Patient Case

Presentation:M.B
Presented by: Ginna Castro, 4th Year
Pharmacy Student at UAMS
 Assessment
Chief complaint Blood Glucose Levels:

● “I’m here for by blood sugars” ● Pre-meal: 170-225 mg/dl

● Post-prandial: 175-340 mg/dl
Patient Information: ● Hypoglycemic episodes: BG as low as 55 over past 3
● Name: M.B weeks
● Age: 59-year-old Other Symptoms:
● Ethnicity: African American male
● Occasional loose stool: ~3 times/week
Consultation Details: ● No previous concerns about stools or stomach
● Initial evaluation at Pharmacotherapy clinic: Lifestyle and Exercise:
10/1/22
● Follow-up visit: 4 weeks later, with wife ● Exercise routine: Walking/weightlifting 4 times a
week since last visit
Physical Measurements: ● Dietary changes: Stopped drinking dark sodas daily;
● Height: 68 inches drinks ginger ale ~3 times/week and a lot of water
● Weight: 96.9 kg ● Smoking: Continues to smoke 1/2 pack per day,
● BMI: 32 willing to try quitting
 Assessment
Complaints and Concerns:

● Leg aches: Inquiring if he should stop lifting weights

● Shortness of breath on exertion, but feels fine at rest

Recent Medical Visit:

● Seen by private family physician on 10/15/22; unsure if medications

were changed

Self-Monitoring:

● Checks weight once a week at night

● Blood pressure: Last home reading was 150/85, reports 'doing great'

Medication Adherence:

● Takes medication daily as directed

 Assessment
Additional Discussion:

● Taking gemfibrozil every other day

● Taking corrective regular insulin occasionally (if he eats
something sweet)
● Pt’s wife reported that he gets some of the medications from
their local pharmacy
 Assessment
Medication Dosage Indication

NPH insulin 52 units QAM and 46 units QPM Diabetes

Regular insulin 17 units QAM and 12 units QPM Diabetes

Metformin IR 1000mg daily Diabetes

Amlodipine 10mg QPM Hypertension

Glyburide 20mg TID Diabetes

Metoprolol 150mg BID Hypertension

Hydrochlorothiazide (HCTZ) 50mg QAM Hypertension

Gemfibrozil 600mg BID Hyperlipidemia

Simvastatin 40mg daily Hyperlipidemia

Levothyroxine 75mcg daily Hypothyroidism

Multivitamin Daily Supplement

 Medication Dosage Indication

Omeprazole 20mg daily GERD

Fenofibrate (Tricor) 145mg daily Hyperlipidemia

Vitamin E 1000IU daily Supplement

Vitamin C 1000mg daily Supplement

Cinnamon capsules 2 daily Supplement

Docusate 100mg BID Constipation

Tiotropium (Spiriva inhaler) 1 inhalation daily COPD

Albuterol inhaler Using 6-8 times/day Asthma/COPD

Aspirin (ASA) 325mg daily Cardiovascular protection

Folic Acid 1mg daily Supplement

Clopidogrel (Plavix) 75mg daily Antiplatelet

Rivaroxaban (Xarelto) 20mg daily Anticoagulant

 Assessment
Pertinent Medical History

● DM type II
● Dyslipidemia
● Hypertension
● Heart Failure
● CAD (asymptomatic)
● History of multiple stents
● PTSD (controlled)
● Impotence
● Hypothyroidism
● Recurrent DVT
● COPD
 Assessment
Family History/Social History: Review of systems:

● Health plan: None ● Overall, without complaints.

● Medical provider: Sean Carter, MD
● Occupation: Unemployed (On 100% disability) Physical exam:
● Family history: Married w/ 2 children
● Overall, patient appears to be alert, well-developed,
● Smoking history: 1⁄2 PPD
well-nourished, and in no acute distress.
● Alcohol use: Socially
● 2+ pitting edema
● Illicit drug use: Denies
Vitals (10/01/2022):
Allergies/ADR:
● BP: 142/74 (Elevated blood pressure, indicating
● Lisinopril (angioedema)
hypertension)
● Rosuvastatin (drowsiness)
● Pulse: 72 (Normal heart rate)
Immunization history: ● Temp: 97.2 F [36.2 C] (Normal body temperature)
● Resp: 16 (Normal respiratory rate)
● Flu (10/21)
● Pneumovax (02/18)
● Td-Adult (08/87)
● Pfizer COVID vaccine (1/21, 2/21, 12/21)
 Assessment
Labs: Blood Glucose, Kidney Function, Electrolytes

