PATIENT DISCHARGE SUMMARY

Congestive Heart Failure — Acute Exacerbation

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FACILITY: [Hospital Name] DEPARTMENT: Cardiology / Internal Medicine DOCUMENT TYPE: Discharge Summary — CONFIDENTIAL

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PATIENT INFORMATION

Field	Details
Patient Name:	[Patient Name]
Date of Birth:	[DOB] — Age: 68 years
Medical Record #:	[MRN]
Admission Date:	[Date]
Discharge Date:	[Date]
Length of Stay:	[X] days
Attending Physician:	[Physician Name, MD]
Primary Diagnosis:	Acute Decompensated Heart Failure (ADHF)
Discharge Disposition:	Home with outpatient follow-up

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SECTION 1: CLINICAL SUMMARY

Reason for Admission

The patient is a 68-year-old with a known history of congestive heart failure (CHF) with reduced ejection fraction (HFrEF, last known EF 35%) who presented to the emergency department with a 3-day history of progressive dyspnea on exertion, orthopnea, bilateral lower extremity edema, and a weight gain of 8 lbs over 5 days. The patient reported reduced compliance with dietary sodium restriction and missed diuretic doses in the week prior to admission.

Pertinent Past Medical History

• Congestive Heart Failure with Reduced Ejection Fraction (HFrEF)
• Hypertension (HTN)
• Type 2 Diabetes Mellitus (T2DM)
• Chronic Kidney Disease, Stage 3a (baseline Cr ~1.4 mg/dL)
• Hyperlipidemia
• Atrial fibrillation (rate-controlled)

Pertinent Physical Findings on Admission

• Vital Signs: BP 158/94 mmHg | HR 98 bpm (irregularly irregular) | RR 22/min | SpO₂ 88% on room air | Temp 37.1°C | Weight 94 kg
• General: Moderate respiratory distress, unable to complete full sentences
• Cardiovascular: Elevated JVD to jaw, S3 gallop present, irregularly irregular rhythm
• Pulmonary: Bilateral crackles to mid-lung fields
• Extremities: 3+ pitting edema bilateral lower extremities to mid-shin

Pertinent Diagnostic Results on Admission

Test	Result	Reference
BNP	2,840 pg/mL	<100 pg/mL
Creatinine	1.7 mg/dL	0.7–1.2 mg/dL
BUN	38 mg/dL	7–20 mg/dL
Potassium	3.3 mEq/L	3.5–5.0 mEq/L
Sodium	132 mEq/L	136–145 mEq/L
Troponin I	0.04 ng/mL (negative)	<0.04 ng/mL
Chest X-Ray	Pulmonary vascular congestion, bilateral pleural effusions, cardiomegaly
ECG	Atrial fibrillation, rate ~98, no acute ST changes
Echocardiogram	EF 30–35%, global hypokinesis, dilated LV, moderate MR

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Hospital Course

The patient was admitted to a monitored telemetry bed and treated with IV furosemide (Lasix) achieving diuresis of approximately 4–5 liters net negative fluid balance over 48 hours with significant symptomatic improvement. Hypokalemia was corrected with oral and IV potassium supplementation. Hyponatremia improved with fluid restriction to 1.5 L/day. Oxygen supplementation was weaned successfully to room air by hospital day 2. Renal function trended toward baseline (Cr 1.5 mg/dL at discharge). The patient was transitioned to oral diuretic therapy on hospital day 3 and monitored for 24 hours prior to discharge. Cardiology service reviewed and optimized guideline-directed medical therapy (GDMT).

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SECTION 2: MEDICATION RECONCILIATION

⚠️ IMPORTANT: Review ALL medications carefully. Several medications were changed during this hospitalization. Do NOT take any medications not listed below unless directed by your doctor.

