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 hospital, with the administration of diuretics and IV antibiotics; will also collect blood cultures and sputum if possible. Treatment will also include O2 and bedrest. Medications administered during treatment 25 mg Capoten po tid, 40 mg Furosemide po qd, 10 mg Nortriptyline HCL po qd, and 0.125 mg Digoxin po qod. The patient was also put on low sodium, low cholesterol, and lactose free diet.

Condition on Discharge: Patient was discharged to a long term care facility closer to her family. Her strength and endurance improved during her treatment at the facility. Also new x-rays show a slight improvement in the left lower lung field infiltrate. Patient was still having problems with shortness breath at discharge, resulting in a dependency upon a wheelchair.

Congestive heart failure (CHF) is most common among elderly patients, the heart is the most important muscle in the body, and without it doing its job right blood would not flow properly throughout the body. It is important to catch any heart issues early to prevent any further complications that can be caused by poor blood circulation. 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 compromised or weak immune systems, for example, patients younger than 2 or older than 65, and patients with other health problems i.e. cystic fibrosis, asthma, COPD (chronic obstructive pulmonary disease), diabetes, heart failure, sickle cell anemia, and HIV/AIDS (National Heart, Lung, and Blood Institute, 2011).
Typical symptoms that are experienced with CHF are: fatigue, weakness, loss of appetite, irregular heartbeat, cough, trouble sleeping from being short of breath, and edema (fluid build-up) can be seen in feet and ankles area (Beckerman, WebMD Heart Disease and Congestive Heart Failure, 2014). Some of these symptoms can also sign of Pleural effusion which includes: rapid breathing, sharp chest pain with cough or a deep breath, fever, hiccups, and rapid breathing (Ratini, 2014). Symptoms of pneumonia include a cough, fever, and difficulty breathing (American Lung Association). To diagnosis CHF, the doctor may decide to run a multiple of different tests to include a physical exam, labs, and x-rays to help. Physical signs of heart failure would include irregular heart rate, leg or ankle swelling, breathing difficulty, and swelling of the abdomen or liver (Pai, 2014).
Labs the doctor would order include: CBC (complete blood count), labs to check the kidney function i.e. Serum Creatinine, BUN (Blood Urea Nitrogen), Urinalysis, all of which can tell if there is kidney damage which could be caused by heart failure. A BNP (Brain Natriuretic Peptide) test which test for the hormone that is made by the heart that tells how well the heart is working. Having a high level of BNP in the blood indicates the heart is working harder than usual which is a marker for heart failure (Pai, WebMD Lab tests for heart failure, 2014). “The best test for diagnosing CHF is an echocardiogram, this examination is able to monitor and determine systolic and diastolic LV performance, the cardiac output, and pulmonary artery and ventricular filling pressures” (Singh, 2013).
To treat CHF the doctor may decide on multiple different care plans; the goal is to slow or stop any further damage to the heart and treat any underlying diseases that could be the cause. This could include surgical procedures to correct heart problems for examples: coronary bypass surgery, heart valve repair/replacement, and if the heart failure is too far advanced a heart transplant can be performed. It is possible with a successful treatment plan signs and symptoms of the disease can improve, sometimes even reversing the heart failure with the correct type of surgical procedure and care. For the most part most treatments begin with medications to help control and pass certain symptoms that present with CHF. Ace-inhibitors are used to widen the blood vessels and lower the blood pressure (Capetone); Diuretics contribute to keeping fluid from collecting in the lungs and to stop edema in the body (Furosemide). Digoxin is a drug used to strengthen the heart's muscle contractions helping to regulate an irregular heart rhythm. Devices can also be used to help control the heart's rhythm; these devices include: ICD (implantable Cardioverter defibrillator), CRT (Cardiac resynchronization therapy), and a heart pump (Mayo clinic staff, 2015).
Jane Dare was a 73-year-old woman admitted from the ER for treatment of CHF symptoms, left pleural effusion, and pneumonia. From looking at the medical chart and comparing it to my research done on the subject my conclusion is that proper care was taken during her treatment apart from missing information in the patient's chart. I agree with the doctor’s care plan that included OT and PT. The proper medication was given to treat the patient’s condition, and it appears the patient responded really well to the Nortriptyline HCL to treat her cognitive impairment. Appropriate labs and x-rays were ordered for this patient to determine the diagnosis. I did notice there is a lack of lab results for the patient’s electrolyte balance, or any notations on other organ performance i.e. kidney function which can be an indicator of heart failure. I think that is made apparent in the patient’s follow-up chest x-ray ordered before her transfer; that shows there was an improvement in the patient’s condition. There is still some symptoms of shortness of breath post-hospital transfer, which again I noticed there was no documentation of future treatment plans or any specialist follow-ups. I'm curious as to why the doctor and family have not discussed a long-term solution for the patient’s condition, or if they have why it is not notated in the chart.