Blog

Imagine that you ask the patient questions (some of which yo…

Imagine that you ask the patient questions (some of which you listed above) and she provides the information below. NOTE: This is not an all inclusive list, and you may have come up with other appropriate questions that are not answered below. This is OK. If you are unsure whether one of your questions was appropriate, consider discussing it with a faculty instructor (during lab or via email). His past medical history includes high blood pressure, high cholesterol, focal seizures, COPD, and tobacco use disorder. He has never had a heart attack, stroke, or other significant cardiovascular event. He reports his father had high blood pressure, high cholesterol, and had a stroke at age 53, while his mother had a history of diabetes and developed unstable angina at age 63. He smokes 1 ppd. He smokes his first cigarette 15 minutes after waking up and he is interested in quitting. He had tried quitting using Chantix in the past but stated the medication made him feel “off” and didn’t work. He would like to try something that is not Chantix to help with quitting. He reports being short of breath throughout the week and needs to use his albuterol inhaler at least 4-5 times a week. He feels like when he using his albuterol inhaler, it quickly works to resolve his shortness of breath. He is able to demonstrate proper inhaler technique for both his albuterol and Spiriva inhalers. He reports missing his Spiriva Respimat 3 times a week. He reports just forgetting to take his Spiriva inhaler because it doesn’t fit in his pillbox so he keeps it in a medicine cupboard. He denies missing any doses of his other medications. He uses a pillbox for his oral medications. He fills it each Sunday and leaves it on his counter to help him remember to take his medications. He was diagnosed with high blood pressure in May 2024. He was started on lisinopril, but only took a few doses before it caused a severely swollen lip. He went to the ER for the reaction and was told to stop taking the medication immediately. His PCP switched him to amlodipine soon thereafter. He reports his amlodipine dose was increased about 1 month ago due to elevated blood pressure during his office visit. Since this visit, he has checked his blood pressure every day and reports it has been running between ~130-140/80s (today’s reading in office was 142/86). He specifically denies any leg swelling, dry mouth, tachycardia, changes in mood, lightheaded and dizziness. He states that he recently has started to have some muscle pain in his legs. He is unsure what the cause is, but it has been bothersome for the past few months and has been progressively worsening. He described it as moderate in severity. He denies any dark colored urine. NOTE: the side effects in the two bullets above are a few of the most important side effects to ask about. Can you match each one up with a medication? He reports that he has not had a seizure since starting levetiracetam many years ago. He follows with his neurologist Dr. Lewis regularly. He had bloodwork completed in September and his kidney function, liver function, and electrolytes came back within normal limits. He was started on a statin over a year ago. You see from his chart that he has a history of elevated lipids. When reviewing his chart you find the following most recent lipid panel from September 2024: LDL: 165 mg/dL HDL: 45 mg/dL Triglycerides: 150 mg/dL Total cholesterol: 240 mg/dL He received all the necessary childhood vaccines, but he is unsure if he is up to date on all of his adult vaccines. He is happy to get any vaccines you think are necessary during the visit today.

Information / potential problems you can identify from the p…

Information / potential problems you can identify from the profile alone (before speaking to the patient): NOTE: This is not all-inclusive. You may have come up with other information in addition to what is listed below. The patient appears to have T2DM based on prescriptions for Trulicity and Jardiance The patient likely has a history of high triglycerides since she was prescribed a fibrate in the past The patient has several cardiovascular medications, which points toward a likely history of cardiovascular issues: She may or may not have HTN since she is on lisinopril (first line for HTN) and metorpolol (second line for HTN) She may have had an MI as she is on medications typically prescribed after an MI (aspirin, beta blocker, ACE, statin), although she does not have an active prescription for nitroglycerin She is on dual anti-platelet therapy. This may be appropriate depending on patient’s cardiovascular history (was a stent placed recently?).  She may or may not have heart failure (on lisinopril / metoprolol ER which are both recommended for mortality benefit) but it is unlikely since she is not on a diuretic (unless she is very early stages and having no issues with volume overload) The patient hasn’t filled gemfibrozil since March or atorvastatin since June. This could be a potential adherence problem – need to find out why these haven’t been filled. The patient is not on metformin, which is typically first line for T2DM if tolerated and not contraindicated – need to find out why she is not on this medication. She was prescribed a course of cephalexin earlier this year. One possible indication for this antibiotic would be a UTI (although we often use different agents for this). If this was used to treat a UTI, this could be indicative of side effects from the patient’s Jardiance. There is a clinically significant drug interaction between atorvastatin and gemfibrozil which may need to be addressed / could affect the plan going forward (depending on what is learned from the patient–it appears based on fill history that the gemfibrozil may not be a current med)