Collection Date Spec A1C GLU SCR BUN K NA

10/01/2022 07:23 PLASM 10.9 H 95 1.2 16 3.2 L 138

(High) (N) (N) (N) (Low) (N)

07/09/2022 09:52 PLASM 10.2 H 103 1.1 14 3.6 136

(High) (N) (N) (N) (Normal) (N)

● High A1C on both dates (poor blood sugar control)

● Normal fasting glucose levels
● Normal serum creatinine and BUN (kidney function)
● Low potassium on 10/01/2022 (hypokalemia), normal on
07/09/2022
● Normal sodium levels
 Assessment
Labs: Thyroid Function, Urine Analysis

TSH Collection DT Spec CREATINE M-ALBUMIN

7.9 10/01/2022 07:39 URINE 55.0 1.9

(high) (N) (N)

● TSH: High, suggesting potential hypothyroidism.

 Assessment
Labs: Lipid Panel, Liver Function Tests

Collection DT Spec CHOL LDL HDL TRG AST ALT

10/01/2022 07:23 PLASM 163 77.6 45 202 H 27 18

(N) (N) (N) (high) (N) (N)

07/09/2022 09:01 PLASM ---- ---- ---- 170 26 18

(N) (N) (N)

08/11/2021 08:37 PLASM 169 55 (d) 46 428 H* ---- ----

(N) (N) (N) (high)

06/06/2020 07:39 PLASM 162 58 L 46 288 H 23 20

(N) (low) (N) (high) (N) (N)

● TRG (Triglycerides): Elevated triglycerides in multiple tests suggest hypertriglyceridemia,

 Medical problem/Drug therapy problem identification
Medical Problem 1: Type 2 Diabetes Mellitus (T2DM)
● Inadequate blood glucose control
● Frequent hypoglycemic episodes Patient Education/Counseling:

● Importance of regular blood glucose monitoring.

Goals of therapy ● Recognizing and managing hypoglycemia.
● Achieve A1C < 7% ● Proper injection technique for insulin.
● pre-meal BG 80-130 mg/dL
● post-prandial BG <180 mg/dL Monitoring Plan:
● reduce hypoglycemic episodes.
● Weekly blood glucose logs.
Intervention ● Follow-up in 4 weeks.
● Adjust Insulin Therapy to prevent hypoglycemia
○ NPH Insulin: Reduce to 48 units QAM and 44 units QPM.
○ Regular Insulin: Reduce to 15 units QAM and 10 units QPM.
○ Discontinue Glyburide because sulfonylureas have a higher rate of
hypoglycemia

● Add a GLP-1, such as semaglutide to help better control A1C

○ Start with 0.25 mg once weekly for 4 weeks, then increase to 0.5
mg once week
 Medical problem/Drug therapy problem identification
Medical Problem 2: Hypertension
● Blood pressure above goal of 130/80
Patient Education:
Goals of Drug Therapy:
● Achieve BP <130/80 mmHg. ● Importance of medication adherence.
● Lifestyle modifications including
Interventions: low-sodium diet and regular physical
activity.
● Adjust Metoprolol:
○ Reduce to 100 mg BID. Monitoring Plan:
○ Rationale: High doses of beta-blockers can cause shortness of
breath. Reducing the dose may alleviate this symptom while ● Home BP monitoring.
maintaining adequate blood pressure control ● Follow-up in 4 weeks.
● Addition of an Angiotensin II Receptor Blocker
○ Losartan 50 mg once daily
○ Rationale: ARBs are effective in managing hypertension and provide
renal protection, especially beneficial for diabetic patients. Losartan
has a lower risk of causing angioedema compared to ACE inhibitors.
 Medical problem/Drug therapy problem identification
Interventions:

Medical Problem 3: Hypokalemia 1. Discontinue HCTZ:

