CASE STUDY Andrew is a semi-retired 59-year-old man and is married to Angela his Italian

CASE STUDY Andrew is a semi-retired 59-year-old man and is married to Angela his Italian wife of 38 years. They have recently moved to Ballarat to be near his wife’s parents who are having increasing difficulties living at home. Her father has dementia, and her mother has increasing restrictions with mobility due to arthritis. They have two children aged 20 & 27, one living with them and attending Ballarat university and the older son working overseas. Previously Andrew worked as a truck driver for a logistics company in Melbourne, requiring him to drive long distances. He now works 3 days a week driving trucks locally. This lifestyle was sedentary, and his diet consisted mostly of take away foods when he was on the road, but now eats a relatively healthy Mediterranean type diet which includes a lot of pasta and home-grown vegetables. He does smoke but has had periods where he tried to kick the habit. He found this very difficult to maintain especially when he felt stressed or struggling with depression and anxiety. You have obtained a copy of Andrew’s chronic health care plan from his GP in Melbourne and along with the discharge documentation from his recent hospital stay, you need to review and update his previous plan. History as documented up to date Andrew weighs 120 Kg and is 185 cm tall, which places him in an overweight category. A loss of 15 kgs would place him back into a healthy weight category. Andrew drinks a couple of glasses of red wine with dinner most nights. He has a history of childhood asthma and a number of episodes of pneumonia and bronchitis in his early adult years but has not had any concerns with his asthma for some time. He has a severe allergy to nuts requiring him to carry an EpiPen. He undertook an oral glucose tolerance test 12 months ago which verified his diabetic status. He plays golf once a week, although this is sporadic and weather dependent. He enjoys gardening for an hour or two each week. He enjoys walking his dog which he does on the weekends when he is working. He was diagnosed 3 years ago with Osteoarthritis in his R) knee and around the same time his chronic lower back pain and sciatica were also confirmed as being caused by disc degeneration in his lumbar spine. He was commenced on regular pain relief, Naprosyn and Panadol-osteo ii TDS and is awaiting surgery for a knee replacement and possible lumbar laminectomy. Family History Andrew is the oldest surviving sibling of 4 children, his father is English and his mother Australian. Both his parents passed away at a very young age. His father was a Type 2 diabetic had CABG X3 and an extensive cardiac history. His mother was a heavy smoker and had airways disease, asthma, and lung cancer. Three of his siblings all passed away in their early forties due to cardiac and diabetes related complications. Information gathered from hospital reports released to the practice. Andrew was admitted with shortness of breath which progressively increased in severity for the preceding 4 days. The shortness of breath was associated with a wheeze. There was also cough with production of mucoid sputum. He was diagnosed with exacerbation of his COPD secondary to an upper respiratory tract infection (URTI). Andrew has been having an insistent chronic cough associated with mucoid sputum for the past 3 months. He also reports becoming breathlessness more easily over the last 12 months. He tires more easily and finds he is not doing as much as he used to in the garden. His physical examination indicated that Andrew was tachypnoeic with a respiratory rate of 28 breaths per minute. There was no cyanosis. Respiratory examination showed use of accessory muscles as well as increased anterior posterior diameter of the chest and reduced crico-sternal distance. On auscultation, generalised rhonchi and coarse early inspiratory crepitations at the lower bases of both lungs were noted. The cardiovascular system examination was normal despite his elevated BP. There were no other abnormalities on examination. Vital signs O/A: BP: 154/89 mmHg – he states that this is normal for him HR: 97 Irregular Respiration:24 bpm SATS: 89% on room air Appears SOB and speaks in short sentences, he has an audible wheeze Investigations: CXR which showed a hyperinflated chest, tubular heart and absence of vascular markings at the peripheries. The ECG showed sinus rhythm with low voltage. No cor pulmonale indicative of right atrial hypertrophy seen. Echocardiogram, awaiting the results. Spirometry, when he was admitted and his FEV1/FVC ratio was low. Percentage of predicted FEV1 value was 55% which indicates moderate to severely abnormal lung function. Peak flow during admission average 180 – 250 L/minute HbA1c- 7.5% Fasting BGL – 15mmol/L Lipids: Total cholesterol 7.9 mmol/L LDL > 2.8 mmol/L HDL > 1.0 mmol/L Triglycerides > 2.5 mmol/L. Andrew was given nebulisation of Salbutamol and normal saline QID and commenced on a decreasing dose of prednisolone. By day 3 dyspnoea had resolved and Andrew was discharged home. He was given metered dose inhaler of Ipratropium bromide 40 micrograms TDS and MDI salbutamol 200micrograms PRN. He has been identified as being a CO2 retainer. His has Asthma maintenance medication prescribed, Spiriva HandiHaler 18mcg once a day mane and Pulmicort Turbuhaler 400mcg BD. His diabetic medications were also altered during this admission with the addition of glipizide 5mg daily with a need to review by GP once prednisolone ceased. Andrew has been newly diagnosed with chronic obstructive pulmonary (COPD), noted from his last hospital admission a month ago. He has hypertension diagnosed a year ago and is taking Amlodipine 5mg OD. Recently commenced Glypizide 5mg mane for his diabetes. He has been a smoker for the past 40 years who smokes approximately 20 cigarettes a day currently. Discharge plan: Discharge to home with wife. Follow up outpatient respiratory and cardiac clinic appointments have been made. GP to follow up chronic management plan and assess eligibility for case conferencing. The meeting: When Andrew enters with his wife, he has an increased work of breathing after walking approx. 