What is the appropriate plan for a 70-year-old post-menopausal female with hypertension (High Blood Pressure), hyperlipidemia (High Cholesterol), diabetes on insulin pump, and recent fractures?

Progress Note: 70-Year-Old Female with Multiple Comorbidities and Recent Fractures

Chief Complaint

Follow-up evaluation post-hospitalization for acute comminuted lumbar spine fractures and left proximal tibia-fibula fracture status-post closed reduction with intramedullary tibial nail placement.

History of Present Injury

Continue current pain management and fracture care as outlined. Patient sustained multiple fractures following slip-and-fall in shower on wet floor, requiring surgical intervention with closed reduction and intramedullary nail fixation of left distal tibia shaft fracture with proximal-distal locking screws. Currently recovering in rehabilitation facility.

Chronic Disease Management

Hypertension

Blood pressure control requires optimization given current readings and high-risk status. Current BP of [BLOOD_PRESSURE] mmHg indicates suboptimal control in this 70-year-old patient with diabetes and multiple cardiovascular risk factors 1.

• Target BP should be <140/90 mmHg, with individualization based on frailty status 1
• For patients <79 years, achieved systolic BP <140 mmHg is appropriate; for those >80 years, 140-145 mmHg if tolerated is acceptable 1
• This patient qualifies as high-risk (diabetes, obesity, multiple comorbidities) and warrants immediate drug treatment optimization 1
• Current regimen includes losartan 25 mg daily and metoprolol succinate 50 mg daily, which may require dose escalation 1
• Consider increasing losartan to full dose (up to 100 mg daily) before adding additional agents 1
• If BP remains uncontrolled, add thiazide-like diuretic as third-line agent 1
• Monitor BP closely during rehabilitation stay with goal to achieve target within 3 months 1
• Avoid excessive diastolic BP lowering below 70-75 mmHg to prevent deleterious reductions in coronary blood flow 1

Hyperlipidemia

Continue rosuvastatin 20 mg daily with current LDL-C of 80 mg/dL indicating adequate statin response. However, triglycerides of 230 mg/dL represent significant residual cardiovascular risk requiring additional intervention 2.

• LDL-C goal of <100 mg/dL is achieved, but elevated triglycerides (230 mg/dL, goal <150 mg/dL) warrant additional therapy 2
• After LDL-C goal is reached, consider adding omega-3 fatty acids (2-4 grams EPA+DHA daily) or fenofibrate for triglyceride reduction 2
• Continue lifestyle modifications including reduction of saturated fat to <7% of total calories and elimination of trans-fatty acids 2
• Recheck lipid panel in 4-12 weeks after any medication adjustment 2
• The combination of diabetes, hypertriglyceridemia, and obesity represents metabolic syndrome with excess cardiovascular risk 3, 4

Diabetes Mellitus Type 1

Continue insulin pump therapy with current HbA1c of 7.5% indicating reasonable but suboptimal glycemic control. Improved glucose control will help address hypertriglyceridemia 5, 6.

• Current HbA1c of 7.5% is acceptable but could be optimized to <7% if achievable without hypoglycemia risk 1
• Continue metformin 1000 mg twice daily and insulin glargine 20 units subcutaneously daily 1
• Improved glycemic control is effective in reducing triglyceride levels in insulin-dependent subjects 5, 6
• Monitor blood glucose closely during rehabilitation given altered activity level and stress of recent trauma 1
• Thiazolidinediones should be avoided given obesity (BMI 35) and multiple comorbidities 1

Obesity (BMI 35 kg/m²)

Weight reduction is critical for improving hypertension, diabetes control, and lipid profile. Target BMI 18.5-24.9 kg/m² with waist circumference <35 inches 7, 2.

• Weight reduction and sodium restriction produce larger BP declines in older adults than in younger patients 1
• Implement DASH eating plan (diet rich in fruits, vegetables, low-fat dairy products, low in saturated and total fat) 1
• Engage in at least 30 minutes of moderate-intensity aerobic activity most days of the week once fractures permit 7, 2
• Obesity is linked to insulin resistance, hyperinsulinemia, and hypertension through altered intracellular calcium metabolism and enhanced renal sodium reabsorption 8

Medication Safety Concerns

Discontinue ibuprofen immediately due to multiple contraindications. NSAIDs raise BP, increase cardiovascular risk, and should be avoided in this high-risk patient 1.

• NSAIDs commonly raise BP levels in older adults, undermining BP control 1
• Substitute with acetaminophen or consider alternative pain management strategies for osteoarthritis 1
• Continue oxycodone-acetaminophen 5-325 mg as needed for fracture-related pain 1

Fracture Management

Continue current orthopedic management with close monitoring for complications. Ensure adequate calcium and vitamin D supplementation given multiple fractures and post-menopausal status.

• Continue enoxaparin 40 mg/0.4 mL subcutaneously once daily for DVT prophylaxis during immobilization period 1
• Monitor for signs of compartment syndrome, infection, or hardware complications 1
• Physical therapy as tolerated to prevent deconditioning and promote fracture healing 1
• Ensure adequate calcium (1200-1500 mg daily) and vitamin D (800-1000 IU daily) supplementation 1

Additional Comorbidities

Continue current management of COPD, obstructive sleep apnea, bipolar disorder, and secondary parkinsonism with close monitoring during rehabilitation stay.

• Continue Advair 200-62.5-25 mcg once daily and albuterol 108 mcg as needed for COPD 1
• Ensure CPAP compliance for obstructive sleep apnea 1
• Continue gabapentin 300 mg daily, ondansetron 4 mg daily, and quetiapine 200 mg twice daily for bipolar disorder 1
• Continue carbidopa-levodopa 25-100 mg and pramipexole 0.5 mg for secondary parkinsonism 1

Assessment Summary

1. Hypertension - suboptimally controlled, requires medication adjustment 1
2. Hyperlipidemia - LDL-C at goal but significant hypertriglyceridemia requiring additional therapy 2
3. Diabetes mellitus type 1 - reasonable control but optimization needed 5, 6
4. Obesity - contributing to metabolic syndrome and cardiovascular risk 3, 8
5. Acute comminuted fractures of lumbar spine and left proximal tibia-fibula - status-post surgical repair, stable 1

Plan

1. Increase losartan to 50 mg daily immediately, with plan to titrate to 100 mg if BP remains elevated 1
2. Discontinue ibuprofen; substitute with acetaminophen for osteoarthritis pain 1
3. Add omega-3 fatty acids 2-4 grams daily for hypertriglyceridemia 2
4. Recheck lipid panel and HbA1c in 4-12 weeks 2
5. Monitor BP daily during rehabilitation stay with goal <140/90 mmHg within 3 months 1
6. Continue current fracture management and DVT prophylaxis 1
7. Implement intensive lifestyle modifications including DASH diet and weight reduction program 1, 7
8. Follow-up in clinic in 2-4 weeks post-discharge from rehabilitation 1