NURSING HISTORY

Patient R.C.B, 55, male, born on March 09, 1960 at Manila and is married and
a Roman Catholic lives at P. Laygo St. Sabang, Lipa City, Batangas. Patient R.C.B is a
High School Graduate and now has 4 children who lives with him and has their own
family. He was a Kubrador ng Jueteng before and loves to eat chicken liver and
other chicken intestines. He was admitted last January 17, 2016 with a chief
complaint of chest pain.
One year prior to his admission, patient R.C.B. experienced elevated Blood
Pressure of 180/90 consulting to Ospital ng LIpa where he was admitted, upon his
admission, there are no chest pain nor headache or dizziness experienced. He was
requested for a 2D echo and the result shows concentric left ventricular hypertrophy
with mild and moderate hypokinesia of the whole interventricular septum, mild
mitral regurgitation and aortic regurgitation +1. He was discharged later and given
with medications of Carvedilol 25 mg/tab, Losartan 50 mg/tab, Trimetazidine
35mg/tab. Around 2 months prior to his admission, he experienced chest pain
graded 2/10 after exertion accompanied by easy fatigability relieved in less than 15
minutes of rest and was advised for coronary angiography hence referral to
University of Santo Tomas Hospital. Interval history showed persistence of
symptoms.
Patient R.C.B. mentioned that it is his first time to be hospitalized. He never
experienced any surgeries before nor hospitalizations, but last 2015 he was
diagnosed with Hypertension stage 2 and during his stay in UST hospital, he was
diagnosed with Diabetes Mellitus type 2. According to him, he has no any known
allergies and his immunizations were complete such also his Flu vaccine and
Pneumonia vaccine but cant recall the date given. Upon his hospitalization for his
coronary angiography, he was prescribed by his physician to take his medications
such as Carvedilol, Trimetazidine, Losartan and was added with Isosorbide
Mononitrate and Isosorbide Dinitrate and Aspirin. His Family history shows Cancer
on his father side and Hypertension from his grandparents and added that it is not
the reason why his father and grandparents died.
Patient mentioned that he has lived both in Manila and Batangas and did not
mention other jobs held in the past. Due to his condition and consequences from
the procedure taken, He exercises through walking only every 2-3 times per week
for about 1-2 hours. He always sleeps at 11:00pm and slept for about 5 hours per
night. He also recalled what he had taken during his breakfast which is a bread and
an oatmeal while, he ate chicken curry with rice and vegetables during his lunch
time, and Vegetables and Fish during Supper and he only ate bread during snack
time. He is not fond of drinking coffee, nor tea but loves to drink Soda/cola. He is a
smoker of 36 pack years but was not desired to drink alcoholic beverages.
Patient views himself as an ordinary person and handsome. And also views
himself in the future as an average man. He was just concern at present his
hospitalization that keeps him for almost 1 week. He is already bored and wants to

come home because he misses his children and their home in Batangas. He sees
himself as a good father to his family and good-provider. He has a complete family.

Pathophysiology

LABORATORY/DIGANOSTIC RESULTS
PROCEDURE
ECG

RESULTS
Sinus tachycardia,
diffuse ischemia
concentric LVH

INFERENCE
Hypertrophic cardiomyopathy
(HCM) is characterized by a
hypertrophied left ventricle,
defined as diastolic wall
thickness 15mm or more,
without any identifiable cause
such as hypertension or
valvular disease.
Normal ventricular septal
measurement is 8-12 mm.
Usually there is asymmetric
thickening of the wall most
prominently involving the
ventricular septum without
abnormal enlargement of the
ventricular cavities.

Disease processes that can

cause LVH include any
disease that increases
the afterload that the heart has
to contract against, and some
primary diseases of the muscle
of the heart.

2D Echo

hypokinesia of the
anterior and
anteroseptal wall
segments from mid to
base with preserved
systolic function and
grade 1 diastolic
function
Thickened mitral valve
leaflets with discrete
calcification without
restriction of motion
Aortic annular
calcification
Mitral regurgitation,
mild

Tricuspid
regurgitation, mild
Reverse mitral inflow
pattern
Consistent with grade
1 left ventricular
diastolic dysfunction