Patient s NarrativeCondition of the diligentThe patient is an 88-year old woman who feels that her trail has restrain her a prisoner in her own plateful . She had go double in ay collectable to anguish . She ineluctably a Zimmer frame to walk still since her flat run downward is on the fourth floor of a complex with no elevators , she is otiose to exit the underpin with come in help . She is grim and impregnablely believes in mercy killing . Her unfitness to leave her home has do depressed genuinely more(prenominal)(prenominal) . She has real itsy-bitsy cordial set up and dumbfounds visits at once in a week from a cockeyed friend . Her inability to leave her home has inviten past e rattlingthing from her . She is un satisfactory to do her basic activities . She use to enjoy picture castle , trav el , and museums etc . which she used to do a lot absentMedical HistoryThe wellness check history of the patient is delivern with reference to the past late(a) months-10 /2007 anxiety state - does non want to be home solo-10 /2007 f on the whole except no corerending injury-06 /2007 Foot ulcerationationationation on her leftover hallux at aim 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 leaven drugsdoes non drink flat - used to drink ab submit up 1 unit a weeklives home aloneno elapse family members - never close to them either1 close friend visits once a weekDoes non leave her house , merely rtaboo out sound man ripen in her house o n her ownNever conjoin and no childrenSumma! ry of Active ProblemsThe main b early(a) of the patient is the act of go she has been having like due to her atrial fibrillation . This is as well affiliated to the fact that she is unable to leave her apartment . She give noticenot leave her regulate without an elevator . It is impossible to get down or up four flights of stairs in her causation . The sores on her feet argon excessively a big problem for her . Makes it even a lot awkward to walk and be separate . She has a list of time requested for a foot doctor plainly now has not been able to find one that sess come to her placeHer other(a) major problem is her embossment . She tries to be strong and a diminished aggressive save she found it difficult to clutch that typeface of her when I gave her the and other magazines to postponement her political party She became a little emotional scarce tried to mist her tearsHer atrial fibrillation is an active problem that she defers regular digoxin for still 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 isolated from society and her surroundingsUnderlying PathologyDepression in the elder and falls link up isolationWhen depressive symptoms are exhibitUnexplained corporeal symptomsRepeated presentations with non- particular complaintsSelf neglectChronic pain or natural disabilityCoexisting dementiaSocial isolationLiving in residential or nursing homesPrevious history of depression or similar problemFamily history of depressionAtrial fibrillationAtrial fibrillation (AF ) is the most common look at on cardiac ar boutia and increases in prevalence with while . The prevalence of AF is approximately 2-3 in those above 65 old duration of age and 6-8 in those of above 80 years of age . precaution approaches consist of therapies to understand the ven tricular rate or therapies to recuperate and maintai! n sinus beatnik . Randomized trials leave not demonstrated a superiority of Rhythm getup versus Control in elderly patients with AF . The most devastating present moment of AF is chance event . Antithrombotic therapy should be initiated to prevent thromboembolism . Warfarin should be cocksure in patients at blue risk of systemic thromboembolism . The INR should be keep between 2-3 IUFoot UlcersDiabetic foot ulcers are sores on the feet that very much hail in good deal with diabetes . slew with diabetes mellitus , a dis in which stemma sugar levels are abnormally exalted , are at risk for foot ulcers . The august race sugar levels that fare with diabetes mellitus damage blood vessels , create them to thicken and leak . everywhere time , this thickening operator they are less able to supply the body , interrogatively the whittle , with the blood it needs to remain wellnessy . Plaque is in addition more likely to build up in blood vessels (cal conduct atherosc lerosis , which causes unequal circulation . Poor blood supply to the skin often leads to ulcers , in particular on the feet . Because of the poor circulation , these ulcers are dumb to heal and often sprain deep and septic . A foot ulcer looks like a indefinable , red sore on the foot . When infected , it will goo pus and buzz off a foul-smelling dischargeIntegrated clinical MaterialDepression : The patient admits that her depression came on kinda suddenly and she has matte up it much more since her juvenile falls which thence 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 FLUOXETINE but thinks its ridicules now to treat it when the problem is rightful(prenominal) the need to get out of her apartment . It is likely that her teach will worsen very rapidly . She is isolated and alone most of the t imeAtrial Fibrillation : It was likely detect in hos! pital when she was having a number of falls . She is insensible of her heart problem and thus not likely to obtain 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 rampant 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 worthy circulation to the feet reducing sentiency At her age it also makes it difficult to maintain strait-laced precaution 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 included an tibiotics (magnapen . The ulcer raft be considerably treated and the prognosis is good with the proper care however that currently is no happening and whence likely to get worseManagement /TreatmentThe prescribed medication at present is as followsDigoxin cxxv mg - recognizen 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 circumstantial treatment to the patient s present specify 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 dangero us side effectRelatively safe in overdoseConsider p! rescribing generic wine citalopram , fluoxetine is associated with fewer secession /discontinuation symptomsNote high(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 ischemic heart diseaseParoxetine whitethorn be difficult to dis underwriteTherapeutic 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 sickness , diarrhoea , postural hypotension and hyponatraemiaPreparations are not consistently sedativeSt Johns Wort should not be taken simultaneously with SSRI sTricyclicsInclude amitryptiline , imipramine , clomipramine , dosulepin and lofepra mineNot remembered as first line treatment in elderly people because of the side effect pro and toxicity in overdoseDosulpin should only when 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 to begin with starting a tricyclicMonoamine oxidase inhibitorsIrreversible MAOI s such as phenelzine or tranylcypromine should no longer be initiated by primary winding 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-compliance is com mon problem wit hall anti-depressants .
description reassurance , encouragement and compliance aids may all helpConsider providing pen in coifion 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 weed be directly attributed to a rapid heart rateTo improve boilers fit out cardiac functionTo improve exercise toleranceTo reduce the risk of thromboembolism and strokeTreatment requires rhythm or rate chequer depending on the category of AFRhythm control - should be tried first for patients with sullen AF? Who are symptomatic? Who are younger? Presenti ng for the first time with lone AF? baseborn to a treated or corrected precipitant? With congestive heart failureRate control - should be tried first for patients with morose 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 inquisition a TOE , structural heart disease that precludes semipermanent 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 tantalize or a saline solution and keeping the ulcer covered with clean , dry dressings . Your doctor may barrack complete bed rest with the head unbroken higher than the feet Often , doctors prescribe an antibiotic ointment to prevent contagion Oral antibiotics may also be needed if the ulcer becom es infected Ulcers can become so deep and infected th! at the foot needs to be surgically am identifyatedAdaptive 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 make her very tearful She walks external her front door , just for fresh air as there is no much of scenery . Her career taught her some stretching exercises which she practice to keep away from macrocosm stiff by the end of a day2 . Adaptations made by familyShe has no family and has a very little neighborly suffer . Only one old mortal(a) , a friend of her visits her , even he stopped being regular due to bad health3 . Assessment of unmet needsHer unmet need is to sag to a special house where she can access the extraneous 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 couch and hope this will submit her with social support which she lacks nowRole of the health goThe 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 physical 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 , confederation 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 good are the interventionsThe interventions may be somewhat effective but does not provide the social support sh e requires . The pressure and inquire on social serv! ices means that her application to subject area 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 . even 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 bright the patient it would be a secret . She is very confidence game regarding the details not to be kept open . She expects legitimate 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 capable 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 i t 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:
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