I. INTRODUCTION Mr.

Boy Pickup, is a 59 y/o, Male, Catholic, and a retired government employee, is currently residing at 280 Ilang-Ilang St. St. Joseph, Orani, Bataan. He is admitted for the first time at Fatima University Medical Center on September 10, 2011.He has a chief complaint of difficulty of breathing and dizziness. He was diagnosed of congestive heart failure. Congestive heart failure is a condition in which the heart can no longer pump enough blood to all body parts. As a result, the cardiac output is low and the body is congested with fluid. The fluids and blood accumulates in the organs and tissues due to the impaired circulation. There are two types of heart failure, left-sided heart failure and the other one is the right-sided heart failure. Left sided heart failure occurs when the left ventricle can no longer pump enough blood effectively to the aorta and the systemic circulation. On the other hand, right sided heart failure occurs when the right side of the heart cannot eject blood and accommodate all the blood that normally returns to it from the venous circulation. Some cases of heart failure are reversible depending on the cause but mostly, it is chronic and a life-long condition. This kind of condition is costly, increases hospitalizations, and decreased the quality of life.

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II. ANATOMY AND PHYSIOLOGY HEART The heart is a myogenic muscular organ found in all animals with a circulatory system (including all vertebrates), that is responsible for pumping blood throughout the blood vessels by repeated, rhythmic contractions. The term cardiac (as in cardiology) means "related to the heart" and comes from the Greek , kardia, for "heart". The vertebrate heart is composed of cardiac muscle, which is an involuntary striated muscle tissue found only in this organ, and connective tissue. The average human heart, beating at 72 beats per minute, will beat approximately 2.5 billion times during an average 66 year lifespan. It weighs approximately 250 to 300 grams (9 to 11 oz) in females and 300 to 350 grams (11 to 12 oz) in males. In invertebrates that possess a circulatory system, the heart is typically a tube or small sac and pumps fluid that contains water and nutrients such as proteins, fats, andsugars. In insects, the "heart" is often called the dorsal tube and insect "blood" is almost always not oxygenated since they usually respirate (breathe) directly from their body surfaces (internal and external) to air. However, the hearts of some other arthropods (including spiders and crustaceans such as crabs and shrimp) and some other animals pump hemolymph, which contains the copper-based 16

protein hemocyanin as an oxygen transporter similar to the ironbased hemoglobin in red blood cells found in vertebrates. The heart pumps oxygenated blood to the body and deoxygenated blood to the lungs. In the human heart there is one atrium and one ventricle for each circulation, and with both a systemic and a pulmonary circulation there are four chambers in total: left atrium, left ventricle, right atrium and right ventricle. The right atrium is the upper chamber of the right side of the heart. The blood that is returned to the right atrium is deoxygenated (poor in oxygen) and passed into the right ventricle to be pumped through the pulmonary artery to the lungs for re-oxygenation and removal of carbon dioxide. The left atrium receives newly oxygenated blood from the lungs as well as the pulmonary vein which is passed into the strong left ventricle to be pumped through the aorta to the different organs of the body.

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III.PATHOPHYSIOLOGY

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IV.HISTORY HISTORY OF PRESENT ILLNESS 6 days PTC, patient experienced dizziness, described as loss of balance, associated with nausea & vomiting of previously ingested food, headache starting from frontal area radiating to the occipital. PS- 6.7/10. This was not associated with chest pain, difficulty of breathing as fever. Patient consulted a private physician who prescribed him with pain reliever and afforded temporary relief. Persistence of symptoms prompted patient consult hence admitted.

PAST MEDICAL HISTORY

(+) HPN diagnosed June 2011, with following medications: Simvastatin

20 mg OD, Spirinolactone 25 mg OD, Furosemide 40 mg OD, Amiodarone 200mg OD, Telmisartan + HCTZ 90 mg OD (+) DM on Metformin 500 mg BID (-) Asthma, goiter, PTB, allergy to medications

FAMILY MEDICAL HISTORY (+) HPN paternal side 16

(+) DM both side

PERSONAL AND SOCIAL HISTORY (+) Smoker 3 sticks/day x 41 years

(+) Occasional alcoholic beverage drinker 2 bottles of Red

Horse/occassion

V. NURSING PHYSICAL ASSESSMENT Boy Pickup is conscious and coherent when he has admitted in Fatima Medical Center with (+) numbness in upper extremities. His Vital signs with a BP of 120/90mmHg, PR= 60bpm, RR=20cpm and T=36.1C. His integument is brown moist, with good skin turgor. HEENT assessment reveals AS, PPC, (-) NAP, (-) TPC and (-) CLAP with Chest and lungs SCR, (-) retraction, CBS, (-) lagging. Heart is AP, normal rate, irregular rhythm and no murmur. Abdomen are flabby, NABS, soft non-tender. Extremities GNE, (-) cyanosis, (-) edema. Cerebrum reveals conscious, coherent and oriented to 3 spheres. Cerebellum with (-) nystagmus and Cranial nerves is intact with pinkish palpebral conjunctival anicteric sclerae and no neck vein engorgement. Symmetrical chest expansion, no retraction, vesicular breath sounds. His abdomen is flabby, normoacative bowel sounds and soft. Grossly normal extremities, no

