Reading a Health Record - Coursework Example

Patient Medical Record Patient Medical Record Patient Diagnosis Jane V. Dare is a patient 73 years of age female diagnosed with Congestive heart failure, left pleural effusion and pneumonia. The patient has a history of Atrial Fibrillation severe regurgitation from tricuspid and mitral valve dysfunction. No family history record is affiliated to the patient’s diagnosis. The patient is diagnosed with sulfa allergy. Physical findings are as follows; good sitting position and difficult fundoscopic exam.

Supple with positive venous distension on the neck. CNS irregular rate of 104 and crackles in left lower lobe: dull on the right. Abdomen: Benign, Genitalia: normal with red sacral area. Extremities 3+ pitting edema to the knees. Neurological: good and on track. The patient doesn’t sleep well, has increased pedal edema and no symptoms of coughing or fever. X-ray displays Left pleural effusion, congestive heart failure and pneumonia.Medication for sulfa allergy: 1. Capoten 25 mg po tid2. Furosemide 40 mg po qd3.

Digoxin 0.125 mg po qod4. Nortriptyline HCL 10 mg po qhs5. Tylenol 325 mg tabs prn for pain6. KLOR 10 mg qd7. Milk of Magnesia 30 cc po qd prnIn the case of patient assessment with cognitive heart failure, left pleural effusion and pneumonia a dosage of Diurese was administered, four antibiotics, blood cultures and sputum test. The patient is admitted and put on bed rest with oxygen mask. The patient is put onto Resident Assessment Protocol to diagnose her condition.Delirium-The patient is suffering from depression, deteriorating of both cognitive and communication skills.

Causative factor would be cardiac findings;Cognitive loss/ Dementia- The patient is suffering from short term memory loss. The RAP factor of this is caused by unhappiness due disconnection from family but no symptom of Dementia.Nutritional status – patient is on No Added Salt Diet and causal factor is Cognitive Heart Failure problem.Communication- the patient refuses to sleep in her room and when she does, she either sleeps on the floor or on chair. She refuses assistance from meds. ADL Functions/Rehabilitation Potential- patient too weak, she needs assistance in her Activities of Daily Function like bathing, toilet visitation.

Causal factor appear to be end-stage cardiomyopathy.Mood state – the patient is unhappy. Causal factor would be disconnection with her husband and family. Complains about food and staffsBehavioral problem – patient constantly complaining of poor living conditions of the facility, staff and food. She doesn’t want to sleep in her room. Causal factor appears to having trouble with anger or adjustment problem and severe end-stage cardiomyopathy. Falls – patient needs assistance due to increased risk of falling as a result of psychotropic medication.

She needs assistance in-case of transfer. Causal factor is psychotropic medication.Pathology of the Ischemic cardiomyopathy diseaseCardiomyopathy is caused by hardening of the arteries responsible for bringing blood into the heart. As the arteries narrow the heart lacks oxygen and gradually it becomes difficult for the heart to pump blood.SymptomsCough, crackles in the lungs, fatigue, irregular heartbeat, lack of sleep, short breath after small activity, swelling of abdomen in adults and loss of appetite.

(Libby & Braunwald, 2008)Laboratory Findings.This condition is diagnosed when heart has irregular heartbeat and fractional ejection is lower. Fractional ejection can be tested through MRI of heart, echocardiogram, cardiac blood pooling image and gated SPECT.Diagnosis and Prognosis Change of certain lifestyle habits that lead to heart failure. Introduction of a Pacemaker to help the heart beat slow down or beat normally. There are surgery procedures like angioplasty and cardiac catheterization that helps good flow of blood in the veins.

If a patient fails all treatment then heart transplant would be the only alternative left. (Libby & Braunwald, 2008) The patient was put under the right diagnosis given her symptoms and the treatment of the disease. The patient tested positive for Ischemic cardiomyopathy. The patient displayed all symptoms as projected in the hospital records that matched the disease.ReferenceLibby, P. & Braunwald, E. (2008). Braunwald’s heart disease. Phildelphia: Saunders/Elsevier.