Therapeutic Use of Medicines (TUM202) T3 2021 Assessment 2 – Polypharmacy case study Background information Judy is a well-known patient of the medical practice, as a result of having multiple chronic conditions which require regular visits to the medical practice. Due to a decrease in available appointments as a result of the covid-19 vaccination rollout, Judy has not visited the clinic in 5/52, following the second dose of the Pfizer vaccine, and a check up to monitor her response to newly prescribed sertraline (Zoloft), which has had an initial positive effect on her mood. Prior to seeing the GP, the Practice Nurse conducts a physical assessment and conducts an interview with the patients, so that when the GP is ready, they will have recent assessment data to expedite and facilitate the consultation. Judy is known to sometimes self-adjust her medication doses to manage the clinical manifestations of heart failure, asthma and diabetes, without consulting her GP. Judy’s chief complaints for booking the appointment today are: Request to review her asthma management planIncreased shortness of breath (SOB), increased chest tightness and heart palpitationsIncreased lower leg oedema, and newly recent bilateral hand oedemaFeeling general aches and pains all over her body Patient DetailsName: Judy HarrisAge: 61 Allergies: NoneLanguage: English speakingReligion: CatholicDiet: Type 2 diabetic dietN.O.K: Husband (Douglass)Medical Past HistoryChronic Heart Failure (CHF)HypertensionHyperlipidaemia (diet controlled)Type 2 diabetes mellitus (T2DM)DepressionObesityAsthmaAtrial fibrillationEczemaSocial HistoryLives with husbandOwns a small business (currently closed due to covid-19)Supportive daughters x2Consumes 1-2 standard alcohol drinks per weekCeased smoking 16 years ago (smoked 5 packs a week for 21 years)Volunteers occasionally with the Country Women’s Association (CWA)Current MedicationsPerindopril 5mg oral Daily Digoxin 250mcg oral DailySertraline 50mg orally Daily Humalog 75/25, 33 units before breakfast and 23 units before dinner.Amiloride 10mg oral dailyAlbuterol MDI PRNGlyceryl trinitrate ½ tablet SL (when symptomatic)Salmeterol MDI PRN (not currently taking)Fluticasone MDI PRN (not currently taking)Prednisolone 5mg-30mg Oral (tapered)Nursing Assessment: Judy was able to walk into the assessment room unaided from the waiting room, and greets you with a smile. Vital Signs Manual BP: 144/88 HR: HR: 72 bpm; feels strong but irregular RR: 21 per minute Sp02: 97% on Room air GCS: 15, PEARL 3mm Temperature: 36.7c Pain 3/10 at rest, 4/10 on movement, cramping in nature, widespread all over the body. Weight: 91kg; height 5′4″ Whilst conducting a pupillary assessment, Judy mentions she recently started noticing halo’s in her visual field, and her vision is mildly blurred despite previously never needing to wear glasses Lungs: Clear on auscultation Electrocardiogram (ECG) shows Atrial Fibrillation, peaked T waves, and a shortened QT segment Lower extremities: +1 pitting oedema bilaterally; pedal pulses present but difficult to palpate as a consequence of oedema Bilateral hand oedema (mild) – unable to fit wedding rings on her fingers. Whilst interviewing Judy, she reveals the following information: Judy has been self-adjusting her medication regime, to try to find the right balance for her symptoms of heart failure, asthma and diabetes, but she feels like she has gotten worse over the last 5-6 days. Judy reports the increasing frequency of exacerbations of asthma require ongoing prednisolone tapers, which she finds a lot of effort to stay on top of, and reports she has been taking prednisolone almost every day for the last month. During her last round of prednisolone therapy, her BGL’s increased to 15-25mmol/L, despite decreasing her carbohydrate intake. To self-manage this, Judy “takes a little more” insulin when she notes high blood glucose readings, but she has not been instructed on the use of an insulin sliding scale. Judy reveals she typically increases the frequency of her fluticasone, salmeterol, and albuterol to 4-5 times/day during an asthma flare-up however, she can no longer afford the fluticasone or salmeterol and so has only been taking prednisolone and albuterol. Judy and her husband have been out of work for 18 months as a result of the global pandemic, and their only source of income is their Job Keeper payments, as their small business has closed. The ongoing costs of regular medications has placed additional stress on Judy’s finances, making her feel anxious and more aware of her chest tightness, and heart palpitations. When Judy experiences chest discomfort, she takes glyceryl trinitrate as prescribed however, this has had no effect on the discomfort or palpitations. Judy reports that on the days her lower legs and hands swell the most, she is active and in an upright position throughout the day. Swelling increases throughout the day, to the point she cannot wear her wedding ring, or fit into close fitting shoes comfortably. Judy makes the decision to take an extra amiloride tablet, sometimes half a tablet, if her swelling is excessive and painful around lunch time; as taking the amiloride later in the day prevents her from sleeping because of nocturnal urination. Disclaimer: This clinical scenario has been developed for educational purposes only, for students undertaking TUM202 in T3, 2021 at Torrens University Australia (TUA). All characters are fictitious, and the clinical scenario does not depict any real person, or event.
