CASE ANALYSIS

I. Case Diagnosis: left-sided heart failure

II. Medical History
Date of Interview: October 12, 2020
Name of Interviewer: Athena Sobremonte
Chief Complaint: “pain in my chest for past 3 weeks
reaching my left arm, feeling tired most of the time”
Patient’s Profile:
Name: Patient X
Age: 41 y/o
Gender: Male
Date of Birth: March 24, 1979
From: Baguio City
Nationality: Filipino
Religion: Roman Catholic
Occupation: Farmer
Civil Status: Married
Date of Admission: October 12, 2020 at 9:00 pm
III. History of Present Illness:
A week prior to check up, patient noticed cough
with pink blood-tinged phlegm., fatigue and weakness,
dyspnea, rapid irregular heart beats, and edema on
legs, ankles, and feet. There were no other signs and
symptoms. The day prior to check up, the patient
experienced shortness of breath and weakness.
Paracetamol Biogesic was taken by the patient as a
self-medication. Persistence of symptoms prompted
patient to seek consultation, prompting admission.
IV. Past Medical and Surgical History:
Patient stated that he was never prone to being
sick when he was younger. He would get cough and colds
only 5-6 times a year that would never least longer
than 5 days at most. He would self medicate with
Lagundi syrup or crushed oregano for his cough and
 would inhale the steam from boiled water and salt when
he had a runny nose.
V. Familial History:
According to Patient X, his father was diagnosed
with Diabetes just last year and most of the members
from his mother’s side of the family had high blood
pressure. His brother is suffering from Coronary
Artery Disease(CAD). His eldest son is also diagnosed
with CAD.

VI. Social and Lifestyle History:

Patient X is a male, Natural-born Filipino citizen
born and raised in Baguio City. He is married with 2
children. When he was young, he lived in a house with his
parents, a brother 3 years older than him. His father
began smoking at the age of 18 and continued until the
age of 52 which caused him to move out of the house. He
was not given a chance to pursue college because of their
lack of finance as a family. He began to smoke cigarettes
as a way to cope with his stress, he then pick up the
habit. He then began working on a farm at the age of 16.
He was a hardworking farmer. He wakes up early in the
morning to drink his coffee and smoke his cigarettes
before going to work. He kept that cycle for 34 years
until his body said otherwise.
VII. Review of Systems:
General Impression:
Upon admission patient was awake, ambulatory,
responsive, and oriented to time, place, and person.
Patient becomes breathless during exertion.

Vital signs: BP - 130/80 mmHg, SP02: 93%, Temperature:

36.1 C, RR: 22, HR: 98
 Head to Toe Assessment:
a. Head: Normocephalic, symmetrical, (-) lesions, (-)
masses or depressions
b. Skin: Warm to touch, (-) lesions, good skin turgor,
(-) cyanosis, (-) pallor
c. Hair: Thick, silky, evenly distributed,(-)
infestation
d. Nails: capillary refill less than 2 seconds in
upper and lower extremities, pinkish nail beds
e. Eyes: eyelashes and eyebrows evenly distributed,
aligned and show equal movement, (-) discharges, (-)
discoloration, PERRLA, (-) nystagmus
f. Ears: Auricles are symmetrical, same color with
facial skin, (-) discharges, (-) lesions, (-) palpable
masses and tenderness
g. Nose and Sinus: Symmetrical, (-) discharge, (-)
lesions, nares are patent, (-) tenderness and masses,
(-) nasal flaring
h. Mouth: (-) cyanosis on lips, (-) retraction of
gums, buccal mucosa is moist, (-) cyanosis on tongue,
(-) lesions or ulcerations
i. Neck: (-) jugular vein distention, trachea located
in midline of neck, (-) palpable lymph nodes and
tenderness
j. Thorax, Lungs, and Abdomen
j.1. Lungs- chest wall intact, (-) masses, (-)
tenderness. Difficulty breathing upon exertion, (+)
adventitious breath sounds.
j.2. Heart- (+) s3 heart sound auscultated in apex,
(+) bruits upon auscultation (left)
j.3. Abdomen- (-) distention, (-) lesions and
palpable masses, (-) pain or tenderness
k. Genitourinary: (-) bladder distention, (-) dysuria,
(-) discharges
 l. Musculoskeletal: (-) joint and muscle pain, ROM not
limited in upper and lower extremities, (-) lesions on
both upper and lower extremities,(-) edema in
extremities
m. Neurologic:
CN I: Intact
CN II: Intact
CN III, IV, and VI: Intact
CN V:Intact
CN VII: Intact
CN VIII: Intact
CN IX and X: Intact
CN XI: Intact
CN XII: Intact
n. Motor and Cerebellar Function: oriented to time,
place, and person, muscle strength 5/5 for upper and
lower extremities, steady gait
VIII. Nursing Diagnoses:

1. Decreased Cardiac Output

2. Activity Intolerance
3. Excess Fluid Volume
4. Risk for Impaired Gas Exchange