Comprehensive CHF (Congestive Heart Failure) Case Study

This is not a real patient chart. The names and data have been created.

Patient Chart

Patient Name: Michael James Henderson
Date of Birth: 02/28/1965
Age: 60
Gender: Male
Medical Record Number: 20250312
Date of Admission: 03/12/2025
Primary Care Provider: Dr. Jennifer Smith

Chief Complaint (CC)

"I’ve been feeling more tired lately, and I’ve had a lot of swelling in my legs and abdomen. I also get short of breath easily."

History of Present Illness (HPI)

Michael Henderson is a 60-year-old male with a history of hypertension, diabetes, and previous myocardial infarction (MI) who presents with worsening symptoms of congestive heart failure (CHF). Over the past two weeks, he has noticed increasing shortness of breath, particularly with minimal exertion, such as walking from his bedroom to the kitchen. He has also experienced significant swelling in his legs, feet, and abdomen. The swelling worsens by the end of the day. He reports a weight gain of approximately 5 pounds over the past week, and he has also noticed that his appetite has decreased due to a feeling of fullness.

The patient has a known history of heart failure with reduced ejection fraction (HFrEF), and although he has been on medical therapy, his symptoms have become more pronounced despite adherence to his medications. He denies chest pain but does report occasional palpitations.

Past Medical History (PMH)

• Hypertension – diagnosed 15 years ago, poorly controlled, currently on Lisinopril
• Diabetes Mellitus Type 2 – diagnosed 10 years ago, managed with Metformin and diet
• Myocardial Infarction (MI) – 4 years ago, treated with angioplasty and stent placement
• Congestive Heart Failure (CHF) – diagnosed 3 years ago, treated with ACE inhibitors, beta-blockers, and diuretics
• Hyperlipidemia – diagnosed 12 years ago, controlled with Atorvastatin

Surgeries & Procedures

• Angioplasty with stent placement for myocardial infarction (4 years ago)
• Cholecystectomy (5 years ago)

Allergies

• Penicillin – Rash

Medications

• Lisinopril 10 mg daily
• Metformin 500 mg twice daily
• Atorvastatin 40 mg nightly
• Carvedilol 25 mg twice daily
• Furosemide 40 mg daily
• Aspirin 81 mg daily

Family History (FH)

• Father: Deceased, 70, with a history of heart disease and stroke
• Mother: Deceased, 68, with a history of hypertension and diabetes
• Brother: Alive, 55, with hypertension and high cholesterol

Social History (SH)

• Smoking: 10 pack-years, quit 20 years ago
• Alcohol: Occasional drinker (1-2 drinks per week)
• Drug Use: Denies illicit drug use
• Occupation: Retired truck driver
• Living Situation: Lives with wife, independent in activities of daily living

Review of Systems (ROS)

• General: Fatigue, weight gain (due to edema), decreased appetite, no fever
• Cardiovascular: Shortness of breath, palpitations, bilateral leg and abdominal swelling
• Respiratory: No cough or wheezing, shortness of breath on exertion
• Gastrointestinal: Decreased appetite, bloating, no nausea or vomiting
• Neurological: No headaches, dizziness, or syncope
• Musculoskeletal: No joint pain or swelling

Physical Assessment Findings

Vital Signs:

• Temperature: 98.2°F (36.8°C)
• Heart Rate: 88 bpm, regular
• Respiratory Rate: 18 breaths/min
• Blood Pressure: 145/90 mmHg
• Oxygen Saturation: 94% on room air
• Height: 5'6"
• Weight: 145 lbs. General Appearance: Obese male, alert, in moderate distress due to shortness of breath
  Cardiovascular: Regular rate and rhythm, bilateral lower extremity edema (3+ pitting), no jugular venous distention
  Respiratory: Mild crackles in the lower lung fields, no wheezing
  Abdomen: Distended, positive for ascites, non-tender
  Neurological: Alert and oriented, no focal deficits

Laboratory Results

Basic Metabolic Panel (BMP)

Complete Blood Count (CBC)

Liver Function Tests (LFTs)

Arterial Blood Gas (ABG)

Electrocardiogram (ECG)

Findings:

• Sinus rhythm, occasional premature ventricular contractions (PVCs), no significant ST-segment changes

Echocardiogram

Findings:

• Left ventricular ejection fraction (LVEF) of 30%, indicating severe systolic dysfunction.
• Mild mitral regurgitation.
• Mild pericardial effusion.