2A. Medications on Admission (Home Medications)

Medication	Dose	Frequency	Status
Furosemide (Lasix)	40 mg	Once daily	DOSE INCREASED — See new list
Carvedilol	6.25 mg	Twice daily	Continued — unchanged
Lisinopril	5 mg	Once daily	CHANGED — See new list
Warfarin (Coumadin)	2.5 mg	Once daily	Continued — INR monitoring required
Metformin	500 mg	Twice daily	HELD during hospitalization — Resumed at discharge
Atorvastatin (Lipitor)	40 mg	Once daily at bedtime	Continued — unchanged
Potassium Chloride	20 mEq	Once daily	DOSE INCREASED — See new list

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2B. Discharge Medication List (COMPLETE — Take THESE medications)

#	Medication	Dose	Route	Frequency	Special Instructions
1	Furosemide (Lasix)	80 mg	Oral	Once daily (morning)	⬆️ DOSE INCREASED from 40 mg. Take in the morning to avoid nighttime urination. Weigh yourself daily.
2	Carvedilol	6.25 mg	Oral	Twice daily	Take with food. Do NOT stop suddenly.
3	Sacubitril/Valsartan (Entresto)	24/26 mg	Oral	Twice daily	🆕 NEW MEDICATION — replaces Lisinopril. Do NOT take with Lisinopril. Wait 36 hours after last Lisinopril dose before starting. Common side effect: dizziness; rise slowly from sitting/lying.
4	Eplerenone (Inspra)	25 mg	Oral	Once daily	🆕 NEW MEDICATION — added for heart failure. Monitor potassium closely. Avoid potassium-containing salt substitutes.
5	Warfarin (Coumadin)	2.5 mg	Oral	Once daily as directed	INR check scheduled — see follow-up below. Do NOT change dose without provider guidance.
6	Potassium Chloride (KCl)	40 mEq	Oral	Once daily	⬆️ DOSE INCREASED from 20 mEq. Take with a full glass of water and food to avoid stomach upset.
7	Atorvastatin (Lipitor)	40 mg	Oral	Once daily (bedtime)	No change.
8	Metformin	500 mg	Oral	Twice daily with meals	✅ RESUMED at discharge. Held during hospitalization due to IV contrast/renal monitoring.

2C. Medications Stopped — Do NOT Take These

Medication	Reason Stopped
Lisinopril 5 mg	❌ DISCONTINUED — Replaced by Sacubitril/Valsartan (Entresto). Do NOT take both together.

2D. Allergies on File

• [Allergy 1]: [Reaction]
• [Allergy 2]: [Reaction]
• Please notify any provider of allergies at every visit.

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SECTION 3: DISCHARGE INSTRUCTIONS FOR PATIENT AND CAREGIVER

📋 Please read these instructions carefully. Your active participation in your care is the most important factor in staying out of the hospital.

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3A. Daily Monitoring — Your Daily Routine Matters

⚖️ Daily Weight — This Is Non-Negotiable

• Weigh yourself EVERY morning after using the bathroom and before eating or drinking, wearing similar clothing
• Record your weight in a journal or log every day
• Action Plan:
  • Gained 2 lbs in 1 day → Call your cardiologist or heart failure nurse
  • Gained 3–5 lbs in 3 days → Call your cardiologist immediately — do NOT wait for your appointment
  • Gained more than 5 lbs in 1 week → Go to the emergency department or call 911

🫁 Breathing Check

• Note if your breathing is harder than usual at rest or with light activity
• Count the pillows you need to sleep comfortably — if this number goes up, call your doctor

💊 Medication Compliance

• Take medications exactly as prescribed, every day, even when feeling well
• Use a pill organizer or phone reminder to help you remember
• Never skip your diuretic (water pill/Lasix) without your doctor telling you to

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3B. Diet and Fluid Instructions

🧂 Sodium (Salt) Restriction — CRITICAL

• Limit sodium to less than 2,000 mg (2 grams) per day
• Avoid: Canned soups and vegetables, processed meats, fast food, frozen meals, table salt, soy sauce, pickled foods
• Read food labels: "Low sodium" means ≤140 mg per serving
• Tip: Cook with herbs, lemon juice, and spices instead of salt
• Excess sodium causes your body to retain water, which strains your heart

💧 Fluid Restriction

• Limit total daily fluid intake to 1.5–2 liters (about 6–8 cups) per day
• This includes ALL liquids: water, juice, coffee, tea, soup, gelatin, ice cream
• Tip: Use a marked water bottle to track daily intake

🍽️ General Heart-Healthy Diet

• Emphasize fruits, vegetables, whole grains, and lean proteins
• Limit saturated fats, trans fats, and refined sugars
• Discuss referral to a registered dietitian at your follow-up visit

🚫 Alcohol

• Avoid alcohol entirely. Alcohol weakens the heart muscle and can worsen heart failure.

