May 30, | nursing, med, NURS, Paper
Maggie Smith- Abdominal Pain SOAP Note assignment
Maggie Smith- Abdominal Pain SOAP Note assignment
Case Study Video Assignment #2
Maggie Smith- Abdominal Pain
Students will watch the video and:
Complete the SOAP documentation.
Describe 3 of the most plausible differential diagnosis. Rule-in and Rule-out each diagnosis. Example: If a patient presents with a painful knee and your top differentials are osteoarthritis, ACL, and Fracture, you would find peer-reviewed Evidence to prove that each of those are possible diagnosis. For osteoarthritis: Rule in: What signs and symptoms match what the patient has. Give the evidence (from peer reviewed based information) to show that the symptoms match. Then rule out: What is lacking to show this is the actual diagnosis? You must demonstrate your thoughts with peer reviewed evidence. Maggie Smith- Abdominal Pain SOAP Note assignment.
Complete the Illness script.
Include a reference page
SUBJECTIVE:
CC-
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HPI –
Onset –
Location-
Duration –
Character –
Aggravating factors –
Alleviating factors –
Radiation –
Timing –
Severity –
PMH –
Medications – Past –
FH
ROS:
OBJECTIVE DATA
.
Student expectations:
ASSESSMENT
Abdominal pain
Differentials –
PLAN
Complete the Illness script for each differential diagnosis. Case Study Video Assignment #2
Illness Scrip
Differentiate #1
Epidemiology
Time Course
Clinical Presentation
Pathophysiology
Maggie Smith- Abdominal Pain SOAP Note assignment
Lab
Imaging
Illness Scrip
Differentiate #2
Epidemiology
Time Course
Clinical Presentation
Pathophysiology
Lab
Imaging
Case Study Video Assignment #2
Illness Scrip
Differentiate #3
Epidemiology
Time Course
Clinical Presentation
Pathophysiology
Lab
Imaging
Maggie Smith- Abdominal Pain SOAP Note assignment
References
SOAP Note
Name: Roger James Date: 11/17/ Time: 1030
DOB: 03 31971 Sex: M
SUBJECTIVE: (Subjective Part of Note This is what the patient tells you. May or may not be correct)
CC– (Chief complaint should be in patient’s own words)
“I am here to establish care and have my medications refilled, but I also have a headache” (or Pt. states that he is “here to establish care and have my medications refilled, and I also have a headache”)
HPI: (History of Present Illness should address all problems in the cc)
45 year old male in office to establish care and have his high blood pressure medications refilled. States to be taking Lisinopril and simvastatin medications as previously prescribed.
Previous provider was Dr. Lynch who does not take the patient’s insurance any longer. When asked about headache, patient states it just started when he was in waiting room. Pain scale is about a 2. It does not radiate anywhere and when he takes deep breaths and stretches his neck muscles it gets better. He denies having chronic headaches, but admits to getting them when he is anxious. He has a history of anxiety, but does not take any medications. Maggie Smith- Abdominal Pain SOAP Note assignment.
PMH:
Hypertension, Hyperlipidemia, Immunizations: are up to date. Significant childhood illnesses include Mumps age 5 and Measles age 8
Hypertension Hyperlipidemia
Immunizations: are up to date
Significant childhood illnesses include Mumps age 5 and Measles age 8
PSH:
Appendectomy age 14
Treadmill Stress test age 40 for approval of exercise program. Done at Dr. Bickers office with “no problems found”
Medications: (Include Name, dosage, route, and schedule if known. Include OTC, Herbs / Supplements also)
Lisinopril 20 mg. po BID Simvastatin 20 mg po at bedtime
OTC- Occasional Tylenol 1x per month, No Herbs or supplements
Allergies: (Include reaction to any allergies)
PCN- Reaction is a fine rash. Denies food or seasonal allergies
FM: (Family History includes grandparents, parents, siblings, and children— and any other blood relatives
with significant problems) Maggie Smith- Abdominal Pain SOAP Note assignment.
Father: Alive , age 62, has hypertension
Mother: Alive, age 62, diagnosed with Breast Cancer 3 months ago, negative for BRCA gene.
Does not know Granparents history and all are deceased. Has no siblings or children.
SH: (Social history is about relationships and life activities)
Lives in Amarillo with wife. Has no children. Has a monogamous sexual relationship with wife. Denies any history of tobacco use or illicit drug use. Does drink one to two drinks of alcohol a week. Works as a Paramedic full time. Exercises for at least 30 minutes to 1 hour 3-5 times a week. Does not follow any special diet. Does not have an AD or Living Will. Offered information on and patient declined. Maggie Smith- Abdominal Pain SOAP Note assignment.
ROS: ( Review of Systems is a quick overview of any other issues that the patient may have.)
