Case Study on a Hypertensive, Diabetic Obese Patient

This case report is to observe and study a 78 years old widower, Mr. Martin Chen, who during a colonoscopic examination had presented signs of extreme hypertension and hence was admitted to stabilize his blood pressure. He also had a medical history of hypercholesterolemia and hyperglycemia along with recent instances of violent outbursts.

Running head: CASE STUDY ON A HYPERTENSIVE, DIABETIC OBESE PATIENT
Case study on a hypertensive, diabetic obese patient
Name of the Student
Name of the University
Author’s Note

1CASE STUDY ON A HYPERTENSIVE, DIABETIC OBESE PATIENT
Executive Summary
This case report is to observe and study a 78 years old widower, Mr. Martin Chen, who
during a colonoscopic examination had presented signs of extreme hypertension and hence
was admitted to stabilize his blood pressure. He also had a medical history of
hypercholesterolemia and hyperglycemia along with recent instances of violent outbursts.
After five days of treatment, Mr. Chen is being discharged and a team of multidisciplinary
specialists is being assigned for his care. This medical team of registered nurse, dietician,
physiotherapist and psychiatrist would structure a special patient focused health care plan to
combat his complex chronic diseases along with introducing him to a balanced diet, guided
physical activities and anger management sessions. Therefore, in conclusion, by medically
controlling his hypertension and altering his diet to a well balanced KETO diet will help in
bringing about a positive change in Mr. Chen and pave the way for a healthier lifestyle.

2CASE STUDY ON A HYPERTENSIVE, DIABETIC OBESE PATIENT
Table of Contents
Introduction................................................................................................................................3
Discussion..................................................................................................................................4
Identification of patient needs................................................................................................4
Assignment of a multidisciplinary team................................................................................5
Strategies required to avoid hospitalization...........................................................................9
Potentialmedical barriers......................................................................................................10
Medical requirements...........................................................................................................10
Conclusion................................................................................................................................11
References................................................................................................................................12

3CASE STUDY ON A HYPERTENSIVE, DIABETIC OBESE PATIENT
Introduction
Complex diseases are caused by a combination of genetic, environmental,
and lifestyle factors which are yet been identified. Complex disease management requires
careful diagnosis, analysis of patient history and proper investigation of the diagnostics to
strategize ways in which the disease can be controlled. Mr. Martin Chen, aged 78, was
admitted for extremely high blood pressure level after his recent visit to the hospital for a
colonoscopy. He has a medical history ofhypertension, hypercholesterolemia, obesity with
his current weight at 110kgs, type 2 diabetes mellitus. He also had a trans-ischemic attack in
the year 2018. He is known to be medically allergic to sulphonamides and non-steroidal anti-
inflammatory medicines. For the last two years, he is showing signs of erratic and violent
behavior along with confusion. During his stay at the hospital, the nurses had called three
code blacks emergencies because of Martin’s aggressive behavior in the ward. After five days
of treatment at the hospital, his blood pressure and blood glucose levels had stabilized and he
was prompted to be discharged. On the day of his discharge, the medical staff assigned to his
care noticed a small ulcer on his left great toe. It was cleared, sterilizedand dressed
accordingly.Now, a strategy needs to be adopted that can combat his hypertensionalong with
checking his aggressive outbreaks and hypercholesterolemia.Amultidisciplinary team needs
to be assigned to his care to control the complex chronic needs and manage further
escalations.

4CASE STUDY ON A HYPERTENSIVE, DIABETIC OBESE PATIENT
Discussion
Identification of patient needs
Mr. Chen, senior citizen aged 78, would require maximum care after
hospitalization given his poorly controlled hypertension and hypercholesterolemia leading to
violent flare-ups. The small ulcer on his left big toe also needs tending to, as he is diabetic
with hyperglycemia.Research on his medical history along with the information regarding
Martin’s social history is vital to the clinical reasoning cycle and assignment of proper
medical care.
Social history discloses Martin and his familyto be originally from Hong Kong and all
to be firm Buddhists. He has two sons named Jason and Kenneth and two daughters called
Mandy and Chu.Martin’s father had heart issues and died at an age of 52 due to myocardial
infarction. His brother met with an accident at the age of 60 and died of cerebrovascular
damage. More than 20 years back, Martin along with his wife and all four children had
immigratedto Australia from Hong Kong in the year 1997. As all his children grew older,
they got married, moved out and had children of their own. Martin used to stay with his wife
Cathy but tragedy struck as his wife passed away, after batting bowel cancer,in 2005.Mr.
Martin Chen now awidower moved into the house where his youngest daughter Chuand her
husband Eric stay with their teenage children named Lily and Cherry.
Over the last few years Martin has started showing signs of erratic behaviour and
agitation. Previously, Martinused to cook for the family and do occasional gardening, but
since the deterioration of his health,he has refrained from it.A steady decline inMartin’s
ability to speak English has been noted over the recent times and his worsened
communication skills in English makes him struggle to find the right words and understand

