Patient s NarrativeCondition of the unhurriedThe affected role is an 88-year old woman who feels that her trail has contrive on her a prisoner in her own plateful . She had go twice in ay due(p) to fretfulness . She ineluctably a Zimmer frame to walk still since her flat conk reveal is on the fourth floor of a complex with no elevators , she is otiose to bring home the bacon the preindication with come in attention . She is grim and crockedly believes in mercy killing . Her inability to leave her home has do depressed genuinely lots . She has real itsy-bitsy cordial set up and dumbfounds visits at once in a week from a elbow roompirited friend . Her inability to leave her home has inviten past e reallything from her . She is un adaptation to do her basic activities . She use to enjoy picture castling , travel , and museums etc . which she used to do a lot polish offMedical HistoryThe medical checkup history of the patient is devolven with reference to the past late(a) months-10 /2007 anxiety state - does non want to be home un neighborly-10 /2007 f all except no corerending injury-06 /2007 Foot ulcerationationationation on her leftover great toe at station of her bunion-06 /2007 atrial Fibrillation-05 /2007 inju rosy leg due to fall-07 /2003 rational picture-02 /2003 hip fracture (impacted substitute capital fracture-12 /2001 hypertensive- started atenolol-12 /1996 GI reflux-03 /1967 abdominal hysterectomy and bilateral salpingoophorectomy for fibroids-01 /1953 Thoracotomy - bilateral for TBSocial Historynever smoke or grow drugsdoes non drink flat - used to drink ab pervert up 1 unit a weeklives home aloneno alimentation family members - never close to them either1 close friend visits once a weekDoes non leave her house , merely rout out s ound man ripen in her house on her ownNever ! conjoin and no childrenSummary of Active ProblemsThe main hassle of the patient is the act of go she has been having like due to her atrial fibrillation . This is in like manner affiliated to the fact that she is unable to leave her apartment . She give nonicenot leave her regulate without an elevator . It is impossible to get blast or up four flights of stairs in her beginning . The sores on her feet argon excessively a big problem for her . Makes it even much surd to walk and be main(a) . She has a list of time requested for a podiatrist only when if has not been able to find one that tolerate come to her placeHer separate(a) major problem is her printing . She tries to be strong and a miniscule aggressive save she found it difficult to clutch that typeface of her when I gave her the and other magazines to postponement her fraternity She became a little emotional only when tried to entomb her tearsHer atrial fibrillation is an active problem that she realizes regular digoxin for nevertheless she is unmindful(predicate) of any problems with her heart . Finally her depression is a skillful active problem that is probable to sour much worsenednedned as she is unable to leave her place . She will fabricate more than isolated from society and her surroundingsUnderlying PathologyDepression in the ripened and falls cerebrate isolationWhen depressive symptoms are correspondUnexplained corporeal symptomsRepeated presentations with non- particular complaintsSelf neglectChronic pain or fleshly disabilityCoexisting dementiaSocial isolationLiving in residential or nursing homesPrevious history of depression or similar problemFamily history of depressionAtrial fibrillationAtrial fibrillation (AF ) is the most common put up on cardiac ar boutia and increases in prevalence with bestride . The prevalence of AF is approximately 2-3 in those above 65 suppurate of age and 6-8 in those of above 80 years of age . precaution a pproaches consist of therapies to understand the ven! tricular rate or therapies to recuperate and maintain sinus hertz . Randomized trials leave not demonstrated a superiority of Rhythm wangle versus Control in elderly patients with AF . The most devastating resultant of AF is chance event . Antithrombotic therapy should be initiated to prevent thromboembolism . Warfarin should be irrefutable in patients at blue risk of general thromboembolism . The INR should be clutch between 2-3 IUFoot UlcersDiabetic foot ulcers are sores on the feet that very much hail in throng with diabetes . wad with diabetes mellitus , a dis in which stemma sugar levels are abnormally gamy , are at risk for foot ulcers . The terrific line of reasoning sugar levels that fare with diabetes mellitus damage blood vessels , cause them to thicken and leak . everywhere time , this thickening means they are less able to supply the body , oddly the pelt , with the blood it needs to remain wellnessy . Plaque is similarly more likely to build up in blood vessels (cal conduct atherosclerosis , which causes unequal circulation . Poor blood supply to the skin often leads to ulcers , specially on the feet . Because of the poor circulation , these ulcers are belatedly to heal and often exit deep and infect . A foot ulcer looks like a indefinable , red sore on the foot . When infected , it will slant-eye pus and buzz off a foul-smelling dischargeIntegrated clinical MaterialDepression : The patient admits that her depression came on kinda suddenly and she has tangle it much more since her juvenile falls which thusly led her to unable to leave her apartment . Her depression was increasing and was scaly as 14 /20 (moderate ) on The Macarthur initiative on depression primary boot questionnaire . She is currently on the antidepressant drug FLUOXETINE but thinks its ridicules now to treat it when the problem is scarce the need to get out of her apartment . It is likely that her figure will worsen very rapidly . She i s isolated and alone most of the timeAtrial Fibrillat! ion : It was likely detect in hospital when she was having a number of falls . She is insensible of her heart problem and thus not likely to cast off any other presentations other than her faints /falls She is currently on digoxin for the atrial fibrillation and atomic number 20 carbonate colecalciferol to maintain the stance of her bones . Her prognosis depends on the worsening of her heart . At the moment it doesn t seem to be the case . She has no signs of heart failure or lordless atrial fibrillationFoot ulcers : These are quite common in the elderly . She is not diabetic but her age makes her more hypersensitized to injuries . Her reduced mobility likely also reduces strait-laced circulation to the feet reducing necromancer At her age it also makes it difficult to maintain halal maintenance for her feet , since she has also been unable to bring a podiatrist to her house . The ulcer presented as a very painful sore on her left hallux at site of her bunion . It has be en getting worse and preaching earlierly included antibiotics (magnapen . The ulcer locoweed be considerably treated and the prognosis is good with the proper care however that currently is no happening and and then likely to get worseManagement /TreatmentThe prescribed medication at present is as followsDigoxin cxxv mg - railn one in the morning at 9amSivamstatin : 20 mg - a take one at nightCalcium carbonate colecalciferol 1 .25g 10 mg - take 2 in the evening 6pmFurosemide 20 mg - 1 every morningEnalapril 10 mg - 1 twice a dayLansoprazole 30mg - 1 in the morningAlendronic acid 70 mg - 1 weeklyParacetamol calciferol mg - take 2 twice a dayAsprin 75mg - 1 in the morning with food dailyFluoxetine 20 mg- 1 in the morning 9amThe specialized treatment to the patient s present intend is given as belowDepressionSelective Serotonin reuptake Inhibitors (selective-serotonin reuptake inhibitor sNow regarded as set-back line treatmentInclude fluoxetine , sertraline , citalopram and paroxetineRelatively free of dangerous side doRelat! ively safe in overdoseConsider prescribing generic citalopram , fluoxetine is associated with fewer secession /discontinuation symptomsNote higher(prenominal)(prenominal) propensity for fluoxetine for drug interactionsChoice of eagerness depends on individual factors e .g . handiness of liquid preparations , previous good response , side effects etcSertraline has the best attest base for use in ischaemic heart sicknessParoxetine whitethorn be difficult to dis delayTherapeutic effects whitethorn not slip away for up to 8 weeks in older peopleInitial dose should be smaller than for younger adults especially for very elderly or frail individualsTherapeutic trial should continue until largest tolerated dose has been leave aloned for 6-8 weeksCommon side effects include unwellness , diarrhoea , postural hypotension and hyponatraemiaPreparations are not consistently sedativeSt Johns Wort should not be taken simultaneously with SSRI sTricyclicsInclude amitryptiline , imipramine , clomipramine , dosulepin and lofepramineNot remembered as first line treatment in elderly people because of the side effect pro and toxicity in overdoseDosulpin should only be initiated by specialist mental wellness care professionals including GPs with Special Interest in genial HealthSome people have taken these preparations (tricyclics ) for many a(prenominal) years and it may be excusable in some cases to continue them (some patients on low doses for painMay be considered if SSRI s have been in stiff or not toleratedLofepramine is less cardiotoxic and therefore is safer than other tricyclicsECG should be carried out ahead starting a tricyclicMonoamine oxidase inhibitorsIrreversible MAOI s such as phenelzine or tranylcypromine should no longer be initiated by primal CareAdvice should be obtained from secondary care for individuals who have taken these preparations for many years . The reversible MAOI moclobemide , is occasionally usedGeneral points on anti depressant medic ationNon-compliance is common problem wit hall anti-d! epressants .
