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

Christina Case Assessment and Plan

Pdf Summary

Christina Popa, a 69-year-old Romanian woman, lives with her daughter Veronika and has a complex medical history primarily involving Stage 3 Ovarian Cancer. Presented by Home Health three weeks post-operation for small bowel obstruction, Christina exhibits significant fatigue and a recent rash on her chest. Christina’s care has been managed solely by an oncologist, leaving her without a primary care provider. She also has a history of hyperlipidemia, hypothyroidism, and hypertension.<br /><br />Christina’s medical history includes significant treatments such as debulking surgery and chemotherapy, and her current state is marked by notable exhaustion, decreased functional status, and ascites. Her complaints during the visit include severe tiredness, a rash on her chest, and ongoing fatigue.<br /><br />Her family history is limited but includes the death of her father in World War II, possible breast cancer in her mother, and a sister currently living in Romania. Christina’s social history records her as a non-smoker, non-drinker who worked as a secretary in Romania.<br /><br />During the examination, Christina displayed a variety of symptoms including gastrointestinal issues such as poor appetite and constipation, musculoskeletal difficulties including fatigue with walking and difficulty rising from a chair, and skin issues like a painful rash and surgical wounds healing. She exhibits anxiety but denies depression.<br /><br />The medication list includes Dexamethasone, Docusate, Atorvastatin, Esomeprazole, Hydrocodone/APAP, Levothyroxine, Diltiazem, and Lorazepam. She recently completed Paclitaxel and Carboplatin chemotherapy. The review of her systems showed complications like early satiety, nausea, trace leg edema, hypothyroid correction, and anemia with a hemoglobin of “9”.<br /><br />Christina’s living situation, financial dependence on her daughter, and increasing difficulties with mobility significantly impact her quality of life. Veronika, her daughter and primary caregiver, has used up FMLA and must juggle her job to maintain health insurance, increasing caregiver burden. <br /><br />The immediate medical goals include managing fatigue, resuming chemotherapy, and improving overall functional status. Long-term planning involves addressing advance directives and possible interventions to reduce caregiver strain on Veronika.

Keywords

Ovarian Cancer

Post-operation care

Fatigue

Rash

Chemotherapy

Caregiver burden

Medical history

Functional status

Primary care

Advance directives