Management Plan for a 41 years old female, Hispanic-American decent who presents to the clinic for a well visit assessment; assessment reveal she is at risk for the following :
• hypertension (bp 134/74);
• breast cancer (first degree family member mom 63 and 1st cousin 44 being diagnosed and early menses at 10.5; latte pregnancy 33; mammogram result pending);
• prediabetes A1c 6.4
• cardiovascular disease due to hyperlipidemia
Use the expert diagnosis provided to create a pertinent, comprehensive, evidenced-based management plan.
Address the following criteria in the plan:
1.) Diagnostic tests;
2.) Medications (write out a complete order, even for OTC meds);
3.) Suggested consults/referrals
4.) Patient education;
5.) Follow-up, including time interval and specific symptoms to prompt a return visit sooner;
6.) Provide rationales for each intervention and include at least 3 references to support your plan. Clinical practice guidelines should be utilized as applicable. (Evidence of Academic Integrity Issues will result in a grade of 0.)
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Management Plan
Full Answer Section
- Thyroid Stimulating Hormone (TSH): To rule out thyroid dysfunction, a common comorbidity with autoimmune diseases.
- Complete Blood Count (CBC): To assess overall health and identify any underlying anemia or infection.
- Comprehensive Metabolic Panel (CMP): To evaluate kidney function, electrolyte balance, and liver function.
- Urinalysis: To screen for urinary tract infection, proteinuria, or glucose in the urine.
- Mammogram results: Review upon completion.
- Metformin 500mg PO BID: To address prediabetes and reduce cardiovascular risk. Metformin is the first-line agent for prediabetes and has cardioprotective effects.
- Lifestyle modifications: Dietary changes, regular physical activity, and weight management are essential for managing prediabetes and reducing cardiovascular risk.
- Aspirin 81mg PO daily: To reduce the risk of cardiovascular events in high-risk individuals.
- Consider lipid-lowering therapy: If lipid profile results are significantly abnormal, statin therapy may be considered.
- Referral to a registered dietitian: To provide personalized dietary guidance and support.
- Referral to a certified diabetes educator: To educate the patient about prediabetes management and prevention of diabetes.
- Referral to a breast specialist: Following mammogram results, if indicated.
- Importance of lifestyle modifications: Emphasize the benefits of regular physical activity, a healthy diet, and weight management for overall health and disease prevention.
- Adherence to medication regimen: Explain the importance of taking medications as prescribed and potential side effects.
- Breast self-awareness: Encourage regular breast self-examinations and prompt reporting of any changes.
- Follow-up care: Explain the importance of regular check-ups and screenings.
- Risk factors for chronic diseases: Discuss the patient's specific risk factors and how to manage them.
- Follow-up in 3 months: To monitor blood pressure, blood glucose, and lipid levels. Assess medication adherence and effectiveness.
- Return sooner if: Experiencing chest pain, shortness of breath, severe headaches, blurred vision, rapid weight gain, or persistent nausea and vomiting.
- Metformin: Shown to reduce the risk of developing type 2 diabetes and has cardioprotective effects (American Diabetes Association, 2023).
- Aspirin: Reduces the risk of cardiovascular events in high-risk individuals (American Heart Association, 2023).
- Lifestyle modifications: Proven effective in managing prediabetes and reducing cardiovascular risk (American Diabetes Association, 2023).
Sample Answer
Management Plan for 41-year-old Hispanic-American Female
Patient Presentation
A 41-year-old Hispanic-American female presents for a well-visit with risk factors for hypertension, breast cancer, prediabetes, and cardiovascular disease.
Diagnostic Tests
- Lipid Panel: To assess cholesterol levels and cardiovascular risk.
- Fasting Blood Glucose: To confirm prediabetes diagnosis and assess glucose control.
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