MDC Reflection Philosophy & Clinical Case

Mr. Drexel is a 55 year old man with a history of hyperlipidemia, hypertension, atrial fibrillation, a mechanical aortic valve, chronic renal insufficiency and ischemic cardiomyopathy with an EF of 40% who presents to the emergency room for increasing shortness of breath. The shortness of breath began about two weeks ago mainly when walking for exercise as he tries to do 3-4 times per week. He walks about 1 mile and usually is able to do so without much difficulty, at a moderately brisk pace. However, he began to have to cut his walks short due to feeling short of breath about halfway through. Over the past week he has had shortness of breath with activities such as walking down a short driveway to get his mail. He has to stop and rest for 5-10 minutes before he can catch his breath again.

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He has not had any shortness of breath at rest, except when sleeping. This has improved by sleeping on a slight incline with 2-3 pillows supporting his back. He is not waking up at night due to shortness of breath and is grateful to finally be able to get 5-6 hours of uninterrupted sleep. Prior to the onset of these symptoms he was urinating frequently at night and it was difficult to fall back to sleep. He has noticed that his shoes feel more tight and has had to wear sandals the past few days. His legs seem to be getting swollen but there is no redness or warmth that he has noticed. He denies having had any chest pain, palpitations, lightheadedness, syncope, cough or wheezing. In the emergency room he has an EKG: Labs are drawn including the following: CBC: Hgb 14.2 WBC 6.8 Platelets 244,000 BNP 1,250 pg/ml Na 139 K 4.2 CO2 28 mEq/L Cl 101 mEq/L BUN 10 mg/dL Cr 2.1 mg/dL (baseline Cr is 2.0-2.2) Troponin < 0.4 ng/mL TSH 2.5 You decide that this patient needs to be admitted for treatment for an acute exacerbation of CHF.

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You talk to him a little bit more to determine the possible reasons for the CHF exacerbation. 1. What are the specific reasons this patient may be having an exacerbation of his CHF? BNP elevated= exacerbation of heart failure. No P waves, irregularly irregular Chest x-ray cloudy= fluid Medication nonadherence or dose adjustment needed. You gather his medication list from him for the admission medication reconciliation. This is a process whereby the admitting team verifies what medications the patient is on so that they can continue essential medications and make any necessary changes based on the patient’s condition. The resident has offered to help you enter the medication orders when the patient is admitted. 1. What are the possible errors or problems that can occur when taking the medication Patient hesitant to recognize they missed doeses, closed ended questions, not gice you all reconciliation from the patient? medications or correct information 2. What are the consequences that could result from these errors or problems? 3. What could be done to prevent them?

1. Lisinopril 10mg PO daily (he takes at 7am with breakfast) 2. ASA 81mg PO daily (he takes at 7am with breakfast) 3. Metoprolol 25mg PO BID (he is taking it at 7am and 7pm, with breakfast and dinner) 4. Digoxin 125 mcg PO daily (he takes at 7am with breakfast) 5. Lasix 20 mg PO BID 6. Warfarin 3mg PO daily 7. Atorvastatin 40mg PO QHS (9pm when brushing his teeth)- often forgets to take it 8. Levothyroxine 75mcg PO daily (takes at 5am upon waking)

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The following questions are regarding the medication list above: Not being adherent is causing the fluid buildup and ultimately the heart failure. Narrow therapeutic window so could have toxicity. Wait until next dose is due and go from there. MDC Reflection Philosophy & Clinical Case

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1. He isn’t sure of his last Digoxin dose. Do you continue the digoxin? If so, when would you give the next dose and how would you determine the best dose and frequency?

2. He discloses to you that because he was urinating too frequently at night he stopped taking the second dose of Lasix. He was instructed to take it BID and took it at the same time as his other BID medications, 7am and 7pm, when he ate breakfast and dinner.

3. Can and should you continue the beta blocker? Explain your rationale. What if the patient is unsure if they have been taking this medication? Would you place them on it for this admission?

4. What are the methods and systems in place that would allow you as a student or practitioner to verify what the patient is most likely taking?

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The nurse calls you and asks if a foley catheter can be placed as the resident has ordered strict I’s and O’s (volume in and volume out measurements). It will be difficult to measure the urine output without the foley helping to collect it and they are worried that the patient might fall in the middle of the night trying to ambulate to the bathroom. What would you like to do and why? Place catherer to be able to measure and because pt doesn’t like to get up to go to restroom. The patient is admitted to a telemetry floor in order to have cardiac monitoring. Labs orders include two more troponin levels 4 hours and 8 hours after admission, along with repeating the EKG. You want to make sure the heart failure isn’t due to a myocardial infarction. These return negative. The morning BMP is unchanged from the admission BMP. Mr. Drexel does much better over the next 2-3 days and the CXR improves back to baseline. He is able to walk around the floor with minimal dyspnea on exertion and he is able to wear his shoes again. He is very happy with his care and thanks you. Before he leaves you review his medications with him. You decide to make some changes to the scheduled time he takes his medications to make them easier to manage. Try to put them as close to each other as posssible.

1. What changes would you recommend to improve patient adherence to his medications?

2. What could you tell/teach/ask the patient to better understand how you could help him in a What’s a typical day like for you? partnership to improve adherence?

3. How can we consider and/or address reduced health literacy in our patients especially when there is a complex medication regimen? Basic instructions. Draw sun/moon,

4. What is your final list of medications? Metoprolol succinate QD Lasix increase to 40 mg QD Case twist: (Complete if time allows) Whether you chose to insert a foley catheter upon the request of the nurse or not, please consider the scenario where one was inserted.

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In this case your Mr. Drexel developed a UTI during the admission. The culture returns positive for E. coli which is only sensitive to Bactrim. Therefore, he is discharged on Bactrim in addition to his other medications.

1. What additional considerations need to be made with regards to the addition of Bactrim to DDI- Bactrim and Warfarin. the other medications?

2. What errors could result in this scenario and what might the consequences be? Decrease warfarin. Check for bleeding and bruising.

3. What are the checks in place to reduce errors in prescribing new medications? Computer system will show DDI aside from physician and pharmacist checking.

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Communication, medication reconciliation End of Case Student Reflective Writing Exercise: Instructions: Reflect on the following prompts and provide a 2-3 sentence response for each prompt. Students have an assignment in Canvas where their individual responses should be entered. Note that this is NOT a group assignment, and should be completed such that it represents independent thought and work. estranged

1. Describe each of the individual profession’s roles and responsibilities related to the care of the patient in the case.

2. Describe some communication strategies that your team employed to enhance interprofessional teamwork. Is there anything that you would add or change for next time?

3. Describe your observations of how leadership developed and evolved within your interprofessional team today.

4. Describe how the capture, organization, tabulation and display of health information can impact patient care and outcomes, facilitate or impede information exchange and influence the efficiency of the health system. … MDC Reflection Philosophy & Clinical Case