Case Description: Doris
\nThe case is of a 65-year-old woman with diabetes, hypertension and depression. She comes in today because she is worried about her diabetes because a friend started dialysis. The past three years she has noticed a burning, tingling pain in her feet that keeps her up at night, as well as swelling in her ankles, especially during the summer. The past year she has experienced a vague chest tightness and shortness of breath when she walks the 60 feet to her mailbox from her trailer home. She doesn\u2019t check her blood sugar at home because the strips are too expensive, but at the clinic she is usually between 10 and 20. Her exercise includes walking to her mailbox, but that is the most she can manage because of the shortness of breath and chest tightness. She sleeps nine hours a night, but wakes 2-3 times a night to void.
\nMedications:
\nMetformin 1000mg PO BID
\nNPH insulin 30 units SQ BID
\nSertraline 50mg PO daily
\nValsartan 80 mg PO daily<\/p>\n
She admits that doesn\u2019t take her Metformin because it gives her diarrhea and she sometimes forgets one of her insulin doses. She takes Evening Primrose oil supplements.
\nSocial:
\nShe was divorced 20 years ago and lives alone with her cat. She talks to her neighbors \u201conce in a great while,\u201d but says she is \u201cnot a busy body,\u201d so she mostly keeps to herself. Her three adult children live out of province and are struggling themselves, so she tries not to bother them. She is retired from retail work, uninsured, and living now on a low fixed income with only $100\/month disposable income. She used to enjoy singing in the choir, but has had a hard time with bus fare to church for the past few years so stopped going. She does enjoy watching daytime TV and creating still life pencil drawings.<\/p>\n
PMHx: DM type 2, HTN, MDD (Major Depressive Disorder)
\nSurg Hx: none
\nGyn Hx: 3 NSVD (normal spontaneous vaginal delivery), no complications
\nAllergies: none
\nImmunizations \u2013 Td at age 15, annual flu shot
\nReview of Systems: neg save the above.<\/p>\n
Labs:
\nHgb 12.8
\nTSH 3.0
\nMicroalbuminuria 90mg\/24hr
\nCr 106 mmol\/L
\nTotal Cholesterol \u2013 6.1 (elevated from last check 12 months ago)
\nLDL \u2013 3.6 (elevated from last check 12 months ago)
\nHDL \u2013 0.92 (decreased from last check 12 months ago)
\nTrig \u2013 2.3 (elevated from last check 12 months ago)
\nFasting Blood Glucose \u2013 7.2 mmol\/L
\nHbA1c \u2013 12.2%<\/p>\n
Vitals: Temperature 37.0\u00b0C, Respiration Rate 18bpm, Heart Rate 80bpm, Blood Pressure 150\/90 mmHg, BMI 32
\nPhysical Exam:
\nGen: obese, quiet female, in no acute distress
\nHEENT: normal
\nLungs: Chest clear throughout, normal breath sounds
\nHeart: HR regular, PMI 5ICS MCL, no murmurs, S1S2 normal, no S3,S4.
\nAbdomen: soft, obese, nontender, no masses, no rebound\/guarding\/rigidity, no CVA Tenderness
\nExtremities: trace pitting edema B to ankles, 2+ pulses bilaterally, no lesions on feet or legs, nails thickened. Joints mobile and comfortable.
\nPsych: reticent, soft-spoken, depressed affect, fluent speech, no suicidal ideation<\/p>\n
Diagnoses today<\/p>\n
Diabetes Type 2 \u2013 uncontrolled
\nExercise intolerance \u2013 r\/o angina
\nHypertension \u2013 uncontrolled prevent cardiovascular disease
\nHyperlipidemia- uncontrolled prevent CVD
\nMicroalbuminuria prevent ckd and repair renal damage
\nDepression \u2013 stable, controlled maintain mood and level of functioning
\nImmunizations \u2013 not up to date prevent serious disease
\nPoor medication adherence, financial issues, social isolation
\nGeneral Information (10%)
\n1. State the indication for use and mechanism of action of the client\u2019s current medications. Include the trade and generic name for each drug.<\/p>\n
Initial Management Plan (60%)
\n1. Identify the overall treatment objective, and the targets for all conditions
\n2. What drug therapy is available for Type II Diabetes
\n3. List the classes of drug therapy available for the client\u2019s chronic conditions \/ goals
\n4. What drugs will you prescribe \/ change Explain why or why not.
\n5. Are there any specific drug contraindications for Doris
\n6. Would you consult a physician or specialist to modify current therapy Any drugs that you would suggest discontinuing Dosage change Why or why not<\/p>\n
Client Education (10%)
\n1. Briefly summarize the key points for drug therapy
\n2. Indicate what non-pharmacology strategies (lifestyle modifications etc) you would recommend to your client today.
\n3. What other health professionals might you recommend she see for a consultation (assuming there is no cost for the consultation)
\n4. What vaccinations would you recommend<\/p>\n
Follow Up Management (10%)
\n1. Identify time frame and parameters for monitoring progress toward goals.
\n2. What specifically would you assess to evaluate drug therapy
\n3. List 2 adverse effects that are indications to modify or change current drug therapy.<\/p>\n
Scholarly Writing (10%)
\n\u2022 APA 6th edition format, references and citations
\n\u2022 Organized, coherent, logical, correct grammar and spelling
\n\u2022 Academic, reputable sources used
\n\u2022 To be a maximum of 3000 words, excluding title page, references, and appendices. Include a word count at the end of the paper following the conclusion. You must stay within the maximum allotted word count