Medical History

Patient Case 2 – DENNIS

Mr Dennis Vale

22 Stretton St

QLD 4112

Diagnosis:

Presenting Complaint: Respiratory infection

 

Medical History:

Hypertension (Since 2000)

Type 2 Diabetes (Recent < 6 months)

 

Medication History:

ramipril 5mg 1 daily

metformin 1g twice a day

simvastatin 40mg 1 at night

aspirin 100mg 1 daily

ibuprofen 400mg 1 tablet three times daily, when needed

 

Allergies/previous Adverse Drug Reactions:

penicillin – anaphylaxis (as a young man; not re-challenged)

Age: 78

Weight: 98 kg

Height: 167cm

Smoking: no

Alcohol consumption: Admits to 2 or 3 glasses of red wine every night

Lab Tests/Diagnostic tests 15/3/17:

BP: 155/95 mmHg

Glycated haemoglobin concentration (HbA1c), 53 mmol/mol (7%)

Renal impairment: CrCl 10 mL/minute.

Potassium: 5.8 mmol/L

 

Dennis is a widower who lives by himself. After losing his wife Pamela a year ago, Dennis has not been himself – he misses his wife. Previously he used to go for regular walks with Pamela, but now prefers to stay in. He cannot be bothered preparing meals and so his diet comprises mainly of fast food or instant pre-packaged meals. He has put on 10kg within 3 months and states he likes to eat 2 to 3 bananas every day.

Dennis was recently diagnosed with Type 2 diabetes which he finds hard to accept, as he had been healthy for most of his life. He was prescribed metformin 5 months ago. Initially he experienced terrible stomach aches and some diarrhoea, but this has resolved in the last few months.

Dennis has been prescribed a new prescription for his respiratory infection: Augmentin Duo Forte 875/125mg: 1 tablet twice a day for one week. He is reluctant to take more prescribed medicines and wonders if a complementary medicine would help with his chest infection.

You are required to present the following in the provided ASE-C-POP template:

Identify all actual and potential therapeutic problems in this case, focussing on Quality Use of Medicines approaches (drug & non-drug strategies or concerns);

Outline & discuss available options to resolve the issues identified (in order of priority);

Explain your team’s therapeutic plan as solutions to the therapeutic problems identified; and

Outline other healthcare professionals that Dennis could be referred to.

 

Refer to the Assignment Instructions for further information.

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