Delroy is a 65 -year-old gentleman admitted to hospital with shortness of breath. He has Stage 3 Heart Failure which was diagnosed 3 years ago. His respiratory symptoms have improved, and he is to be discharged home

Case Study

Delroy is a 65 -year-old gentleman admitted to hospital with shortness of breath.  He has Stage 3 Heart Failure which was diagnosed 3 years ago. His respiratory symptoms have improved, and he is to be discharged home.

Signs and symptoms

Breathlessness

Fatigue

Pain mobilising due to osteoarthritis in his knees (Pain score 6/10)

Loss of appetite

Low mood

Constipation

Grade 2 Pressure Ulcer on his sacrum

BMI – 42

Limited mobility

Past Medical History

Worsening Heart Failure (Stage 3 NYHA Classification)

Angina

Osteoarthritis

Chronic Obstructive Pulmonary Disease

Depression

Acute renal Failure

Hypertension

Cardiovascular Accident with residual left sided weakness

Smokes 5 Cigarettes a day

Occasionally drinks 2-3 units of beer

Current Medication

Salbutamol 2.5 mgs inhalers prn

Atrovent 2.5mg tds

Co-codamol 50/500mg, 2 tablets tds

Amlodipine 10mg once a day

Atorvastatin 40mg once a day

Glycerine Trinitrate sublingual spray (PRN)

Prednisolone 10mg daily

Aspirin 75mg daily

Fluoxetine 40mg once a day

Multivitamins

Family History

Married to Lucy and has 14-year-old daughter.

Has 3 older children for previous marriage. Now estranged from family.

Social History

He has recently retired as a pub Landlord due to his worsening condition. Delroy used to have a very active social life and was described as ‘the soul of the party’ but due to his ill health, he has not been able to go out and has become reliant on social media to keep up with his social life. He spends many hours on Facebook and twitter and appears to be taking up on-line gambling which is a deep concern for his family.  

He is unable to carry out most of his activities of daily living and relies on his wife for help, but this is taking its toll on their marriage. Delroy is unable to sleep in their marital bed upstairs or engage in a sexual relationship with his wife as a result of his worsening symptoms.

Delroy identifies himself religiously as a Rastafarian. He migrated to England from Jamaica 40 years ago and considers Jamaica his spiritual home. He has a house in Kingston, Jamaica and would like to return there in the future. He is very proud of his achievements and who he is as a person but finds it challenging to express his struggles with people who are not close to him.

Delroy is a 65 -year-old gentleman admitted to hospital with shortness of breath.  He has Stage 3 Heart Failure which was diagnosed 3 years ago. His respiratory symptoms have improved, and he is to be discharged home