○ Reason: HCTZ (hydrochlorothiazide) is a
● Hypokalemia: M.B. has a potassium level of 3.2 mmol/L, which
thiazide diuretic that can cause potassium
is below the normal range (3.5-5.0 mmol/L). loss, contributing to hypokalemia.
2. Initiate BiDil, a vasodilator
Goals of therapy (Hydralazine/Isosorbide Dinitrate):
○ Dose: Start with hydralazine 37.5 mg and
● Normalize Potassium Levels: Increase potassium to within the
isosorbide dinitrate 20 mg, three times
normal range (3.5-5.0 mmol/L). daily.
● Prevent Future Episodes: Ensure sustained normal potassium ○ Reason: BiDil is particularly effective in
levels. African American patients with heart failure
● Manage Blood Pressure and Heart Failure: Effectively manage and can help manage blood pressure and
M.B.'s hypertension and heart failure without causing heart failure symptoms without causing
hypokalemia. hypokalemia.
● Improve Quality of Life: Reduce symptoms related to ○ Efficacy: Clinical trials have shown that
hypokalemia and optimize overall cardiovascular health. BiDil reduces mortality and
hospitalizations in African American
patients with heart failure
 Medical problem/Drug therapy problem identification
Medical Problem 3: Hypokalemia

Important Patient Education:

1. Medication Adherence:
○ Emphasize the importance of taking BiDil and potassium
supplements as prescribed.
○ Provide clear instructions on how to take the medications and
the importance of consistency.
2. Diet and Lifestyle:
○ Educate on incorporating potassium-rich foods into the diet.
○ Advise on maintaining adequate hydration.
3. Recognizing Symptoms:
○ Teach M.B. to recognize signs of low potassium (e.g., muscle
weakness, cramps) and high potassium (e.g., palpitations,
irregular heartbeat).
○ Instruct him to report these symptoms promptly.
 Medical problem/Drug therapy problem identification
Medical Problem 4: Dyslipidemia Patient Education/Counseling:
● Patient is non-adherent to gemfibrozil, elevated TG levels
● Patient is experiencing leg aches while being on simvastatin ● Medication Adherence: Ensure M.B.
40mg understands the importance of adhering to the
● Patient’s calculated ASCVD risk is 27.4% prescribed medication regimen and the risks
associated with any deviations.
Goals of Drug Therapy: ● Recognizing Side Effects: Educate M.B. on
● Achieve TG <150 mg/dL, LDL <100 mg/dL. recognizing signs of muscle pain or weakness,
which could indicate adverse effects from
Interventions: statin therapy, and instruct him to report these
symptoms immediately.
● Discontinue gemfibrozil and Tricor. Combining fenofibrates with ● Lifestyle Modifications:
a statin increases myalgias, which the patient is experiencing. ○ Continue with a heart-healthy diet and
regular physical activity as tolerated.

Monitoring Plan:

● Lipid panel in 3 months.

● Follow-up as needed.
 Medical problem/Drug therapy problem identification

Medical Problem 5: Hypothyroidism Monitoring Plan

● Patient has elevated TSH levels
● TSH levels should be monitored
regularly,
Goals of Drug Therapy:
● adjust the dose as needed based on
● Normalize TSH levels (0.4 and 4.0 mIU/L)
follow-up TSH results.
Interventions:
● Increase levothyroxine the dose by 25 mcg:
○ 100 mcg daily (an increase of 25 mcg from the
current dose of 75 mcg)
 Medical problem/Drug therapy problem identification
Medical Problem 6: COPD
Consider adding a LABA (long acting beta
● Patient overuses his rescue inhaler (albuterol) 6-8x per day agonist, such as Salmeterol (Serevent
● This suggests that the current maintenance therapy is not Diskus)
controlling the symptoms.
● Dose: 50 mcg (1 inhalation) twice
Goals of Drug Therapy:
daily
● Optimize maintenance therapy to reduce reliance on rescue ● Administration: Inhale 1 dose (50
inhaler. mcg) in the morning and 1 dose (50
● Improve overall control of COPD symptoms. mcg) in the evening, approximately 12
● Reduce frequency of rescue inhaler use. hours apart.
● Adding a LABA can provide additional
● Enhance the patient’s quality of life and exercise tolerance.
bronchodilation, helping to reduce
● Prevent exacerbations and hospitalizations.
symptoms and improve lung function.
Interventions: Combination therapy with LAMA and
LABA is often more effective than
Ensure Proper Use of Spiriva (Tiotropium) (LAMA):
monotherapy.
● Current Dose: 1 inhalation daily using the Respimat or HandiHaler device.
● Rationale: Tiotropium is a long-acting muscarinic antagonist (LAMA) that
helps to maintain open airways and reduce symptoms. Ensuring proper
inhaler technique is crucial for its effectiveness.
 Medical problem/Drug therapy problem identification
Medical Problem 6: COPD
Monitoring

