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Posted: September 4th, 2023

CB is a 76-year-old female with a history of chronic renal disease

CB is a 76-year-old female with a history of chronic renal disease, HTN, and peptic ulcer disease due to NSAID use. She complains of pain in both her knees in which the right is worse than the left that started five years ago. The pain is worse when walking or climbing stairs, and she describes the pain as stiff and achy. She rates her pain a 5/10 with NSAID use, and 7/10without NSAID use. The patient at first took Ibuprofen for pain relief but had to discontinue it due to bleeding and is now taking Acetaminophen. She denies falls and trauma to her knees. Patient also complains of stiffness on her knuckles bilaterally. On exam she is bow-legged and obese.

THE SETTING I see patient is a family practice

Address the following questions: Consider how the setting in which you see clients may impact your recommendations for medications, treatments, or follow-up care. How would your recommendations have changed for this client if she was underinsured? What about if the encounter had occurred at a mobile clinic for unhoused clients?   Include the following components:

answer all questions in the reflection prompt
demonstrate clinical judgment appropriate to the virtual patient scenario
cite at least one relevant scholarly source as defined by program expectations
communicate with minimal errors in English grammar, spelling, syntax, and punctuation

In the given scenario, CB is a 76-year-old female with chronic renal disease, hypertension (HTN), and peptic ulcer disease related to NSAID use. She presents with bilateral knee pain, worse in the right knee, which started five years ago. The pain is aggravated by walking or climbing stairs and is described as stiff and achy. CB rates her pain as 5/10 with NSAID use and 7/10 without NSAID use. Due to bleeding complications, she had to discontinue Ibuprofen and is currently taking Acetaminophen. She also reports stiffness in her knuckles bilaterally and demonstrates physical findings of bow-leggedness and obesity.

The setting in which patients are seen can impact recommendations for medications, treatments, or follow-up care due to various factors such as available resources, accessibility, and patient preferences. Let’s consider two different scenarios: if CB was underinsured and if the encounter occurred at a mobile clinic for unhoused clients.

Underinsured Client:
If CB was underinsured, it would be important to consider the financial constraints she may face in obtaining medications and accessing specialized care. In this case, it would be necessary to explore cost-effective options for pain management and provide her with affordable treatment alternatives. This might involve prescribing generic medications or exploring patient assistance programs or community resources that provide financial support for healthcare services.
Additionally, considering CB’s comorbidities, it would be crucial to address the underlying chronic renal disease and HTN. Medication choices and monitoring may need to be adjusted to accommodate her insurance coverage and financial situation. Collaboration with a social worker or case manager could be helpful in identifying resources and advocating for appropriate healthcare services.

Mobile Clinic for Unhoused Clients:
If the encounter took place at a mobile clinic for unhoused clients, there are additional considerations to address. Firstly, the lack of stable housing and access to regular healthcare may have contributed to CB’s delayed presentation and underutilization of healthcare resources. Therefore, it would be essential to provide comprehensive care within the limitations of the mobile clinic setting.
In this case, a multidisciplinary approach involving healthcare providers, social workers, and community outreach workers would be beneficial. The focus should be on managing pain, addressing CB’s musculoskeletal issues, and optimizing her overall health. Non-pharmacological interventions such as physical therapy, assistive devices, and weight management strategies should be emphasized. Collaboration with local organizations and resources that provide housing support, food assistance, and social services could help improve CB’s overall well-being.

In both scenarios, it is crucial to consider the limitations and challenges faced by the patient in terms of access to healthcare resources, financial constraints, and social determinants of health. The recommendations should be tailored to the specific needs of the patient, utilizing available resources, and ensuring a patient-centered approach to care.

World Health Organization. (2021). Social determinants of health. Retrieved from

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