Pharmacotherapy and drug reconciliation


Case Study: Pharmacotherapy Care Plan with Medication Reconciliation and Profile Review

This assignment aims to assist the student to :(a)Recognize the importance of completing a medication history for each patient; (b) Identify the prescriber’s role in the assessment of appropriate medication therapy; and (c)Resolve medication related problems during the patient follow up visit. 

Read the case study below, answer questions, and conduct a medication profile review and reconciliation for the patient below with multiple comorbidities.

Case Scenario:

The patient presents to the clinic today for care transition follow up after a recent hospital admission.

Jim is a 62-year-old patient who has difficulty coming in for primary care visits due to limited mobility.He also sees cardiology, pulmonary and endocrine specialists for his comorbid conditions of diabetes mellitus, postcoronary artery bypass grafting (CABG) 2 years ago and mild chronic obstructive pulmonary disease issues related to a 30 pack-year history of smoking.He is also recently discharged from the hospital following a brief stay due to a flare up of his COPD.His last visit with you was over a year ago.During the triage by the nurse, the patient indicates he needs a refill of his Crestor prescription, which was ordered by cardiology soon after his CABG.Per the electronic link to the cardiology service within your facility, the medication was due to be renewed about 2 months ago.His last lipid labs were a year ago.His most recent complete metabolic panel taken during the hospital stay was notable for a blood glucose of 187 and his last recorded HgA1C was 9.0 from a visit to endocrine 4 months ago.

Review of records include a prescription for his hypertension of lisinopril 20 mg daily for five years, metformin 1000mg twice a day for his diabetes four months ago and no known medications for his pulmonary issues.The Crestor prescription appears to have multiple dosing levels over the past few refills.The patient also reports being prescribed Protonix 40mg daily at hospital discharge, but he is unsure why he is taking this medication.

His last vital signs were blood pressure (BP) 170/110 mmHg, pulse 88 and respirations 22.His body mass index is 30 and he indicates a pain level of four out of five.His pulse oximetry was 92% on room air.

Answer the following questions related to this case study.Cite at least 3 current, peer-reviewed, scholarly sources in your answers and include a reference list.Cite at least one drug information resource (i.e., UpToDate, Micromedex, Lexicomp).

How do you respond to the request for the Crestor refill?

Identify the medication therapy issues that should be addressed in clinic today.

For each medication prescribed, assess if the medication, dose, frequency, and indication are appropriate for Jim.

Reconcile Jim’s medication list based on his current problem list to determine if each medication should be continued, discontinued, modified or new therapy initiated.Provide rationale for each therapy recommendation.

How can the primary care provider (PCP) assist Jim in improving his medication compliance and coordination of care?

  • Complete the Medication Profile and Reconciliation Review form provided for Jim’s clinic visit.

Pharmacotherapy and drug reconciliation

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