History of Present Complaint (HPC)
Patient presented to the clinic with complaints of palpitation, chest pain that
radiates from the left arm and breathlessness exertion for a period of six weeks.
Name Malin Ahmed
Age 57 years
Date of admission 26th 08 2023
Date of discharge 30th 08 2023
Duration of hospitalization Five days
3. Past Medical History (PMH)
• History of Hypertension.
• History of Coronary artery disease (CAD
• History of Dyslipidemia (DLP)
Ramipril 2 years
Atorvastatin 1 year
Aspirin 2 years
No known family history.
4. Vital Signs
Day 1 Day 2 Day 3 Day 4 Day 5
Blood pressure 140/90 162/80 125/80 130/80 140/90
Respiration rate 87 80 80 83 80
Pulse rate 24 18 20 23 20
Physical Examination (Focus Assessment)
Height: 164 cm
Weight: 55 kg
Based on the complaints of the patients and medical history, the patient was
diagnosed Acutely decompensated Heart Failure with severe LV dysfunction, severe
Tricuspid regurgitation (TR), and Moderate Pulmonary arterial hypertension (PAH).
The plan was to provide progress report of the patient during the five hospitalization
days and discharge the patient. Medication to be used were provided to the patient
and to be reviewed after two weeks.
9. Patient progress report
Day 1 Complaints from patients
High Chest discomforts
Day 2 Persistence of Hypokalemia
Reduction in Trop.I
Reduction in manifestations
Day 3 Reduced significant Trop.I
No new complaints
Normal potassium levels
Day 4 No now complaints
Day 5 No new complaints
Discharge of patient
10. Patient Discharge Medications
T. lasix 40 mg, ( 1-1-1/2)
T. Cardivas 6.26 mg (1-0-1)
T. Aztolet 75/20 mg ( 0-0-1)
T. Natrise 15 mg (1-0-0)
T.Lanoxin 0.125 mg (OD)
T. Rmistar 5 mg (1-0-0)
T.pan 40 mg (1-0-0)
11. SBAR REPORT
A 57 years old presented to the clinic with known history of Hypertension, Coronary
artery disease (CAD) and Dyslipidemia (DLP).
Patient presented to the clinic with complaints of palpitation, chest pain that radiates
from the left arm and breathlessness exertion for a period of six weeks
• Blood pressure 140/90mmHG,
• Respiration rate 87BP,
• Pulse rate 24 beats per minute.
• Height: 164 cm
• Weight: 55 kg.
Based on the complaints of the patients and medical history, the patient was diagnosed
Acutely decompensated Heart Failure with severe LV dysfunction, severe Tricuspid
regurgitation (TR), and Moderate Pulmonary arterial hypertension (PAH).
12. R Recommendation:
• Patient to be hospitalized for five days.
• Monitoring of vital signs for the entire hospitalization.
• Patient to be treated with diuretics, digoxin and other medications
• Patient to be discharged when in stable condition.
Challenges With The Case
• There is no review of system of the patient.
• Physical examination of the patient included only taking the height and weight of the patient.
Factors That Influenced Decision Case Presentation
• Heart failure is a complex health condition associated with structural and functional cardiac impairment.
Therefore, this case was decided upon because case demonstrates how important it to investigate
Acutely decompensated Heart Failure and provide required medical intervention to patients.