i-Human Case Study; Heart Failure
Patient Information
Name: Wilson Smith
Age: 64 years
Sex: Male
Occupation: Retired schoolteacher
Chief Complaint
Progressive shortness of breath and fatigue over the past three months.
History of Present Illness
Wilson Smith reports increasing difficulty in performing his daily activities. Initially, he
could walk around his compound comfortably, but now he becomes breathless after
walking a few meters or climbing a short flight of stairs. He has also noticed swelling of
his feet and ankles, which worsens in the evening. For the past week, he has had
difficulty sleeping flat, requiring two pillows at night (orthopnea). He occasionally wakes
up at night gasping for air (paroxysmal nocturnal dyspnea).
He denies any chest pain but reports a dry cough that worsens when lying down. No
recent fever or palpitations. He has gained about 3 kg in the last month without dietary
changes.
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,i-Human Case Study; Heart Failure
Past Medical History
Longstanding hypertension (15 years), poorly controlled
Type 2 Diabetes Mellitus for 8 years
No previous history of myocardial infarction, but he recalls being told about
“enlarged heart” two years ago
No known history of asthma or chronic obstructive pulmonary disease (COPD)
Medication History
Amlodipine 10 mg once daily (irregular use)
Metformin 500 mg twice daily
Occasional use of herbal remedies for “high blood pressure”
Family and Social History
Father died of stroke at 70 years
Mother has hypertension
Non-smoker for the last 10 years (smoked 1 pack/day for 20 years)
Drinks alcohol occasionally
Diet high in salt and fried foods
Sedentary lifestyle
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,i-Human Case Study; Heart Failure
Review of Systems
Cardiovascular: Fatigue, ankle swelling, breathlessness
Respiratory: Orthopnea, nocturnal dyspnea
Gastrointestinal: Occasional loss of appetite, abdominal fullness
Genitourinary: Reduced urine output
Neurological: No dizziness or fainting spells
Physical Examination
General appearance: Elderly male, sitting upright in mild respiratory distress
Vital signs:
o BP: 156/92 mmHg
o HR: 104 bpm (regular)
o RR: 24 breaths/min
o Temperature: 36.7°C
o SpO₂: 93% on room air
Neck: Elevated jugular venous pressure (JVP)
Chest: Bilateral basal crackles on auscultation
Heart: Displaced apical impulse, S3 gallop present
Abdomen: Mild hepatomegaly, shifting dullness (ascites)
Extremities: Pitting edema up to mid-shin
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, i-Human Case Study; Heart Failure
Diagnostic Investigations
Test Result Interpretation
Cardiomegaly, pulmonary
Chest X-ray Suggestive of heart failure
congestion
Chronic hypertension
ECG Left ventricular hypertrophy (LVH)
effect
Left ventricular ejection fraction
Echocardiogram Reduced systolic function
(LVEF) 35%
BNP (Brain Natriuretic
420 pg/mL (↑) Marker of heart failure
Peptide)
Contributing factor to
CBC Mild anemia
fatigue
Sodium 130 mmol/L (↓), Hyponatremia due to fluid
Serum Electrolytes
Potassium 4.5 mmol/L retention
Renal congestion
Renal Function Tests Mildly elevated creatinine
secondary to HF
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Patient Information
Name: Wilson Smith
Age: 64 years
Sex: Male
Occupation: Retired schoolteacher
Chief Complaint
Progressive shortness of breath and fatigue over the past three months.
History of Present Illness
Wilson Smith reports increasing difficulty in performing his daily activities. Initially, he
could walk around his compound comfortably, but now he becomes breathless after
walking a few meters or climbing a short flight of stairs. He has also noticed swelling of
his feet and ankles, which worsens in the evening. For the past week, he has had
difficulty sleeping flat, requiring two pillows at night (orthopnea). He occasionally wakes
up at night gasping for air (paroxysmal nocturnal dyspnea).
He denies any chest pain but reports a dry cough that worsens when lying down. No
recent fever or palpitations. He has gained about 3 kg in the last month without dietary
changes.
1|Page
,i-Human Case Study; Heart Failure
Past Medical History
Longstanding hypertension (15 years), poorly controlled
Type 2 Diabetes Mellitus for 8 years
No previous history of myocardial infarction, but he recalls being told about
“enlarged heart” two years ago
No known history of asthma or chronic obstructive pulmonary disease (COPD)
Medication History
Amlodipine 10 mg once daily (irregular use)
Metformin 500 mg twice daily
Occasional use of herbal remedies for “high blood pressure”
Family and Social History
Father died of stroke at 70 years
Mother has hypertension
Non-smoker for the last 10 years (smoked 1 pack/day for 20 years)
Drinks alcohol occasionally
Diet high in salt and fried foods
Sedentary lifestyle
2|Page
,i-Human Case Study; Heart Failure
Review of Systems
Cardiovascular: Fatigue, ankle swelling, breathlessness
Respiratory: Orthopnea, nocturnal dyspnea
Gastrointestinal: Occasional loss of appetite, abdominal fullness
Genitourinary: Reduced urine output
Neurological: No dizziness or fainting spells
Physical Examination
General appearance: Elderly male, sitting upright in mild respiratory distress
Vital signs:
o BP: 156/92 mmHg
o HR: 104 bpm (regular)
o RR: 24 breaths/min
o Temperature: 36.7°C
o SpO₂: 93% on room air
Neck: Elevated jugular venous pressure (JVP)
Chest: Bilateral basal crackles on auscultation
Heart: Displaced apical impulse, S3 gallop present
Abdomen: Mild hepatomegaly, shifting dullness (ascites)
Extremities: Pitting edema up to mid-shin
3|Page
, i-Human Case Study; Heart Failure
Diagnostic Investigations
Test Result Interpretation
Cardiomegaly, pulmonary
Chest X-ray Suggestive of heart failure
congestion
Chronic hypertension
ECG Left ventricular hypertrophy (LVH)
effect
Left ventricular ejection fraction
Echocardiogram Reduced systolic function
(LVEF) 35%
BNP (Brain Natriuretic
420 pg/mL (↑) Marker of heart failure
Peptide)
Contributing factor to
CBC Mild anemia
fatigue
Sodium 130 mmol/L (↓), Hyponatremia due to fluid
Serum Electrolytes
Potassium 4.5 mmol/L retention
Renal congestion
Renal Function Tests Mildly elevated creatinine
secondary to HF
4|Page
