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History and Physical

MC is brought to the hospital from home and is admitted through the emergency department.

Subjective CC: Right ankle pain and dizziness

HPI: 53 yo Spanish-speaking male (54, 65 kg) with metastatic prostate cancer on chemotherapy and hospitalized for pulmonary edema secondary
to hypertensive crisis (3 weeks ago). Patient has been having worsening right ankle pain over the past week and also states that he has
been experiencing episodes of dizziness. A week prior to admission the patient had a witnessed fall, no loss of consciousness observed. At
the most recent clinic visit (2 weeks ago) the patient was recently started bicalutamide 50 mg daily and leuprolide 75 mg every 4 weeks for his
prostate cancer.

PMH: Prostate CA

FH: Father died of MI at 45 years old; mother is alive and well

SH: Patient is a retired police officer. He is married for 23 years, wife is alive and well. He has 3 children.
(+) Drinks 3 beers per day, (+) tobacco 1/2ppd, (-) illicit drug use

MED: Amlodipine 2.5 mg po QD

Doxazosin 4 mg po QD
Bicalutamide 50 mg po QD
Leuprolide 7.5mg q4 weeks
Ferrous sulfate 325 mg po BID
Senna 17.2 mg po QHS
Docusate 100 mg po BID
Polythethylene glycol 3350 powder 34 grams po QHS
Finasteride 5 mg po QD
Tamsulosin 0.4 mg po QD


ROS: General Symptoms: (-) fever, chills

Skin: redness on right ankle (Pretest probability of DVT >2)
ENMT: (-) sinus symptoms, post-nasal discharge, dysphagia
Respiratory: (+) dyspnea, cough, pleuritic chest pain
CV: (-) chest pain, palpitations
GI: (+) diarrhea
Neurologic: (-) syncope

History and Physical

Objective PE: Gen Patient is spanish speaking male (54, 65 kg) in moderate respiratory distress due to pain
VS BP 160/95 (sitting, routinely 150s/90s), HR 72, RR 36, T 98.8F, O2 sat 86% on RA (inc to 100% with supp O2);
Skin Warm and dry
HEENT EOMI, neck supple
Neck (-) JVD, bilateral carotid bruits
Heart RRR, no mumurs
Lungs Breath sounds equal; CTA bilaterally, no intercostal retractions, no wheezing
Abd Soft, ND/NT, (-) HJR
Gent/Rect Normal, guaiac (-) stool
Ext Tender RLE, RLE 1+ pedal edema
Musc right medial malleolar redness and swelling
Neuro A&O x 3, CNs intact, responds to pain

155 | 95 | 20 / 120 8\ 13.1 /260
5.1 | 29 | 2.99 (baseline 2) / 39 \

aPTT: 30.3, [27.5 - 37.4 sec]

PT: 11.3, [9.4 - 13.0 sec]
INR: 1.03, [0.88 - 1.16 ratio]

Calcium, Total Serum: 8.7, [8.4 - 10.5 mg/dL]

Protein Total, Serum: 6.9, [6.0 - 8.3 g/dL]
Albumin, Serum: 2.4, [3.3 - 5.0 g/dL]
Bilirubin Total, Serum: 0.5, [0.2 - 1.2 mg/dL]
Magnesium, Serum: 2.2, [1.6 - 2.6 mg/dL]
Phosphorus Level, Serum: 5.9, [2.5 - 4.5 mg/dL]
Alkaline Phosphatase, Serum: 102, [40 - 120 U/L]
Aspartate Aminotransferase (AST/SGOT): 39, [10 - 40 U/L]
Alanine Aminotransferase (ALT/SGPT): 44, [10 - 45 U/L RC]
eGFR if Non African American based on MDRD: 57 mL/hr, [>=60 mL/min], Cockcroft Gault eGFR = CrCl 26 mL/min

US Duplex Venous Lower Ext, Right
Indication: Right leg swelling and pain
Impression: Right common femoral vein deep vein thrombosis and redemonstration of an enlarged 1.8 cm right inguinal lymph node

EKG: sinus tachycardia 105 bpm, with 1st degree AV block, No ST elevations or depressions, QTc 449

History and Physical

New medication orders on admission:

Heparin 5200 units IVP once
Heparin 1200 units/ hour continous infusion
Amlodipine 10 mg
Bicalutamide 50 mg po qd
Leuprolide 75 mg q4weeks
Ferrous sulfate 325 mg po bid
Senna 17.2 mg po qhs
Docusate 100 mg po bid
Polyethylene glycol 3350 powder 34 grams po qd
Finasteride 5 mg po qd
Tamsulosin 0.4 mg po qd

Assessment/Plan :
This is a 53 year old male with history of hypertension, BPH, prostate CA, and anemia presenting RLE extremity pain and edema indicative of DVT.

Use the table below to guide you in identifying the subjective and objective findings, creating an assessment with rationale, making an appropriate
recommendation/intervention, describing the goal of therapy/therapeutic endpoint and determining monitoring parameters for each of the health-related

History and Physical

Health-related problems Subjective or objective Recommendation / Goal of Therapy/ Efficacy Safety / Toxicity
findings Intervention Therapeutic
What evidence from the Endpoint
case support the therapeutic

Health-related problems

#1 DVT Ankle pain, edema, Continue heparin gtt for Reduce risk of clot Symptoms do not Bleeding, platelet
redness, Doppler results, now (cant use propagation and post worsen, findings in count
active cancer NOACs/LMWH 2/2 thrombotic syndrome S/O column
kidney dysfunction, resolve
warfarin not
recommended in
cancer) can switch to
LMWH if SCr returns
to baseline of 2mg/dL
(ClCr = 40mL/min)

