1. ADVANCED HEALTH ASSESSMENT PRACTICAL
(NURS -512)
CASE PRESENTATION AND DEMONSTRATION
HEART FAILURE CASE PRESENTATION

2. CASE
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.
Demographic Data
Name Malin Ahmed
Age 57 years
Department Cardiology
Date of admission 26th 08 2023
Date of discharge 30th 08 2023
Duration of hospitalization Five days
Diagnosis

3. Past Medical History (PMH)
• History of Hypertension.
• History of Coronary artery disease (CAD
• History of Dyslipidemia (DLP)
Drug History
Medication Period
Ramipril 2 years
Atorvastatin 1 year
Aspirin 2 years
Allergies
No allergies.
Family History
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

5. Laboratory Results Confirming The Diagnosis
Blood Counts
TLC 7,400 cells/mm3
Platelets 2.20 lakh cells/mm3
PCV 45.6
RBC 5.47 * 10 cells/mm3
Hemoglobin 15.0 g/dl
RBS 168 mg/dl
FBS 107 mg/dl
Renal Function Tests
Urea 34.71
Uric acid 1,55
S.cr 4.71

6. Electrolytes
Day 1 Day 2 Day 3 Day 4 Day 5
Sodium 128 134 135 135 140
Potassium 3.4 3.4 3.3 3.5 3.8
Other tests
Troponin-I 98 91 66 67 60
Echo Results Concentric LVH, LV dysfunction

7. Medication
Medication Dosage Day 1 Day 2 Day 3 Day 4 Day 5
Furosemide 40 mg, I,v TID Administered Administered Administered Administered Administered
digoxin 0.125 mg, OD Administered Administered Administered Administered Administered
Ramipril 5mg, OD Administered Administered Administered Administered Administered
Nitroglycerin 2.6mg ( 1-0-1) Administered Administered Administered Administered Administered
Cervedilol 6.25 mg, (1-0-1) Administered Administered Administered Administered Administered
Atorvastatin &
clopidogrel
20/75mg HS Administered Administered Administered Administered Administered
Heparin 5000 IU, s,c
Q8H
Administered Administered Administered Administered Administered
Tolvaptan 15mg, (1-0-1) Administered Administered Administered Administered Administered
Administered Administered Administered Administered Administered

8. Assessment
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).
Plan
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 Observation
Day 1 Complaints from patients
High Chest discomforts
palpitations
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
Drug Dosage
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
S Situation
A 57 years old presented to the clinic with known history of Hypertension, Coronary
artery disease (CAD) and Dyslipidemia (DLP).
B Background
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
A Assessment
Vital signs:
• Blood pressure 140/90mmHG,
• Respiration rate 87BP,
• Pulse rate 24 beats per minute.
Physical assessment
• Height: 164 cm
• Weight: 55 kg.
Clinical assessment:
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.