Essential Elements of Home-Based Primary Care Workshop-Betty Case Assessment and Plan

Betty Case Assessment and Plan
Pdf Summary
Betty Maldonato, a 61-year-old morbidly obese Caucasian woman, presents with numerous medical and psychological issues, including severe physical limitations, depression, and anxiety. She has been housebound in her basement for months due to weakness, pain, and fear, and has not been able to see her primary care provider.<br /><br />Her medical history includes Stage 3 COPD (oxygen-dependent), Stage 4 CKD, type 2 diabetes with peripheral neuropathy, degenerative osteoarthritis, chronic pain, migraines, major depression with anxiety, sleep apnea, and more. Her family history reveals a mother who died of CHF and diabetes complications, and a father and brother alive with CHF, HTN, and other conditions. Socially, Betty's husband is a long-distance truck driver, her son is incarcerated, and one of her daughters, who lives with her, is verbally abusive but aids her with medications.<br /><br />During her recent visit on October 16, 2021, Betty reported feeling extremely depressed with little pleasure in daily activities, experiencing increased wheezing and coughing due to COPD, and a new, untreated abscess under her right axilla. Her general state includes generalized pain, difficulty moving, and severe obesity with a weight of 465 pounds.<br /><br />Betty's living conditions are poor; she resides in a cluttered basement with unsafe egress, and the kitchen environment is highly unsanitary. She relies on oxygen, uses a walker, and her nutritional intake is poor, often comprising of what family members provide. Hygiene is poor, and she has significant mobility issues, making her a high fall risk.<br /><br />Her current medication regimen includes a variety of drugs for her multiple chronic conditions, and a new abscess treatment plan is a priority. Her goals include improving living conditions, better managing her health, and seeking support to address her complex needs. She has also expressed the desire for upliftment from her depressive state and heightened physical functionality. <br /><br />Further strategies involve addressing her mobility issues, assessing her mental health more thoroughly, reconsidering her medication management, and exploring additional resources to enhance her living conditions and overall well-being.
Keywords
morbidly obese
COPD
CKD
diabetes
depression
anxiety
chronic pain
mobility issues
poor living conditions
medication management