Case Study: Pharmacotherapy Care Plan with Medication Reconciliation and Profile Review
This assignment aims to assist the student to : (a) Recognize the importance of completing a medication history for each patient; (b) Identify the prescriber's role in the assessment of appropriate medication therapy; and (c) Resolve medication related problems during the patient follow up visit.
Case Scenario:
The patient presents to the clinic today for care transition follow up after a recent hospital admission due to COVID-19.
Jim is a 62-year-old patient who has difficulty coming in for primary care visits due to limited mobility.
He also sees cardiology and endocrine specialists for his comorbid conditions of diabetes mellitus and postcoronary artery bypass grafting (CABG) 2 years. His last visit with you was over a year ago. During the triage by the nurse, the patient indicates he needs a refill of his Crestor prescription, which was ordered by cardiology soon after his CABG. Per the electronic link to the cardiology service within your facility, the medication was due to be renewed about 2 months ago. His last lipid labs were a year ago.
His most recent complete metabolic panel taken during the hospital stay was notable for a blood glucose of 187 and his last recorded HgA1C was 9.0 from a visit to endocrine 4 months ago.
Review of records include a prescription for his hypertension of lisinopril 10 mg PO daily for five years, metformin 1000mg PO twice a day for his diabetes four months ago (Hint: make sure the patient is taking his medications). His last vital signs were blood pressure (BP) 170/110 mmHg (Hint: B/P needs to be addressed at this visit), pulse 88 and respirations 22. His body mass index is 30. His pulse oximetry was 98% on room air.
Answer the following questions related to this case study. Cite at least 3 current, peer-reviewed, scholarly sources in your answers and include a reference list. Cite at least one drug information resource (i.e., UpToDate, Epocrates, Micromedex, Lexicomp).
1. How do you respond to the request for the Crestor refill?
2. Identify the medication therapy issues that should be addressed in clinic today (Hint: B/P 170/110 is not controlled).
3. For each medication prescribed, assess if the medication, dose, frequency, and indication are appropriate for Jim (Hint: Crestor, Lisinopril, and metformin, and any new drug to help manage B/P and Diabetes).
4. Reconcile Jim's medication list based on his current problem list to determine if each medication should be continued, discontinued, dose adjusted. Provide rationale for each therapy recommendation.
Example: You can use a chart similar to the chart below. Cite your references using national guidelines (Hint: JNC 8 guidelines)
| Problem |
Medication |
Continued |
Discontinued |
Dose adjusted |
Rationale |
| Hypertension |
Lisinopril |
yes |
no |
No |
Started Jim on hydrochlorothiazide |
5. Clinical Nurse Specialist provided patient education?