RECORD 11 | TYPE: INPATIENT DISCHARGE SUMMARY

PATIENT: Synthetic-011 | AGE: 61 | SEX: M | ADMISSION: 2026-10-04 | DISCHARGE: 2026-10-09
ADMISSION DIAGNOSIS: Acute decompensated heart failure with volume overload.
DISCHARGE DIAGNOSES:
1. Acute decompensated heart failure with reduced ejection fraction (HFrEF, LVEF 28%).
2. Non-ischemic cardiomyopathy.
3. Essential hypertension.
4. Chronic kidney disease stage 3a (baseline Cr 1.3 mg/dL).

HOSPITAL COURSE:
A 61-year-old male with known HFrEF presented with progressive dyspnea, orthopnea (3 pillows), paroxysmal nocturnal dyspnea, and bilateral lower extremity edema up to the mid-shins, accompanied by a 14-pound weight gain over two weeks. Examination on admission demonstrated elevated JVP to 12 cm H2O, bibasilar lung crackles, and an S3 gallop.

Patient was placed on telemetry and started on IV Furosemide 80 mg BID. Over 5 hospital days, he achieved a net negative fluid balance of 6.2 liters, returning to his dry weight of 88.5 kg. Dyspnea and orthopnea fully resolved. Inpatient echocardiogram showed severely decreased LV systolic function (LVEF 28%), similar to prior study 1 year ago. Baseline guideline-directed medical therapy (GDMT) was reviewed and optimized.

DISCHARGE MEDICATIONS:
1. Sacubitril-Valsartan 49/51 mg PO BID.
2. Metoprolol Succinate 100 mg PO daily.
3. Spironolactone 25 mg PO daily.
4. Empagliflozin 10 mg PO daily.
5. Furosemide 40 mg PO daily (adjusted maintenance dose).
6. Potassium Chloride 20 mEq PO daily.

DISCHARGE PLAN & EDUCATION:
- Strict daily morning weights; call heart failure clinic if weight gains > 3 lbs in 24 hours or > 5 lbs in one week.
- Sodium restriction < 2,000 mg/day; fluid restriction 2.0 L/day.
- Outpatient appointment with Heart Failure Transition Clinic in 7 days, including BMP and renal panel.
