CASE STUDY IN
CHRONIC HEART FAILURE
INTRODUCTION
• On 24th of December in 2022, my
assigned patient was admitted at University of
Minnesota Medical Center, Minneapolis, USA.
He is 72 years old and was diagnosed with
diastolic Heart failure. He was admitted
immediately for emergency surgery 25th of
December in 2022.
A. SIGNIFICANCE OF THE STUDY
• Students. They refer to the researcher that is
currently studying on the patient’s diagnosis.
The purpose of this study is for the students to
be able to facilitate creative problem solving.
• Teachers. They refer to the professionals who
would be assessing our case study. This case
study will be given them insights of the final
diagnosis of our patient, including the patient’s
lifestyle, family, history, and medical history.
B. SCOPE AND LIMITATION
• This study primarily focuses on the patient’s
diagnosis including its risk factors and clinical
manifestations that the patient encountered and
all the necessary information that the patient
willingly shared with us. This include the patient’s
history, family history, medications, as well as the
medical information that we have gathered during
his admission in the USA which are very useful and
can help us better understand the patient’s current
state or diagnosis.
III. PATIENT’S DESCRIPTION
• Biographical Data:
•
• Name: Steven James Bradley
• Age: 72 years old
• Birthday: November 18, 1950
• Birthplace: St. Paul, Minnesota USA
• Sex: Male
• Address: 03 Ben Lu Subd. Batinguel, Dumaguete City
• Religion: Roman Catholic
• Civil Status: Married
• Family Type: Extended Family
• Occupation: Retired
• Med Record: 010530667
• Att. Physician: Dr. Vincent Zenarosa MD. GP
• Diagnoses: Heart Failure
• Hypertension
B. Nursing Assessment
B1. Chief Complaints:
• The patient is complaining of shortness of breath and
tightness in his chest which made it difficult to take deep
breaths.
B2. History of Present Illness:
• The patient was complaining about having cough, and having
shortness of breaths.
• b3. Past Medical History:
• At age 12 - patient had a removal of tumor
from the back.
• 1990 - Patient had a left ankle fracture.
• 2004 - Heart attack.
B4. Previous Hospitalization/ Surgery/ Trauma
• 2004- Patient was hospitalized with low heart function and was admitted
for triple bypass surgery. Procedures required mitral valve repair. Vein
removal was done from the left leg for bypass replacement of blocked
arterial veins. Hospital recovery was 2 weeks. Patient returned to work 30
days later.
• 2018 - Patient received a replacement defibrillator.
B5. Immunization
• The patient has complete immunization during childhood.
B6. Allergies
• The patient has no allergies in any kind of food or drugs.
C. Social and Lifestyle History:
• My patient graduated with a Bachelor’s
Degree in Construction Technology and Architectural
Technology and in business as a Flooring Installation
Contractor. He started a business as a General
Contractor building new homes and townhouses. He
also has a partnership with House of Rothschild
owning and renting single family homes. He spent
little time with his family because of his divorce from
his ex-wife. He only visits his kids twice a month but
now is happily spending his time with his lovely wife.