5CASE STUDY ON A HYPERTENSIVE, DIABETIC OBESE PATIENT
conversations with people. This leads to unnecessary aggravation and violent outburst. For
almost a year, Martin has being showing signs of perplexed delusions along with disturbed
sleep. He awakens in the middle of the nightand cries out. He seems overtly anxious and
puzzled and imagines that he is back in Hong Kong. It may also imply that grievance of the
lost dear ones perplexes the social and psychological boundaries of Martin, as his brain
interprets a more comfortable memory of prior times.
Last year, Martin had a trans-ischemic attack due to blood loss in the brain but has not
caused any lasting damage or tissue death. Recently, Martin has also presentedsigns of
memory loss, personality changes, and confusions along with irritability and violent temper
over the recent few years. His family members have noticed a few incidents when Martin had
unmindfully left the stove unattended, hence burning the food. Martin has started fumbling,
trying to recollect names of common house hold objects and has becomeincreasingly
forgetful. His family members are also concerned about his delusions of the neighbours
poisoning the soil and intentionally killing the vegetables growing in the garden.All these
issues are a direct result of the poorly controlled chronic diseases of Martin that have gravely
converted into complex forms over time and it requires immediate attention.
Assignment of a multidisciplinary team
A thorough examination of Martin’s medical history revealedsignificant disabling
effectsby the complex disease, on his mental and physical health. Proper detection of all the
underlying factors is of utmost priority and those need to be sorted efficiently to improve his
quality of life. A multidisciplinary team based approach is required for correct management
and to highlight the objectiveand ensure adherence to the treatment and advised goal. The
specialized team must includea registered nurse, medicinespecialist, social psychiatrist,
dietician and a physiotherapist must be assigned to his care.

6CASE STUDY ON A HYPERTENSIVE, DIABETIC OBESE PATIENT
The registered nurse allotted for assisting with the medical care must carefully
examine Martin’s way of life at first, recognize the potential risk factors, note the areas for
change and incorporate those guidelines while focusing on a customized plan that will help
Martin accomplish his goal and improve his lifestyle (Holt 2017). The foundation of
antihypertensive therapy is lifestyle modification that prevents risk of developing further
complications.Interaction of the nurse via interpersonal relationship can be a valid approach
for neutralization of certain exasperated outbursts of the patient. The doctor can also
recommend an appointment of midwife in Martin’s home, to sustain proper care and collect
timely measurements of his blood pressure, blood sugar level, cholesterol count and
formulated dressing for amelioration of his ulcer.
The registered nurse along with the medicine specialist must analyze his diagnostics
and upgrade his prescribed medications along with the doses while keeping in mind his
allergies. Martin is known to be hypersensitive to non-steroidal anti-inflammatory drugs
(NSAIDs) and to sulphonamides.Sulphonamides have been detected as a potential mediator
of peptic ulcer (Buzás et al. 2016) in clinically sensitive patients. He is currently on Lipitor,
an atorvastatin drug, which is to check his hypercholesterolemia by lowering the level of
lipid. Given the medical history of Martin’s family, where his father died of myocardial
infarction at an age of 52, Lipitor is the right medication to treat high-risk cardiovascular
disease. Martin isalso under the treatment of Metformin,which is the first line medication to
treat diabetes mellitus type 2, especially in obese patients (Viollet 2012). Several effectors
like hyperglycemia, hypercholesterolemia, obesity, hypertension-all of these factors had
significant contributionin disruption of normal glucose homeostasis in him, leading to T2DM.
Also in this case, the cost of medication in almost 2-3 times higher due to prevailing diabetes-
related complications. Since his recent hospitalization, Carvedilol IR 6.25mg has also been
advised, twice a day, to check his severehypertension although it should be noted that

