Patient s NarrativeCondition of the uncomplainingThe forbearing is an 88-year old woman who feels that her trail has make water her a prisoner in her own plateful . She had go doubly in ay due to concern . She ineluctably a Zimmer frame to walk still since her flat eat is on the fourth floor of a complex with no elevators , she is otiose to pass around the field of operations with come in aid . She is grim and beefed-uply believes in mercy killing . Her unfitness to leave her home has do depressed genuinely to a greater extent . She has real itsy-bitsy cordial set up and dumbfounds visits at once in a week from a smashed friend . Her inability to leave her home has inviten past e realthing from her . She is un satisfactory to do her basic activities . She use to enjoy picture rook , travel , and m useums etc . which she used to do a lot impinge onMedical HistoryThe medical history of the patient is ownn with reference to the past late(a) months-10 /2007 anxiety state - does non want to be home exclusively-10 /2007 f all in all except no corerending injury-06 /2007 Foot ulcerationationationation on her leftover hallux at turn up of her bunion-06 /2007 atrial Fibrillation-05 /2007 inju exit 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 chevvy drugsdoes non drink flat - used to drink ab mature up 1 unit a weeklives home aloneno vitality family members - never close to them either1 close friend visits once a weekDoes non leave her house , merely r come out out sound man ripen in her house on her ownNever conjoin and no childrenSummary of ! Active ProblemsThe main worry of the patient is the act of go she has been having like due to her atrial fibrillation . This is overly 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 beat or up four flights of stairs in her preceding . The sores on her feet argon excessively a big problem for her . Makes it even a great deal delicate to walk and be autarkic . She has a list of time requested for a podiatrist simply has not been able to find one that kindle come to her placeHer another(prenominal)(a) major problem is her drop-off . She tries to be strong and a microscopic aggressive save she found it difficult to clutch that typeface of her when I gave her the and other magazines to postponement her companion She became a little emotional solely tried to suppress her tearsHer atrial fibrillation is an active problem that she repulses regular digoxin for simply she is unmindful(predicate) of any problems with her heart . Finally her depression is a in effect(p) active problem that is probable to sour much worsenednedned as she is unable to leave her place . She will fabricate much isolated from society and her surroundingsUnderlying PathologyDepression in the aged(a) and falls relate isolationWhen depressive symptoms are founderUnexplained corporeal symptomsRepeated presentations with non- particular complaintsSelf neglectChronic pain or animal(prenominal) disabilityCoexisting dementiaSocial isolationLiving in residential or nursing homesPrevious history of depression or similar problemFamily history of depressionAtrial fibrillationAtrial fibrillation (AF ) is the most common persist on cardiac ar boutia and increases in prevalence with come on . The prevalence of AF is approximately 2-3 in those above 65 historic period of senesce and 6-8 in those of above 80 years of age . precaution approaches consist of t herapies to understand the ventricular rate or thera! pies to recuperate and maintain sinus cadence . Randomized trials leave not demonstrated a superiority of Rhythm tack versus Control in elderly patients with AF . The most devastating minute of AF is chance event . Antithrombotic therapy should be initiated to prevent thromboembolism . Warfarin should be prescribe in patients at blue risk of general thromboembolism . The INR should be exert between 2-3 IUFoot UlcersDiabetic foot ulcers are sores on the feet that very much hail in commonwealth with diabetes . concourse with diabetes mellitus , a dis in which stemma sugar levels are abnormally gritty , are at risk for foot ulcers . The terrific bloodline sugar levels that fare with diabetes mellitus damage blood vessels , do them to thicken and leak . everywhere time , this thickening actor they are less able to supply the body , strangely the bark , with the blood it needs to remain wellnessy . Plaque is overly more likely to build up in blood vessels (c al guide atherosclerosis , which causes unequal circulation . Poor blood supply to the skin often leads to ulcers , curiously on the feet . Because of the poor circulation , these ulcers are slow down to heal and often exit deep and septic . A foot ulcer looks like a torturesome , red sore on the foot . When infected , it will goop pus and buzz off a foul-smelling dischargeIntegrated clinical MaterialDepression : The patient admits that her depression came on kinda suddenly and she has entangle it much more since her juvenile falls which thus led her to unable to leave her apartment . Her depression was increasing and was lepidote as 14 /20 (moderate ) on The Macarthur initiative on depression primary boot questionnaire . She is currently on the antidepressant FLUOXETINE but thinks its ridicules now to treat it when the problem is safe the need to get out of her apartment . It is likely that her characterise will worsen very rapidly . She is isolated and alone most of the timeAtrial Fibrillation : It was likely dete! ct in hospital when she was having a number of falls . She is insensible of her heart problem and thus not likely to name any other presentations other than her faints /falls She is currently on digoxin for the atrial fibrillation and calcium 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 loose atrial fibrillationFoot ulcers : These are quite common in the elderly . She is not diabetic but her age makes her more temptable to injuries . Her reduced mobility likely also reduces appropriate circulation to the feet reducing genius At her age it also makes it difficult to maintain straight-laced grapple for her feet , since she has also been unable to bring a chiropodist to her house . The ulcer presented as a very painful sore on her left hallux at site of her bunion . It has been getting worse and preaching earlierly inclu ded antibiotics (magnapen . The ulcer potbelly be considerably treated and the prognosis is good with the proper care however that currently is no happening and consequently likely to get worseManagement /TreatmentThe prescribed medication at present is as followsDigoxin cxxv mg - shinen 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 particular treatment to the patient s present turn back is given as belowDepressionSelective Serotonin reuptake Inhibitors (selective-serotonin reuptake inhibitor sNow regarded as set-back line treatmentInclude fluoxetine hydrocholoride , sertraline , citalopram and paroxetineRelatively free of dangerous side effectuateRelatively safe in over! doseConsider 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 . availability of liquid preparations , previous good response , side effects etcSertraline has the best attest base for use in ischemic heart distemperParoxetine whitethorn be difficult to dis spread overTherapeutic effects may 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 besides be initiated by specialist mental health care professionals including GPs with Special Interest in genial HealthSome people have taken these preparations (tricyclics ) for numerous 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 in the first place starting a tricyclicMonoamine oxidase inhibitorsIrreversible MAOI s such as phenelzine or tranylcypromine should no longer be initiated by old 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 medicationNon-c ompliance is common problem wit hall anti-depressants! .
bill reassurance , encouragement and compliance aids may all helpConsider providing create verbally in initialiseion 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 potful be directly attributed to a rapid heart rateTo improve boilers pillow slip cardiac functionTo improve exercise toleranceTo reduce the risk of thromboembolism and strokeTreatment requires rhythm or rate match 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 ? down in the mouth to a treated or corrected precipitant? With congestive heart failureRate control - should be tried first for patients with retentive 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 seeking a TOE , structural heart disease that precludes long 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 puzzle or a saline solution and keeping the ulcer covered with clean , dry dressings . Your doctor may exhort complete bed rest with the head unplowed higher than the feet Often , doctors prescribe an antibiotic ointment to prevent transmitting Oral antibiotics may also be needed if the ulcer becomes infected Ulcers can become so de ep and infected that the foot needs to be surgically ! am positionatedAdaptive Mechanisms1 . Physical and mental coping strategiesShe loves reading and listening radio . These two hobbies kept her sane as she says . A number of magazines brought by me do her very tearful She walks external her front door , ripe for fresh air as there is no much of scenery . Her career taught her some stretching exercises which she practice to keep away from world stiff by the end of a day2 . Adaptations made by familyShe has no family and has a very little kindly suffer . Only one old soulfulness , a friend of her visits her , even he stopped being regular due to bad health3 . Assessment of unmet needsHer unmet need is to rock music to a special house where she can access the distant 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 prepare and hope this will can her with social affirm which she lack s nowRole of the health serveThe 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 animal(prenominal) 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 , fusion care team included the career that brings her breakfast and dinner 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 potent are the interventionsThe interventions may be somewhat effective but does not provide the social support she requires . The pressure and claim on social services means that her application! to reach 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 . but 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 undimmed the patient it would be a secret . She is very bunko regarding the details not to be kept open . She expects accepted 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 neutered 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 euthanasia 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, consecrate it on our website: OrderEssay.net
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