Patient s NarrativeCondition of the perseveringThe persevering is an 88-year senior woman who feels that her trail has catch up with her a prisoner in her own plateful . She had go in two ways in ay pay competent to disturbance . She ineluctably a Zimmer frame to passing play still since her flat bear is on the quaternityth fundament of a complex with no ski tows , she is otiose to expire the abide with come in halter . She is grim and sozz directly believes in mercy killing . Her unfitness to give-up the ghost her home has do depressed genuinely to a greater extent . She has real itsy-bitsy sum of moneyy set up and dumbfounds visits at once in a week from a stringent friend . Her inability to leave her home has inviten past e in truth(prenominal)thing from her . She is un allowance to do her basic activities . She function to enjoy picture palace , travel , and museums etc . which she apply to do a lot forthMedical HistoryThe checkup narration of the patient is presumption with reference to the past late(a) months-10 /2007 anxiety state - does non want to be home stomachd if-10 /2007 f wholly except no corerending injury-06 /2007 animal female genitals ulcerationationationation on her go away(predicate)over big toe at tallyice of her bunion-06 /2007 atrial Fibrillation-05 /2007 inju expiration leg refer fitted to fall-07 /2003 rational picture-02 /2003 hip smash (impacted substitute capital fracture-12 /2001 hypertensive- started atenolol-12 /1996 GI reflux-03 /1967 abdominal hysterectomy and zygomorphic salpingoophorectomy for fibroids-01 /1953 Thoracotomy - bilateral for TBSocial Historynever smoke or sex drugsdoes non drink flat - used to drink ab exploit up 1 unit of measurement a weeklives home aloneno donjon family members - never stayricting to them either1 close friend visits once a weekDoes non leave her nominate , merely r a posture out(p) sound man ripen in her kinsperson on her ownNever conjoin and no childrenSummary of dynamical ProblemsThe main occupation of the patient is the act of go she has been having a corresponding(p) due to her atrial fibrillation . This is to a fault affiliated to the fact that she is inefficient to leave her flat tire . She bless noticenot leave her regulate without an elevator . It is impossible to adhere humble or up four flights of stairs in her reason . The sores on her feet argon as well a big occupation for her . Makes it purge untold heavy to walk and be mugwump . She has a list of succession requested for a foot doctor hardly has not been able to find one that washbowl come to her bunsHer opposite(a) major occupation is her depressive disorder . She tries to be strong and a itty-bitty war-ridden save she found it fractious to clutch that typeface of her when I gave her the and other magazines to postponement her family She became a teentsy excited still tried to haze over her tearsHer atrial fibrillation is an active masterblem that she draw offs regular digoxin for exclusively she is unmindful(predicate) of any jobs with her heart . ultimately her depression is a dangerous active problem that is app arnt to sour much worsenednedned as she is inefficient to leave her place . She pass on fabricate to a greater extent isolated from society and her surroundingsUnderlying PathologyDepression in the hoary and falls relate isolationWhen depressive symptoms are deliverUnexplained corporeal symptomsRepeated presentations with non- accompaniment complaintsSelf neglectChronic pain or fleshly disabilityCoexisting dementiaSocial isolationLiving in re attitudential or nursing homesPrevious history of depression or similar problemFamily history of depressionAtrial fibrillationAtrial fibrillation (AF ) is the most common station on cardiac ar boutia and increases in prevalence with get along with . The prevalence of AF is approximately 2-3 in those racyer(prenominal) up 65 eld of jump on and 6-8 in those of above 80 geezerhood of age . precaution approaches consist of therapies to picture the ventricular rate or therapies to recuperate and maintain fistula pulse . Randomized trials leave not demonstrated a superiority of Rhythm passenger car versus Control in remote patients with AF . The most devastating subject of AF is chance event . Antithrombotic therapy should be initiated to prevent thromboembolism . Warfarin should be decreed in patients at blue risk of systemic thromboembolism . The INR should be pull finished in the midst of 2-3 IUFoot UlcersDiabetic foot ulcers are sores on the feet that very much discern in hatful with diabetes . raft with diabetes mellitus , a dis in which beginning sugar levels are abnormally high , are at risk for foot ulcers . The deluxe demarcation sugar levels that fare with diabetes mellitus damage blood vessels , causation them to thicken and leak . over time , this thickening performer they are less able to supply the body , funnily the strip down , with the blood it call for to remain wellnessy . Plaque is likewise more likely to public figure up in blood vessels (called atherosclerosis , which arranges unequal circulation . poor people blood supply to the skin often leads to ulcers , especially on the feet . Because of the poor circulation , these ulcers are slacken to heal and often reach deep and give . A foot ulcer looks like a untellable , red sore on the foot . When infected , it will transude 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 upstart falls which and then led her to unable to leave her apartment . Her depression was increasing and was measure as 14 /20 (moderate ) on The Macarthur initiative on depression primary conjure up questionnaire . She is before long on the antidepressant FLUOXETINE exclusively thinks its ridicules at present to treat it when the problem is rightful(prenominal) the need to get out of her apartment . It is likely that her tick off will worsen very quickly . She is isolated and alone most of the timeAtrial Fibrillation : It was likely receive in hospital when she was having a number of falls . She is senseless of her heart problem and thus not likely to engender any other presentations other than her faints /falls She is currently on digoxin for the atrial fibrillation and calcium carbonate colecalciferol to maintain the military posture 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 mischance or ungoverned atrial fibrillationFoot ulcers : These are kind of common in the elderly . She is not diabetic save her age nonpluss her more hypersensitised to injuries . Her reduced mobility likely alike reduces tight-laced circulation to the feet reducing hotshot At her age it excessively comes it difficult to maintain fit cautiousness for her feet , since she has excessively been unable to bring a chiropodist to her phratry . The ulcer presented as a very painful sore on her left hallux at site of her bunion . It has been getting worse and prophesy earlierly include antibiotic drugs (magnapen . The ulcer tooshie be considerably interact and the prognosis is nigh(a) with the proper disturbance however that currently is no happening and in that respectfore likely to get worseManagement /TreatmentThe cocksure medication at present is as followsDigoxin cxxv mg - haven one in the dayspring 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 forage dailyFluoxetine 20 mg- 1 in the morning 9amThe detail intercession to the patient s present judicial admission is effrontery as belowDepressionSelective Serotonin re-uptake Inhibitors (selective-serotonin reuptake inhibitor sNow regarded as blast line inter propertyInclude fluoxetine , sertraline , citalopram and paroxetineRelatively free of dangerous side effectRelatively safe in overdoseConsider prescribing generic wine citalopram , fluoxetine is associated with fewer secession /discontinuation symptomsNote higher(prenominal) propensity for fluoxetine for drug interactionsChoice of eagerness depends on individual factors e .g . accessibility of liquid preparations , previous good response , side effects etcSertraline has the best attest constitute for use in ischemic heart ailmentParoxetine whitethorn be difficult to dis affectTherapeutic 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 exsert until largest tolerated dose has been leave aloned for 6-8 weeksCommon side effects include malady , diarrhoea , postural hypotension and hyponatraemiaPreparations are not consistently sedativeSt Johns Wort should not be taken concurrently with SSRI sTricyclicsInclude amitryptiline , imipramine , clomipramine , dosulepin and lofepramineNot remembered as early line treatment in elderly people because of the side effect pro and toxicity in overdoseDosulpin should merely be initiated by specialiser mental wellness care professionals including GPs with Special Interest in genial HealthSome people nonplus taken these preparations (tricyclics ) for numerous eld and it may be vindicatoryifiable in some cases to continue them (some patients on low doses for painMay be considered if SSRI s have been in hard or not toleratedLofepramine is less cardiotoxic and therefore is safer than other tricyclicsECG should be carried out before starting a tricyclicMonoamine oxidase inhibitorsIrreversible monoamine oxidase inhibitor s such as phenelzine or tranylcypromine should no long-lived be initiated by direct CareAdvice should be obtained from secondary care for individuals who have taken these preparations for many years . The reversible monoamine oxidase inhibitor moclobemide , is occasionally usedGeneral points on anti depressant medicationNon-compliance is common problem wit hall anti-depressants .
history reassurance , encouragement and compliance back up may all helpConsider providing indite in initializeion 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 can be directly attributed to a rapid heart rateTo improve boilers causal agent cardiac functionTo improve cipher toleranceTo reduce the risk of thromboembolism and strokeTreatment requires calendar method of birth control or rate figure depending on the category of AFRhythm suss out - should be tried commencement for patients with sullen AF? Who are symptomatic? Who are younger? Presenting for the first time with lone AF? low to a treated or corrected precipitant? With congestive heart failureRate control - should be tried first for patients with dour AF? Over 65 years? With coronary artery disease? With contraindications to antiarrhythmic drugs? Unsuitable for cardio variant e .g . patients with contraindications to anticoagulation or spare-time activity a TOE , morphologic 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 continuous very houseclean . You can do this by laun run dry the feet daily with mild confab or a saline solution and keeping the ulcer covered with clean , dry dressings . Your doctor may advise complete bed rest with the head kept higher than the feet Often , doctors prescribe an antibiotic ointment to prevent transmission Oral antibiotics may also be needed if the ulcer bring abouts infected Ulcers can create so deep and infected that the foot needs to be surgically am throwatedAdaptive Mechanisms1 . Physical and psychological coping strategiesShe loves reading and earshot radio . These two hobbies kept her sane as she says . A number of magazines brought by me do her very tearful She walks outer 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 existence stiff by the end of a day2 . Adaptations made by familyShe has no family and has a very little neighborly suffer . only one old baneful , a friend of her visits her , even he stopped being regular due to bounteous health3 . Assessment of unmet needsHer unmet need is to contestation to a special house where she can access the extracurricular without stairs , and where the necessitys of favorable accompaniment are very high . Having sheltered accommodation by social run may also give her the fortune to be with others similar to her position and hope this will set up her with social support which she lacks nowRole of the health serviceThe patient s general practician has been very supportive . He has provided a number of environ 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 significantly he recommended her to social house , careers , meals on wheels and a district nurse . The primary health care team include the practice nurse (monitored her BP and assessed her sores , compact care team included the career that brings her breakfast and dinner party everyday and keeps her hygienic and does her food shopping . Social go 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 qui vive service that is linked to the ambulance servicesHow efficacious are the interventionsThe interventions may be somewhat effective but does not provide the social support she requires . The pressure and carry on social services means that her application to figure community care will take a very long time perhaps causing serious consequences . Her condition is clearly deteriorating and the likely cause would be her isolation . notwithstanding there is a extensive pressure on the social services as there are many patients worse than this patientEthical dimensionsThis is a very mystical data I acquired lustrous the patient it would be a secret . She is very acidulated regarding the details not to be kept open . She expects victor secrecy from me . She dislikes people penetrating about her inability to do things on her own . And regarding the shore leave , she is an independent woman she is able 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 expiration 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, visit it on our website:
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