TARLAC STATE UNIVERSITY

COLLEGE OF SCIENCE
DEPARTMENT OF NURSING
Awarded Level III Status by the Accrediting Agency of Chartered Colleges and Universities in the Philippines

CLINICAL CASE ANALYSIS

Name of Patient MR. BRO KEN H. Age: 57 Gender: Male

Address San Roque, Tarlac City Date August 26, 2021

Admitted:

Diagnosis Congestive Heart Failure

NURSING HISTORY
Present Health History:
A 57-year-old, male patient was admitted to the hospital with a chief complaint of shortness of breath.
1 week ago. He experienced shortness of breath which occurs when performing simple task such as sweeping the
floor and walking at a short distance (5-10 meters). He reports sleeping with 3-4 pillows at night to relieve
breathlessness, and he recalls having shortness of breath that awakened him from sleep. He also noticed that his
feet and legs started to swell. No other medications were taken except for his maintenance medications (losartan,
atorvastatin, aspirin). No consultation done.
Few hours ago. His symptoms worsened and he became restless, prompting him to consult to the nearest Tertiary
Hospital, hence admission.
Upon assessment, the patient reported DoB upon exertion, easy fatiguability, mild pain in the nape area, and felt a
drowning sensation specially when he is lying flat in bed. The patient was observed to have bipedal pitting edema
grade 2 +, coughing without phlegm, orthopnea present, and with bibasilar crackles upon auscultation. He was cold
to touch especially in both hands and feet.
Vital signs taken as follows: BP – 150/100 mmHg; RR – 26 cpm; PR – 121 bpm; Temperature – 36.2 C; and O2
saturation of 89% at room air.
Past Health History:
Patient Ben reported that he was previously diagnosed with hypertension, hyperlipidemia, and Coronary artery
disease, during the year of 2018. Then next year after (2019), he was admitted to the hospital due to hypertensive
urgency. He then said that he could not really take his medications on time due to his work.
Lifestyle and Diet:
Upon asking, the patient used to smoke for about 3-5 sticks of cigarettes starting from 16 years old. He occasionally
drinks alcohol per week with family or friends. The usual food he eats are “crispy pata” and any other fatty foods.
Currently, he stated that he usually eats samgyupsal because it’s the trend. During his younger days, he said that
he works as a professor in school and then preaches in churches.

PATHOPHYSIOLOGY:
Heart failure occurs when the heart muscle does not function normally, leading to fluid retention and reduced blood
flow. This can be caused by heart muscle weakness or stiffness, or a heart valve problem. When the left side of the
heart is failing, it can’t handle the blood it is getting from the lungs. Pressure then builds up in the veins of the lungs,
causing fluid to leak into the lung tissues. This may be referred to as congestive heart failure. This causes you to
feel short of breath, weak, or dizzy. These symptoms are often worse with exertion, such as climbing stairs or walking
up hills. Lying flat is uncomfortable and can make your breathing worse. This may make sleeping difficult and force
you to use extra pillows to elevate your upper body to help you sleep well. You may also feel weak or tired and have
less energy during exertion.

DIAGRAM BELOW:

DIAGNOSTIC PROCEDURES:

ECHOCARDIOGRAPHY:

IMPRESSION: Left ventricle hypertrophy

Analysis: Ventricular hypertrophy is an initial compensatory mechanism in response to the chronic pressure
overload that preserves the cardiac output and delays cardiac failure.

URINALYSIS:

Color Dark Yellow

Clarity/Turbidity Clear
PH 7
Specific Gravity 1.012
Glucose Negative
Bilirubin Negative
Ketone None
Nitrites Negative
Leukocyte esterase Negative
Bacteria Many
Crystals None
Protein Negative
WBC 2-3 /HPF
RBC 7-8 /HPF

Analysis: There is a high count of bacteria seen in the urinalysis, which can mean that there could be an infection
somewhere in the urinary tract.