General- denies any fever, chills, malaise, denies pain or discomfort, no distress noted Skin: denies any lesions or rashes
Eyes: denies any eye pain, denies any itching or watery eyes, denies any eye discomfort. Uses glasses and sees opthamologist yearly.
Ears: denies any ear pain or discharge. Can hear without aides. NoseMouthThroat: denies any discomfort, denies any post nasal drainage and no redness or swelling
Neck: Denies any lumps or bumps in neck. States no difficulty moving neck or swallowing. Denies coughing after swallowing. Maggie Smith- Abdominal Pain SOAP Note assignment.
Cardiovascular: Denies any chest pain, denies any history of heart problems. Denies palpitations.
Respiratory: Denies any shortness of breath, denies wheezing or coughing at present. Has never used an inhaler. Has never had any blood in a cough.
Gastrointestinal: Denies any nausea, vomiting, constipation, or diarrhea recently. Denies abdominal pain. Reports normal bowel movement 1 -2 times daily. No current weight loss or trouble eating.
Genitourinary: Denies any pain upon urination, reports normal urinary stream. Musculoskeletal: Denies any joint pain. Denies any arthralgias or myalgias.
Neurological: Denies any problems with chronic headaches. Denies any numbness or tingling of the extremities.
Psychological: Denies any feelings of sadness or depression. Does have a history of mild anxiety with stressors. Is c/o mild anxiety today and feels that is the cause of his headache. Denies ever being treated with medicine for anxiety. Has never suffered from chest pain, SOB, or hyperventilation with anxiety. Denies anxiety being a chronic problem. Does not interfere with quality of life. Maggie Smith- Abdominal Pain SOAP Note assignment.
OBJECTIVE: (This is your work and is considered objective.) Case Study Video Assignment #2
Physical Examination
Weight- 175 lbs Height- 5’9 BMI- 25.8 Temp- 97.6, P78, R18, BP 128/80
General appearance: well appearing gentleman in no apparent distress. Appears stated
age. Answers questions without hesitation.
Skin: skin is clean, dry and intact, no apparent lesions or rashes noted
HEENT: Head is normocephalic with no masses or bumps felt. Eyes: PERRLA. Ears:
TM clear, gray bilaterally, with no noted exudates, minimal ear wax noted. Nares: negative for any swelling or nasal drainage. Oropharynx: negative for PND, erythema or lesions, good dentition noted, negative for tonsillar swelling or exudate. Maggie Smith- Abdominal Pain SOAP Note assignment.
NeckLymphatic: Neck: is supple with good ROM without pain or discomfort, no lymphadenopathy noted upon palpation, negative for thyromegaly or thyroid masses. Cardiovascular: Regular rate and rhythm. S1 and S2 without S3, S4. No murmurs,
gallops, rubs, or clicks noted. Peripheral Pulses +2 bilaterally in radial pulses, and dorsalis pedis pulses. No carotid bruits heard.
Respiratory: Lungs clear to auscultation anteriorly, posteriorly, and bilaterally. Easy
respiratory effort with no use of accessory muscles noted.
Gastrointestinal: Abdomen soft, no distention noted, bowel sounds active and present in
all quadrants, with no masses palpated. No tenderness noted. No hepatosplenomegaly noted. Scar in RLQ well healed.
Genitourinary: Normal genitally noted with testicles descended. No inguinal hernias felt.
Musculoskeletal: Bilateral equal strength noted in all 4 extremities with full ROM noted.
No pain or discomfort with movements of joints, and no joint laxity or crepitus. Gait normal with walking.
Neurological: CNII-XII grossly intact.
Psychological: Interacts cooperatively for exam, good eye contact, calm and pleasant
affect.
Diagnostics: none
ASSESSMENT : (Diagnoses, Differentials, and problems)
Annual wellness visit to establish care
Hypertension
Hyperlipidemia
Headache
History of mild Anxiety
PLAN: (Pharmacological and non-pharmacological management, diagnostics ordered education,
referrals, and follow up)
Patient to return to clinic in a.m. for fasting labs. CBC, CMP, and Lipid
Lisinopril 20 mg twice daily by mouth for high blood pressure. Patient is to monitor blood pressure at least twice a week and report any consistently high or low
Simvastatin 20 mg once daily at hour of sleep. Will adjust according to lab results
Call back if headache does not resolve with OTC Tylenol or Ibuprofen. Pt. feels that headache is simple due to anxiety of
Anxiety is a self-diagnosis and patient has never had any treatment for this. Discussed at length with patient and he feels that he does not need any treatment for this problem. Will obtain old records from Dr. Lynch and Dr. Bickers Maggie Smith- Abdominal Pain SOAP Note assignment
Follow-up in clinic in 2 weeks to discuss la
Alternative Assessment and Plan
ASSESSMENT / PLAN:
Annual wellness visit to establish care – Patient to return to clinic in a.m. for fasting labs. CBC, CMP, and Lipid
Hypertension – Lisinopril 20 mg twice daily by mouth for high blood pressure. Patient is to monitor blood pressure at least twice a week and report any consistently high or low readings. Pt. given pamphlet on low salt, low cholesterol
Hyperlipidemia – Continue Simvastatin 20 mg once daily at hour of sleep. Will adjust according to lab results
Headache – Call back if headache does not resolve with OTC Tylenol or
Pt. feels that headache is simple due to anxiety of visit.
