Things to look for in a new patient

[Confusant]

---

Members don't see this ad.

Hey all,
I have got an oral examination coming up, in which I will be presented with a case study of a patient showing symptoms of a particular disease (e.g. dyspeptic pain) and I have to formulate a treatment plan. I'm just wondering what are the things that you look for / ask for when a case study is received? So far I've got the following:

1) Is the patient alcoholic?
2) Is the patient a smoker?
3) Current medication
4) Co-morbidities?
5) Age group / Ethnicity / Sex

Suggestions appreciated 🙂

 

[FAMUPharmD09]

Alot of people overlook patient allergies when doing case studies, but they are important

 

[ttopping]

along with current meds, make sure you get any herbs/supplements/OTC stuff they're taking. Some people may just think prescription

 

[Quiksilver]

you can do a full workup:
pupils, gait, appearance, speech, facial appearance (stroke),BP, HR, SOB? respiration rate, reflexes, etc...

 

[Confusant]

Thanks for the replies.

Quiksilver: The laboratory data will be available to my in the case studies 🙂

 

[DAW2]

and food/grapefruit/greens

 

[Confusant]

Greens? How so?

 

[UMN_MJS_2010]

Greens? How so?

Think about it..... i'll give you one clue. warfarin

 

[Confusant]

Warfarin - anti-coagulant - something to do with vitamin K?

 

[UMN_MJS_2010]

ding, ding, ding ..... you got it.

here are a couple resources i pulled up after a quick google search

http://www.stoptheclot.org/documents/KandWarfarin(Web).pdf

http://ods.od.nih.gov/factsheets/cc/coumadin1.pdf

 

[Confusant]

Cool, thanks

 

[IWantTheGenetic]

6.) Could she be preggers?

 

[aboveliquidice]

Alot of people overlook patient allergies when doing case studies, but they are important

+1

Honestly - this is a wide open skill... It starts with what the CC is - then you work your way back towards a diagnosis and treatment plan.

PS - This is more of physcian skill - but it is definitely an important one to develop

 

[Confusant]

Allergies - yup, big point here.

 

[Pianopooh]

7) Any intake of caffeine? (In any form: coffee, gum, beans, energy drink, etc)

 

[Confusant]

I'm guessing that would affect the cardiovascular system?

 

[Farmercyst]

I've got an appointment on Friday to do an initial MTM consult with a 79 yo female. Having only gone through P2 year it'll be interesting to see what comes out of it. So far I have our medlist from her profile. I've told her to bring in everything she takes (OTC, herbal, Rx). I can start going over DDIs right now, but it somewhat worries me because she prefers to communicate in Spanish (though she seemed to handle English fairly well) and I have to have a technician do the translating for me.

I put this here as it is an initial consult and I'll probably be looking at the factors listed above.

 

[aboveliquidice]

I've got an appointment on Friday to do an initial MTM consult with a 79 yo female. Having only gone through P2 year it'll be interesting to see what comes out of it. So far I have our medlist from her profile. I've told her to bring in everything she takes (OTC, herbal, Rx). I can start going over DDIs right now, but it somewhat worries me because she prefers to communicate in Spanish (though she seemed to handle English fairly well) and I have to have a technician do the translating for me.

I put this here as it is an initial consult and I'll probably be looking at the factors listed above.

So far - the MTMs that I have completed - it was not the DDI that have been common (except for PPI + Clopidogrel... That is rampant still).

Rather it was that there are indications for meds - but patients simply aren't on them. Look at JNC 7 for compelling indications. Also, the guidelines for ACS / Unstabel Angina / STEMI / NSTEMI, and of course Asthma / GOLD.

Patients were missing statins or an ACE-I. Patients were switched from ASA to plavix, then DCd the plavix and nothing gets restarted. Some patients have advair, but have not gotten new scripts for Albuterol in several years... or worse - only on serevent w/o a steroid addition.

Just something else to keep in mind...

 

[Farmercyst]

I'm kind of at a loss. So MM is an 80 yo F. With the attached med list. This is really all I have to this point. I don't have labs, medical hx or anything like that. But the initial med list from April confuses me, especially considering her fills ~6 weeks later. She switches from propranolol to metoprolol, lotrel to benazepril. Not that big of a deal. But where's the refill on the psych meds. 4 weeks isn't a sufficient trial for a diagnosed GAD or MDD. What else would you use those doses of those meds for? Why no more Albuterol?

The limited searching I've done to this point doesn't like Darvocet+amitriptyline b/c of elevated TCA levels and CNS depression. Both of them appear to have been D/Cd anyway. Betablocker and Gemfib clash, but I'm thinking perhaps the Gemfib is to counteract potential increase in TGs d/t BB therapy.
I wonder what kind of fatigue issues there could be in a 80yo with BB, Vicodin, and ACEI each of which have fatigue as a possible SE (Though I suppose would be more likely with BBs and Vicodin than benazepril.)

Just the thoughts of a soon-to-be P3 who hasn't had Cardio, or Pain management yet.

 

[konkan]

Hey all,
I have got an oral examination coming up, in which I will be presented with a case study of a patient showing symptoms of a particular disease (e.g. dyspeptic pain) and I have to formulate a treatment plan. I'm just wondering what are the things that you look for / ask for when a case study is received? So far I've got the following:

1) Is the patient alcoholic?
2) Is the patient a smoker?
3) Current medication
4) Co-morbidities?
5) Age group / Ethnicity / Sex

Suggestions appreciated 🙂

Insurance

 

[aboveliquidice]

I'm kind of at a loss. So MM is an 80 yo F. With the attached med list. This is really all I have to this point. I don't have labs, medical hx or anything like that. But the initial med list from April confuses me, especially considering her fills ~6 weeks later. She switches from propranolol to metoprolol, lotrel to benazepril. Not that big of a deal. But where's the refill on the psych meds. 4 weeks isn't a sufficient trial for a diagnosed GAD or MDD. What else would you use those doses of those meds for? Why no more Albuterol?

