MM+401+-+2

=Case 2 - Janice Johnson=

//Janice Johnson is a 68yr old woman who lives alone at home who requires a review of her webster-packs as she appears confused about forgetting to take her medications.//

• Confusion and decline in memory affecting ability to take daily medications from webster pack. • Worsening asthma symptoms. Complains of being breathless almost daily. • Hypercholesterolaemia   • Hypertension   • Glaucoma • Dry eyes • GORD   • HRT • TIA   • Asthma • <span style="FONT-FAMILY: Arial, Helvetica, sans-serif">Urge incontinence  <span style="FONT-SIZE: 10pt; LINE-HEIGHT: 115%; FONT-FAMILY: 'Arial','sans-serif'"><span style="FONT-FAMILY: Arial, Helvetica, sans-serif"> • <span style="FONT-SIZE: 10pt; FONT-FAMILY: 'Arial','sans-serif'">Creatinine 100 micromol/L (45-90 micromol/L) • CLcr is 41mL/min (mild renal impairment) • <span style="FONT-SIZE: 10pt; LINE-HEIGHT: 115%; FONT-FAMILY: 'Arial','sans-serif'">Blood pressure 140/95 mmHg (130/85 mmHg)
 * Current issues:**
 * Medical history:**
 * Test Results from one month ago (excluding values inside the range):**
 * Current medications:**

Problems
<span style="FONT-SIZE: 10pt; FONT-FAMILY: 'Arial','sans-serif'">- Confusion and decline in memory may be due to oxybutynin (anticholinergic) or onset of dementia <span style="FONT-SIZE: 10pt; LINE-HEIGHT: 115%; FONT-FAMILY: 'Arial','sans-serif'"> - Worsening asthma symptoms due to lack of preventer medication use - CLcr is 41mL/min (mild renal impairment) - blood pressure is high
 * Current issues:**
 * Test results:**

//Esomeprazole// - use with ranitidine? //Simvastatin// - //Oestrogen/medroxyprogesterone continuous tablet// - 5yrs use maximum recommended - current indication? - increases blood pressure, and clot formation (interaction with dipyridamole) - however, lack of oestrogen contributes to atrophic vaginitis (thinning of vaginal tissue), causing irritation and can worsen urinary urgency and contribute to incontinence //Ranitidine// - use with esomeprazole? - dose in GORD is 300mg as a single evening dose or 2 divided doses (current dose is too high - no evidence of increased benefit and cost advantages over PPIs may be lost) //Verapamil// - can cause constipation and abdominal pain //Ramipril// - risk of hyperkalaemia in renal impairment and elderly - could cause cough and worsen stress incontinence + monitor renal function //Dipyridamole// - interaction with HRT therapy (increased clot formation) - need to combine with aspirin? + take on an empty stomach (reduce stomach pain) //Budesonide/eformoterol turbuhaler// + education on new regimen //Oxybutynin// - can aggravate GORD - can precipitate confusion - could worsen glaucoma (if closed-angle) - cause dry eyes //Timolol XE// - only needed once daily - possible systemic effects (bronchospasm) //Carmellose// - is a PRN medication, but is used twice a day regularly
 * Current Medications:**

//Review of webster packs// - can try to reduce number of medications and administrations required + timolol only once daily + ranitidine only once daily (and can eliminate use of esomeprazole) + slowly wean off HRT medication (only use for 5 years maximum)
 * Other problems:**

= =

What to do
subtherapeutic dosage failure to receive drug || Budesonide / Eformoterol turbuhaler 100mcg/6mcg (1 inh bd and 1 inh prn) //commenced SMART regimen 2 weeks ago. Previously used salbutamol as reliever. Good technique but forgets new regimen sometimes.// || - new inhaler medication, but reduces the need to use two different inhalers (reduce confusion) - significance of using topical beta-blocker on bronchospasm? (systemic absorption) + educate patient on new regimen || adverse drug reaction || Oxybutynin 5mg (1 tds) || - side effect of anticholinergics (blocks the effects of the neurotransmitter ACh - affected in Alzheimer's disease) - onset of dementia (vascular dementia caused by TIAs or old age being a risk factor?) || subtherapeutic dosage failure to receive drug ||  || - currently taking 11 medications, including 2 eyedrops and an inhaler - some medications could be eliminated and others can reduce frequency of dosing + will lead to improvements in compliance and effectiveness of therapy || improper drug selection || Dipyridamole SR cap 200mg (1 bd) || - combination of dipyridamole and aspirin is recommended for the prevention of TIA (risk of aggravating GORD?) || drug without indication || Oestrogen/medroxyprogesterone continuous tablet 0.625/2.5mg (1 mane) //Commenced 8 years ago.// || - duration of HRT is usually 2-5 yrs - review need by gradually withdrawing HRT over 3-6 months and watching for any return in symptoms || subtherapeutic dosage || Ramipril tablet 5mg (1 d) and Verapamil SR cap 240mg (1 m) || - BP currently 140/95 mmHg - may improve once compliance with medications and asthma (allowing more exercise) improve ||
 * **Drug Related Problem** || **Current Treatment** || **Comments** ||
 * //__1. Worsening asthma symptoms__//
 * //__2. Confusion and decline in memory__//
 * //__3. Review of webster packs__//
 * //__4. Prevention of TIA__//
 * __//5. Review of hormone replacement therapy//__
 * //__6. High blood pressure__//