History of Anxiety- This is a self diagnosis and patient has never had any treatment for this. Discussed at length with patient and he feels that he does not need any treatment for this
voiced understanding of all instructions and will return in 2 weeks to discuss labs.
Will obtain old records from Dr. Lynch and Dr. Bickers. Maggie Smith- Abdominal Pain SOAP Note assignment
May 30, | nursing, med, NURS, Paper
Aquifer High Value Care 04: 80-year-old woman – Medications and value
Aquifer High Value Care 04: 80-year-old woman – Medications and value
High Value Care 04: 80-year-old woman – Medications and value
Author(s): Susan Merel, MD University of Washington Medicine; Anne Eacker, MD University of Washington Medicine
REASON FOR ADMISSION
HISTORY
You are rounding on Mrs. Miller, a newly admitted 80-year-old patient with a heart failure (HF) exacerbation. She had been discharged from the hospital just 10 days ago after presenting with the same problem after a 5 day hospitalization. Aquifer High Value Care 04: 80-year-old woman – Medications and value.
You review her list of chronic problems:
Problem list
Systolic heart failure due to ischemic cardiomyopathy with EF of 35% on last echocardiogram
Well-controlled diabetes: A1c of 6.5
Chronic kidney disease Stage 3
Recurrent urinary tract infections
Mild cognitive impairment
Osteoarthritis
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You have found no evidence of infection, Mrs. Miller has not changed her diet, and her EKG is unchanged from previous. On rounds today your attending asks you why you think this patient had a second HF exacerbation so soon after discharge. Aquifer High Value Care 04: 80-year-old woman – Medications and value.
Question
Which of the following are likely to contribute to a HF exacerbation requiring readmission? Select all that apply.
Medication nonadherence
Residence in a skilled nursing facility
Chronic kidney disease
Diabetes
Hyponatremia
Medication side effects
References
Flacker J, Park W, Sims A. Hospital discharge information and older patients: do they get what they need? J Hosp Med. 2007;2(5):291-296.
Amabile CM SA. Keeping your patient with heart failure safe: a review of potentially dangerous medications. Arch Intern Med. 2004;164(7):709-720.
Krumholz HM, Chen YT, Wang Y, Vaccarino V, Radford MJ, Horwitz RI. Predictors of readmission among elderly survivors of admission with heart failure. Am Heart J. 2000;139(1 Pt 1):72-7.
DEEP DIVE Aquifer High Value Care 04: 80-year-old woman – Medications and value
References
Journal of Managed Care & Specialty Pharmacy, Volume 22 Issue (5) 2016 May 22 (5): 516-523.
Answer Comment
The correct answers are A, C, D, F.
Medication nonadherence (A) and medication side effects (F) are important risk factors for readmission in patients discharged after a hospitalization for HF.
Medication nonadherence is a pervasive problem; up to 25% of prescriptions ordered are never filled. In one study of elderly patients discharged from a county hospital with medication changes, only about 50% reported getting their prescriptions filled. (See the Expert to learn about the types and prevalence of medication nonadherence.)
Older patients are likely to take multiple medications and are more susceptible to side effects and adverse drug events than younger patients because of comorbidities, frailty, and age-related physiologic changes in drug metabolism and excretion. Drug-induced HF exacerbations are also common. Medications to consider include non-steroidal anti-inflammatories (NSAIDS), corticosteroids, alpha-blockers, calcium-channel blockers, and tricyclic antidepressants.
Elderly patients with renal failure (C) and diabetes (D) are at increased risk for readmission after an exacerbation of HF. Both conditions make it more difficult to control heart failure.
Hyponatremia (E) is a common condition in the elderly and may make it more difficult to treat heart failure, but has not been shown to be associated with HF readmission.
Advanced age and residence in a skilled nursing facility (B) have not been shown to be risk factors for HF readmission.
REASON FOR ADMISSION
HISTORY
READMISSION QUESTION
HISTORY
Question
Why is readmission to the hospital within 30 days of discharge a concern? Select all that apply.
