Home Medicines Review 20

Patient details
Mrs Wentworth
77 yrs
Geelong, Victoria
79 kg
Referring GP:
Dr Maranucci
161 cm
Patient information from HMR referral
Allergies or adverse reactions: None
Smoking status: Nil, never smoked
Quitting stage:
Alcohol consumption: Nil
Reason for referral for HMR
New patient to the practice whose previous GP retired after 40 years of community care. Her new GP would like a better understanding of how Mrs Wentworth manages her medicines. In addition, he would appreciate your input in appropriateness of current medicines
Patient history (social/medical) from HMR referral
Medical history: T2DM, osteoarthritis, depression, vitamin D deficiency, GORD, leg pain, hypercholesterolaemia, hypertension, dry eye, hypothyroidism
Social history
• Widowed, two adult children, lives alone, neighbours are helpful with shopping
• She has previously done some charity work. However, as she has not been feeling well recently, she has not been volunteering to assist
Current medications
Dose (according to patient)
Purpose/comments (according to patient)
Metformin (Formet) 1000 mg
1 m
Glibenclamide (Daonil) 5 mg
1 bd
Sugar, but skips days as she can feel unwell occasionally and thinks this is the cause.
Mirtazapine (Avanza) 30 mg
1 n, but taking ½
Mood, but now very sleepy in the mornings
Pantoprazole (Sozol) 40 mg
1 m
Stomach (taken for some years)
Perindopril (Coversyl) 5 mg
1 m
Atorvastatin (Atorvachol) 80 mg
1 n
Thinks it is for cholesterol
Aspirin (Cartia) 100 mg
1 m
Blood thinner
Page 2
Current medications
Dose (according to patient)
Purpose/comments (according to patient)
Paracetamol SR (Panadol Osteo) 665 mg
2 tds
Knee pain, but not so effective
Systane eye drops
1 drop prn
Colecalciferol (Ostelin) 25 mcg
1 m
Loperamide (Gastro-Stop) 2 mg
1 – 2 prn
Loose bowels, takes once or twice a week
Levothyroxine (Oroxine)
100 mcg
1 m
Targin 10/5
(Oxycodone / Naloxone) 10 mg / 5 mg)
1 bd
Pain, recently started
Relevant test results
3 months ago:
• Sodium: 142 mmol/L (135 – 145 mmol/L)
• Potassium: 4.8 mmol/L (3.4 – 4.5 mmol/L)
• Cholesterol: 3.6 mmol/L (<5.5 mmol/L) • Creatinine: 62 micromol/L (50 - 110 micromol/L) • Blood pressure 141/79 mmHg • HbA1c 68 mmol/mol (8.4%) • TSH 0.95 mIU/L (0.50 - 4.00 mlU/L) Last week, new GP requested CK level: 340 U/L (30 – 180 units/L) Information from patient interview Whilst at the patient’s home the following information is obtained: • She has been taking mirtazapine for about a year, but her mood is not much better so about 10 days ago she reduced her antidepressant dose. • Says that weight has surprisingly increased by about 7 kg in the last 6 months or so. She has not felt like exercising. • She monitors and records her blood glucose levels in the morning before breakfast most days and shows you her readings. You notice that there are several around 4 mmol/L. She thought that this was a good result. When asked, she acknowledged there was some concurrent dizziness and light-headedness. • Saw the doctor last week as her calf muscles have been sore. Page 3 • Also said her feet can feel tingly but did not mention this to the doctor. Pain restricts her daily activities, and this makes her depression worse. She tells you that the doctor did a ‘blood test for her legs’. • Has milk in her tea every morning but does not eat dairy food as her cholesterol has been high. • Says that she rarely misses taking any doses of her medicines Questions Consider the patient needs or concerns, medication-related problems, and medication management issues. 1. What further information would assist in making your assessment of this patient? Explain reasons for obtaining this information. Who/where would you obtain this information? 2. Based on the information provided, identify potential and actual medication-related and disease-related problems, and patient concerns. Suggest how these could be addressed and/or monitored. 3. Write a letter or report to the referring GP, outlining your key findings for this patient and your suggestions or recommendations. Order Now

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