Mr. K is a 74-year-old male who presents to a cardiology clinic for routine follow-up. You initially met Mr. K in the hospital 5 years ago when he was admitted for a heart failure exacerbation, and now you see him regularly in your clinic. It has been challenging to optimize goal-directed medical therapy for his ischemic cardiomyopathy, as Mr. K has symptomatic hypotension with beta-blockers and progressive chronic kidney disease.

In today's clinic visit, Mr. K says he has been feeling quite fatigued, which he attributes to waking up frequently to urinate. He also endorses loss of appetite and leg swelling, which have been ongoing for the past few months. He continues to walk around the block for 20 minutes daily, and he denies new shortness of breath.

Mr. K says his wife wanted to phone in to the visit today (she was not able to accompany him to the office due to COVID restrictions). When you speak with Mrs. K over the phone, she expressed concern that her husband has seemed more forgetful recently. For example, last week he got lost while driving in a familiar neighborhood. She also noticed that he forgot to take his medication several times this month, which is unusual.

Past Medical History:

Type 2 diabetes mellitus, hypertension, hyperlipidemia, chronic kidney disease, osteoporosis.
Remote history of right hip fracture.

Past Surgical History:
CABG 8 years ago
Hip Replacement 5 years ago

Medications:
Lisinopril 2.5mg qd
Metoprolol succinate 3.125 mg bid
Furosemide 20mg qd
Spironolactone 12.5 mg qd
Pantoprazole 40mg qd
Aspirin 81-mg qd

Vitals
BP 101/68, HR 80, RR 16, SpO2 93% on RA

Exam
Gen: elderly man in no acute distress, no muscle wasting
HEENT: moist mucous membranes, mild conjunctival pallor
CV: Healed sternotomy scar, no JVD, heart sounds regular rate and rhythm without murmurs, rubs, or gallops
Pulm: trace end expiratory wheezing, no accessory muscle use
Abd: soft, mildly distended, mild tenderness to deep palpation in all quadrants
Ext: 2+ pulses in all extremities, warm, 1+ pitting edema in bilateral LE past the ankles
Neuro: CN II-XII intact, no gross focal deficits, alert to self, place, and time

Electrocardiogram
LBBB with QRS width

Echocardiogram
Mildly dilated LV without wall motion abnormality, LVEF 45%, no significant valvular disease

Clinical Topics: Cardiac Surgery, Dyslipidemia, Geriatric Cardiology, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Prevention, Valvular Heart Disease, Cardiac Surgery and Heart Failure, Cardiac Surgery and VHD, Novel Agents, Statins, Acute Heart Failure, Interventions and Structural Heart Disease, Hypertension, Sleep Apnea

Keywords: Geriatrics, Heart Failure, Aged, Metoprolol, Furosemide, Spironolactone, Lisinopril, Pantoprazole, Heart Sounds, Respiratory Sounds, Diabetes Mellitus, Type 2, Cicatrix, Hyperlipidemias, Sternotomy, Follow-Up Studies, Edema, Hypotension, Hypertension, Renal Insufficiency, Chronic, Ambulatory Care, Osteoporosis, Hospitals, Electrocardiography, Heart Valve Diseases, Dyspnea, Mucous Membrane, Cardiomyopathies, Palpation, Aspirin, Coronary Artery Bypass, Dementia, Neurocognitive Disorders

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