● Encourage the patient to keep a symptom diary to track the frequency

of albuterol use and COPD symptoms.
● Schedule follow-up visits to assess the effectiveness of the treatment
and make any necessary adjustments.
 Medical problem/Drug therapy problem identification
Pharmacotherapy Options:
Medical Problem 7: Smoking
● Nicotine Replacement Therapy (NRT):
● The patient smokes 1/2 pack per day (PPD) and has expressed a ○ Starting Dose for Patch:
willingness to quit. ■ Since he is smoking ≤10
cigarettes/day: Start with 14
Goals of Therapy:
mg/24-hour patch.
○ Rationale: NRT provides a controlled dose
● Achieve complete smoking cessation.
of nicotine to reduce withdrawal symptoms
● Reduce the risk of smoking-related diseases, including COPD exacerbations,
and craving
cardiovascular disease, and cancer.
● Monitoring and Follow-Up:
● Improve overall health and quality of life.
○ Regular Follow-Up Visits: Schedule
follow-up visits to monitor progress,
Smoking Cessation Plan:
manage withdrawal symptoms, and provide
1. Assessment and Counseling: ongoing support. Initially, follow-up every
○ Assess Readiness to Quit: Confirm the patient’s readiness to quit 1-2 weeks for the first month, then monthly.
smoking and discuss motivations and barriers. ○ Assess and Adjust: Evaluate the
○ Counseling: Provide brief motivational interviewing and behavioral effectiveness of pharmacotherapy and
counseling to encourage smoking cessation. Discuss the benefits of behavioral support, and adjust the plan as
quitting and address any concerns the patient may have. needed.
 Medical problem/Drug therapy problem identification
Medical Problem 8: Lose stools Switch Metformin to Extended-Release (ER) Formulation:

● Current Dose: Metformin IR 1000 mg daily

● The patient reports experiencing loose stools
● Adjusted Dose: Switch to Metformin ER 1000 mg daily
approximately 3 times per week. ● Rationale: The extended-release formulation of metformin is often
better tolerated and associated with fewer gastrointestinal side
Goals of Therapy: effects, including diarrhea.

● Alleviate loose stools to improve the patient's Review and Adjust Docusate Use:
quality of life.
● Identify and address the underlying cause(s) of ● Current Dose: Docusate 100 mg BID
the loose stools. ● Adjustment: Consider reducing the dose to once daily or
discontinuing if not absolutely necessary.
● Rationale: As a stool softener, docusate can contribute to loose
Current Medications Potentially Contributing:
stools. Reducing or discontinuing it may help alleviate symptoms.

● Metformin IR 1000 mg daily Evaluate Omeprazole Use:

● Omeprazole 20 mg daily
● Docusate 100 mg BID ● Current Dose: Omeprazole 20 mg daily
● Adjustment: Assess the ongoing need for omeprazole. Consider
dose reduction or discontinuation if appropriate, after discussing
with the healthcare provider.
● Rationale: Long-term use of PPIs can contribute to gastrointestinal
disturbances, including diarrhea.
 Medical Problems being managed adequately
Recurrent DVT

● Current Medications: Xarelto 20 mg daily.

● Management: The patient is on an appropriate anticoagulant regimen for preventing
thromboembolic events.
a. Suggestion: D/C cinnamon due to bleeding risk

PTSD

● Management: The PTSD is reported as controlled, indicating that the current management
strategy, likely involving ongoing support and therapy, is effective.