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cyanosis, no edema, fill and equal pulses with no meningeal signs and no pathologic reflex. VI.RELATED TREATMENT Mr. Boy Pickup was admitted to Fatima University Medical Center last September 15, 2011 with a chief complaint of dizziness and difficulty of breathing accompanied by his relatives, inserted Intravenous Fluid of PNSS 1L regulated at KVO rate started at 7:30 pm on the same day. Boy Pickup was admitted with the following medications as:

Duxaril ( ALMITRINE & RAUBASINE ) Antihypoxic Drug, 1 tab , for pathological loss of cognitive function

Vestar ( TRIMITAZIDINE ) Anti-anginal Drug, 35 mg tab , for chest pain and hypertension

Olmetec ( OLMESARTAN ) Angiotensin II receptor antagonist, 50 mg tab , for hypertension

Lanoxin ( DIGOXIN ) Cardiotonic , 0.25 mg / tab , useful in the treatment of heart failure and cardiac arrhythmia

Plavix ( CLOPIDOGREL ) Antiplatelet, 75 mg / tab , inhibits platelet aggregation

Lipitor ( ATORVASTATIN ) HMG-CoA reductase inhibitor, 20 mg / tab , used to treat high cholesterol 16

Galvus ( VILDAGLIPTIN ) DDP-IV Inhibitor/Oral Antidiabetic Agent, 50 mg /tab , used to treat type 2 or non insulin dependent diabetes mellitus

Dolcet ( PARACETAMOL + TRAMADOL ) Opioid analgesic, 1 tab , for acute pain

Pradaxa ( DABIGATRAN ) Anticoagulant, 110 mg / tab , used to prevent blood clots and to reduce the risk of stroke in people with a certain type of heart rhythm disorder.

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Name : Mr. Boy Pickup Age : 59 years oldsex : Male PARAMETER LVID (ed) LVID (es) LV VOL (ed) LV VOL (ed) SV CO HR VCF FS EF EF(Simpsons 52 42 114 62 52.3 5.4 104 0.08 20 40 46 NORMAL (33-50mm) (17-31mm) MI MI ml/ beat L/ min (60100bpm) (0.88-1.55) (28-44%) (55-83%)

Date : September 6 , 2011 X: 2D echo with Doppler PARAMETER LA DIA (ed) AORTA (ed) 1.diameter 2.valve opening 3.amplitude LVET EPSS MV E-F slope 2D ECHO LVOT AV annulus RVOT MPA RV RA TV annulus MV annulus IVC diameter 40 32 20 7 253 7 99 20 18 28 22 33 39 22 26 NORMAL (26-36mm) (21-36mm) (15-20mm) (4-13mm) 265-325 (<10mm) 40-104mm 18-21mm 18-24mm (mm) (16-22mm) 27-35mm 33-41mm 19-25mm 21-27mm 12-33mm

) IVST (ed) 13 IVST (es) 15 IVSA 5 LVPWT (ed) 7 LVPWT (es) 15 LVPWA 7 LV MASS 225 LVmass index 108 SPECTRAL STUDY Valve Mitral Tricuspid LVOT/ aortic Pulmonic Velocity 0.9 0.18 0.7 0.32 0.7 1.11 7 0.46

6-11mm 5-8 mm 7-11 mm 5-12mm G

Gradient 3.3 0.1 2.0 0.4 2.3 4.9 0.8

Normal 0.8-1.3m/sec 0.5-0.8m/sec 1.2-1.8m/sec 0.7-1.1m/sec

Area

Regurgitation

PAT m/sec NV:>100ms 152

Pressure Gradient m/sec mmHg

SPAP(mmHg )

Qp:Qs

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DIASTOLIC INDICES INDICES E/A ratio Deceleration Time IVRT Pulmonary Venous Flow Pulm systolic Flow Pulm diastolic flow S/D ratio NORMAL 1.1.- 1.5 160-240m/sec <81 m/sec <25 m/sec (m/sec) (m/sec)

139 108

INTERPRETATION Mr. Boy Pickups 2D echo with Doppler revealed dilated left ventricle with segmental wall abnormally as described with evidence of systolic dysfunction, Interventricular septal hypertrophy, dilated left atrium with no evidence of thrombus formation, thickened aortic valve annulus and aortic root, thickened non-coronary cusps with no restriction of motion, trivial mitral regurgitation, mild tricuspid regurgitation, trivial aortic regurgitation, Pulmonic regurgitation and mild pulmonary hypertension.