Association with increased mortality
Increased occurrence in patients with depression
Cost to health care facility
Cost to the patient
SUBMIT
TEACHING POINT
Early readmission, within 30 days of discharge, is associated with an increased rate of all-cause mortality for community-dwelling elderly patients. Patients over age 80, with five or more comorbidities, or depression are at greater risk of early readmission
References
Lum HD, Studenski SA, Degenholtz HB, Hardy SE. Early hospital readmission is a predictor of one-year mortality in community-dwelling older Medicare beneficiaries. J Gen Intern Med.2012;27(11):1467-74.
Marcantonio ER, McKean S, Goldfinger M, Kleefield S, Yurkofsky M, Brennan TA. Factors associated with unplanned hospital readmission among patients 65 years of age and older in a Medicare managed care plan. Am J Med. 1999;107(1):13-17.
Centers for Medicare and Medicaid Services. Readmissions Reduction Program.
Question
Why is readmission to the hospital within 30 days of discharge a concern? Select all that apply.
The best options are indicated below. Your selections are indicated by the shaded boxes.
Association with increased mortality
Increased occurrence in patients with depression
Cost to health care facility
Cost to the patient
SUBMIT
Answer Comment
The correct answers are A, B, C, D.
All of the above are correct.
Early readmission, within 30 days of discharge, is associated with an increased rate of all-cause mortality (A) for community-dwelling elderly patients initially admitted for any diagnosis. It is more common in patients who:
Are over age 80
Have five or more comorbidities
Have depression (B).
The Affordable Care Act currently requires the Center for Medicare and Medicaid Services (CMS) to reduce payments to hospitals in the setting of “excess readmissions” of patients hospitalized for acute myocardial infarction, heart failure, and pneumonia within 30 days of the first hospitalization. If readmission rates exceed the expected rate, a penalty is charged to the hospital (C). The amount of these penalties will increase in the future, and additional medical conditions will be added.
Even with insurance, Medicare or otherwise, most patients still have to pay (D) some portion of their health care costs. For example, Medicare Part A covers 80% of inpatient costs. The average cost of inpatient care per day in the U.S. is about $2270. Hospital Adjusted Expenses per Inpatient Day 2015.
MEDICATION REVIEW
HISTORY
While you are rounding, Mrs. Miller’s daughter arrives with her mother’s home medications in a grocery bag. You express your appreciation that she was able to bring these in for review. They are as follows:
Scheduled medications
Aspirin 81 mg po daily
Calcium carbonate 500 mg po bid
Furosemide 20 mg po daily
Glipizide 5 mg po daily
Lisinopril 10 mg po daily
Metformin 500 mg po bid
Metoprolol XL 50 mg po daily
Multivitamin one tab po daily
Nitrofurantoin 50 mg po daily
Pravastatin 40 mg po daily
Cholecalciferol 800 IU po daily
Naproxen over-the-counter, patient has been taking 500 mg twice a day for a week.
As needed medications
Diphenhydramine 25 mg po q 6 hours prn pruritus
Zolpidem 5 mg po qhs prn insomnia
Hydrocodone/acetaminophen 5/500 mg po q 6 hours prn pain
Question
After a discussion with the patient and her primary care doctor, which of the following medications would be appropriate to consider discontinuing during this hospitalization? Select all that apply.
Aspirin
Nitrofurantoin
Metoprolol
Diphenhydramine
Naproxen
Vicodin
Zolpidem
SUBMIT
TEACHING POINT
Older patients are at increased risk of adverse drug events.
The Beers Criteria is an evidence-based list developed by experts documenting medications which are potentially inappropriate in the elderly and should be referenced when caring for older patients.
References
Budnitz DS, Lovegrove MC, Shehab N, Richards CL. Emergency hospitalizations for adverse drug events in older Americans. N Engl J Med. 2011;365(21):2002-12.
Steinman MA, Landefeld CS, Rosenthal GE, Berthenthal D, Sen S, Kaboli PJ. Polypharmacy and prescribing quality in older people. J Am Geriatr Soc. 2006;54(10):1516-23.
Steinman MA, Story PS. Managing medications in clinically complex elders: “There’s got to be a happy medium.” JAMA. 2010;304(14):1592-1601.
Kolla BP, Lovely JK, Mansukhani MP, Morgenthaler TI. Zolpidem is independently associated with increased risk of inpatient falls. J Hosp Med. 2013;8(1):1-6.
DEEP DIVE
References
Brater DC. Effects of nonsteroidal anti-inflammatory drugs on renal function: Focus on cyclooxygenase-2-selective inhibition. Am J Med. 1999;107(6A):65S-71S.