7CASE STUDY ON A HYPERTENSIVE, DIABETIC OBESE PATIENT
carvedilol has a side effect on hyperglycemic patients (Merel and Paauw 2017). Therefore,
the nurse must take extra precaution while administering the carvedilol and scrutinize his
blood glucose levels daily to check acceleration of his hyperglycemia. Such diverse effect
occurred as insulin signaling regulates numerous metabolic pathways of a human body
(Saxton and Sabatini 2017).A combination of Lipitor and carvedilol could be prescribed by
the medicine specialist to calibrate preferable results.
A social psychiatrist must also be assigned toMartin Chento help him control his
emotional aggressions and violent outbursts. Factors influencing these obligations must be
detected and deconstructed carefully. Social engagements which lead to hostile behaviors
should be avoided at any cost. Thetriggers upsetting him and causing disturbing eruptions
must be recognized and measures have to be taken to defocus those triggers to minimize
occurrence of such incidents.Supervisingthe outbursts of patients suffering from dementia
and other complex disorders requires skilled approach. Validation principles by Feil (2012)
and principles of customized patient centered dementia care by Williams, Newman and
Hammar (2017)is highly recommended to equip the caregiver to manage practical situations
and enhance them with knowledge to carry on or induce a communication with the patient
that will help to gain trust and reassurance. One of the various strategies used by Feil (2012)
in anger management is to avoid the usage of the word “why” as asking for reasons makes it
difficult and challenging for the patient to communicate. Another approach to reduce
outbursts is to ask questions which can be addressed easily with only simple “yes” for
affirmation or “no” for refusal (Feil 2012).
Additionally, some priority must be given to weight management also. Genetic
inheritance along with low levels of physical activity effects body weight enormously (Paoli
2014). The problem could be deciphered by consulting a nutritionist who will improve the
food chart of his daily life. Obesity is also considered as a principal risk factor in patients

8CASE STUDY ON A HYPERTENSIVE, DIABETIC OBESE PATIENT
with cardiovascular difficulties, alluding the metabolic problems of hypertension and
diabetes.Inclusion of a properly supervised weight loss planwill automatically improve
Martin’s medical condition along with his lifestyle. The dietician must workwiththe
physiotherapist to focus on an integrated plan to structure acompetent healthcareto manage
the diet and reduce the obesity. The exercises, planned andprescribed for Martin, must be
executed in a guided manner by making sure it does not aggravate his heart ailments and
other health complications. To achieve the better results, introduction of physical activity
must be alongside a well balanced diet. On previous admission to the hospital, he was
suggested a low energy, high protein diet (LEHP) which was ignored. LEHP diet has
immense metabolic advantage due to its reduced intake of calories, dietary proteins obtained
from saturated fatty acids, which are healthier than high carbohydrate sources. LEHP diet is
also advantageous and has potential markers for bone density, nutritional value,
cardiovascular symptoms, and accumulation of body fat resulting in obesity or weight gain.
The ketogenic diet of high protein ratio is often 60% fat, 35% protein and 5% carbs (Azar,
Beydoun&Albadri 2016). Recent studies have demonstrated, decreasing the amount of
carbohydrate intake can actually be beneficial for lowering of cholesterol in obese patients.
Ketogenic diet is known to have several benefits in managing hypertension and type 2
diabetes and its symptoms. These include lowering of the blood glucose level, weight loss
and improvement of blood lipid profile. Studies show that ketogenic diet is beneficial in
checking hypertension too (Siegmann et al. 2019). However, a diet must be planned, keeping
in mind food choices and allergies of the patient (Feinman et al. 2015). A constant
monitoring of the renal function of the patient along with smooth transition of normal to
ketogenic diet should be attained.The ketogenic diet has proved convenient, safe, feasible and
effective therapeutic treatment for patients with hypertension and obesity (Tóth and Clemens
2015).

9CASE STUDY ON A HYPERTENSIVE, DIABETIC OBESE PATIENT
The hospital staff must introduce Mr. Martin Chen to the Australian senior card
facility as it gives senior citizen medical benefits along with subsidized medical care services.
It will positively help Mr. Chen to effectively manage the medical costs and also reduce the
financial strain on his daughter’s family. As he has been diagnosed with type 2 diabetes
mellitus, it is inevitable that his healthcare treatment would be expensive.The Australian
senior card will also help infunding the cost of his future treatment.
Strategies required to avoid hospitalization
To reduce chances of hospitalization, multiple strategies must be adopted. Proper
patient follow up program must be ensured.A robust healthcare program at home must be
implemented. The dressing of the small ulcer on the left big toe must be cleaned in a
sterilized manner regularly. It must be noted that the patient is hyperglycemic which reduces
the rate of healingcompared to a healthy adult. As the patient is extremely hypertensive, the
blood pressure must be observed at least twice daily, and if there is any significant change
then the physician must be alerted instantly so that the medicine doses can be titrated
accordingly.Counseling and initiating optimistic conversations at home, can act as an added
cure provided through medication. Positive and placid attitudes are also expected from the
neighbors. An endeavor for silent recovery of the gardening plants could elucidate this
process and establish faith in psychological mindset of the patient.Cooking occasional food
that Martin has an affection for, can be prepared to encourage his mental health. Although,
proper diet ought to be maintained, combined with physical exercises to avoid any deleterious
effect of obesity and age-related complicacies. Meals that contain high percentage of fat
should be completely avoided. Uptake of bakery products and desserts are strictly to be
refrained as they facilitate accumulation of low density lipid (LDL) and clogging of
cardiovascular arteries, leading to atherosclerosis, which is damaging for functionality of the
heart.

