CASE ANALYSIS
I. Case Diagnosis:
Left-sided Heart Failure
II. Medical History:
Patient’s Profile
Name: Patient X
Age: 55 years old
Gender: Male
Date of Birth: October 12, 1965
From: Baguio City
Nationality: Filipino
Religion: Roman Catholic
Date of admission: October 14, 2020 at 11:11 PM.
Chief complaint:
“ My cough wont go away its been more than 2 months
whenever I cough there is pink blood-tinged phlegm.
I also often feel out of breath and weak.”
Interviewer: Sobremonte, Athena Kayl E.
A. History of Past Illness:
According to Patient X, he experienced episodes of
shortness of breath and persistent cough lasting for more
than 2 months. Patient X stated he started smoking at 16
years old, consuming 365 packs a year until he stopped at
the age of 53.
B. 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.
C. Familial History
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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 were prone to high blood
pressure.
D. Social and Lifestyle History
He lived with his father who is a chronic smoker. He
explained that when he was in college, he was frequently
under a lot of stress due to a lot of factors but mostly
because of his studies. As a result, he hung out with a
group of friends who often smoked and cut classes to
relieve stress until eventually he picked up the habit of
smoking as well.
E. Review of systems
General Impression:
Upon admission patient was awake, ambulatory, conscious,
responsive, oriented to time, place, and person. Patient
becomes breathless during exertion.
To record: Write (+) for presence of symptoms, describe
correspondingly as to duration, onset and character,
and (-) for its absence.
□ Constitutional symptoms: Significant change in weight
(specify if loss or gain,quantify and indicate
period of time involved), generalized body
weakness; fatigue;
□ fever; chills; and appetite
□ Skin: itchiness, excessive dryness or sweating,
change in color (cyanosis, pallor,jaundice or
erythema)
□ Head: headache, dizziness/vertigo
□ Eyes: pain, blurring of vision, double vision,
lacrimation, photophobia, use of eyeglasses
□ Ears: earache, deafness, tinnitus, ear discharge
□ Nose and Sinuses: changes in smell, nose bleeding,
nasal obstruction, nasal discharge, pain over
paranasal sinuses
□ Mouth and Throat: toothache, gum bleeding,
disturbance in taste, sore throat, hoarseness
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□ Neck: pain, limitation of movement, presence of a
mass
□ Breast: pain, lumps, nipple discharge
□ Respiratory: difficulty of breathing (DOB), pleuritic
chest pain, cough, sputum production,
hemoptysis, audible wheezing
□ Cardiovascular:substernal pain, palpitations,
orthopnea (how many pillows used), paroxysmal
nocturnal dyspnea, syncope, easy fatigability
□ Gastrointestinal: abdominal pain, nausea, vomiting,
dysphagia, diarrhea, constipation, hematemesis
(vomiting of blood), melena (passing out tarry
stool), hematochezia (fresh blood in the
stools), regurgitation
□ Genitourinary: dysuria, urinary frequency, urgency,
hesitancy, polyuria, hematuria, incontinence,
genital pruritus, urethral discharge
□ Extremities: edema, swelling of joints, stiffness,
numbness, intermittent
claudication,limitation of movement
□ Nervous: headache, vertigo, syncope (fainting), loss
of consciousness, focal weakness, paralysis,
numbness, paresthesia, speech disorder, loss of
memory, confusion
□ Hematologic: bleeding tendency, pallor, easy bruising
□ Endocrine: intolerance to heat and cold; excessive
weight gain or weight loss, polyuria,
polydipsia
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