StudentShare
Contact Us
Sign In / Sign Up for FREE
Search
Go to advanced search...
Free

Reading a Health Record - Coursework Example

Cite this document
Summary
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…
Download full paper File format: .doc, available for editing
GRAB THE BEST PAPER94.3% of users find it useful
Reading a Health Record
Read Text Preview

Extract of sample "Reading a Health Record"

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.

Read More
Cite this document
  • APA
  • MLA
  • CHICAGO
(“Reading a Health Record Coursework Example | Topics and Well Written Essays - 500 words”, n.d.)
Reading a Health Record Coursework Example | Topics and Well Written Essays - 500 words. Retrieved from https://studentshare.org/nursing/1631678-reading-a-health-record
(Reading a Health Record Coursework Example | Topics and Well Written Essays - 500 Words)
Reading a Health Record Coursework Example | Topics and Well Written Essays - 500 Words. https://studentshare.org/nursing/1631678-reading-a-health-record.
“Reading a Health Record Coursework Example | Topics and Well Written Essays - 500 Words”, n.d. https://studentshare.org/nursing/1631678-reading-a-health-record.
  • Cited: 0 times

CHECK THESE SAMPLES OF Reading a Health Record

Stanford Hospital & Clinics

he record Keeping of Patients: The process of record keeping is very crucial for the reputation of the hospital.... Such record keeping not only helps in better care for the patient, but... I have selected 'Stanford Hospital & Clinics' for the purpose of this study, because a friend of mine who has been working for this hospital is quite happy with the working environment and the support being provided to the employees and quality care being extended to the patients....
10 Pages (2500 words) Essay

Importance of Health Records

The health record also helps as a foundation for devising patient care, recording the dialogue between the healthcare supplier and any other medical professional leading to the patient's aid helping in defending the legal concern of the patient and the health care suppliers trustworthy for the care of the patient and recording the aid and services rendered to the patient.... Moreover, the health record may serve as study material for medical students, occupant physician, to render information for inner hospital inspecting and quality sureness and to render information for medical research....
4 Pages (1000 words) Essay

How Apps Can Change Our Health Care Environment

This discussion, How Apps Can Change Our health Care Environment, stresses that modern technology has completely changed the pattern in which numerous functions are being performed.... umerous operating systems have launched applications for the purpose of medical health....
5 Pages (1250 words) Essay

Procedures for the Release of Electronic Health Information

This Report outlines the procedures to be… ertaken when releasing electronic health records as per the Federal, State and HIPAA laws about disclosing and protecting health information, and releasing that Electronic Health information. Both Maryland federal laws govern ways of maintaining medical information between the Moreover, the burden of maintaining confidentiality lies with health care providers and staff that may have access to the medical record.... Electronic health information is a digitized version of a patient's record book; it contains a patient's medical history, treatment plans, immunization dates, medications, allergies, radiology images, and laboratory and test results....
15 Pages (3750 words) Assignment

Annotated Bibliography-Sheila

It is important if the report could be implemented to reduce the health hazard.... The social determinants of health are well determined that provide an excellent literature review.... H.... M.... .... Phelan, R.... M.... c, Wilson, R.... PhD.... Ross-white, A....
5 Pages (1250 words) Coursework

Health Science and Medicine

nbsp;… As the report, health Science and Medicine, stresses every hospital is required to exercise the meaningful of Electronic health Records in order to ensure that their patients have access to the best medical care possible and ensure the safety of the patients' information.... his study highlights that patient education is one of the most important factors when it comes to ensuring that their health is made a priority.... Patients who have been empowered with knowledge will be able to spot any problems in their health, signs and symptoms of various ailments....
5 Pages (1250 words) Essay

Electronic Medical Records

hellip; Research, record keeping has enabled maximum utilization of the medical records for the benefit of the patients, government, and the scholars (Card & Chandler, 2011).... Information Technology has played critical; roles in medical health.... There are various factors that enable motivation and conveyance of information in the health care systems.... health care providers are able to get useful information in a timely manner....
5 Pages (1250 words) Literature review

Leading Tampa Bay Health Indicator

Tampa Bay had a record high of low mortality rates resulting from suicide and stillbirths.... This paper "Leading Tampa Bay health Indicator" tells that according to the One Bay Report (2011), it was discovered that most Americans are living longer yet their healthy productive years are less than ten percent of their average life expectancy.... nbsp;… Many individuals are dying young from both natural and unnatural causes and this is alarming to the overall nation's health statistics....
1 Pages (250 words) Assignment
sponsored ads
We use cookies to create the best experience for you. Keep on browsing if you are OK with that, or find out how to manage cookies.
Contact Us