Cases: Mrs. Jones - prescribing cascade example:
85 yrs female pretty healthy – widow 110 lbs
-bad knee – ortho  ibuprofen 800 mg 2x/day
-F med – abdomeninal pain & edema  K &
furosemide
-cimedidine on side for ab pain
-urine incontinence – oxybutine
-slow & sedated in gait – dementia?
-neurologist – eresept
-GI bleed – ER – EGD  meteripine & verset
-fell  nursing home
-6 meds, 13 doses, dif side effects
Case 1:
The husband of a 78 year-old woman with Alzheimer’s
disease notes that she has had an increase in aggressive
behavior, delusions, and confusion over the past 2 weeks.
She is also treated for hypertension, depression and
urinary incontinence. Medications include donepezil 5
mg daily, lisinopril 10 mg daily, hydrochlorothiazide
25 mg daily, oxybutynin 5 mg twice per day (increased
from 2.5 mg twice daily 1 month ago), and citalopram 20
mg daily (increased 2 months ago from 10 mg). Her
urinalysis is normal (final common pathway). What
would you recommend?:
A. Start lorazepam
B. Start risperidone
C. Increase the dose of donepezil
D. Discontinue oxybutynin.
E. Reduce the citalopram dose.
Case 2:
A 72 year-old woman presents with recent onset of
dizziness, difficulty with ambulation, and lethargy. She
is treated for epilepsy, allergic rhinitis, overactive bladder
and recently was diagnosed with depression. Medications
include phenytoin 300 mg daily, tolterodine 2 mg twice
per day, fexofenadine 180 mg daily and she began
fluoxetine 20 mg daily 2 weeks ago.
Lab tests from 1 month ago reveal:
Phenytoin concentration: 13.7 microgram/ml
(therapeutic 10-20)
Sodium:
138 mEq/L
Potassium
4.0 mEq/L
Urea Nitrogen
15 mg/dL
Creatinine
1.0 mg/dL
Albumin
2.6 g/dL (normal 3.5-4.5)
Which would be the most appropriate next step in
evaluating her symptoms?
A. Obtain an unbound (free) phenytoin level.
B. Discontinue tolterodine.
C. Discontinue fluoxetine.
D. Discontinue fexofenadine.
Case 3: Mr. Rodriguez
An 83 year-old nursing home patient has seemed more
confused over the past 2 weeks. The staff describe
variable levels of alertness throughout the day. Appetite
and fluid intake seem OK. He has Alzheimer’s disease,
atrial fibrillation, depression and osteoarthritis. For the
past 3 years he has taken digoxin and warfarin. Fluoxetine
was added 2 months ago and ibuprofen 1 month ago. His
BP is 130/80, pulse is 54. What is most likely causing the
worsening confusion?
A. Advancing Alzheimer’s disease
B. Worsening depression
C. Digoxin toxicity
D. Bradycardia
E. Fluoxetine toxicity
Case 4: Mrs. Smythe
An 80 year-old woman comes to the office for a diabetes
recheck. She also has atrial fibrillation, class 3 heart
failure and had a myocardial infarction 3 years ago.
Medications include furosemide 40 mg twice daily,
potassium 10 mEq daily, lisinopril 5 mg daily, warfarin 2
mg daily, metoprolol 25 mg twice daily and glipizide 20 mg
twice daily.
Her blood glucose record over the past 2 weeks lists levels
ranging from 195 mg/dL to 225 mg/dL. Her hemoglobin
A1C level is 8.5%. Her creatinine is 1.7 mg/dL and
potassium is 4.3 mEq/L.
What would be the best next step to improve her diabetic
control?
A. Start metformin
B. Start insulin
C. Start rosiglitazone
D. Discontinue metoprolol
Case 5: Mr. Maki
An 82 year-old man comes to the office for a check-up. He
is treated for hypertension and atrial fibrillation. He
reports episodes of dizziness and has occasional diarrhea,
without melena or hematochezia. He also notes fatigue
and a poor appetite, but does not think that he is
depressed. His wife died 1 year ago. His medications are
atenolol, digoxin and warfarin.
His exam shows a BP of 138/70 and a pulse of 56 bpm. He
has lost 14 pounds (6% of his body weight) in the past 6
mos. The rest of his exam is unremarkable.
Which of the following is most likely to reveal the cause of
this man’s weight loss?
A. Serum digoxin level
B. Geriatric depression scale
C. Fecal occult blood testing
D. Chest X-ray
E. A home visit
Case 6: Mrs. Chin
A 92 year-old woman is being treated for major
depression with paroxetine, following successful surgery
for a hip fracture. Her physical and cognitive status have
otherwise been good. She takes acetaminophen for
osteoarthritis and hydrochlorothiazide for hypertension.
Ten days after paroxetine is started, her daughter calls to
report that her mother is lethargic and confused.
Which of the following metabolic disturbances is the most
likely cause of her delirium?
A. Hyponatremia
B. Hypernatremia
C. Hypoglycemia
D. Hyperglycemia
Answers
1. D (highly anticholenergic meds, recently inc dose
at same time as change in behavior)
2. A – phenytoin is albumin bound. Fluoxetine is
also albumin bound, knocks it off leading to an inc
in pheytoin  ataxia
3. C. ibuprofen dec renal bld flow, digoxin is renal
clearance  toxic range (slow pulse). Could also
be ulcer.
4. B – insulin. Not metfomin cuz of lactic acidosis, not
rosiglitazone cuz heart failure & edema,
metoprolol cuz needs for CHF
5. A – check digoxin level – may be in toxic range. He
is toxic – lost weight, low pulse. Geriatric
depression scale – specific for their age. Home
visit is never a bad idea
6. A – SIADH! Know it!