Case Description: Doris
The 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 doesnt 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.
Metformin 1000mg PO BID
NPH insulin 30 units SQ BID
Sertraline 50mg PO daily
Valsartan 80 mg PO daily
She admits that doesnt take her Metformin because it gives her diarrhea and she sometimes forgets one of her insulin doses. She takes Evening Primrose oil supplements.
She was divorced 20 years ago and lives alone with her cat. She talks to her neighbors once in a great while but says she is not a busy body 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.
PMHx: DM type 2 HTN MDD (Major Depressive Disorder)
Surg Hx: none
Gyn Hx: 3 NSVD (normal spontaneous vaginal delivery) no complications
Immunizations Td at age 15 annual flu shot
Review of Systems: neg save the above.
Cr 106 mmol/L
Total Cholesterol 6.1 (elevated from last check 12 months ago)
LDL 3.6 (elevated from last check 12 months ago)
HDL 0.92 (decreased from last check 12 months ago)
Trig 2.3 (elevated from last check 12 months ago)
Fasting Blood Glucose 7.2 mmol/L
Vitals: Temperature 37.0C Respiration Rate 18bpm Heart Rate 80bpm Blood Pressure 150/90 mmHg BMI 32
Gen: obese quiet female in no acute distress
Lungs: Chest clear throughout normal breath sounds
Heart: HR regular PMI 5ICS MCL no murmurs S1S2 normal no S3S4.
Abdomen: soft obese nontender no masses no rebound/guarding/rigidity no CVA Tenderness
Extremities: trace pitting edema B to ankles 2+ pulses bilaterally no lesions on feet or legs nails thickened. Joints mobile and comfortable.
Psych: reticent soft-spoken depressed affect fluent speech no suicidal ideation
Diabetes Type 2 uncontrolled
Exercise intolerance r/o angina
Hypertension uncontrolled prevent cardiovascular disease
Hyperlipidemia- uncontrolled prevent CVD
Microalbuminuria prevent ckd and repair renal damage
Depression stable controlled maintain mood and level of functioning
Immunizations not up to date prevent serious disease
Poor medication adherence financial issues social isolation
General Information (10%)
1. State the indication for use and mechanism of action of the clients current medications. Include the trade and generic name for each drug.
Initial Management Plan (60%)
1. Identify the overall treatment objective and the targets for all conditions
2. What drug therapy is available for Type II Diabetes?
3. List the classes of drug therapy available for the clients chronic conditions / goals
4. What drugs will you prescribe / change? Explain why or why not.
5. Are there any specific drug contraindications for Doris?
6. Would you consult a physician or specialist to modify current therapy? Any drugs that you would suggest discontinuing? Dosage change? Why or why not?
Client Education (10%)
1. Briefly summarize the key points for drug therapy
2. Indicate what non-pharmacology strategies (lifestyle modifications etc) you would recommend to your client today.
3. What other health professionals might you recommend she see for a consultation (assuming there is no cost for the consultation)?
4. What vaccinations would you recommend?
Follow Up Management (10%)
1. Identify time frame and parameters for monitoring progress toward goals.
2. What specifically would you assess to evaluate drug therapy?
3. List 2 adverse effects that are indications to modify or change current drug therapy.
Scholarly Writing (10%)
APA 6th edition format references and citations
Organized coherent logical correct grammar and spelling
Academic reputable sources used
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