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

MJ Case Assessment and Plan

Pdf Summary

The document details the medical history, current condition, and care plan for MJ Arzoumanidis, an 83-year-old patient discharged from the hospital one day prior to the visit on December 3, 2021. MJ, who immigrated from Greece at age 14, has a complex medical history, including multiple ischemic strokes resulting in right-sided weakness, Parkinson’s disease, a large left inguinal hernia, heart failure with preserved ejection fraction (HFpEF), hypertension, type 2 diabetes with peripheral neuropathy, and other conditions such as renal stones, benign prostate hypertrophy, osteoarthritis, and atrial fibrillation.<br /><br />He's experienced frequent hospital admissions, missing many primary care appointments. He currently lives with his niece, Olivia, who works part-time and provides his primary support, especially important given his mobility issues and history of frequent falls.<br /><br />MJ's physical examination reveals him to be thin, frail, and with an irregular pulse. Specific findings include a tremor, increased rigidity in arms and legs, and a shuffling gait. His medical management includes complex medication regimens for various chronic conditions, and he currently uses a walker but appears to have difficulty with gait and balance.<br /><br />The document highlights various screenings conducted for MJ, including assessments for alcohol abuse, opioid risk, mobility, depression, and cognitive status. His fall risk is notable, and he has functional concerns which indicate occasional assistance needed with dressing and significant falls when attempting to ambulate with a walker. He also has financial concerns due to the cost of his wife’s care, currently residing in a facility due to advanced dementia.<br /><br />Recommendations include evaluating the patient and family preferences for care, conducting comprehensive mental status exams, addressing fall risks, ensuring optimal medication management, and considering the complexity of MJ's care plan in coordination with his niece's support capabilities. The goal is to establish a plan that minimizes hospital readmissions and aligns with MJ’s preferences.

Keywords

MJ Arzoumanidis

medical history

Parkinson’s disease

ischemic strokes

heart failure

type 2 diabetes

mobility issues

fall risk

care plan

hospital readmissions