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

Ralph Case Assessment and Plan

Pdf Summary

Ralph Wade, a 77-year-old African-American man, suffers from multiple chronic conditions including oxygen-dependent Chronic Obstructive Pulmonary Disease (COPD), pulmonary hypertension, and heart failure with reduced ejection fraction (HFrEF). Recently, he experienced worsening shortness of breath, necessitating an ambulance call and hospital observation. He was discharged two days ago.<br /><br />Ralph lives alone on limited financial resources in a precarious neighborhood, relying on his nephew Reggie and sister Jessica for daily check-ins and groceries. He has a complicated medical history including stage 4 COPD, atrial fibrillation, hypertension, chronic kidney disease, and previous coronary artery bypass graft (CABG) surgery. Ralph has sporadic adherence to a low-sodium diet and faces challenges in medication management due to cost constraints.<br /><br />Physical examination revealed an initial blood pressure of 170/88, improving to 140/76 by visit end, along with other concerns such as decreased O2 saturation, irregular heart rhythms, and significant leg edema. His comprehensive medication regimen includes furosemide, carvedilol, amiodarone, and various other drugs to manage his conditions, though cost and access issues complicate adherence.<br /><br />Ralph's social history indicates occasional smoking, no alcohol or drug use, and a history as a factory worker and Army veteran. His living environment presents several safety hazards, such as tripping over oxygen tubing and extension cords.<br /><br />Several key assessments highlight Ralph's condition:<br />- PHQ-9 score indicates positive depression,<br />- Mobility issues necessitate a cane,<br />- Functional decline with NYHA class 3 heart failure,<br />- Independence in self-care but needs assistance with groceries and showering.<br /><br />Goals of care include improving Ralph's quality of life, reducing emergency room visits, managing breathlessness, and ensuring safe, supportive living conditions. Specific recommendations may involve revising his complex medication schedule, enhancing his support network, and addressing environmental hazards to bolster his capacity for self-management and overall well-being.

Keywords

Ralph Wade

COPD

heart failure

chronic conditions

medication management

financial constraints

social support

environmental hazards

quality of life

self-management