Question
After a discussion with the patient and her primary care doctor, which of the following medications would be appropriate to consider discontinuing during this hospitalization? Select all that apply.
The best options are indicated below. Your selections are indicated by the shaded boxes.
Aspirin
Nitrofurantoin
Metoprolol
Diphenhydramine
Naproxen
Vicodin
Zolpidem
SUBMIT
Answer Comment
The correct answers are B, D, E, F, G.
Adverse Drug Events in the Elderly
Older patients are at high risk for adverse drug events due to age-related changes in physiology, including changes in drug metabolism.
Older patients generally have more comorbid conditions and are prescribed more medications: 40% of adults over age 65 take 5 to 9 medications and 18% take 10 or more.
Frail elderly patients who take multiple medications are at increased risk for falls, fractures and delirium; these conditions can have serious consequences for an elderly patient’s health and independence.
As many as 10% of hospital admissions in older adults may be related to adverse drug events.
The Beers Criteria is an evidence-based list developed by experts documenting medications which are potentially inappropriate in the elderly.
Medication
Category
Risks
Nitrofurantoin
Antibiotic
Pulmonary toxicity
Diphenhydramine
Anticholinergic
Side effects include somnolence, confusion, constipation and dry mouth
Naproxen
NSAID
Increased risk of gastrointestinal bleeding, acute kidney injury
Hydrocodone/acetaminophen (Vicodin)
Opioid
Associated with delirium and falls in the elderly
Zolpidem
Sedative-hypnotic (nonbenzodiazepine)
Associated with increased risk of falls, fractures, and delirium in older adults
Nitrofurantoin (B), diphenhydramine (D), naproxen (E), Vicodin (F), and zolpidem (G) are all medications which may be appropriate to discontinue:
Nitrofurantoinis generally an inappropriate medication in the elderly because of its pulmonary toxicity; it is also less effective in patients with a creatinine clearance less than 60 ml/min due to inadequate concentration in the urine. It should not be used for long-term suppression of urinary tract infections in elderly patients. The reason for the nitrofurantoin should be determined and this medication should be stopped or replaced with a safer appropriate antibiotic. If she is taking nitrofurantoin as suppressive therapy to reduce the risk of recurrent UTI’s, the role of suppressive therapy should be reconsidered as the evidence supporting this is not strong.
Diphenhydramine(Benadryl) should be avoided in all elderly patients because of its strong anticholinergic properties, unless it is necessary for acute treatment of a severe allergic reaction. Side effects include somnolence, constipation, and dry mouth. Anticholinergic drugs (view list) increase the risk of both delirium and falls in elderly patients.
Naproxenis an NSAID. The American Society of Nephrology recommends that patients of all ages with hypertension, heart failure or chronic kidney disease avoid NSAIDs when possible (read the ASN’s recommendation). NSAIDs should also be avoided in many elderly patients, especially those over age 75 or those taking antiplatelet agents, anticoagulants, or corticosteroids because of the increased risk of gastrointestinal bleeding. See the Deep Dive to learn about the physiologic effects of NSAIDs on the kidney. NSAIDs can also contribute to both hypertension and congestive heart failure exacerbations, and should be avoided in patients with these conditions.
Diphenhydramine and NSAIDs are both examples of over-the-counter medications that are inexpensive, but of low value in many patients because of their associated toxicities. It is important to ask about over-the-counter and herbal medications when taking a medication history.
Zolpidem, which binds the benzodiazepine receptor subunit of the GABA-A receptor complex, is associated with an increased risk of falls, fractures, and delirium in older adults, and is not proven to be very effective in the elderly. Always teach patients about sleep hygiene before considering a sedative-hypnotic.
Vicodinis an opioid combined with acetaminophen. Opioids can be associated with delirium and falls in the elderly population and should be used with caution. They also carry the risk of addiction.
If the patient has osteoarthritis pain that is refractory to conservative measures, such as exercise, acetaminophen, and physical therapy, judicious use of hydrocodone/acetaminophen is reasonable if it improves her function. Although opioids can be associated with delirium and falls in the elderly population, untreated pain can also contribute to delirium, decreased mobility and decreased quality of life. Opioids should be used with caution in the elderly patient for pain that has been refractory to acetaminophen and non-pharmacologic measures at the lowest effective dose with the goal of improved function. While opioids should be used with caution, they are often appropriate in older adults with refractory pain and would not need to be stopped in this patient if they are used sparingly and improve her function.
Aspirin (A), metoprolol,(C) and lisinopril are indicated in this patient because of her systolic heart failure and ischemic cardiomyopathy.
Question
Which of the following contribute to increased drug costs, particularly for elderly patients? Select all that apply.
The best options are indicated below. Your selections are indicated by the shaded boxes.
Medication price inflation has far exceeded general inflation.
