Name Add Name Here Him 2214 Module 2 Medical Record Abstract

Nameadd Name Herehim 2214 Module 2 Medical Record Abstractinginstruc

In this medical record abstracting assignment, you are tasked with analyzing a patient's medical record focusing on cardiovascular issues. You must identify and explain various medical terms, conditions, and treatments based on the provided history and physical document. Your responses should include definitions of medical terminology such as exertional chest pain, orthopnea, atrial fibrillation, and others, as well as explanations of diagnostic tests and treatments used in this case. The assignment emphasizes understanding cardiac conditions, their etiology, and management, including medication purposes and procedural concepts.

Paper For Above instruction

The medical record provided describes a 76-year-old male patient with a complex cardiac history, presenting with symptoms indicative of worsening congestive heart failure and associated conditions. This case offers an opportunity to explore various cardiovascular terms and conditions, as well as clinical management strategies pertinent to the patient.

Understanding the Patient’s Cardiovascular Conditions

Exertional chest pain refers to discomfort or pain experienced during physical activity, often related to inadequate blood flow to the myocardium, typically due to coronary artery disease (CAD) (Fihn et al., 2014). It is crucial in diagnosing ischemic heart conditions and guides further testing and management (Amsterdam et al., 2014). In this case, the patient reports occasional chest pain, which warrants closer evaluation of ischemic symptoms.

Orthopnea is a symptom characterized by shortness of breath when lying flat, caused by pulmonary venous congestion due to left-sided heart failure (Fletcher et al., 2013). Interestingly, the patient denies orthopnea, which suggests that while he has heart failure, certain typical symptoms may not manifest in this patient, possibly due to the chronicity or compensation mechanisms.

Atrial fibrillation (AF) is an irregular and often rapid heart rhythm originating from disorganized electrical activity in the atria, leading to ineffective atrial contractions (January et al., 2014). The patient’s telemetry indicates atrial fibrillation with occasional rapid ventricular response, which can increase the risk of thromboembolism and exacerbate heart failure (McMurray et al., 2012). Management includes rate control, rhythm control, and anticoagulation, though this patient is not on Coumadin presently.

Etiology of atrial fibrillation can vary but often includes hypertension, ischemic heart disease, pulmonary hypertension, and valvular heart diseases, such as mitral regurgitation (Nattel et al., 2014). This patient’s severe mitral regurgitation and pulmonary hypertension likely contribute to the development and perpetuation of AF.

Cardiac Murmurs and Pulmonary Findings

The statement “4/6 systolic ejection murmur” describes a grade 4 murmur heard during systole, likely indicative of significant mitral regurgitation, confirmed in the patient’s echocardiogram. Murmurs are abnormal heart sounds caused by turbulent blood flow; a grade 4 murmur suggests a loud, palpable thrill indicating severity (Shiva et al., 2014).

Basilar crackles are abnormal breath sounds heard at the bases of the lungs, often related to pulmonary edema or congestion from heart failure (Yancy et al., 2013). Their presence in this patient indicates fluid overload, consistent with his congestive heart failure.

Clinical Terms and Laboratory Findings

Palpitations refer to the sensation of rapid, fluttering, or irregular heartbeat, often associated with arrhythmias like AF (Khan et al., 2014). Cyanosis is a bluish discoloration of the skin and mucous membranes due to hypoxia, which the patient does not exhibit, aligning with his current adequate oxygenation status.

The abbreviation BUN stands for Blood Urea Nitrogen, a renal function indicator; elevated BUN levels suggest renal impairment or dehydration (McDonald & Vanholders, 2012). In this case, BUN is slightly elevated but decreased from previous levels, indicating some renal function variability.

Terms Related to Heart Failure and Its Management

Exacerbation refers to the worsening of a clinical condition, here indicating worsening of congestive heart failure episodes (Yancy et al., 2013). Pulmonary hypertension is characterized by elevated pressure in the pulmonary arteries, which complicates heart failure by increasing right ventricular workload (Ramu et al., 2020). The patient has severe pulmonary hypertension, aggravating his cardiac status.

Congestive heart failure (CHF) is a condition where the heart's ability to pump blood is impaired, leading to fluid accumulation and inadequate perfusion of tissues (Yancy et al., 2013). Pathophysiologically, CHF results from systolic or diastolic dysfunction, causing elevated end-diastolic pressures, pulmonary congestion, and systemic hypoperfusion (Braunwald, 2013). In this patient, diastolic CHF is suggested by his clinical presentation and echocardiographic findings.

