Patient Case
Presentation
Objectives
Present patient JD’s clinical course
Prior to Admission
Evaluate the appropriateness of During inpatient stay
JD's medication management At discharge
Optimize JD's medication management upon discharge
Meet JD
Demographics Chief Complain Social History Family History
87 y.o. white female Current smoker, 10
Nonhealing wounds cigarettes every day; Multiple myeloma in
Weight: 54.4 kg
on left foot started smoking 71 her mother
BMI: 24 kg/m2 years ago
No current alcohol Unknown cancer in
Fatigue
and drug use her father
Meet JD
History of Present Illness (HPI) Past Medical History (PMH)
• 2022: 2 stent @ left distal super facial • A-fib, chronic iron deficiency anemia,
femoral artery (SFA) anxiety, depression, CKD (G3b), CHF,
COPD, CAD, PAD, DM, hyperlipidemia,
• 1/2024: extensive ulcers of left lower HTN, osteomyelitis, recurrent UTI
extremities secondary to PAD (most recent 1/31/24 ED admission),
urinary incontinence
• 5/28/2024: atherosclerotic plaque on
lower extremity vessels; angiography • History of IV iron transfusion, dental
and stent placement were disease, joint pain, left
recommended by cardiologist femoropopliteal balloon angioplasty
ED admission over last year
• Respiratory
6/15/23 • Pain of left lower 10/7/23 • Congestive heart 12/12/24 • UTI
distress • Left foot extremity • Respiratory failure with • SOB, recent • Hyperglycemia
osteotomy distress, AKI, COPD weight gain of 9 (270)
metatarsal sepsis exacerbation lbs in 1 week
and LE edema
4/20/23 8/9/23 12/7/23 1/31/24
Meet JD
Past surgical history Allergies & ADRs
• Appendectomy, • Atropine, iodine, latex (hives,
cholecystectomy, palpitation)
hysterectomy, • Epinephrine, meperidine,
• Left foot debridement penicillin
• Blue dye, shellfish-containing
products, methylprednisolone,
statins (tolerates atorvastatin)
COPD
• Albuterol and Trelegy prescribed, but not using
Prior to Anxiety
• Alprazolam 0.25 mg: 1 tablet PO qd prn
admission Depression
medication • Escitalopram 10 mg: 1 tablet qAM
• Trazodone 100 mg: 1 tablet q.h.s
list CHF
• Furosemide 20 mg: ½ tablet qd
• Furosemide 40 mg: 1 tablet qd
DM
• Dapagliflozin 5 mg: 1 tablet qd
HTN
• Metoprolol succinate 50 mg ER: 1 tablet q12h
Prior to Hyperlipidemia
admission • Atorvastatin prescribed, but not taking due to
the big pill size
medication
list UTI
• Cranberry 400 mg capsule: 1 capsule qd
Post-angioplasty
• Aspirin 81 mg: 1 tablet qd
Neuropathic pain
• Gabapentin 250 mg/5 mL solution: 5 mL TID prn
Prior to Urinary incontinence
• Mirabegron 50 mg ER: 1 tablet qd
admission Smoking cessation
medication • Nicotine 14 mg/24 hr patch: 1 patch qd
• Nicotine 21 mg/24 hr patch: 1 patch 1 qd
list Potassium supplement
• Potassium chloride 40 mEq/15 mL: 15 mL PO qd
Generalized pain
• Acetaminophen 500 mg: 2 tablets q4-6h prn
5/29 at ED
ROS and PE
• Vitals normal
• Alert and oriented,
HEENT, heart, lungs,
and abdomen are
Review of Physical unremarkable
systems Normal heart and lungs examination • Foot examination:
dorsal soft tissue
(ROS) (PE) swelling, with no
evidence of
osteomyelitis or
septic arthritis
Labs and tests
Laboratory results
• Sodium 133 ↓
• Glucose 157 ↑
• Creatinine 1.51 (CrCl = 22 mL/min eGFR = 32.6 mL/min/1.73 m²
• RBC 3.41↓ Hemoglobin 10.5 ↓ Hematocrit 30.5 ↓
• BNP 74, troponin 8
Imaging
• Chest x-ray normal
Cardiovascular testing
• ECG 5/29/24: sinus rhythm with baseline artifact and rudimentary P waves, minimal nonspecific ST-T wave
abnormality
• Echo 4/21/23: LVEF 75%, no regional wall motion abnormalities
• Arterial ultrasound 5/24/24: 70% lesions of left femoral and proximal SFA vessels
https://www.kidney.org/professionals/kdoqi/gfr_calculatorcoc
Assessment and Plan
Principal problems Active problems
Peripheral vascular
CKD w/baseline
disease with poorly Ulcerated left foot Dysuria Hyponatremia Anemia
creatinine 1.2-1.5
healing left heel ulcer
Plan for IV fluids, hold IV iron infusions,
Plan for angiography Plan for surgery Send UA for UTI IV NS, monitor BMPs
Lasix, monitor BMPs monitor CBCs
Controlled problems
CHF A-fib COPD DM Hyperlipidemia
Last echo 12/2023 Most recent A1c
Stable sinus rhythm
Stable without
(12/15/2023) 6.5%, not
Continue dietary and
EF > 70%, normal BNP & exacerbation statin therapy
troponin, normal X-ray on any meds
Start insulin sliding scale
Cautious with IV fluids,
Continue home inhaler to cover possible
hold Faxiga and Lasix for CHA2DS2-VASc 7
therapy hyperglycemia due to
next day procedure
steroid use
Anticoagulation not
recommended
considering chronic iron