The number of medications prescribed to patients is rising over time.
The elderly pay a larger percentage of their prescription medication costs out of pocket.
Medicare Part D pays 80% of the cost of each prescription medication for those over 65.
SUBMIT
Answer Comment
The correct answers are A, B, C.
Nonadherence with medications can increase the use of medical resources. Always ask your patients if they are able to afford their prescriptions. Patients on minimal fixed incomes (most elderly patients) may be unable to afford necessary medications. Aquifer High Value Care 04: 80-year-old woman – Medications and value
Since 1980, prescription medication prices have increased (A) two to three times faster than all consumer prices.
Prescription drug use in the U.S. has been steadily increasing over time. Between 1999 and 2008, the percentage of Americans taking at least one prescription drug increased (B) by 10% and use of five or more drugs increased by 70%; spending for prescription drugs doubled during that time period.
Medicare Part D subsidizes the cost of prescription medications; however, there is a monthly premium, a yearly deductible, and a per prescription co-pay (C), which varies by plan. In addition there is a coverage gap for patients who have more than about $3000 in annual drug costs in 2013. While a patient is in the coverage gap (a.k.a. “donut hole”), he or she pays 79% of the costs of all generic medications and 47.5% of the costs of all brand-name medications. This coverage gap ends at $4750 of drug coverage annually. Because of these costs, not all patients sign up for Medicare Part D.
Medicare Part D does not provide 80% coverage of each prescription (D).
References
Gu Q, Dillon CF, Burt VL. Prescription drug use continues to increase: U.S. prescription drug data for 2007-2008. Centers for Disease Control. NCHS Data Brief. No. 42, September 2010:1-8.
REASON FOR ADMISSION
HISTORY
READMISSION QUESTION
HISTORY
MEDICATION REVIEW
HISTORY
MEDICATION NON-ADHERENCE
MANAGEMENT
MEDICATION COST
THERAPEUTICS
During her hospitalization, some of Mrs. Miller’s medications have been stopped or changed, and some have been added. Her current medication list in the hospital is as follows:
Hospital Medications
Medications at Home
Scheduled Aquifer High Value Care 04: 80-year-old woman – Medications and value
Aspirin 81 mg po daily
Aspirin 81 mg po daily
Calcium carbonate 500 mg po bid
Calcium carbonate 500 mg po bid
Cholecalciferol 800 IU po daily
Cholecalciferol 800 IU po daily
Furosemide (Lasix) 40 mg po daily
Furosemide 20 mg po daily
Glipizide 5 mg po daily
Glipizide 5 mg po daily
Lisinopril (Prinivil) 10 mg po daily
Lisinopril 10 mg po daily
Metformin 500 mg po bid
Metformin 500 mg po bid
Multivitamin 1 tab po daily
Multivitamin 1 tab po daily
Carvedilol (Coreg) 25 mg po bid
Metoprolol XL 50 mg po daily
Rosuvastatin (Crestor) 10 mg po daily
Pravastatin 40 mg po daily
Omeprazole 20 mg po daily
Nitrofurantoin 50 mg po daily
Naproxen (over-the-counter) patient has been taking 500 mg twice a day for a week
As Needed
Hydrocodone/acetaminophen 5/500 mg po q 6 hours prn pain
Hydrocodone/acetaminophen 5/500 mg po q 6 hours prn pain
Benadryl 25 mg po q 6 hours prn pruritus
Zolpidem 5 mg po qhs prn insomnia
Question
How could you make this medication list more cost-effective? Document an appropriate discharge medication list here. Aquifer High Value Care 04: 80-year-old woman – Medications and value
Letter Count: 805/1000
SUBMIT
TEACHING POINT
Six Simple Rules for High-Value Medication Prescribing
Have a compelling reason for every medication you prescribe. Consider non-pharmacologic alternatives when appropriate.
Keep your patient’s medication list as short as possible. Discontinue all non-essential medications and review the list for duplicates.
Evaluate affordability before prescribing new medications to patients. This may mean reviewing the patient’s actual copay, generic versus brand name, and the medication tier in their insurance plan. (See High Value Care 06: 65-year-old man – Paying for value: Insurance Part 1.)
Make every effort to prescribe generic equivalent medications. Also be aware of lists of less expensive generic prescriptions available at large chain pharmacies, often for as little as $4 per month.
Collaborate with pharmacists to avoid drug-drug interactions and help provide lower-cost alternatives.
Ask the patient to “teach-back” to show they understand the reason for each medication on the list and how/when to take it.
References
Bulger J, Nickel W, Messler J, et al. Choosing wisely in adult hospital medicine: five opportunities for improved healthcare value. J Hosp Med. 2013;8(9):486-92.