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Name : Mr. Boy Pickup Age : 59 years old Gender : Male

Date : September 6 , 2011 Examine for : Urinalysis

CLINICAL MICROSCOPY MACROSCOPIC Color Transparency Yellow Clear Chemical Specific pH NITRATE PROTEIN GLUCOSE KETONE UROBILINOGEN BILIRUBIN LEUKOCYTES BLOOD YEAST CELLS OTHERS MICRAL TEST PREGNANCY Date : September 16 , 2011 Examine for : HEMATOLOGY RESULT 16
NORMAL VALUES

1.015 7.5 NEGATIVE NEGATIVE NEGATIVE NEGATIVE NEGATIVE NEGATIVE NEGATIVE

MICROSCOPIC RBC PUS CELLS BACTERIA EPITHELIAL CELLS MUCUS THREADS CRYSTALS AMORPHOUS URATES AMORPHOUS PHOSPATES AMORPHOUS BIURATE CALCIUM OXALATE CAST PUS CAST HYALINE CAST FINE GRANULAR CAST Name : Mr. Boy Pickup

0-1/HPF 0-1/HPF FEW FEW FEW FEW

Age : 59 years oldGender : Male

Interpretation CBC WBC DIFFERENTIAL COUNT NEUTROPHIL LYMPHOCYTES MONOCYTES EOSINOPHILS BASOPHILS HEMOGLOBIN :MALE HEMOGLOBIN : MALE HGT RBC MCV MCH MCHC RDW PLATELET MPV
REMARKS: CBG 9/16 5:30AM VII. RECOMMENDATION

7.2 0.48 0.40 0.08 0.02 0.02 168 0.50 94 5.98 83 28.1 338 12.2 207 4.89

5.0-10.0 x 10 g/L

NORMAL

0.40-0.60 NORMAL 0.20-0.40 NORMAL 0.02-0.08 NORMAL 0.01-0.03 NORMAL 0-0.02 NORMAL M:140-175 g/L NORMAL M:0.42-0.48 SLIGHTLY E. 80-120 mg/Dl NORMAL M:5.5-6.5 x 10 12/L NORMAL 88-96 NORMAL 27-33 pg NORMAL 300-360 g/L NORMAL 12.7-22.7% LOW 150-450 x 10 g/L NORMAL 4.5-7.5FL NORMAL

Medication Duxaril (ALMITRINE&RAUBASINE) Vestar (TRIMITAZIDINE) Lanoxin (DIGOXIN) Galvus (VILDAGLIPTIN) Lipitor (ATORVASTATIN) Pradaxa (DABIGATRAN) Plavix (CLOPIDOGREL) 16

Olmetec (OLMESARTAN) Dolcet (PARACETAMOL + TRAMADOL)

Exercise Walking atleast 10-16 times daily Perform deep breathing and coughing exercise

Treatment LIFESTYLE MODIFICATION Low sodium diet Severe restriction of alcohol consumption The total fluid consumed must be regulated Frequent measurement of body weight

Addressing potentially reversible factors *Depending on the underlying cause of congestive heart failure, potentially reversible factors should be explored. For example: 16

 In certain persons whose congestive heart failure is caused by inadequate blood flow to the heart muscle, restoration of the blood flow through coronary artery surgery or catheter procedures (angioplasty, intracoronary stenting) may be considered. Congestive heart failure that is due to severe disease of the valves may be alleviated by valve surgery in appropriate patients.
When congestive heart failure is caused by chronic, uncontrolled high

blood pressure (hypertension), aggressive blood pressure control will often improve the condition.

Heart muscle weakness that is due to longstanding, severe alcohol abuse can improve significantly with abstinence from drinking.

Congestive heart failure that is caused by other disease states may be similarly partially or completely reversible by appropriate measures.

Health Teachings Take prescribed medications in right time with the right dose. Call physician immediately if a certain medical problem occurs. A weight gain of two to three pounds over two to three days should be prompt a call to the physician

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 Diet

Follow prescribed diet Limit fluid intake Exercise Avoid alcohol Avoid Fatigue

Reduce sodium -Choose food with low-salt content.

*Eat low-fat and low-calorie foods - A low fat consists of fruits, vegetables, fish, cereals, nuts and seeds. - Avoid high fat foods like milk, ice-cream, cheese, process meats, butter, oil and eggs.

* Restrict Fluids - Fluid intake should be moderate, no more than 8 glasses per day. This includes all types of fluids at meals and between meals. - ALCOHOL must be avoided!!!!!!

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Spiritual Pray everyday Attend mass and bible studies.

Sex
-

Can resume sexual activities if tolerated.

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