Diuresis, the increased production and excretion of urine, is used therapeutically in CHF to reduce volume overload, relieve pulmonary congestion, and improve symptoms (Yancy et al., 2013). Furosemide (Lasix) is the diuretic administered to this patient to control volume status.

Valvular and Diagnostic Tests

Mitral regurgitation is a condition where the mitral valve does not close properly during systole, allowing blood to flow backward into the left atrium (Nishimura & Otto, 2014). This results in volume overload of the left atrium and ventricle, contributing to heart failure symptoms.

Cardiac enzyme tests, such as troponin I, are ordered to detect myocardial injury, especially during suspected ischemic events (Thygesen et al., 2018). Although the patient’s cardiac enzymes are being checked, his troponin level will help determine if a myocardial infarction is contributing to his clinical deterioration.

Medications and Interventions

Cardizem (diltiazem) is a calcium channel blocker used to control heart rate in atrial fibrillation and reduce myocardial oxygen demand (Dalal et al., 2014). It helps in rate control and potentially improves diastolic relaxation in heart failure patients.

Foley catheter is a urinary catheter inserted into the bladder for continuous drainage, often used in hospitalized patients to monitor urine output and manage urinary retention (Miller & Longbottom, 2013). In this case, the patient declines the Foley catheter placement.

I’s and O’s refer to intake and output measurements, critical in managing fluid balance in patients with heart failure (Yancy et al., 2013). Monitoring these helps determine fluid retention or depletion and guides diuretic therapy.

Summary and Conclusion

This case highlights the complexity of managing patients with chronic cardiovascular conditions, emphasizing the importance of understanding pathophysiology, diagnostic tools, and therapeutic strategies. The patient’s presentation with atrial fibrillation, mitral regurgitation, pulmonary hypertension, and congestive heart failure illustrates interconnected cardiac dysfunctions requiring a tailored, multi-faceted approach. Effective management includes medication adjustments, monitoring laboratory and imaging findings, and addressing patient preferences and limitations. Continuous evaluation and integrated care are essential for optimizing outcomes in such high-risk patients (Yancy et al., 2013; Braunwald, 2013).

References

  • Amsterdam, E. A., Wenger, N. K., Brindis, R. G., Casey Jr, D. E., Ganiats, T. G., Holmes Jr, D. R., ... & Zieman, S. J. (2014). 2014 AHA/ACC guideline for the management of patients with non–ST-elevation acute coronary syndromes. Journal of the American College of Cardiology, 64(24), e139-e228.
  • Braunwald, E. (2013). Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine. Elsevier Saunders.
  • Dalal, S., Bhat, A., & Goyal, A. (2014). Calcium channel blockers in heart failure: old agents, new insights. Indian Heart Journal, 66(4), 342-347.
  • Fihn, S. D., Gardin, J. M., Abrams, J., Berra, K., Bennett, S. M., & Beller, G. (2014). 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease. Journal of the American College of Cardiology, 61(23), e78-e142.
  • Fletcher, S. M., et al. (2013). Orthopnea: pathophysiology and clinical implications. European Journal of Heart Failure, 15(10), 1074-1079.
  • January, C. T., Wann, L. S., Calkins, H., et al. (2014). 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation. Journal of the American College of Cardiology, 64(21), e139-e247.
  • Khan, F. Z., et al. (2014). Palpitations: etiology, evaluation, and management. Cleveland Clinic Journal of Medicine, 81(5), 330–338.
  • McDonald, J. S., & Vanholders, J. (2012). BUN as a marker of renal function: clinical relevance and interpretation. Clinical Nephrology, 77(2), 91-97.
  • McMurray, J. J., et al. (2012). Management of atrial fibrillation in heart failure. European Heart Journal, 33(19), 2323-2327.
  • Nattel, S., et al. (2014). Atrial fibrillation: mechanisms, therapeutics, and future directions. Circulation Research, 115(9), 913-930.
  • Nishimura, R. A., & Otto, C. M. (2014). Valvular heart disease. Circulation, 129(23), e521-e523.
  • Ramu, P., et al. (2020). Pulmonary hypertension in left heart disease. European Respiratory Review, 29(157), 190179.
  • Thygesen, K., et al. (2018). Fourth universal definition of myocardial infarction. European Heart Journal, 40(3), 139-171.
  • Yancy, C. W., et al. (2013). 2013 ACCF/AHA guideline for the management of heart failure. Circulation, 128(16), e240-e327.

Related Assignments