The medication list can be made more cost effective by ensuring the list is as short as possible and ensuring that there is a compelling reason for each prescribed medication. When appropriate, non-pharmacologic alternatives and generic equivalent medications should be considered. It will also be important to find out if there are other lower-cost alternative medications used to treat same health condition and have them replace the medications on the list. Lastly, I will collaborate with pharmacists to help suggest lower-cost alternatives.
Furosemide (Lasix) 40 mg po daily
Multivitamin 1-tab po daily
Aspirin 81 mg po daily
Lisinopril 10 mg po daily
Pravastatin 40 mg po daily
Metformin 500 mg po bid
Rosuvastatin (Crestor) 10 mg po daily
Hydrocodone/acetaminophen 5/500 mg po q 6 hours prn pain
Answer Comment
The table below outlines a suggested higher-value medication list for this patient, with a comparison of actual monthly costs of the initial and the higher-value medication list, without consideration of her prescription drug plan coverage:
Initial hospital medication list
Cost for 30-day
supply ($)
Higher-value medication list
Cost* for 30-day
supply ($)
Aspirin 81 mg po daily
0.30
Aspirin 81 mg po daily
0.30
Calcium supplement with Vitamin D
1.20
Calcium supplement with Vitamin D
1.20
Coreg (carvedilol) 25 mg po bid
164.24
Metoprolol XL 50 mg po daily
17.65
Crestor (rosuvastatin) 10 mg po daily
188.29
Atorvastatin 40 mg po daily
17.00
Furosemide 40 mg po daily
3.37
Furosemide 40 mg po daily
3.37
Glipizide 5 mg po daily
4.00
Glipizide 5 mg po daily
4.00
Metformin 500 mg po bid
4.00
Metformin 500 mg po bid
4.00
Multivitamin
0.90
(discontinued)
–
Prinivil (lisinopril) 10 mg po daily
44.44
Lisinopril 10 mg po daily
4.00
Omeprazole 20 mg po daily
10.25
(discontinued)
–
Hydrocodone/acetaminophen 5/500 mg po q 6 hours prn severe pain, thirty tabs
17.00
Hydrocodone/acetaminophen 5/500 mg po q 6 hours prn severe pain
17.00
Total cost for a one-month supply
$437.99
Total cost for a one-month supply
$68.52
*Costs are based on GoodRx.com using the zip code 98115 and cheapest Costco prices for over-the-counter medications.
Using a Medicare Part D plan, the per-month cost for these medications using the higher value medication list could be reduced to about $20/month out of pocket, including the monthly premium, copay, and annual deductible. However, many patients do not sign up for Medicare Part D due to the cost.
Discontinue nonessential medications started during a hospital stay.
In the hospital, this patient was started on a proton pump inhibitor, omeprazole. Proton pump inhibitors are sometimes started as prophylaxis against stress ulcers, but there is no evidence to support thisoutside of the intensive care unit, and proton-pump inhibitors are associated with an increased risk of pneumonia and difficile colitis.
Always switch back to generics from brand-name hospital formulary medications.
Hospital formularies often contain expensive brand-name medications obtained through special pricing arrangements between the hospital and pharmaceutical companies.
In this case, generic lisinopril was substituted for the brand name Prinivil and carvedilol was substituted for brand name Coreg. Although brand name Crestor is available as generic rosuvastatin, another high intensity statin, atorvastatin, was less expensive in Mrs. Miller’s town. Aquifer High Value Care 04: 80-year-old woman – Medications and value
If there is no generic for the brand-name drug chosen, consider whether it is appropriate to switch to a drug in the same class that does have a generic option available.
CARE DISCUSSION
CARE DISCUSSION
It is hospital day four. Mrs. Miller’s dyspnea has resolved, and she is near her goal weight. You plan to discharge her later this morning.
Question
What is the best way to educate your patient about her medications before discharge? Choose the single best answer.
Use the teach-back method to review the medication list with the patient and her daughter.
Have the nurse review the medication list with the patient and her daughter.
Ask the clinical pharmacist to do discharge medication education.
Order home health nursing and have the nurse check to make sure she is taking her medications correctly.
SUBMIT
TEACHING POINT
The teach-back method assesses the patient’s recall and comprehension of any new concept. It is an effective method for both assessing a patient’s understanding of a situation and providing education. It should be used to educate patients about their medications before hospital discharge.
References
Coleman EA, Smith JD, Raha D, Min SJ. Posthospital medication discrepancies: prevalence and contributing factors. Arch Intern Med. 2005;165(16):1842-1847.
Wong JD, Bajcar JM, Wong GG, et al. Medication reconciliation at hospital discharge: evaluating discrepancies. Ann Pharmacother. 2008;42(10):1373-1379.
