Clinical Application 7 Robert Parker is a 68 year old gentleman who is two weeks
ID: 243334 • Letter: C
Question
Clinical Application 7 Robert Parker is a 68 year old gentleman who is two weeks post op from coronary artery bypass grafting. Medical history includes hypertension, dyslipidemia, BPH and a 30 year history of type 2 diabetes. He reports that he has been somewhat sporadic in his commitment to health care. He is sedentary and not judicious in following the diet prescribed by his primary care physician. He seldom monitored his blood sugar, ate out frequently and often forgot his medications. He presents for follow up. He has remained fairly sedentary since discharge. His incisional discomfort is well controlled. He does experience some DOE. His lower extremities have shown some swelling worse over the past week. He is not monitoring his glucose although he does have equipment and is fairly comfortable with the procedure. Vitals: B/P 145/90 to 174/90 Heart rate 90 to 130 SR/ST with a single episode of atrial fib immediately post op Respirations 18 -22 Afebrile Weight 128.4 kg He is 6 foot tall Lab analysis includes Na 134 K 4.2 CL 111 CO2 24 BUN 57 Calcium 8.2 Creatinine 2.7 FBS 257 UA shows microalbuminemia WBC 6.7 RBC 4.2 Hgb 8.2 Hct 37MCV 121 MCH 42 Platelet count 250,000 HgbAle 10.8 Chol 267 Triglycerides 324 HDL 21 LDL 194 LFTs within normal limits with an albumin of 3.2 TFTs within normal limitsExplanation / Answer
1.inffective breathing pattern related to presence of cough.
2.abnormal heart sound S4 heard as a result of failure of left ventricular impaired functioning resulting in forceful filling by the atrial contraction via the atrioventricular valve
3. Having a sedentary lifestyle 2+ edema is noted and also as the patient shows the signs congestive heart failure and being over weight.
4. A known case of diabetes, hypertension, BPH, dyslipidemia.
Care for diabetes, :
1.strict diet regime,reduction of weight
2. Regular exercise, avoidance of sedentary lifestyle
3. Regular monitoring of Blood sugar levels.
4. Proper care and immediate care if any wound to get proper wound care.
5. Strict adherence to the medications prescribed metaformin and timely follow up.
Care for hypertension
1.strictly salt restricted diet
2.avoidance of stress
3.weight management
4. Proper fluid regulation
5. Medication ecotrin can be deleted as the patient is afebrile
Because of diabetes and hypertension the kidneys function is impaired resulting in proteinuria. It is essential to explain and teach the patient to strictly adhere to the care in controlling BP and diabetes and regular follow up to prevent the resultant proteinuria.
Care for dyslipidemia: the goal is to bring the lipid profile within the control limits.
His reports reveals the values of trigylcerides high and also abnormal LDL and HDL values, so it is important to regulate his fats primilary by diet by asking to consume less saturate fat diet, and low sugar .regukar exercise also helps in improving the lipid profile .as the patient is receiving simvastatin which helps to lower LDL and correct his lipid profile so there is no need to add any other medicine .
As per his CBC nothing is significant. He may also go for Doppler studies for his extremities.
Health education regarding the importance of
1. Diet: salt restricted, sugar free, low fat diet will be recommended
2. Exercise : advice regular exercise but not heavy
3. Rest
4.medication , strict adherence to medication , regular monitoring of Blood sugar and BP
5. Proper and timely follow up
6. Avoidance of stress
Additional diagnostic that can be recommended are
1. Cardiac markers
2. USG
3. Echo
4. Doppler
The follow up can be planned within 7 days and then even telephonic follow up can be done and emphasis can be laid own reducing his weight, exercise diet in order to achieve his goals1. To control blood sugar levels
2. To control is BP
3. To control is lipid profile.
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