Description
age 76
Summarise the overall management plan for this patient considering patient priorities for their care, current symptoms, physical examination and investigations findings, chronic disease targets
( Dyslipidaemia , Diabetes (Type 2) , Hypertension , Arrythmia , GERD )
1- BP target in management of hypertension and how to prevent
2- LDL target in management of hyperlipidaemia and how to achieve it other than the meds
3
a – how to monitor the diabetes by the patient and make him aware of all his conditions
b -preventative care of diabetic feet complications and how to prevent it
4- since he is old and has chronic disees he should take all his vaccinations and attend his appointments and participate in his management plan positively by losing weight taking his meds
i will attach a an example need similar
but that one for different case
that is the example
Patient care plan
A/ Summarise the overall management plan for this patient considering patient priorities for their care, current symptoms, physical examination and investigations findings, chronic disease targets (e.g. BP target in management of hypertension, LDL target in management of hyperlipidaemia etc.) and preventative care.
COPD assessment
Explain to the patient the progressive nature of COPD (FEV1 indicates ‘severe’ disease) and the correlation to his continued cigarette smoking. Discussion about the number of exacerbations over the last 12 months and his ongoing breathlessness indicate that his condition is not fully controlled at present. Advise to
switch inhaler to a combined inhaled ICS/LABA inhaler instead of inhaled salmeterol to see if this will
improve symptoms and reduce exacerbations of COPD (1). Consider level of motivation for, and referral to, local smoking cessation clinic and community pulmonary rehabilitation programme. In view of recent
bereavement it may not be not appropriate to push this agenda too much at this time. Check vaccinations are up to date – five yearly pneumococcal and annual flu vaccines recommended as per national guidelines
(2). Liaise with the practice nurse to check inhaler technique is adequate and signpost to educational resources at e.g. videos, support groups, helpline.
Hypertension, lipids and CVS risk
Discuss results of his lipids blood test. Advise that this is a risk factor for cardiovascular and cerebrovascular disease and that overall CVS risk will be calculated once repeat ABPM results are available (3). Discuss
dietary advice to reduce lipids and advise to increase physical activity as much as possible. Depending on overall CVS risk calculation (e.g. QRisk3) a statin may be required (4).
Additional issues
Discuss other problems raised by the patient during CDM consultation. Elicit how much pain in right hip is causing and if impacting on activities of daily living. Consider ordering X-ray imaging if appropriate. In the
interim advice to take paracetamol regularly (1g four times daily) and keep as active as possible. Explore with the patient his feelings of grief following his wife’s death and explore treatment options for him with
his grief. Check regarding other social supports in place and signpost him to the Irish Hospice Bereavement support telephone line. Explain the normal process of grief and suggest bereavement counselling may be helpful. If interested, give some options of services locally to contact. Arrange follow up to assess progress.
let me know if you have any questions i gave you some headings feel free to add to them