10CASE STUDY ON A HYPERTENSIVE, DIABETIC OBESE PATIENT
Potentialmedical barriers
Recognizing the potential medical barriers will help in avoiding them. Martin Chen is
a strong believer of Buddhism and he might not be comfortable if his beliefs are challenged.
Avoiding religious conversations is advised to steer clear of awkward situations. To evade
conflicts discussion about positive and peaceful topics should be chosen. Solitude can also
aggravate mental instability, for that reason, Martin’s family should aware of him not being
alone or in a solitary confinement for prolonged hours. Born and brought up in Hong Kong,
Mr. Chen is not much accustomed to the Australian way of life. Getting accustomed with the
instrumental outdoor lifestyle can trigger certain anxiety related anger management issues,
typical of people with old age. Due to the complications of his complex disease, he is also
suffering memory loss along with dementia. He keeps forgetting English words, which makes
it difficult for him to communicate. This results in confusion and anger that has to be handled
tactfully.Providing enough time to express and frequent use of sign languages can suffice an
alternative approach.
Medical requirements
Martin’s medical history includes hypertension,
hyperglycemia,hypercholesterolemia, obesity coupled with high levels of lipid with allergic
reactions to non-steroidal anti-inflammatory drugs (NSAIDs) and to sulphonamides. He has
been prescribed Lipitor to treat his hypercholesterolemia, which helps in lowering the lipid
level in the blood. Lipitor also reduces the chances of myocardial infarction which serves as
an added benefit as his father had died of myocardial infarction at the age of 52. Martin is
also under the treatment of Metforminto treat hyperglycemia in obese patients. Since his
recent hospitalization, Carvedilol IR 6.25mg has been prescribed twice daily for his severe
hypertension. However, carvedilol increases hyperglycemia in diabetic patients risking the

11CASE STUDY ON A HYPERTENSIVE, DIABETIC OBESE PATIENT
destruction of normal glucose homeostasis (Merel and Paauw 2017). Therefore, blood
glucose levels must be monitored daily to check hyperglycemic escalations.
Conclusion
In conclusion, a patient focused integrated healthcare has to be structured to manage
Mr Martin Chen’s who has been diagnosed with chronic diseases by delivering competent
professional care. The priorities have to be given to medically check the blood pressure level
along with hyperglycemia coupled with weight loss program in Martin who is also dealing
with obesity.Allotting foods rich in high-density-lipid (HDL) can be prescribed to lower the
elevated levels of cholesterol.Martin would require professional psychiatric help him control
his emotion aggressive outburst. Introduction of ketogenic diet will also assist the weight
management program in improving the blood glucose level, reduction of hypertension,
improving the quality of sleep and controlling violent outbursts along with a weekly profile
of renal functionality. To keep a track of all these physiological factors like blood glucose
level, blood pressure, cholesterol content, renal function tests, a nurse or midwife can be
appointed. Additional diagnosis related to his foot ulcer have to be performed and suitable
medication has to be consumed as per the recommendation of medicine specialist.Introducing
Mr. Martin Chen to the Australian senior card facility, could be useful as it provides senior
citizen medical benefits along with subsidized medical care services. It will positively help
Mr. Chen to effectively manage the medical costs and reduce the financial strain on his
daughter’s family along with it. Moreover, a special focus for Martin, from the family and
exchanging optimistic ideas and thoughts can be amiable for his mental health. Therefore, by
incorporating all the clinical aspects of his condition and providing a guided integrated
healthcare will pave the way for a smooth recovery without much complication while
bringing in a positive change to his lifestyle.

12CASE STUDY ON A HYPERTENSIVE, DIABETIC OBESE PATIENT
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Buzás, G.M. and Supuran, C.T., 2016. The history and rationale of using carbonic anhydrase
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Feinman, R. D., Pogozelski, W. K., Astrup, A., Bernstein, R. K., Fine, E. J., Westman, E.
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