150meters from where the car was parked to the clinic. You note he is sweating, pale, confused, weak, tremulous hands and is tearful. He complains of tingling around his mouth and that he is feeling shaky and lightheaded. What could be wrong with Andrew? What clinical assessments should you perform? What first aid should you give? – How do you respond? What would you need to do first? What questions can you ask Andrew and his wife about to help explain his presenting symptoms? After Andrew is settled, conduct your interview. During the interview Andrew shares the following: He shares with you that being in pain all the time stops him from doing a number of things that he used to enjoy like gardening, golfing and other activities with the kids. He is worried about becoming a burden to his wife and feels embarrassed that he is like this at his age. He states that he suffers from Asthma as a child and only have severe asthma episodes at the change of season. Andrew has been in denial about his diabetes and says he loves his food. He does not test his blood glucose levels at home and expresses doubt that this would help him improve his diabetes control. He now struggles with playing a full 18 holes of golf and usually plays 9 holes due to his knee and back pain mainly but he also gets “a bit puffed out” walking and is really “wrung out” needing a lay down when he gets home. It is his right leg that he uses on the pedals when driving the truck and finds that his knee aches after a day of driving He has also noticed that he is getting seasonal sinus problems and sometimes is wheezy when there is a lot of pollen and wind. These are symptoms he hasn’t experience since he was a child and thinks his asthma is playing up since living in Ballarat. His wife is worried about him. She says he doesn’t like talking about his health issues much and that when she tries to talk to him, about his family’s history and why he should take better care of himself, he gets angry and walks away. She noticed he is becoming more withdrawn lately and not wanting to socialise as much. This has become worse since they had to put the dog down about 6 months ago. You check Andrew’s BGL and vital signs again now that it has been half an hour since his acute episode. T36.2, P88 irreg, R 24 with some increased WOB and an audible wheeze, BP 140/90, BLG 4.6mmol/L. You also check his peak flow 280L/min. Follow up appointment: At the end of the interview, fast forward and pretend it is now one month later. Review the plan. Ask Andrew and Angela how they went following the plan and note if improving/ongoing/worsening. Patient’s Name …………………………………………. Aboriginal ??? Torres Strait Islander ??? Works status ……………………………………………. Male Female DOB: __/__/____ or Age: __ Aboriginal and Torres Strait Islander ??? NOK/ EPOA/ PRIMARY CARER details Current contact details Address …………………………………………………………… …………………………………………………………… State…………………………Post code……………… Phone …………………………………………………… Name…………………………………………………… Relationship…………………………………………… Address …………………………………………………………… …………………………………………………………… State…………………………Post code……………… Phone …………………………………………………… Patient Consent Explanation of health check given Yes Patient consent for health check given Yes Date consent was given: __/__/____ Consent given for information to be collected by: Aboriginal and Torres Strait Islander health practitioner Practice nurse Other suitably qualified health professional Previous health assessment Has the patient had a previous health assessment? Yes No Date of last health assessment (if known) __/__/____ Service provided by Dr………………………………….. PATIENT’S OVERALL HEALTH ……………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………… RISK FACTORS IDENTIFIED AND DISCUSSED WITH PATIENT ……………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………… Tests undertaken, results and what they mean for the patient TEST AVAILABLE RESULTS AND WHAT THEY MEAN FOR ANDREW Hba1c Chest Xray Serum lipids Peak flow measurements Current or potential issues the patient sees as most important ……………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………… Actions to be taken by patient ……………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………… MEDICAL HISTORY FAMILY RELATIONSHIP Does the patient care for someone else? No Yes Is the patient cared for by someone else? No Yes ALLERGIES/ ADVERSE DRUG REACTIONS …………………………………………………………………………………………………………………… CURRENT MEDICATIONS (including prescription and over the counter and supplied by doctor without prescription) …………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………… RELEVENT FAMILY MEDICAL HISTORY …………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………… PHYSICAL ACTIVITY IDENTIFIED ISSUES ACTION e.g. Physical activity is limited by SOB Set exercise regimen in short sessions, low impact and with physiotherapy input to develop exercise plan. NUTRITION IDENTIFIED ISSUES ACTION ALCOHOL, TOBACCO AND OTHER SUBSTANCE USE IDENTIFIED ISSUES ACTION HEARING LOSS IDENTIFIED ISSUES ACTION VISUAL ACUITY (ask about clarity and comfort of vision at distance and near, recommended for over 40’s) IDENTIFIED ISSUES ACTION ENVIRONMENTAL AND LIVING CONDITIONS IDENTIFIED ISSUES ACTION SKIN/FEET IDENTIFIED ISSUES ACTION iNVESTIGATIONS (INCLUDING HEALTH SCREENING, vaccinations) and follow up arrangements (e.g. referrals) REQUIRED …………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………… SUMMARY ASSESSMENT OF PATIENT – TO BE COMPLETED WITH THE PATIENT ON THE DAY OF THE HEALTH INTERVIEW (based on consideration of evidence from patient history, examination and results of any investigation) EXISTING HEALTH ISSUES ACTIONS PLANNED PERSON RESPONSIBLE DATE FOR REVIEW 1 2 3 EVALUATION OF INTERVENTIONS: HOW WILL THE HEALTH ISSUE BE EVALUATED? OUTCOME – RESOLVED/ ONGOING/IMPROVING/WORSENING UPDATE CARE PLAN – IS THERE ANYTHING ELSE TO TRY? 1 2 3 HEALTH ADVICE AND OTHER INFORMATION PROVIDED TO THE PATIENT E.g., education provided, information given to the patient to take home, contact information for supportive services etc. ……………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………………

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