The limited searching I've done to this point doesn't like Darvocet+amitriptyline b/c of elevated TCA levels and CNS depression. Both of them appear to have been D/Cd anyway. Betablocker and Gemfib clash, but I'm thinking perhaps the Gemfib is to counteract potential increase in TGs d/t BB therapy.
I wonder what kind of fatigue issues there could be in a 80yo with BB, Vicodin, and ACEI each of which have fatigue as a possible SE (Though I suppose would be more likely with BBs and Vicodin than benazepril.)

Just the thoughts of a soon-to-be P3 who hasn't had Cardio, or Pain management yet.

Were you given the sigs for any of these meds??? The Amitriptyline dosage is high for chronic pain - but it is seldom used for depression nowadays. I could be a high dose for chronic pain or migraine prophy (off-label).

I am not really all that familiar with GAD / MMD - but I do know that Buspirone is not completely effective until 6-8 weeks. Looking at it on Lexi - it is only indicated for GAD - so a 4 week course was / is insufficient.

Curious about the gemfibrozil - why no statin? Liver issues?

Patient was on several pain meds in April, switched to vicodin in June - what happened there - Pain seems to be present still - does patient need baseline pain coverage in addition to breakthrough?

As far as followup and management goes - When was the last TSH level done? What about re-evaluation for asthma sx? When was a fasting lipid panel done?

Thats all I got right now without notes in front of me... let us know how it goes.

Oh... without proper diagnosis - it is very difficult to use the compelling indication / guideline approach. At Kaiser / VA / IHS - that isn't an issue as it is readily available. At various other sites though, this really impedes your ability to select appropriate treatments.

 

[Farmercyst]

Were you given the sigs for any of these meds??? The Amitriptyline dosage is high for chronic pain - but it is seldom used for depression nowadays. I could be a high dose for chronic pain or migraine prophy (off-label).

I am not really all that familiar with GAD / MMD - but I do know that Buspirone is not completely effective until 6-8 weeks. Looking at it on Lexi - it is only indicated for GAD - so a 4 week course was / is insufficient.

Curious about the gemfibrozil - why no statin? Liver issues?

Patient was on several pain meds in April, switched to vicodin in June - what happened there - Pain seems to be present still - does patient need baseline pain coverage in addition to breakthrough?

As far as followup and management goes - When was the last TSH level done? What about re-evaluation for asthma sx? When was a fasting lipid panel done?

Thats all I got right now without notes in front of me... let us know how it goes.

Oh... without proper diagnosis - it is very difficult to use the compelling indication / guideline approach. At Kaiser / VA / IHS - that isn't an issue as it is readily available. At various other sites though, this really impedes your ability to select appropriate treatments.

Yeah for migraine prophy I've seen 50-100, not 150. Not to say it can't be, but like you say, it's rarely used for depression anymore. Especially in an elderly population prone to trip/fall and osteoporotic breaks.

 

[Farmercyst]

Ok, so she comes in for her 3pm appt at 3:23pm and says her ride will be there to pick her up at 4pm. Brings in an Rx for Benadryl Cream and Hydrocortisone cream to add to whatever else she's taking. I take her to the office in the back and she hands me her meds which she swears is all she's taking right now. So I have the Gemfibrozil, Metoprolol, CiproDex (which wasn't on my list, but in our pharmacy software so not a total surprise), Patanol, and Prevacid. She said she doesn't really take the prevacid anymore, so whatever. She says her BP was "normal" at her last appt, but doesn't know what the numbers were. Her lipids and thyroid she said were normal. She said the metoprolol was prescribed for Angina. The albuterol from April she said was due to SOB/wheezing associated with the exercise-induced angina that they originally thought may have been asthma, but she's never took. She has no idea why insurance shows that she'd been given buspirone or amitriptyline and says she's never used it. She seems to have Dupuytren's contracture (http://www.mayoclinic.com/health/dupuytrens-contracture/DS00732/DSECTION=treatments-and-drugs) based on her explanation which required 3 surgeries to allow her to open and close her hand normally. That may be why she was on pain meds for an extended period. Patanol was for her eyes which were overlacrimating and it seems to be working for her. Ciprodex was for inflamed ear canal which has now been D/C'd and she is now supposed to apply her benadryl cream with a q-tip to the ear canal qid and the hydrocortisone tid.
So as of right now, I'll be making a few phone calls to 3 of the 8 different docs she's seeing to assess their view of her need for prevacid, levothyroxine, and gemfibrozil) The prevacid she is probably not needed now that Darocet/Ibu have been d/c'd and she said she doesn't have reflux issues anymore. The thryoid and gemfib are probably necessary but she just doesn't realize it, but I have to check since she's saying her values are normal.

 

[njac]

I thought topical diphenhydramine was a no-no in old folks.

How with it/active was she?

 

[Farmercyst]

I thought topical diphenhydramine was a no-no in old folks.

How with it/active was she?

She didn't seem mentally impaired, I'm not sure if she just isn't aware of her true medical state like most other patients or has forgotten, but didn't seem to have any mental cloudiness during the consultation. Though she doesn't drive, I'm not sure what the issue is with driving. Said she runs (not walks per her) 6 miles/day. Lives with her daughter, but says her daughter isn't there in any assistive capacity. Pretty spry for a 79 year old. Oral diphenhydramine I understand, what's the issue with topical?

 

[njac]

I think it is still absorbed systemically, particularly by the more brittle skin of the old folk. That came up on my retail rotation 3 days ago, so I may be wrong.

I need to pay more attention to this stuff, found out the Target here can use me prn...