Reading a Health Record


Readinga Health Record

Readinga Health Record

Essentially, a health record gives any medical practitioner the fulldetails of a patient’s medical history. The information obtained isnecessary in the successful diagnosis and treatment of the patient.Health records are kept in hospitals in their safe conditions forfuture analysis and references.

Therefore, in thatregard, I obtained the following information from a patient’shealth record. It is as reported below:


  1. Health Record-# 822999

  2. Diagnosis-

  • Primary Diagnosis: Congestive heart failure, severe

end-stage ischemic cardiomyopathy

  • Admitting Diagnosis (within 24 hours

Congestive heart failure, left pleural effusion, pneumonia.

  • Principal Diagnosis

Congestive heart failure, left pleural effusion, pneumonia.

  1. Related History

  • Family history: Non contributory

  • Social History: Has been living with husband. Negative for alcohol. Ex-smoker for many years.

  • Medical History: This patient has history of atrial fibrillation severe regurgitation from tricuspid and mitrial valve dysfunction.

  • Allergy: Sulfa

  1. Physical Findings

Pleasant, sitting upright

HEENT: Difficult fundoscopic exam.

Neck: Supple with positive venous distension.

CNS: Rate104, irregular with gallop. Crackles in left lower lobe. Right isdull.


Genitalia:Normal except for red sacral area. No obvious breakdown.

Extremities:3+ pitting edema to knees.

Neurological:Appropriate. Alert.

  1. Lab/X-Ray Findings

Chest x-ray: Left pleural effusion,congestive heart failure, pneumonia.

  1. Course of Treatment-including medications administered.

  • Plan: Admit.



Bloodculture and sputum if possible


Bed rest

  • Medication

1. Capoten 25 mg po tid

2. Furosemide 40 mg po qd

3. Digoxin 0.125 mg po qod

4. Nortriptyline HCL 10 mg po qhs

5. Tylenol 325 mg tabs prn for pain

6. KLOR 10 mg qd

7. Milk of Magnesia 30 cc po qd prn

  1. Condition on Discharge

  • 6/7/xx Chest: PA and Lateral

  • INDICATION: CHF, pleural effusion, pneumonia.

  • FINDINGS: PA and lateral chest compared with 6-7-xx. There has been slight improvement in the left lower lung field infiltrate. Small bilateral pleural fluid collections persist. Stable cardiac and mediastinal silhouettes.

  • CONCLUSION: Slight interval improvement of the appearance of the chest.

  • Discharged alive



I also embarked on an advanced analysis and investigations process ofthe disease of the patient in the health record above. Theinformation below illustrates my findings:

  1. Pathology of the disease

A pleuraleffusion is an upsurge of fluid between the layers of the tissue thatline the lungs and the chest cavity. Therefore it is an abnormalcollection of the pleural fluid. Congestive heart failure is the maincause for the excessive build up of the fluid into the pleural space.Additionally, the Congestive heart failure is caused by an increasedpressure in the blood vessels or a low count in blood protein.Pneumonia which may also be a viral case infection can lead topleural effusion.

  1. Symptoms and Signs

Patients will experience Dyspnea, chest pains, coughing and fever.

  1. Laboratory Findings

Thin and transparent pleural fluid from the lungs is observed throughpleural fluid analysis.

  1. Diagnosis

Person’s symptoms and physical examination will reveal the presenceof the disease. Among the methods used are:

  • Auscaltation- Listening with a stethoscope

  • Percussion- Tapping on the chest

  • Imaging tests- Chest X-Ray

  • Pleural fluid analysis

Chest X-Ray films reveal a white space form at the base of the lung.

  1. Prognosis

Primarily, the outcome depends on the underlying disease. However,common complications are:

  • Lung damage

  • Empyema abscess infections

  • Pneumothorax

  1. Treatment Alternatives

Most importantly,the objective of the treatment is:

  • Removing the pleural fluid- Thoracentesis.

  • Prevention of fluid build-up.

  • Determining and treating the underlying cause of the fluid build-up.

Congestive heart failure (CHF) is treated by the administration ofdiuretic pills and other combined medications. Small tubes are placedin the pleural space to drain away the excessive fluid present(Emerson et al, 1920).

Performing radiotherapy, chemotherapy and surgery are effective waysof curing the disease.

With all theinformation above, it is clearly understood that the patient had aserious disease that needed extra health care. According to her heathrecord, we are not given the full details of how the diseasesaffecting her are acquired. The pathology of the disease is alsomissing. All the basic diagnostics procedures are not listed, forinstance the pleural fluid analysis test was not done under amicroscope to identify the bacteria and viruses in the patient’slungs that could narrow down the underlying diseases dynamics. Theprognosis outcome is also not precisely shown as compared to theresearch part whereby all necessary details are shown clearly.

In that regard,the patient was not fully treated. According to my research, not onlyshould the treatment use drugs or medications but it should also useother alternative treatments such as chemotherapy and surgery.Therefore, all hospitals should ensure that they have all the basicand advanced treatment techniques that can fight the majority ofchronic diseases.


Emerson, Charles. P.(1920). Clinical Medicine: Nursing Manual, Philadelphia: J.BLippincot Company, (1920). p. 219-240. Retrieved from, &ltMerck Manual or the NIH National Institutes of Health,[project]=4918885 &gt