Rigoberto's Dilemma Case Study Harvard Case

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Constipation-Medium risk.
Goal: Rigoberto will maintain regular bowel elimination through the use of medications and diet for the next 12 months AEB no need for fleet enemas or rectal suppositories.
Rigoberto did not have any documented or reported constipation episode. He did not require any enemas, suppositories or manual impaction checks. EGD and Colonoscopy was not indicated. Diagnostic fecal occult blood test on 03-10-17 was negative. He has an active diagnosis of Constipation for what he takes Miralax 17G QAM and docusate sodium 100mg QHS. Dietary measures includes High fiber, Fruit butter, and Flaxseeds mix with cereal at breakfast. Current supports have been effective. Supports were effective.

Dental-High risk
Goal: During the
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His last annual EKG was normal with NSR.
Rigoberto was noted with persistent Anemia that is being treated with oral daily Folic Acid and Vitamin B12; he was also treated with Ferro-sequels from 1/9/17 to 6/1/17. His last consult with Oncology for Macrocytosis anemia with Dr. Sarhill indicated that his condition was improved/corrected and recommended to continue Folic acid and Vitamin B12; no need for Bone Marrow Biopsy. Rigoberto’s blood pressure and pulse for the most part within normal with the exception of a few episodes of elevated pulse and slight low blood pressure. Previous treatment for dyslipidemia was not effective. Previous goal was not met.

Metabolic Syndrome-Medium risk
Goal: With the use of medications and diet, client’s abdominal waist will remain 39]), Cholesterol  227-previous 217. Fish oil and Crestor were d/c on 4/11/17. Previous treatment with Fish oil and Crestor was not effective. Lopid 600 mg Oral daily was started 7/10/17, lipid panel is being monitored every 3 months.
Last dietary change 01/31/17 D/C Heart Healthy, evening snack @ 6:30 pm while awake; Start 1200 calorie diet.
Encourage low calorie foods and sugar free beverages from outside
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Client is currently on Fosamax 70 mg weekly, vitamin D3 2000 units daily, as well as calcium carbonate/vitamin D twice daily. DEXA scan was repeated on 07-20-17 and showed “mild osteoporosis of the lumbar spine and bilateral hips”. His las vitamin D level on 7/3/16 was 28.2 and was low for it is recommended to be 30-100 ng/ml. Vitamin D level will be checked every 6 months. Next DEXA scan will be in 2019 to monitor effectiveness of treatment.
Rigoberto did not have any mobility changes, he ambulates independently without the need of assistive equipment. During the past 12 months he had a total of 8 falls that for the most part occur when he was being redirected/behavioral. There were no serious injuries as a result of these falls. Rigoberto risk for falls increased due to his Seizures diagnosis and his bone osteoporosis condition. During this year he did not have any documented falls due to seizure episodes. Supports have been effective in preventing fractures and decreasing his falls. Last year he had a total of 12

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