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3C. Activity and Exercise

• Do not engage in strenuous activity immediately after discharge
• Gradually increase activity as tolerated — start with short, flat walks (5–10 minutes) and increase slowly over several weeks
• Stop any activity and rest if you develop shortness of breath, chest pain, dizziness, or palpitations
• Avoid activities that involve heavy lifting (>10 lbs) until cleared by your cardiologist
• Discuss cardiac rehabilitation enrollment at your follow-up appointment — structured cardiac rehab has been shown to reduce hospitalizations and improve quality of life
• Driving: Check with your physician before resuming driving, particularly given your atrial fibrillation and new medications

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3D. Other Important Instructions

• Smoking: If you smoke, quitting is one of the most important things you can do for your heart. Ask your provider about cessation programs and nicotine replacement therapy.
• Medication refills: Ensure all prescriptions are filled BEFORE you leave the hospital or pharmacy. Do not run out of heart medications.
• Potassium-containing salt substitutes (e.g., "No Salt," "Nu-Salt"): AVOID — can cause dangerously high potassium levels, especially with Eplerenone and increased potassium supplements.
• NSAIDs (Ibuprofen/Advil, Naproxen/Aleve, etc.): AVOID — these medications cause fluid retention, worsen kidney function, and can precipitate heart failure exacerbations. Use Acetaminophen (Tylenol) for pain instead.
• New medications: Always tell your cardiologist and primary care physician before starting any new prescription, over-the-counter medication, herbal supplement, or vitamin.
• INR/Warfarin monitoring: Your INR is [X.X] at discharge. See follow-up schedule below for anticoagulation monitoring.

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SECTION 4: FOLLOW-UP CARE PLAN

✅ These appointments are part of your treatment. Missing follow-up is one of the leading causes of hospital readmission. Please keep ALL appointments.

Scheduled Follow-Up Appointments

Priority	Provider	Purpose	Timeframe	Contact
🔴 URGENT	Cardiologist / Heart Failure Clinic	Post-discharge assessment, medication review, lab results, weight check	Within 5–7 days of discharge	[Phone Number]
🔴 URGENT	Primary Care Physician (PCP)	Overall health management, medication reconciliation	Within 7–10 days of discharge	[Phone Number]
🟡 Routine	Anticoagulation Clinic / PCP	INR check (Warfarin monitoring)	Within 3–5 days of discharge	[Phone Number]
🟡 Routine	Endocrinology / PCP	Diabetes management, Metformin resumption, HbA1c	Within 4 weeks	[Phone Number]
🟡 Routine	Registered Dietitian	Medical nutrition therapy for CHF and diabetes	Within 4 weeks	[Phone Number]
🟢 Elective	Cardiac Rehabilitation Program	Supervised exercise, education, lifestyle support	Discuss at cardiology visit	[Phone Number]

Labs to Be Drawn

Test	Timing	Reason
BMP (Basic Metabolic Panel) — Creatinine, BUN, Potassium, Sodium	Within 3–5 days of discharge	Monitor renal function and electrolytes after diuretic dose increase and new Eplerenone
INR / PT	Within 3–5 days of discharge	Warfarin monitoring
BNP	At cardiology follow-up	Assess response to therapy
HbA1c, Fasting Glucose	Within 4 weeks	Diabetes management

📞 If you are unable to keep any of these appointments, call the scheduling number immediately to reschedule. Do NOT simply skip the appointment.

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SECTION 5: RED FLAG SYMPTOMS — WHEN TO SEEK IMMEDIATE HELP

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🚨 CALL 911 OR GO TO THE NEAREST EMERGENCY DEPARTMENT IMMEDIATELY FOR:

Do NOT drive yourself. Do NOT wait. Do NOT call the office first. Call 911.

