Thu NguyenMontefiore Medical CenterInstitutional IPPE7/25/16

Pharmaceutical Care Plan #1Patient Initial: F.D. Age: 60 y.o. Height: 5’9”MRN#: 02049566 DOB: 08/14/1955 Weight: 82.4kgDate of Admission: 07/19/16 Gender: M Date of Discharge: awaiting for SAR IBW: 70.7kg CrCl: 59.4 mL/min BMI: 34.43kg/m2

Subjective

Chief of Complaint: Pt was admitted ED with slurred speech at baseline A&Ox2, denies pain. Evaluation showed right leg swelling according to EMS.

HPI: 60 y/o M with hx of CVA in 2001 w/ reported spastic hemiparesis, which left him bedbound, currently wheelchair bound, and lower extremity DVT for which he received IVC filter and one year of A/C (Coumadin therapy). Pt was recently admitted for an extensive acute-on-chronic RLE swelling and found to have chronic IVC thrombus distal to the IVC filter. At the time he was recommended to have thrombolysis but wife decided against surgery and opted for medical management. He was bridged to Coumadin at the time and discharged home. He is now returning with complaint of increased swelling. He and his wife are now opting for thrombolysis. No pain in RLE. Per patient, medical team’s examination, and repeat imaging patient improved from prior discharge. Now awaiting SAR placement.

PMH: HTN, T2DM, reported CVA in 2001, Hx of heat stroke, StrokePSH: Inner ear surgeryFH: CVD, stroke (cerebrovascular disease)SH: Pt is married and staying with wifeAllergies: NKDA

Home medications:Alcohol swabs 1 ea by msc route bid

Amlodipine (Norvasc) 10mg tablet

1 tab po qd HTN

ASA 81mg EC tablet 1 tab po qd HTN

Atorvastatin (Lipitor) 40mg tablet

1 tab po qd HTN

Blood sugar diagnostic strips 1 ea by msc route bid

Blood glucose meter

Enalapril (Vasotec) 20mg tablet

1 tablet po qd HTN

HCTZ 25mg tablet 1 tablet po qd HTN

Insulin detemir (Levemir) 100 units/ml (3mL)

Inject 10 units SC qhs T2DM

Lancets 28-G msc Test daily before all meals/snacks and once before hs

T2DM

Metformin (Fortamet) 1000mg 24hr tablet

2 tablets po qd with breakfast T2DM

Wheelchair devi utd

Objectives:

Vital Signs (On admission):BP: (goal based on JNC8: <140/90) : 134/87HR: (normal: 60-80) : 88Temp: (normal: 97-98) 97.9oF (36.6oC)RR: (normal: 12-20) 18SpO2: 96%

Physical Exam (On admission):Gen: NAD, difficult to understand d/t dysarthriaRLE: Mild swelling from thigh down to ankle. Compartments soft. No tenderness, erythema, or phlegmasia. 2+DP and femoral pulse.

CMP 7/19/16 7/20/16 7/21/16 7/22/16 7/23/16 7/24/16 07/25/16 07/26/16

Na (135-147 mEq/L) 145 144 142 141 141

K (3.5-5 mEq/L) 4.6 4.5 4.5 4.5 4.5

Cl (95-105 mEq/L) 108 106 104 104 104

CO2 (22-28 mEq/L) 23 23 24 21 23

BUN (6-20 mg/dL) 34 31 23 19 19

SCr (0.6-1.2 mg/dL) 1.3 1.2 1.2 1.1 1.2

Calcium (8.5-10.5 mg/dL)

9.5 9.3 9 8.8 9

Phosphorous (2.5-4.5 mg/dl)

3.6 3.1

Magnesium 1.7 1.5 1.8

Glucose (70-99 mg/dL)

146 161 181 132

Glucose (POC)

FBG (80-130)

PPG (<180)

(0724)

136

(0611)

158

(1725)

247

(1647)

159

(1741)

145

(0631)

127

(1714)

133

(1612)

128

(0553)

128

HbA1C 12.8

CBC 7/19/16 7/20/16 7/21/16 7/22/16 7/23/16 7/24/16 7/25/16 7/26/16

Hgb (12.3-15.3 g/dL) 12.4 11.5 12 11.9 11.6 11.3

Hct (41.5-50%) 36.7 34.7 35.4 35.2 34.6 33.8

Platelet Count (150-400 K/UL)

319 297 295 318 280 264

WBC (4.8-10.8 K/uL) 9.2 8.3 9.2 8.8 8.8 7.9

7/19/16 7/20/16 7/21/16 7/22/16 7/23/16 7/24/16 7/25/16 7/26/16

INR (2-3) 1 1.1 1.35 1.3 1.2 1.4 1.5 2.4

Warfarin dose 5mg 5mg 5mg 5mg 7.5mg 7.5mg 6mg

Imaging:LE Doppler 7/19/16Right: there is evidence of persistent partially occlusive superficial vein thrombosis noted on the right lower extremity within the great saphenous vein from mid thigh to the proximal thigh.Left: No evidence of deep or superficial vein thrombosis noted on the left lower extremity

