Comprehensive Care Plan for T2DM with CKD, Post-Stroke Dysphagia, Femur Fracture, and Walking Difficulties
A comprehensive care plan for this complex patient should prioritize management of diabetes with kidney protection, dysphagia rehabilitation, fracture healing, and mobility restoration while addressing cardiovascular risk factors.
Diabetes and CKD Management
Medication Management
- First-line therapy: SGLT2 inhibitor (empagliflozin, canagliflozin, or dapagliflozin) is recommended as the foundation of treatment due to proven cardiovascular and renal benefits in patients with T2DM and CKD 1
- Metformin should be continued if eGFR ≥30 mL/min/1.73m², with dose adjustment when eGFR <45 mL/min/1.73m² 1
- Consider adding GLP-1 receptor agonist (liraglutide, semaglutide, or dulaglutide) if glycemic targets not met with SGLT2i and metformin 1
- Avoid thiazolidinediones due to risk of heart failure 1
- Avoid saxagliptin in patients with high risk of heart failure 1
Glycemic Targets
- Target HbA1c: 7.0-8.0% (individualized based on comorbidities)
- Avoid rapid reduction in HbA1c (>3% drop) to prevent treatment-induced neuropathy 1
- Monitor blood glucose regularly with self-monitoring
Cardiovascular Risk Management
- Statin therapy: High-intensity statin recommended for very high CV risk 1
- Target LDL-C: <1.4 mmol/L (<55 mg/dL) with at least 50% reduction from baseline 1
- Blood pressure target: 130-139/70-80 mmHg (systolic not <120 mmHg) 1
- ACE inhibitor or ARB recommended for hypertension management 1
- Consider combination of RAAS blocker with calcium channel blocker or thiazide-like diuretic 1
- Antiplatelet therapy: Aspirin 75-100 mg/day for secondary prevention 1
- Consider adding ticagrelor to aspirin if recent history of MI (1-3 years) 1
CKD Monitoring
- Monitor eGFR and urine albumin-to-creatinine ratio every 3-6 months 1
- Avoid nephrotoxic medications (NSAIDs, high-dose contrast media) 2
- Adjust medication dosages based on eGFR 1
- Monitor electrolytes, especially potassium and bicarbonate 2
Post-Stroke Dysphagia Management
Swallowing Assessment and Rehabilitation
- Conduct formal swallowing evaluation by speech-language pathologist
- Implement swallowing exercises and compensatory strategies
- Position patient upright at 90° during meals and for 30 minutes after
- Monitor for signs of aspiration (coughing, choking, wet voice quality)
Nutritional Support
- Modify food and liquid consistency based on swallowing evaluation
- Consider early enteral nutrition if oral intake is insufficient
- Provide low-fat diet (<30% of total calories) with protein at 0.8 g/kg/day 2
- Monitor weight, albumin, and prealbumin levels
- Consider dietitian consultation for optimized meal planning
Femur Fracture Management
Fracture Healing and Rehabilitation
- Ensure appropriate weight-bearing status as prescribed by orthopedic surgeon
- Implement progressive physical therapy focusing on hip and knee strengthening
- Monitor for signs of delayed union or non-union
- Provide adequate pain management with acetaminophen as first-line
- Consider bone health assessment with DXA scan 3, 4
Osteoporosis Management
- Calcium supplementation: 1000-1200 mg/day (adjusted for CKD)
- Vitamin D supplementation to maintain 25(OH)D levels >30 ng/mL
- Consider antiresorptive therapy (bisphosphonates are effective regardless of diabetes status) 4
- Monitor for fracture healing before initiating antiresorptive therapy
Walking Difficulties Management
Mobility and Fall Prevention
- Implement comprehensive physical therapy program focusing on:
- Progressive resistance training for lower extremities
- Balance training and proprioception exercises
- Gait training with appropriate assistive device
- Occupational therapy for activities of daily living
- Home safety evaluation and modifications
- Consider removable walker initially, transitioning to non-removable device when infection is controlled 1
Fall Risk Reduction
- Regular vision and hearing assessments
- Review medications for those increasing fall risk (sedatives, antihypertensives)
- Proper footwear with non-skid soles
- Nightlights and clear pathways at home
- Consider alarm or alert system for emergency assistance
Monitoring and Follow-up
Regular Follow-up Schedule
- Endocrinology: Every 3 months until stable, then every 6 months
- Nephrology: Every 3-6 months based on CKD stage
- Physical therapy: 2-3 times weekly initially, then as needed
- Speech therapy: 2-3 times weekly until dysphagia improves
- Primary care: Monthly initially, then every 3 months
- Orthopedics: As recommended for fracture healing
Laboratory Monitoring
- HbA1c: Every 3 months
- Renal function (eGFR, electrolytes): Every 3 months
- Lipid panel: Every 6-12 months
- Bone markers: Consider baseline and follow-up
- Urinalysis and urine albumin-to-creatinine ratio: Every 3-6 months
Patient Education and Self-Management
- Diabetes self-management education
- Medication adherence strategies
- Home blood glucose monitoring techniques
- Recognition of hypoglycemia symptoms and management
- Dysphagia management techniques
- Safe mobility practices and fall prevention
- Dietary guidance for CKD and diabetes
- When to seek medical attention
Common Pitfalls to Avoid
- Overaggressive glycemic control increasing hypoglycemia risk
- Inadequate monitoring of renal function with medication adjustments
- Insufficient attention to dysphagia leading to aspiration pneumonia
- Overlooking bone health in patients with diabetes and CKD
- Neglecting cardiovascular risk reduction in focus on mobility issues
- Failing to coordinate care among multiple specialists
This comprehensive care plan addresses the complex interplay between T2DM with CKD, post-stroke dysphagia, femur fracture, and walking difficulties while prioritizing interventions that will reduce morbidity and mortality and improve quality of life.