Assignment
Case Study: Complex Health Needs and Polypharmacy
MW is a 68-year-old female with complex health needs who has been referred to you for assessment and management of her conditions.
• Past Medical History
1. History of vascular disease, coronary bypass at 53
2. Type 2 diabetes (diagnosed 10 years ago)
3. Hyperlipidemia
4. Hypertension
5. Atrial fibrillation
6. Asthma (history of multiple emergency admissions for exacerbations)
7. Arthritic knee pain
8. Depression
MW retired reluctantly from her job as a physical education teacher three years ago because of her arthritic knee pain. She often feels breathless and has a moderate amount of ankle swelling, which she says is almost always present regardless of time of day. She has also suffered from moderately lengthy depressive episodes in the past, since her husband died suddenly and her only daughter moved out of the country.
MW lives alone. She is new to your primary care practice after having the same general practitioner for 35 years. MW's daughter has noted that her mother seems to have become more agitated recently when she calls. MW is reporting palpitations, fluctuations in her blood sugar readings from 55 to 330, and shortness of breath on exertion. Bnc the body release left is below.
• Medications
1. Amitriptyline 25mg PO qhs
2. Temazepam 15mg PO qhs
3. Metformin 500mg PO BID
4. Aspirin 81mg PO daily
5. Digoxin 0.25mg PO daily
6. Simvastatin 40mg PO daily: CK leve
7. Amlodipine 5mg PO daily
8. Furosemide 40mg PO daily
9. Telmisartan 40mg PO daily
10. Tramadol 50mg q6h prn pain
11. Diclofenac extended release 100mg PO daily
12. Nitroglycerin 0.4 SL PRN chest pain: under 150, ck, lft
13. Salmeterol inhaler 1 inhalation BID
14. St John's Wort 300mg PO TID
Denies alcohol and tobacco use.
No known allergies.
• Physical Assessment
1. Pitting edema to lower extremities
2. BP: 160/80
3. BMI: 38 (clinically obese)
4. Blood glucose: 230
5. Cholesterol: Total 230, HDL 39, LDL 97
6. Hypokalemia: K 3.1 mmol/L
7. Chronic Pain: Decreased ROM in bilateral knees with crepitus; difficulty sitting and with rising from chair and limp with ambulation; pain 7 from scale 0-10
8. Shortness of breath - no wheeze audible
9. Liver function normal, but digoxin levels are moderately high
Task
A. Craft a Therapeutic Plan.
B. Using Beers Criteria and rational drug prescribing, review the medications and diagnoses listed for MW. What three prioritized changes would you make to the medication regimen? Include a detailed and evidence-based rationale for all changes to include, but not limited to, monitoring, drug-drug interactions, drug-disease interactions, pharmacokinetics/pharmacodynamics, age, gender, and culture.
C. What would be your pharmacological-related patient education?
D. Would you order any laboratory testing? Provide rationale for all decisions.
E. Describe a follow-up plan of care with rationale.