White M, Garbez R, Carroll M, Brinker E, Howie-Esquivel J. Is “teach-back” associated with knowledge retention and hospital readmission in hospitalized heart failure patients? J Cardiovasc Nurs.2013;28(2):137-46.
Schillinger D, Piette J, Grumbach K, et al. Closing the loop: physician communication wtih diabetic patients who have low health literacy. Arch Intern Med. 2003;163(1):83-90.
Question
What is the best way to educate your patient about her medications before discharge? Choose the single best answer.
The best option is indicated below. Your selections are indicated by the shaded boxes.
Use the teach-back method to review the medication list with the patient and her daughter.
Have the nurse review the medication list with the patient and her daughter.
Ask the clinical pharmacist to do discharge medication education.
Order home health nursing and have the nurse check to make sure she is taking her medications correctly.
SUBMIT
Answer Comment
The correct answer is A.
Discrepancies between what a patient is prescribed upon discharge from the hospital and what they actually take at home are common and are associated with a higher rate of hospital readmission, as happened in this case. Thoughtful patient education may improve adherence and reduce the chance of readmission. The teach-back method (A), in which a clinician assesses the patient’s recall and comprehension of any new concept, is an effective method for both assessing a patient’s understanding of a situation and providing education if the patient cannot demonstrate understanding. Using teach-back simply involves asking patients to restate information that has been presented to them. It allows the provider to check the patient’s understanding, reinforce important concepts, and engage in open dialogue.
Answers B and C are not the best answers as it is not clear that the nurse and pharmacist will use the teach back method. Ordering home health nursing and having the nurse check to make sure she is taking her medications correctly (D) is a strategy to identify medication nonadherence after it occurs. The best strategy should prevent nonadherence.
View guidelines for using teach-back in patient education.
Mrs. Miller receives her discharge instructions:
Mrs. Miller discharge instructions
Click here for a transcript of the video above.
DISCHARGE FOLLOW-UP
CARE DISCUSSION
You see Mrs. Miller in clinic with your preceptor three months later. Mrs. Miller has not been rehospitalized, and her heart failure has been stable. She has had one fall without serious injuries and continues to have trouble with her memory.
Your preceptor asks you to review the patient’s diabetes control during this visit. She has been on metformin and glipizide, and a recent HbA1C was 6.5%. She has stage II chronic kidney disease with a recent creatinine of 1.2 mg/dL and eGFR of 45. She watches her diet carefully, and in fact has lost ten pounds in the past year. Her BMI is 25. Aquifer High Value Care 04: 80-year-old woman – Medications and value
Question
What should you do today regarding Mrs. Miller’s diabetes management? Choose the single best answer.
The best option is indicated below. Your selections are indicated by the shaded boxes.
Continue her metformin and glipizide; recheck a HbA1C in three months
Continue her metformin but stop the glipizide
Reduce the metformin to 500 mg po daily and stop the glipizide
Stop her metformin but continue the glipizide
Stop both her metformin and her glipizide
SUBMIT
Answer Comment
The correct answer is B.
Reducing medications in the elderly reduces harm. Elderly patients on more than 4 medications are at higher risk of adverse events such as falls.
Mrs. Miller is a frail, community-dwelling elderly person, with a life expectancy that is likely less than 10 years. See the Expert for more information regarding prognosis in the elderly. Her goal HbA1C should be about 8% based on current guidelines (see guideline #3).
Comorbidities
Goal HbA1C
Healthy older adults with long life expectancy
7-7.5%
Older adults with comorbidities and life expectancy <10 years
7.5-8%
Multiple comorbidities and shorter life expectancy, including most patients in long-term care facilities
8-9%
Because Mrs. Miller’s HbA1C was 6.5%, and because she had fallen and is at increased risk of falling with hypoglycemia, her glipizide should be stopped, thus answers (A) and (D) are incorrect. In the future, the metformin could be decreased (C) or stopped (E) depending on her A1c and renal function. Her weight should be monitored closely because weight loss in the elderly is a marker of frailty and may reflect difficulties with self-care in a patient with cognitive impairment.
Glipizide should be stopped before metformin because of the risk of hypoglycemia with sulfonylureas and better evidence for efficacy and safety in the older population with metformin.
TEACHING POINT
Reducing medications in the elderly reduces harm. Considering an elderly patient’s life expectancy before offering interventions is an important part of high-value care in this population.
References
Sue Kirkman M, Briscoe VJ, Clark N, et al. Diabetes in older adults: a consensus report. J Am Geriatr Soc. 2012;60(12):2342-56.
DEEP DIVE
References
Yourman L, Lee S. Prognostic Indices for Older Adults: A Systematic Review. JAMA. 2012;307(2);182-192.
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