Case Summary
Polypharmacy guidance: realistic prescribing
Patient Details
79 year old man
Current medical history
- Mild cognitive impairment
- Coronary heart disease
- Moderately impaired left ventricular systolic function on ECHO
Results
- BP 160/80 mmHg
- Continues to smoke 5 cigarettes daily
- Respiratory Rate 26 per minute (rest)
- U&Es all within normal range
- Pulse 86 bpm regular
- MMSE 18
Current Medication
- Omeprazole 20 mg once daily
- Simvastatin 40 mg at night
- Clopidogrel 75 mg once daily
- Bisoprolol 2.5 mg once daily
- Amlodipine 10 mg once daily
- Furosemide 40 mg once daily
- Trazodone 100 mg at night
- Tolterodine MR 4 mg at night
- Salbutamol MDI 2 puffs as required
Current Function
Has been in care home for 12 months. Intermittent behavioural upset . Diet and general personal hygiene improved since been in care home. Generally inactive during the day, apart from when goes to have a cigarette. Becomes short of breath whilst walking to have a cigarette. Shows signs of early dementia and can be difficult to engage depending on mood. Sleeps deeply at night and is difficult to rouse in the mornings.
Most Recent Consultations
Nursing staff tell you that they have recently requested salbutamol as they think he has asthma as he’s a little breathless. He is unable to co-ordinate using the salbutamol and it has had no effect on his symptoms of breathlessness. He is breathless at rest, and this becomes worse with a short walk. He has to be propped up in bed at night. Persistent issues with peripheral oedema, and lower limbs leak serous fluid at times.