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❗ Symptom	Why It's Dangerous
Sudden, severe shortness of breath at rest or inability to breathe while lying flat	May indicate flash pulmonary edema — life-threatening fluid in lungs
Chest pain, pressure, tightness, or squeezing lasting more than a few minutes, or pain radiating to arm, jaw, neck, or back	Could indicate a heart attack or acute coronary syndrome
Fainting (syncope) or near-fainting (presyncope) — sudden loss of or near-loss of consciousness	May indicate dangerous cardiac arrhythmia or severely low blood pressure
Heart racing very fast, fluttering, or pounding with dizziness, shortness of breath, or chest pain	Could indicate a dangerous arrhythmia requiring immediate treatment
Coughing up pink, frothy, or bloody mucus	Sign of severe pulmonary edema — emergency
Sudden confusion, slurred speech, facial drooping, arm weakness, or vision changes	Signs of stroke — every minute matters
Weight gain of more than 5 lbs in one week combined with worsening shortness of breath	Indicates significant fluid accumulation requiring emergency evaluation
Lips, fingertips, or face turning blue (cyanosis)	Indicates critically low oxygen levels
Severe dizziness or lightheadedness that does not resolve with sitting/lying down	Could indicate dangerous low blood pressure or arrhythmia
Cold, clammy skin with confusion and inability to stay awake	Signs of cardiogenic shock — life-threatening emergency

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📞 CALL YOUR CARDIOLOGIST OR HEART FAILURE NURSE PROMPTLY (Same Day) FOR:

• Weight gain of 2 lbs in one day or 3–5 lbs in 3 days
• Increasing swelling in legs, feet, or abdomen not present yesterday
• Worsening shortness of breath with activities that were manageable before
• Needing one or more additional pillows to sleep comfortably at night (increased orthopnea)
• Dry, persistent cough (may be medication-related — do not stop medication without calling first)
• Nausea, vomiting, or inability to take oral medications for more than 24 hours
• Any new or unusual irregular heartbeat that is mild and without the above emergency symptoms
• Feeling more fatigued or dizzy than usual — particularly after starting new medications
• Questions about any medications or dosing instructions

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ℹ️ Key Contact Numbers

Resource	Number
Cardiologist's Office	[Phone Number]
Heart Failure Nurse Line	[Phone Number]
Primary Care Physician	[Phone Number]
Anticoagulation Clinic	[Phone Number]
Pharmacy	[Phone Number]
Emergency — 911	911
Poison Control	1-800-222-1222

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SECTION 6: CLINICIAN SIGNATURE AND ATTESTATION

Attending Physician: Dr. [Name], MD — Cardiology / Internal Medicine Date: [Date] | Time: [Time] Electronic Signature: [Signature]

Discharge Summary Prepared By: [Resident/NP/PA Name, Credentials] Date: [Date]

Medication Reconciliation Completed By: [Clinical Pharmacist Name, PharmD] Date: [Date]

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SECTION 7: PATIENT / CAREGIVER ACKNOWLEDGMENT

By signing below, I acknowledge that: 1. I have received and reviewed this discharge summary 2. My discharge medications have been explained to me 3. I understand the red flag symptoms that require emergency care 4. I have been given the opportunity to ask questions 5. I understand my follow-up plan

Patient Signature: _________________________ Date: ___________

Caregiver/Authorized Representative (if applicable): Name: _________________________ Relationship: _____________ Signature: _________________________ Date: ___________

Patient states they understand the discharge instructions: ☐ Yes ☐ No — If No, document barrier and plan: _______________

Language/Communication needs addressed: ☐ Instructions provided in patient's primary language ☐ Interpreter services used ☐ Large print provided ☐ Other: _______________

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📄 DOCUMENT DISTRIBUTION: ☐ Original to Medical Record | ☐ Copy to Patient | ☐ Copy to Cardiologist | ☐ Copy to PCP | ☐ Copy to Anticoagulation Clinic

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This discharge summary is a confidential medical document. Any unauthorized use or disclosure is prohibited under applicable law.

[Hospital Name] | [Address] | [Phone] | [Website]

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END OF DOCUMENT

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⚕️ Clinician Note: This is a template document. All bracketed fields must be individualized to the specific patient. Lab values, medication doses, follow-up timelines, and clinical details should reflect the actual clinical encounter. This document does not substitute for professional clinical judgment.

PATIENT DISCHARGE SUMMARY

Date of Discharge: [Date] Attending Physician: [Physician Name & Contact]

PATIENT INFORMATION

• Name: [Patient's Name]
• Date of Birth: [DOB] (Age: 68)
• MRN: [Medical Record Number]

PRIMARY ADMISSION DIAGNOSIS Acute exacerbation of congestive heart failure (CHF), systolic.

