Continue ASA 81 mg daily.

• Continue metoprolol 50 mg daily.

• Continue rosuvastatin 20 mg daily.

# CKD4

• Stable Cr at baseline (1.8–2).

• Avoid nephrotoxic agents.

# T2DM

• AM glucose 130 mg/dL.

• A1c 7.0%).

• Continue lispro SSI.

• Hold linagliptin, metformin.

# Anemia (IDA)

• Hgb stable at 9.9.

• Continue iron supplementation.

# ILD

• Recent PFTs: mild DLCO reduction.

• Continue montelukast.

# F/E/N

• Cardiac, consistent carbohydrate diet.

• Hypokalemia → corrected.

• Continue Vit C, Vit D, folic acid.

Comorbidities on Admission

• Chronic HFpEF (EF 59%)

• CKD4

• Pulmonary HTN

• T2DM

• CAD with NSTEMI/PCI

• Anemia (IDA)

• ILD

Orders / Management:

Diet: Cardiac Consistent Carbohydrate
VTE PPx: Heparin 5000 units SQ q12h

Medications:

• Vitamin C 500 mg daily

• Aspirin 81 mg daily

• Bumex 2 mg IV daily

• Vitamin D3 1000 units daily

• Folic acid 1 mg daily

• Heparin SQ 5000 units q12h

• Metoprolol 50 mg daily

• Montelukast 0.4 mg daily

• Rosuvastatin 20 mg daily

Communication: Consultants updated.
Medication Reconciliation: Pending pharmacist review.