Health Record Abstracting Essay

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Health Record Number: 822999
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
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It is also important to diagnose the underlying medical condition that caused the heart to fail. CHF is considered a chronic disease which affects the heart's ability to adequately pump blood in and out. The Congestive (fluid build-up) part of the illness is caused by the decrease in the heart's ability to adequately pump blood throughout the body. Since the right side of the heart provides blood to all other parts of the body besides the lungs; when it fails it causes fluid build-up beginning in the legs and feet, but can spread to multiple areas of the body. The left side of the heart supplies blood to the lungs; and when it is failing it causes an accumulation of fluid in the lungs (Pulmonary edema) (Beckerman, 2014).
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

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