Health Record Abstracting Essay
Diagnosis: Congestive heart failure (CHF), Left pleural effusion, pneumonia
Related History: The patient has a history of atrial fibrillation, severe regurgitation from the tricuspid and mitral valve dysfunction.
Physical Findings: The patient had a difficult fundoscopic exam, with a heart rate of 104, with an irregular gallop, crackles in left lower lobe, right side is dull, red sacral area, 3+ pitting edema to knees, and shortness of breath, difficulty sleeping.
Lab/X-ray findings: Chest x-ray: left pleural effusion, CHF, Pneumonia.
Course of Treatment: Course of treatment includes admission into the …show more content…
Pleural effusion is defined as “A buildup of fluid between the layers of tissue that line the lungs and chest cavity.” (Hadjiliadis, 2014) The pleural fluid is used to lubricate surfaces of the pleura (a thin membrane that lines the chest cavity); this condition is divided into two different categories transudative and exudative. Transudative pleural effusions (caused by fluid leaking into pleural space) which are most commonly caused by CHF; Exudative effusion are caused by blockage from inflammation, injury, or drug reactions.) (Davis, 2015) Pneumonia occurs when there is inflammation in one or both lungs, most likely caused by the three most common infections: fungi, viruses, or bacteria. It usually affects those who have