# 2 Uncontrolled According to JNC 8: Both ASH/JNC 8 Both ASH/JNC 8 Prevent CV morbidity General:
Hypertension Uncontrolled BP & Guidelines recommend Guidelines and mortality
the same approach: recommend the same Monitor BP to ensure
According to ASH he is goal: Monitor for signs and that patient does not
Stage 2 Uncontrolled HTN Discontinue: symptoms of experience
BP <140/90 mmHg progressive hypotension (BP
(acutely elevated Doxazosin 4 mg hypertension <90/50 mmHg) in
possibly secondary Rationale: Achieve lifestyle associated target-organ light of dizziness
to pain (Currently patient is recommendations damage complaint
in the 160s; experiencing Incorporate Renal function
Generally in the falls and this diet and Sr.Cr. acutely Lab monitoring should
150s) medication exercise elevated, occur 2-4 weeks after
may increase recommendat however starting a new agent or
History of HTN/ Recent the risk. Also ions baseline is at dose increase then
hypertensive crisis is not the first successfully 2mg/dL; every 6-12 months
line therapy Reduced further Specific:

History and Physical
Amlodipine 2.5 mg alcohol evaluation of Indapamide
Increased CV risk Rationale: intake renal function Electrolytes:
Positive Family Starting dose Reduce must be K, Mg, Ca,
history for amlodipine tabacco use conducted; uric acid
No evidence of is 5 mg; ACEI or ARB Renal: SrCr,
physical activity Starting doses a strong BUN
Moderate drinking of 2.5 mg consideration A/E:
should be once CKD is
Smoking dizziness, fall,
started in established. dehydration,
AV Block noted on ECG elderly or those glucose
with soft Gradual BP lowering tolerance,
(consideration for
pressures every 2 to 3 months A1C
Therapies Initiate: Modify other risk Amlodipine:
Renal function noted
Amlodipine 10 mg factors
(consideration for Edema
Rationale: Physical
therapies) Sr.Cr increase Gingival
50% According to inactivity
JNC 8 this Tabacco use
patient should Alcohol intake
be started on
CCB, TZD, Assess BP 2-4 weeks
ACEI, or ARB Constipation
after therapy change;
as first line then monitor every 3 to
therapy. The 6 months
starting dose
should have Self BP monitoring
been 5 mg and may be necessary with
the progression this patients history
would be 10
mg dose.The
dose should be
because the
amlodipine is
being under-
Counseling tip:
Take once daily
in the

History and Physical
morning ;
excersice good
dental hygiene;
may occur,
improves over
time; Check BP
routinely in the
am before
Alert MD if
Indapamide 2.5 mg
According to
JNC8 should
be considered
therapy due to
the extent of
high blood
pressure and
the history. In
the past the
patient did
require 2
medications for
even moderate
ACEI would be
a good choice
in light of the
patients kidney
however since
the kidneys

History and Physical
seem to be
elevated ACEI
or ARBs
should be
initially. Renal
function should
be re-evaluated
should be
once renal
function returns
to baseline;
evaluation of
renal function
should be
tips: take once
daily in the
morning to
avoid nocturia;
Make sure to
drink plenty of
water with
Alert MD if

Lifestyle changes
According to

History and Physical
changes can
reduce BP. 1)
activity may be
limited with
episodes of
have been
exercised may
be encouraged
as tolerated =
up to 9 mmHg
drop in SBP. 2)
DASH diet:
Rich in fruits
and veggies,
low saturated
fat = up to 8
mmHg drop in
SBP. 3) Na
intake: reduce
to < 1.5 g = up
to 8 mmHg
drop in SBP. 4)
Educate on
proper alcohol
intake = </= 2
equivalent in
men; let him
know to reduce
is beer intake to
</= 2 beers a
day = up to
4mmHg drop
in SBP 4)

History and Physical
Educate on the
importance of
resources (i.e.
Adherence assessment
adherence and
increase risk
and cost if
adherence is
neglected in
of ASH
# 3 Diarrhea secondary to
# 4 Anemia
#5 BPH
#6 Prostate CA

The following are hospital medications that you, as the pharmacist, must assess and determine whether you are going to dispense.
For this part of the table, identify if you would dispense each medication, your justification, and what recommendation / intervention should be made / taken.
Medication Orders Would you Dispense? Justification and/or Recommendation / Intervention
Dispense or not dispense Yes or No

#1 Heparin 5200 units IVP Yes Correct drug/dose/route/frequency, weight-based dose


#2 Heparin 1200 units/ hour YES Same as above

History and Physical
continous infusion

#3 Amlodipine 10 mg Yes Call MD and ask to initiate a TZD and ACEI (possibly after renal function returns to
#4 Bicalutamide 50 mg po Yes

#5 Leuprolide 7.5 mg Yes


#6 Ferrous sulfate 325 mg po YES Patient complains of diarrhea; reassess use and need

# 7 Senna 17.2 mg po qhs NO

#7 Docusate 100 mg po bid YES Patient complains of diarrhea; reassess use and need

#8 Polyethylene glycol 3350 NO Patient complains of diarrhea; reassess use and need
powder 34 grams po qd

#9 Finasteride 5 mg po qd YES

# 10 Tamsulosin 0.4 mg po qd YES

Additional discussion questions:

1) Discuss the medicinal chemistry/ pharmacologic properties of the following agents:

Hydrochlorothiazide, and amlodipine

2) Compare and contrast heparin from low molecular weight heparin from a pharmacologic and medicinal chemistry standpoint

History and Physical
3) Discuss the pharmacology/medicinal chemistry of the NOACs/DOAC. Which ones are contraindicated in this patient? Explain why?

4) What are the typical causes for DVT and briefly indicate the physiological signs of such an event?

5) What might be the physiological and anatomical factors contributing to this patients DVT?

6) What events concerning the DVT might have led to the patients respiratory difficulty?