LIPID PROFILE (8/26/21):

FBS 6.3 mmol/ L (3.5- 5.6 mmol/ L)

BUN 8.2 mmol/L (2.1- 8.5 mmol/L)
Creatinine 125 mmol/L (65- 120 mmol/L)
RBS 110 mg/dL
Cholesterol 320 mg/dL (<200 mg/dL)
LDL 290 mg/dl (60-130 mg/dL)
HDL 38 mg/dL (60 mg/dL)
Triglyceride 230 mg/dL
Uric acid 5.9 mg/dL (4.6- 7.0 mg/dL)

Analysis: With elevated creatinine levels are a marker of poor cardiac output, leading to diminished renal blood
flow. With high cholesterol, LDL, Triglyceride, and low HDL values, can develop fatty deposits in your blood vessels.
Eventually, these deposits grow, making it difficult for enough blood to flow through your arteries.

COMPLETE BLOOD COUNT (8/26/21):

Hemoglobin 9.6 g/dL

RBC 4.5 x10 12/L
WBC 11 x 10 9/L
Neutrophils 6 x10 9/L
Lymphocytes 0.50 x10 9/L
Basophils 0.080 x10 9/L
Eosinophils 0.30 x10 9/L
Platelets: 268 x10 9/L
CHEST XRAY (8/26/21):

IMPRESSION:
✓ Cardiomegaly
✓ Pleural Effusion

Analysis: The heart begins to enlarge due to the force for the heart to work harder to pump blood on to the rest of
the body.

PROTIME & APTT

Normal Values Results Analysis Interpretation
PROTIME Mild activated partial
Patient 12 – 14 sec 12.9 sec Normal thromboplastin time
Control 10.6 – 13.4 sec 12.3 sec Normal (aPTT) increased.
% Activity 79 – 100% 90.1% Normal Test done to see how
INR 0.94 – 1.20 1.04 Normal well your liver’s
ISI N/A 0.97 working, since it
APTT makes the clotting
Patient 26..1 – 36.3 sec 59.4 sec High factors.
Control 30.3 – 38.5 sec 33.1 sec Normal
ECG (8/26/21) 9:15 AM
ECG monitoring revealed a T wave inversion.

MEDICAL MANAGEMENT:

• NPO temporarily, then resume to Low salt and low-fat diet if not dyspneic
• Low salt low fat diet
Too much salt and fat bumps up your blood pressure and makes your heart work harder. High amounts of
sodium (the main part of salt) can lead to stroke, heart disease, and heart failure.
• Insert heplock aseptically
Establish IV line for medications that needs to be administered directly through the blood
• O2 inhalation per venturi mask at 60% Fio2
The practice makes logical sense -- heart attacks occur when a blocked artery prevents oxygen from
flowing to the heart. If the heart needs oxygen, then giving a person oxygen should help.
• Furosemide 40mg IVP now, then q 6 hours
Given as a diuretic wherein it inhibits the sodium-potassium 2 chloride co transporter. Used as treatment
for patient’s bipedal pitting edema.
• Atorvastatin 40 mg 1 tab OD at HS
These drugs help control your blood cholesterol (Mayo Clinic, 2020).
• Lactulose 30 cc OD at HS
Lactulose is used as a non-diuretic medication to reduce volume overload, used for treat of CHF.
• Metoprolol 50 mg tab, ½ tab BID
It is given to people who have already had a heart attack. In addition, metoprolol is used to treat patients
with heart failure.
• Discontinue Aspirin
• Limit Oral fluid intake at 1L/ day
In heart failure, the body often retains fluid. Doctor may recommend limiting your
intake of fluid to help control the symptoms of increased blood pressure (more work for the heart), difficulty
breathing and shortness of breath (due to fluid in your lungs), swelling on ankles, hands and face, and
nausea and bloating.
• Complete bed rest
To lessen the cardiac workload on the heart.
• Weigh patient daily and record
 To see and compare weight each day, and see the effectiveness of the medications given such as the
diuretics.

Name of Student: Diolazo, Kristin Erika M.

Date Submitted: 04/09/21 C.I.’s Signature

Form No.: TSU-COS-SF-

Revision No.: 00 Effectivity Date: June 22, 2016 Page 1 of 1
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