deficiency anemia
Controlled
problems
HTN Current smoker DVT prophylaxis
Continue
Continue Start heparin
metoprolol 50
nicotine patch subq
mg BID
Start
hydralazine PRN
5/29/2024 5/30/2024 5/31/2024 6/4/2024
Admitted from ED Peripheral Osteotomy metatarsal Discharge
angiography
Urine culture back Complain of perineal
shows MRSA UTI pruritus
• Nystatin powder and
Diflucan one dose
Start 5 - day course of IV
vanco
Meds used during hospitalization
PAD w/angioplasty T2DM HTN
• Heparin 5,000 units subq q8h • Insulin lispro 1-6 units subq before • Hydralazine 10 mg q6h PRN
• Aspirin 81mg PO qAM meals & nightly
COPD HFpEF
• Budesonide 0.5 mg nebulization qd • Metoprolol succinate 50 mg PO BID
• Revefenacin 175 mcg nebulization
qd
• Formoterol 20 mcg nebulization BID
Meds used during hospitalization
Depression Anxiety MRSA UTI
• Escitalopram 10 mg PO qd • Alprazolam 0.25 mg PRN • Vancomycin IV
• Trazodone 100 mg PO q.h.s • Gabapentin 125 mg TID PRN • 1,000 mg in 250 mL NS @ 250
mL/hr over 60 mins
• 750 mg in 250 mL NS
Vaginal yeast infection Surgery preparation
• Nystatin powder 100,000 • Diphenhydramine 25 mg PO
unit/g powder topically BID BID
• Fluconazole 150 mg tablet PO • Methylprednisolone sod suc 40
once mg IV once
• Oxybutynin 5 mg PO BID
Prior to Admission Discharge
COPD
• Not using any inhaler
Albuterol HFA 90 mcg/actuation: 2 puffs q6h prn for SOB
Anxiety
• Alprazolam 0.25 mg: 1 tablet PO qd prn
Depression
• Escitalopram 10 mg: 1 tablet qAM
• Trazodone 100 mg: 1 tablet q.h.s
Heart failure
• Furosemide 20 mg: ½ tablet qd Remove furosemide 20 mg
• Furosemide 40 mg: 1 tablet qd 40 mg in the morning, 20 mg at bedtime
DM
• Dapagliflozin 5 mg: 1 tablet qd Discontinue dapagliflozin due to multiple UTIs
Prior to Admission Discharge
HTN
• Metoprolol succinate 50 mg ER: 1 tablet q12h
Hyperlipidemia
• Not taking statins
UTI
• Cranberry 400 mg capsule: 1 capsule qd
Post-angioplasty
• Aspirin 81 mg: 1 tablet qAM
Prior to Admission Discharge
Neuropathic pain
• Gabapentin 250 mg/5 mL solution: 5 mL TID prn
Urinary incontinence
• Mirabegron 50 mg ER: 1 tablet qd
Smoking cessation
Nicotine 14 mg/24 hr removed
• Nicotine 14 mg/24 hr patch: 1 patch qd
• Nicotine 21 mg/24 hr patch: 1 patch 1 qd
Potassium supplement
• Potassium chloride 40 mEq/15 mL: 15 mL PO qd Discontinue potassium chloride
Generalized pain
• Acetaminophen 500 mg: 2 tablets q4-6h prn
Discussion
PAD management COPD management
• Based on 2018 AHA/ACC guidelines • Per 2024 GOLD guideline, assess
on the management of blood mMRC, CAT score, history of
cholesterol, JD has a major ASCVD exacerbation, and hospitalization, JD
event (symptomatic PAD), and statin should at least be on
is warranted; according to the CLEAR bronchodilators, long-acting is
trial, bempedoic acid can lower the preferred over short-acting
risk of MACE in the statin-intolerant • Spiriva Respimat (tiotropium) 2.5
patient group. mcg/actuation, 2 inhalation once
• Initiate bempedoic acid 180 mg PO daily
qd if JD cannot tolerate statins
Steven E. et al, CLEAR trial, N Engl J Med 2023;388:1353-1364
Discussion
DM management
• Dapagliflozin d/c due to recurrent UTI, and the patient is not on any glycemic
control medications; per 2024 diabetes guidelines, 1st line therapy metformin is
warranted. JD was on metformin 500 mg BID historically but was d/c on 12/2023
due to AKI on CKD. Aggressive BP control is needed, considering adding ACEi
• No metformin? No dapagliflozin? Would recommend GLP-1 agonist due to
established ASCVD event
• Initiate Trulicity 0.75 mg once weekly; may increase to 1.5 mg once weekly after
4 to 8 weeks if needed to achieve glycemic goals.
Discussion
Anxiety management
• JD started alprazolam 0.25 mg BID 1/5/21 (depression has not been
diagnosed, escitalopram has not been started), then up to 0.25 mg
TID 2/2022, then down to 0.25 mg BID 4/2022, qd since 12/2022.
Per 2019 NICE guidelines, 1st line treatment for GAD is SSRI and
SNRI.
• Assess the patient and discuss with the psychiatrist the need to
discontinue alprazolam, while closely monitoring withdrawal
symptoms such as nausea, nightmares, and headaches.
NICE Clinical Guidelines, 2019, No. 113
Discussion
Polypharmacy
• Escitalopram: SSRI
• Trazodone: serotonergic CNS depressant
• Alprazolam: CNS depressant
• Gabapentin: CNS depressant
• Monitor closely for additive CNS depressant effects, serotonin
syndromes ( shivering, sweating, fast heartbeat, tremor, clonus,
muscle rigidity), and suicidal ideation.
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