This inpatient case study follows the complex hospitalization of a 65-year-old male admitted for worsening edema and dyspnea—symptoms that ultimately unveiled acute on chronic heart failure with reduced ejection fraction. As the care team navigates his comorbidities—including uncontrolled diabetes, hypertension, and a long-standing history of tobacco use—the evolving treatment plan reveals how intricate chronic disease management becomes during acute exacerbations. Diagnostic findings, daily clinical decisions, and multidisciplinary discharge planning come together to highlight the clinical, social, and financial dimensions of caring for a medically fragile patient. Key topics include:

• Pathophysiology of HFrEF (Heart Failure with Reduced Ejection Fraction):
  Mechanisms of fluid overload, neurohormonal activation, and the role of diabetes and tobacco in accelerating myocardial decline.

• Diagnostic Highlights:
  Interpretation of chest X-ray, venous duplex, and lab findings (e.g., BNP, Cr, HbA1c) in diagnosing decompensated heart failure and poor glycemic control.

• Medication Adjustments and Rationale:
  Diuretic titration, insulin initiation or adjustment, and antihypertensive strategies in the setting of low cardiac output and end-organ strain.

• Nursing Priorities:
  Monitoring fluid status, strict I&Os, education on sodium restriction, medication adherence, foot care for neuropathy, and recognizing signs of worsening HF.

• Discharge Planning Challenges:
  Coordination with social work regarding financial limitations, need for medication access, and post-discharge support to reduce readmission risk.