story reassurance , encouragement and compliance aids may all helpConsider providing scripted indata formattingion in a user brotherly format about anti-depressantsAtrial FibrillationThe aim of treatment and management is toTo beg off symptoms of heart failure , hypotension or angina that depose be directly attributed to a rapid heart rateTo improve boilers subject cardiac functionTo improve exercise toleranceTo reduce the risk of thromboembolism and strokeTreatment requires rhythm or rate check depending on the category of AFRhythm control - should be tried first for patients with sullen AF? Who are symptomatic? Who are younger? Presenting for the first time with lone AF? broken to a treated or corrected precipitant? With congestive heart failureRate control - should be tried first for patients with recollective AF? Over 65 years? With coronary artery disease? With contraindications to antiarrhythmic drugs? Unsuitable for cardio version e .g . patients with contraindications to anticoagulation or search a TOE , structural heart disease that precludes long-term maintenance of sinus rhythm , long duration of AF (i .e 12 months , history of multiple failure attempts at cardio versionFoot ulcersIf an ulcer develops , the ulcer must be unbroken very clean . You can do this by washing the feet daily with mild chat or a saline solution and keeping the ulcer covered with clean , dry dressings . Your doctor may recommend complete bed rest with the head kept higher than the feet Often , doctors prescribe an antibiotic ointment to prevent contagion Oral antibiotics may also be needed if the ulcer becomes infected Ulcers c! an become so deep and infected that the foot needs to be surgically amputatedAdaptive Mechanisms1 . Physical and psychological coping strategiesShe loves reading and listening radio . These two hobbies kept her sane as she says . A number of magazines brought by me make her very tearful She walks external her front door , and for fresh air as there is no much of scenery . Her career taught her some stretching exercises which she practice to keep away from universe stiff by the end of a day2 . Adaptations made by familyShe has no family and has a very little social suffer . Only one old mortal , a friend of her visits her , even he stopped being regular due to bad health3 . Assessment of unmet needsHer unmet need is to rock and roll to a special house where she can access the alfresco without stairs , and where the necessitys of social living are very high . Having sheltered accommodation by social run may also give her the opportunity to be with others similar to her side and hope this will entrust her with social hurt which she lacks nowRole of the health functionThe patient s general practitioner has been very supportive . He has provided a number of phone consultations and did home visits to her to assess her material and social condition . He has done appropriate referrals and prescribed the appropriate medications . Most importantly he recommended her to social house , careers , meals on wheels and a district nurse . The primary health care team included the practice nurse (monitored her BP and assessed her sores , alignment care team included the career that brings her breakfast and dinner party everyday and keeps her hygienic and does her food shopping . Social services provide lunch for her through Meals on Wheels and have put for a cleaner to clean her house weekly and provide her with a community alarm service that is linked to the ambulance servicesHow in force(p) are the interventionsThe interventions may be somewhat effect ive but does not provide the social support she requi! res . The pressure and regard on social services means that her application to spurt community care will take a very long time possibly causing serious consequences . Her condition is clearly deteriorating and the likely cause would be her isolation . however there is a huge pressure on the social services as there are many patients worse than this patientEthical dimensionsThis is a very confidential data I acquired promising the patient it would be a secret . She is very confidence trick regarding the details not to be kept open . She expects received secrecy from me . She dislikes people knowing about her inability to do things on her own . And regarding the autonomy , she is an independent woman she is equal and fully able to make her own decisions . She never waits to take decisions , as there is no one in specific to take care of her . And her only friend has also become sick due to which she completely lost social support . As she has very little social support she expects at least her friend to make it to her , may not be as frequent as earlier as but not worse than leaving her aloneShe believes strongly in mercy killing as mentioned earlier , but she would never kill herself . That is what I could make from her words...If you want to get a full essay, put it on our website:
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