Hospital Course:

07/19/16: Upon examination, pt had no PE, no suspicious lung lesion or thoracic lymphadenopathy, small nonspecific hypodense lesion in the spleen. Otherwise, there was no mass, lymphadenopathy or fluid collection in the abdomen or pelvis, cholelithiasis, infrarenal IVC filter with likely chronic thrombosis of the IVC distal to the filter. Pelvic veins are not adequately evaluated for thrombus due to relatively early timing of the study. Primarily SC edema of the right buttock and flank with more diffuse edema of the right thigh extending along the right lateral pelvic wall.Pt had CVA in 2001, and DVT around the same time treated by IVC filter and A/C, now with RLE swelling due to IVC thrombus. Swelling (right left) didn’t improve with medical therapy and the pt is amenable to thrombolysis now. Resident start Heparin drip 5,000 units bolus and then start at 1200 units per hour. Q6h PTT, goal 60-80, RLE compression and elevation

7/20/16: Vital signs: BP 138/87 mmHg, HR 88, Temp 98.4oC, RR 16, SpO2 96%Pt is wheelchair bound, and prior LE DVTs s/p IVC filter and ACx 1yr (2001). Pt was recently d/c earlier this month for an acute on chronic extension of RLE DVT, start on Lovenox and bridged to Warfarin, per wife worsening leg swelling. Pt currently has no complaints, denies pain, recent trauma, decreased range of motion, numbness, paresthesia, decreased sensation. Also denies SOB, chest pain, or palpitations. Positive for constipation, difficulty urinating. Negative for dysuria, urgency, frequency and flank pain.As per wife, leg has not improved and feels like it has gradually become larger in size. Was discharged on Warfarin, however there was no prescription for Warfarin or Enoxaparin at her pharmacy. She asked RPh if a “blood thinner” was prescribed, however was told by him that ASA was a blood thinner, so she continued him on his ASA 81mg. D/t concern over the night leg swelling, she tried to reschedule the f/u appt with Dr. Yap to a sooner date. Was rescheduled for 7/21/16. However, when the visiting nurse came to home 7/15/16, she was concerned for the swelling in his right leg and urged his wife to bring him back to ER. S/p 80mg Enoxaparin SC in ED, no sx of PE.Wife wants him to have surgery, but pt feels he is improving, no s/sx of compartment syndrome. Treatment dose of Enoxaparin 120mg qd, f/u with vasc about surgical plans. Add on and restart home meds Amlodipine 10mg, HCTZ 25mg, Enalapril . T2DM is poorly controlled, HbA1C 12.8 (7/5/16), home meds Metformin 1000mg and 7 units lantus. Started Metformin 1000mg BID, Lantus 5 units qhs, can titrate prn. Add-on: Start Lovenox, first dose Coumadin tonight, f/u final duplex results. Continue Enalapril 20mg po qd, monitor BPs and slowly add/titrate meds prn. Continue Metformin 1000mg XL PO qd, monitor FBG today and likely to increase Detemir dose tonight.

7/21/16; Pt’s sx improved while he was at hospital, with significant reduction in swelling and no pain. No signs of PE throughout hospital stay. Vascular surgery was consulted to discuss the option of thrombolysis. Pt preferred medical therapy. Add-on: start Coumadin 5mg on 7/20/16 night. No events overnight. Pt denies LE swelling, pain, cough, SOB.LE Dopper on 7/19: Right- there is evidence of persistent partially occlusive deep vein thrombosis, noted on the right lower extremity within common femoral vein, femoral vein, popliteal vein, one of the peroneal and posterior tibial veins. Current meds: Amlodipine 10mg po qd, Enalapril 20mg po qd, Enoxaparin inj 1.5mg/kg/dose SC q24AD, Insulin Detemir (Levemir) 5 units SC qhs, Metformin 1,000mg XL po bid w/meals, Warfarin 5mg po qhs, Dextrose 25mL IV q15min prn, Glucagon (human recombinant) 1mg IM q15min prn. Continue to hold HCTZ. Plan to bridge to Coumadin.T2DM, CVa hx- stable.

7/22/16 Pt feeling well today. Agreeable to SAR. Pt improved from prior, both on exam and confirmed with imaging. Bridging to Coumadin, continue Enalapril 20mg po qd, and Amlodipine 10mg po qd. Continue Metformin 1000mg XL po daily, determir 5 units SC qhs. Continue to hold HCTZRecommend 2 doses of Coumadin 5mg, 3rd dose tonight 5mg. No event overnight, cough, SOB, LE swelling or pain. Pt rec SAR, will bridge in hospital with Lovenox then once pt is therapeutic, will send to SAR.

