Case:

Chief Complaint:
"Why can't we get my weight stabilized?"

HPI:
A 67-year-old man presents to the ED with shortness of breath and bilateral lower extremity edema. Symptoms began approximately 3 weeks ago with a weight gain of about 1-2 lb daily, totaling 25 lb over the month prior to admission. Attempted relief with albuterol/ipratropium MDI was ineffective. His primary care physician increased his furosemide dose to 80 mg twice daily over the phone more than a week ago. In the ED, the patient was hypoxic with increased oxygen needs (from 2 to 4 L by nasal cannula). He received one dose of IV furosemide 80 mg with minimal improvement and was admitted for further evaluation and management.

PMH:
- CAD (s/p STEMI 10 years ago)
- COPD × 5 years
- HFpEF × 6 years (last hospitalization 4 months ago)
- Dyslipidemia × 15 years
- HTN × 25 years
- Type 2 DM × 5 years

FH:
- Father: Alive at 88, type 2 DM
- Mother: Alive at 87, HTN, dyslipidemia
- Two brothers (60 and 64): Both have type 2 DM and HTN

SH:
- History of tobacco use (40 pack-year), quit 5 years ago
- Denies alcohol or substance abuse
- Lives alone

Meds:
- Albuterol/ipratropium MDI, two puffs inhaled Q 6 H PRN
- Aspirin 81 mg PO daily
- Clopidogrel 75 mg PO daily
- Lisinopril 40 mg PO daily
- Carvedilol 12.5 mg PO BID
- Furosemide 80 mg PO BID (previously 40 mg PO BID)
- Amlodipine 5 mg PO daily
- Metformin 1000 mg PO BID
- Nitroglycerin 0.4 mg SL q 5 minutes PRN chest pain
- Potassium chloride 20 mEq PO daily
- Rosuvastatin 20 mg PO daily
- Seasonal influenza vaccine (previous year)

All:
NKDA

ROS:
- Gen: Recent 25-lb weight gain over past month
- CV: No chest pain
- Resp: Increased shortness of breath from baseline, dyspnea on exertion
- GI: No changes in bowel habits
- GU: No complaints
- MS: No pain or weakness
- Neuro: No complaints

Physical Examination:
- Gen: 25-lb weight gain with increased shortness of breath
- VS: BP 150/82, P 64 (regular), RR 26, T 36.9°C; Wt 102 kg, Ht 5′10′′, oxygen saturation 95% on 4-L nasal cannula
- Skin: Chronic venous stasis changes, 3+ edema to knees
- HEENT: PERRLA, EOMI, normocephalic, atraumatic
- Neck: (+) JVD at 30° (6 cm), no carotid bruit, no lymphadenopathy or thyromegaly
- Lungs/Thorax: Even respirations, crackles in lung bases
- Heart: RRR, no murmurs, rubs, or gallops
- Abd: Obese, nontender, nondistended, hypoactive bowel sounds
- Genit/Rect: Guaiac (-), genital exam not performed
- MS/Ext: 3+ pitting pedal edema, poor radial and pedal pulse intensity
- Neuro: A&O × 3, CNs intact, DTR intact

Labs:
- Na 138 mEq/L, Hgb 15.3 g/dL, Mg 1.7 mEq/L, CK 20 IU/L
- K 4.0 mEq/L, Hct 47.2%, Ca 9.1 mg/dL, CK-MB 0.8 IU/L
- Cl 103 mEq/L, Plt 298 × 10³/mm³, AST 60 IU/L, PT 12.6 s
- CO₂ 26 mEq/L, WBC 6.4 × 10³/mm³, ALT 60 IU/L, INR 1.1
- BUN 30 mg/dL, Troponin I 0.5 ng/mL, Alk phos 80 IU/L, TSH 1.12 mIU/L
- SCr 1.2 mg/dL, GGT 24 IU/L, A1C 7.5%
- Glucose 108 mg/dL, T. bili 0.2 mg/dL, BNP 2000 pg/mL

ECG:
Sinus rate 66; QRS 0.08; no ST-T wave changes; low voltage

CXR:
PA and lateral views show interstitial and early alveolar edema.

Assessment:
Decompensated heart failure with pulmonary and lower extremity edema

Clinical Course:
Patient admitted to telemetry. Known history of HFpEF (EF 52%) from 6 months ago. 2D echocardiogram shows impaired ventricular relaxation, elevated left atrial pressures, and grade III diastolic dysfunction. EF 53%, no mitral stenosis or pericardial disease. Dilated inferior vena cava suggests increased right atrial pressure. Moderate pulmonary HTN evident.

Request:
Can you create a pharmacotherapy care plan based on the following format?
1. Medical Problem List
2. Current Drug Regimen
3. Drug Therapy Problems
4. Therapy Goals
5. Therapeutic Recommendations
6. Rationale
7. Therapeutic Alternatives
8. Monitoring

The patient is experiencing decompensated heart failure with inadequate response to diuretics. A pharmacotherapy care plan includes optimizing current medications, potentially adding a second diuretic or other agents, and monitoring key health indicators to improve symptoms and prevent readmissions.

Pharmacotherapy Care Plan for Decompensated Heart Failure

Medical Problem List: Decompensated heart failure (HFpEF), Type 2 diabetes mellitus, hypertension, dyslipidemia, coronary artery disease, chronic obstructive pulmonary disease, bilateral lower extremity edema, and shortness of breath.
Current Drug Regime: Includes furosemide, albuterol/ipratropium, aspirin, clopidogrel, lisinopril, carvedilol, amlodipine, metformin, nitroglycerin, potassium chloride, and rosuvastatin.
Drug Therapy Problems: Inadequate diuresis indicated by continued weight gain and edema, possible furosemide resistance, and worsening shortness of breath despite increased furosemide dosage.
Therapy Goals: Stabilize weight, reduce edema, improve oxygen saturation, and prevent hospital readmission.
Therapeutic Recommendation: Consider the addition of a second diuretic with a different mechanism of action such as spironolactone or hydrochlorothiazide, assess and optimize fluid and sodium intake, and consider increasing the dose of current medications or adding additional agents for better blood pressure and diabetes control.
Rationale: To enhance diuresis, improve symptom control, and reduce hospital readmission risks.
Therapeutic Alternatives: Evaluate for drug interactions or contraindications, possibility of an inotrope such as digoxin, or device therapy if indicated.
Monitoring: Monitor weight, edema, electrolytes (potassium, magnesium), renal function, blood sugar levels, blood pressure, and signs of congestion or hypoperfusion.