Heart Failure Clinical Reasoning Case Study
Mr. Kelly
Chief Complaint/History of Present Illness:
It has now been 3 years since Mr. Kelly has been discharged from the hospital for CAD & MI.
He is now 56 years old. He has not had any recurrent CP, but has had to sleep with 3 pillows to
keep from becoming SOB at night the last 2 weeks. He has had difficulty getting his shoes on
the last month because of increased swelling around his ankles. He forgets to take his
medications every day but does at least 4-5 times a week. He weighs himself once a week and
today his weight has increased from 255 lbs. to 264 lbs. the last 7 days. He makes an appt.
through his clinic when he becomes concerned that he is now becoming SOB at rest and is
more fatigued. The clinic physician recognizes that he will need acute inpatient care and
coordinates a direct admission to the hospital by EMS.
Past Medical History:
• HTN - HCTZ, lisinopril
• Hyperlipidemia – simvastatin and fish oil
• CAD -
• MI
• DM-type II - glyburide
Home Medications:
• Simvastatin 20 mg po daily
• Glyburide 10 mg po daily
• HCTZ 50 mg po daily
• Lisinopril 20 mg po daily
• ASA 81 mg po daily
• Fish oil 1000 mg po 2 tabs daily
Social/personal history
Lives alone in own home. He is divorced with three grown children. He has had to cut back
working to only 4 hours a day as a mechanic because of fatigue and weakness since the first of
the year.
I. Pre-Clinical Critical Thinking: Identifying Relationships
1. What is the relationship of his medical history and current medications?
(Which medication treats which disease? Draw a line to connect)
Past Medical History: Home Medications:
• HTN • Simvastatin 20 mg po daily
• Hyperlipidemia • Glyburide 10 mg po daily
• CAD • HCTZ 50 mg po daily
• MI • Lisinopril 20 mg po daily
• DM-type II • ASA 81 mg po daily
• Fish oil 1000 mg po 2 tabs daily
, 2. One disease process often influences the development of other illnesses. Based on
your knowledge of pathophysiology, in Mr. Kelly which disease likely developed first that
initiated a “domino effect” in his life?
Past Medical History: What Came First:
• HTN, Hyperlipidemia
• Hyperlipidemia
• CAD What then followed:
• MI DM, HTN, CAD, MI, Heart Failure
• DM-type II
• Heart failure
(new dx)
3. What is the relationship of his past medical history and current chief complaint?
Are there any pre-existing conditions that directly influenced his current problem? Explain your
rationale if present
Past Medical History: Chief Complaint:
• HTN, • Has had to sleep with 3 pillows to keep from becoming SOB at night
• Hyperlipidemia the last 2 months. Heart failure
• CAD • He has had difficulty getting his shoes on the last month because of
• MI increased swelling around his ankles. Heart failure (right)
• DM-type II • His weight has increased from 255 lbs. to 264 lbs. the last 7 days.
• Heart failure Heart failure (left)
(new dx) • Becomes concerned that he cannot get out of his chair without
becoming more SOB and is more fatigued heart failure
Mr. Kelly arrives to your telemetry unit
You are the telemetry floor nurse and you have just received him as a direct admit. You review
his history through the electronic medical record. The paramedics relate the above story of why
he is being admitted.
Current Status:
Admission VS:
o T:98.4
o P:126-regular
o R:28/labored
o BP:184/108
o O2 sats:90% 2l per n/c
Admission Nursing Assessment:
o CV: pale, cool to the touch. Pulses 2+ throughout. 2-3+ pitting edema lower
extremities
Mr. Kelly
Chief Complaint/History of Present Illness:
It has now been 3 years since Mr. Kelly has been discharged from the hospital for CAD & MI.
He is now 56 years old. He has not had any recurrent CP, but has had to sleep with 3 pillows to
keep from becoming SOB at night the last 2 weeks. He has had difficulty getting his shoes on
the last month because of increased swelling around his ankles. He forgets to take his
medications every day but does at least 4-5 times a week. He weighs himself once a week and
today his weight has increased from 255 lbs. to 264 lbs. the last 7 days. He makes an appt.
through his clinic when he becomes concerned that he is now becoming SOB at rest and is
more fatigued. The clinic physician recognizes that he will need acute inpatient care and
coordinates a direct admission to the hospital by EMS.
Past Medical History:
• HTN - HCTZ, lisinopril
• Hyperlipidemia – simvastatin and fish oil
• CAD -
• MI
• DM-type II - glyburide
Home Medications:
• Simvastatin 20 mg po daily
• Glyburide 10 mg po daily
• HCTZ 50 mg po daily
• Lisinopril 20 mg po daily
• ASA 81 mg po daily
• Fish oil 1000 mg po 2 tabs daily
Social/personal history
Lives alone in own home. He is divorced with three grown children. He has had to cut back
working to only 4 hours a day as a mechanic because of fatigue and weakness since the first of
the year.
I. Pre-Clinical Critical Thinking: Identifying Relationships
1. What is the relationship of his medical history and current medications?
(Which medication treats which disease? Draw a line to connect)
Past Medical History: Home Medications:
• HTN • Simvastatin 20 mg po daily
• Hyperlipidemia • Glyburide 10 mg po daily
• CAD • HCTZ 50 mg po daily
• MI • Lisinopril 20 mg po daily
• DM-type II • ASA 81 mg po daily
• Fish oil 1000 mg po 2 tabs daily
, 2. One disease process often influences the development of other illnesses. Based on
your knowledge of pathophysiology, in Mr. Kelly which disease likely developed first that
initiated a “domino effect” in his life?
Past Medical History: What Came First:
• HTN, Hyperlipidemia
• Hyperlipidemia
• CAD What then followed:
• MI DM, HTN, CAD, MI, Heart Failure
• DM-type II
• Heart failure
(new dx)
3. What is the relationship of his past medical history and current chief complaint?
Are there any pre-existing conditions that directly influenced his current problem? Explain your
rationale if present
Past Medical History: Chief Complaint:
• HTN, • Has had to sleep with 3 pillows to keep from becoming SOB at night
• Hyperlipidemia the last 2 months. Heart failure
• CAD • He has had difficulty getting his shoes on the last month because of
• MI increased swelling around his ankles. Heart failure (right)
• DM-type II • His weight has increased from 255 lbs. to 264 lbs. the last 7 days.
• Heart failure Heart failure (left)
(new dx) • Becomes concerned that he cannot get out of his chair without
becoming more SOB and is more fatigued heart failure
Mr. Kelly arrives to your telemetry unit
You are the telemetry floor nurse and you have just received him as a direct admit. You review
his history through the electronic medical record. The paramedics relate the above story of why
he is being admitted.
Current Status:
Admission VS:
o T:98.4
o P:126-regular
o R:28/labored
o BP:184/108
o O2 sats:90% 2l per n/c
Admission Nursing Assessment:
o CV: pale, cool to the touch. Pulses 2+ throughout. 2-3+ pitting edema lower
extremities