7/23/16 Pt feeling well this morning, no complaints, eager to be discharged to SAR.

7/24/16: Vital signs: Temp 97.9oF, HR 98, RR 18, BP 132/90 @0632, 141/87 @ 2200 Pt felt slightly nauseous this morning. Reports some mild nausea after takinig Metformin. Otherwise without complaints, awaiting SAR placement. Pt was given Ondansetron 4mg IV qhs for nausea. Bridging to Coumadin, increase to 7.5mg tonight and f/u INR tomorrow. Continue HTN meds. Continue Metformin 1000mg XL po qd, hold LA insulin 5 units qhs. Hypomagnesemia- repleted with Magnesium oxide po. Pt rec SAR, will bridge Lovenox then once pt is therapeutic will send to SAR.

7/25/16 Vital signs: Temp 97.6oF, HR 82, RR 20, BP 131/97 @0512Pt had no complaint today. Feeling well. No nausea. Pt requesting more assistance during mealtime for help with feeding himself. Pt denies CP, SOB, abd pain, n/v, worsening LE edema. BP was at goal, continue HTN meds. Monitor FBG, well-controlled today, continue Metformin 1000mg XL po qd, hold LA insulin. D/c to SAR when bed available. Will bridge in hospital with Lovenox then once pt is therapeutic will send to SAR. Resident ordered Warfarin 7.5mg tonight again.

7/26/16: Pt INR was 2.4 (range 2-3). MD ordered Warfarin 6mg start on 7/26/16 @2200 qhs. Pt is improved from prior, both on exam and confirmed with imaging. BP at goal, continue Enalapril 20mg po qd and Amlodipine 10mg po qd. Metformin 1,000mg XL po qd, hold LA insulin. Need INR check in 3 days. Pt is medically ready for discharge. Pt will be discharged to Jewish Home and Hospital for SAR, will be transported by ambulance.

Immunization:

No record. However, pt is eligible for immunizations based on comorbidity.HepB, PPSV23, Influenza immunizations are recommended. Need to confirm whether pt already had these.

Inpatient Medications

Problem list:Chronic DVT Assessment: Mr. Dejesus w/ acute on chronic RLE DVT underwent Doppler which showed DVT pf RLE w/i common femoral vein, femoral vein, popliteal vein, peroneal and posterior tibial vein which is much improved from his last doppler from last hospitalization 7/3- 8. Pt’s sx improved while he was here, with significant reduction in swelling and no pain. No signs of PE throughout hospital stay. Vascular surgery was consulted to discuss the option of thrombolysis. Pt preferred medical therapy.

Treatment Goal: - Resolution of s/sx (RLE swelling)- Make sure pt is stable on Warfarin upon discharged (INR in therapeutic range)- Manage pt’s T2DM condition, check FBG and PPG regularly.- Manage pt’s HTN condition, monitor BP regularly. Make sure pt has adequate BP

monitor.- Refer pt to social worker, dietitian, physical therapist upon discharge. - Make sure pt has adequate nutrition intakes, well-hydrated and well-nourished. - Schedule appropriate follow up appointments to medical providers.

Plan:- Pharmacological Therapy:

+ Initial Heparin drip 5,000 units bolus and then start @1200 unit/hour on 7/19/16+ Switch to Enoxaparin 80mg SC qd, and then Enoxaparin 120mg SC qd on 7/20/16+ Bridge pt to Warfarin 5mg on 7/20/16 evening, continue for 7/21/16, and 7/22/16, and

7/23/16+ Increase Warfarin dose to 7.5mg on 7/24/16 and 7/25/16+ Reduce Warfarin dose to 6mg on 7/26/16

- Monitoring Parameters: + Monitor target INR daily (range 2-3) following the initial dose until the INR stabilized to therapeutic range, then periodically based on clinical need, generally every 1-4 weeks.+ Monitor for bleeding risk.

Discharge Medications:

Medication Dose/Frequency Indication

Amlodipine 10mg tablet 1 tablet po daily HTN

ASA 81mg EC tablet 1 tablet po daily HTN

Atorvastatin 40mg tablet 1 tablet po daily

Enalapril 20mg tablet 1 tablet po daily HTN

HCTZ 25mg tablet 1 tablet po qd HTN

Insulin Determir (Levemir)100 units/mL

Inj 10 units SC qhs T2DM

Metformin 1,000mg q24hr tablet

2 tablets po qd with breakfast T2DM

Warfarin 6mg tablet 1 tablet po qhs DVT