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