SECONDARY DIAGNOSES

1. Hypertension
2. [List any other chronic conditions, e.g., Atrial Fibrillation, Diabetes Mellitus Type 2, Chronic Kidney Disease Stage 3]

HOSPITAL COURSE Mr./Ms. [Last Name] was admitted on [Admission Date] with symptoms of worsening dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, and bilateral lower extremity edema. Diagnostics confirmed volume overload and worsened systolic function consistent with an acute CHF exacerbation. During the hospitalization, the patient was treated with intravenous diuretics (IV furosemide), achieving significant diuresis with improvement in respiratory symptoms and edema. Other medications were optimized for heart failure management. The patient tolerated the treatment well, with vital signs and clinical status stabilizing for discharge.

DISCHARGE CONDITION The patient is discharged in stable condition. At discharge, the patient is alert and oriented, with improved respiratory status. Vital signs are within acceptable limits: BP [e.g., 128/78 mmHg], HR [e.g., 72 bpm regular], RR [e.g., 16], O2 Sat [e.g., 96% on room air].

DISCHARGE MEDICATION RECONCILIATION Please take all medications as prescribed. Do not stop or change doses without discussing with your doctor.

Medication	Dose & Frequency	Instructions & Purpose	Changes from Prior to Admission
Furosemide	[e.g., 40 mg]	Take [e.g., once daily] in the morning. Weigh yourself daily at the same time. Helps remove extra fluid.	DOSE INCREASED from [e.g., 20 mg daily].
Lisinopril	[e.g., 10 mg]	Take [e.g., once daily]. Helps your heart work more efficiently and lowers blood pressure.	NEW medication started during admission.
Carvedilol	[e.g., 3.125 mg]	Take [e.g., twice daily]. Slows heart rate and helps heart function.	Dose CONTINUED (or adjusted if applicable).
Spironolactone	[e.g., 25 mg]	Take [e.g., once daily]. Potassium-sparing diuretic that helps with heart failure.	CONTINUED (or started if new).
Aspirin	[e.g., 81 mg]	Take [e.g., once daily]. For heart protection.	CONTINUED.
Atorvastatin	[e.g., 40 mg]	Take [e.g., once daily at bedtime]. For cholesterol management.	CONTINUED.
Allergies: [List Allergies, e.g., NKDA]

FOLLOW-UP CARE INSTRUCTIONS

1. Primary Care Physician (PCP) Follow-up: Schedule and see your PCP, Dr. [Name], within 5-7 days. Contact: [Phone Number].
2. Cardiology Follow-up: Schedule an appointment with your cardiologist, Dr. [Name], within 2-3 weeks. Contact: [Phone Number].
3. Daily Weight Monitoring: Weigh yourself every morning after using the bathroom and before eating/drinking, wearing similar clothing. Record your weight.
4. Dietary Restrictions:
   • Fluid Restriction: Limit total fluids to < 2 liters (approx. 68 oz) per day unless otherwise instructed. This includes all beverages, soups, and ice cream.
   • Sodium (Salt) Restriction: Follow a strict low-sodium diet (< 2,000 mg per day). Do not add salt to food. Avoid processed, canned, and fast foods.
5. Activity: Rest as needed. Gradually increase walking as tolerated. Avoid heavy lifting and strenuous activity until cleared by your doctor.

RED FLAG SYMPTOMS - RETURN TO EMERGENCY DEPARTMENT Go to the nearest Emergency Department or call 911 immediately if you experience any of the following:

• Sudden or worsening shortness of breath at rest or that awakens you from sleep.
• Chest pain, pressure, or tightness.
• Rapid weight gain: Gaining more than 3 pounds in one day or more than 5 pounds in one week.
• Worsening swelling in your feet, ankles, legs, or abdomen.
• Feeling dizzy, lightheaded, or faint, or nearly fainting.
• A rapid, irregular, or pounding heartbeat (palpitations) that is new or worsening.
• Confusion, disorientation, or extreme fatigue.

DISCHARGE DISPOSITION Discharged to home. The patient and family/caregiver verbalized understanding of discharge instructions, medications, and warning signs.

Prepared by: [Physician/NP/PA Name & Signature]