Chief Complaint “I am here to see if I need additional meds.” HPI Thomas Smith is a 52-year-old man who presents to phar

[answerhappygod]

Chief Complaint
“I am here to see if I need additional meds.”
HPI
Thomas Smith is a 52-year-old man who presents to
pharmacotherapy for optimization of risk reduction therapy clinic
by referral from his primary care provider following an
ST-elevation myocardial infarction (STEMI) 6 months ago. He reports
good adherence to his medications since having his heart
attack.
PMH
Obesity (BMI 30.5 kg/m2)
Dyslipidemia × 6 years
HTN × 10 years
Chronic kidney disease (stage 3) × 5 years
CAD, s/p STEMI 6 months ago (drug-eluting stents placed in right
circumflex and left anterior descending arteries)
GERD × 5 years
FH
Father: age 72 with MIs at age 50 and again at age 60
Mother: age 70 with no major medical conditions noted
Patient has one older brother age 55 with HTN and a history of
one MI at the age of 48.
He has no children.
SH
Patient is married and lives with his wife.
College graduate, works as an accountant.
Admits to drinking one to two beers most days of the week and
has never used tobacco.
Exercise regimen has increased since his MI; currently rides the
bike at the gym for 30 minutes 2–3 days a week.
Meds (Per medication fill history)
Carvedilol 25 mg PO BID
Atorvastatin 80 mg PO once daily
Aspirin 81 mg PO once daily
Clopidogrel 75 mg PO once daily
Pantoprazole 40 mg PO once daily
Lisinopril 40 mg PO daily
Chlorthalidone 25 mg PO daily
Acetaminophen 500 mg, one to two tablets PO PRN every 6
hours for pain
Garlic capsules
All
No known drug allergies
ROS
Patient states that he had a heart attack about 6 months ago and
was put on a number of medications after that happened. He saw his
PCP last month who said he should be seen in the pharmacotherapy
clinic for evaluation of his cardiovascular risk reduction
medications. He reports he has been adherent to his medication
regimen over the last 6 months. He went to cardiac rehab for the
first 3 months after his MI but has just been going to the gym to
ride the bike two to three times a week now. He denies unilateral
weakness, numbness/tingling, or changes in vision. He denies CP and
only has SOB if he really pedals hard on the bike for longer than
15 minutes. He denies changes in bowel or urinary habits. He denies
any lower extremity edema.
Physical assesment
Gen
Obese, African-American man
VS
BP 136/84, P 64, RR 18, T 38.2°C; Wt 102.3 kg, Ht 6′0″
Skin
Warm and dry to touch, normal turgor, (–) for acanthosis
nigricans
HEENT
PERRLA; EOMI; funduscopic test deferred; TMs intact; oral mucosa
clear
Neck/Lymph Nodes
Neck supple, no lymphadenopathy, thyroid smooth and firm without
nodules
Chest
CTA bilaterally, no wheezes, crackles, or rhonchi
CV
RRR, no MRG, normal S1 and S2; no
S3 or S4
Abd
(+) BS, no hepatosplenomegaly
Genit/Rect
Deferred
Ext
No pedal edema, pulses 2+ throughout
Neuro
No gross motor-sensory deficits present
Labs (Fasting)
| Download (.pdf) | Print
Assessment
Mr Smith is an obese African-American man who presents to
pharmacotherapy clinic for follow-up about further optimization of
this cardiovascular risk reduction therapy. He had a STEMI 6 months
ago and has a significant family history of cardiovascular disease.
He has uncontrolled dyslipidemia treated
with atorvastatin and uncontrolled HTN treated
with carvedilol, lisinopril, and chlorthalidone. He
reports no drug allergies and rides the bike at the gym two to
three days a week. He reports using acetaminophen, but no
NSAIDs for occasional aches and pains. Patient is interested in
what can be done to lower his risk of another heart attack as his
dad has had two and his brother has had one. He consistently drinks
one to two beers a day but has no history of tobacco use.
QUESTIONS
Listen
Collect Information
1.a. What subjective and objective
information indicates the presence of dyslipidemia?
1.b. What additional information is needed
to fully assess this patient’s dyslipidemia?
Assess the Information
2.a. Assess the severity of dyslipidemia
based on the subjective and objective information available.
2.b. Create a list of the patient’s drug
therapy problems and prioritize them. Include assessment of
medication appropriateness, effectiveness, safety, and patient
adherence.
2.c. What economic, psychosocial,
cultural, racial, and ethnic considerations are applicable to this
patient?
Develop a Care Plan
3.a. What are the goals of pharmacotherapy
in this case?
3.b. What nondrug therapies might be
useful for this patient?
3.c. What feasible pharmacotherapeutic
alternatives are available for treating dyslipidemia?
3.d. Create an individualized,
patient-centered, team-based care plan to optimize medication
therapy for this patient’s dyslipidemia and other drug therapy
problems. Include specific drugs, dosage forms, doses, schedules,
and durations of therapy.
Implement the Care Plan
4.a. What information should be provided
to the patient to enhance adherence, ensure successful therapy, and
minimize adverse effects?
4.b. Describe how care should be
coordinated with other healthcare providers.
Follow-up: Monitor and Evaluate
5.a. What clinical and laboratory
parameters should be used to evaluate the therapy for achievement
of the desired therapeutic outcome and to detect and prevent
adverse effects?
5.b. Develop a plan for follow-up that
includes appropriate time frames to assess progress toward
achievement of the goals of therapy.
CLINICAL COURSE: ALTERNATIVE THERAPY
Mr Smith is already taking garlic capsules, but he is not sure
about the type or dose. Because you are making changes to his
current prescription regimen, you need to investigate the
advisability of continuing the garlic. Because Mr Smith is taking a
statin drug as indicated, he should not take red yeast rice, a
common supplement used for dyslipidemia, because it contains
mevacolin K, a lovastatin analogue, and would be
duplicative therapy. Would fish oil be a possible option for him?
See Section 19 in this Casebook for questions about the use of
garlic and fish oil for treatment of dyslipidemia.
SELF-STUDY ASSIGNMENTS
1. Describe how this patient’s other
drug/disease interaction issues that are unrelated to dyslipidemia
should be managed.
2. What changes, if any, would you make to
the pharmacotherapy regimen for this patient if he had presented at
the initial visit with each of the following characteristics?
Cirrhosis of the liver
Stage 5 chronic kidney disease receiving hemodialysis
Significant alcohol use
Posttransplant
Human immunodeficiency virus