Patient #1
History of Present Illness
A 56 year old man presents as a new patient to your clinic. He is seeking care because his blood pressure
was elevated at 152/91 during a health screening at work. His only complaint today is heartburn which
occurs after heavy meals in the evenings approximately 2 times per month.
Past Medical History: None
Past Surgical History: None
Allergies: NKDA
Medications: None
Social History:
He works as a high school math teacher. Married with 2 children. No tobacco, alcohol, or illicit drug
use.
Family History:
Mother: 68 years old, Hypertension
Father: 72 years old, High Cholesterol
Physical Exam:
Temp: 97.8 HR: 82 RR:14 BP: 154/89 BMI:31
Normal
Laboratory Results:
Fasting basic metabolic panel is normal
Cholesterol: 261
Triglycerides: 73
HDL: 64
LDL:190
He has Blue Cross/Blue Shield Health Insurance.
Please list his active medical problems and appropriate treatment for each. For medications, please
write the medication, dose, and frequency. The team that best treats that patient’s problems in the
most cost effective manner wins.
Patient #2
History of Present Illness
A 45 year old woman presents as a new patient to your clinic. She has a history of diet controlled
Diabetes Mellitus. She is concerned because she has been getting blood sugar measurements in the
180-200 range when she checks her blood sugar in the morning. Additionally, she reports heartburn
pain 2-3 times per day. She also states that 2 days ago she developed burning upon urination,
frequency, and urgency. Otherwise, she has no other issues at today’s visit.
Past Medical History:
Diabetes Mellitus
Past Surgical History: None
Allergies: NKDA
Medications: None
Social History:
She works part time as a sales clerk in a local store. She is married with 2 children. No tobacco, alcohol,
or illicit drug use.
Family History:
Mother: 68 years old, Diabetes Mellitus
Father: 72 years old, High Cholesterol
Physical Exam:
Temp: 97.8 HR: 82 RR:14 BP: 124/78 BMI:31
Normal
Laboratory Results:
Fasting basic metabolic panel is normal
HgA1C: 8.6%
Total Cholesterol: 230
LDL: 130
She has Alabama State Medicaid.
Please list his active medical problems and appropriate treatment for each. For medications, please
write the medication, dose, and frequency. The team that best treats that patient’s problems in the
most cost effective manner wins.
Patient #3
History of Present Illness
A 50 year old man presents as a new patient to your clinic. His chief complaint is shortness of breath. He
has noticed increasing shortness of breath with physical activity over the last year. He states that he
gets short of breath when climbing stairs or walking greater than 1-2 blocks. He has an associated dry
cough that has gotten worse recently. He denies any fever, malaise, or weakness.
Past Medical History: None
Past Surgical History: None
Allergies: NKDA
Medications: None
Social History:
He works for a local construction company. He is married with 2 children. He smokes 1 pack per day
(x35 years), drinks 1-2 beers each night, and denies illicit drug use.
Family History:
Unknown, adopted
Physical Exam:
Temp: 97.8 HR: 92 RR:18 BP: 124/78 BMI:20
Thin man not in distress
Lungs: diffuse wheezing
Spirometry Results:
FEV1:68%
FVC: 85%
FEV1/FVC ratio: 62%
Chest X-ray: Hyperinflated lungs without consolidation, masses, or other infiltrates
He has no health insurance
Please list his active medical problems and appropriate treatment for each. For medications, please
write the medication, dose, and frequency. The team that best treats that patient’s problems in the
most cost effective manner wins.
Patient #4 (Outpatient)
History of Present Illness
A 58 year old woman presents as a new patient to your clinic. She tells you that she has not seen a
doctor in 2 years. She tells you that she has been very depressed lately. She lost her job 5 months ago.
She feels sad and no longer enjoys activities that were previously fun to her. She has a decreased
energy level and trouble sleeping at night. She has a history of diabetes but stopped taking her diabetes
medications several months ago.
3 days ago she developed a cough productive of yellow sputum, fever, and right sided chest pain (worse
with coughing).
Past Medical History:
Diabetes Mellitus
Past Surgical History: None
Medications: None currently
Family History:
Unknown, adopted
Allergies: NKDA
Social History:
She is currently unemployed. She previously worked as a bank teller. She is married with 2 children. No
tobacco, alcohol, or illicit drug use.
Physical Exam:
Temp: 102.5 HR: 92 RR: 20 BP: 124/78 BMI:33 Oxygen: 98%
Obese woman in no acute distress
Lungs: crackles in right base, otherwise clear
Chest X-ray: Focal lobar consolidation in right lower lung field consistent with pneumonia
Laboratory Data
BMP normal except glucose 380
WBC: 13
HCT: 37
Platelet: 265
Hga1c: 13.8%
She has no health insurance.
Please list her active medical problems and appropriate treatment for each. For medications, please
write the medication, dose, and frequency. The team that best treats that patient’s problems in the
most cost effective manner wins.
Patient 4 (Inpatient)
You are switching to the University medicine service today. Your first task is to discharge a patient who
is ready to go home, but is waiting on prescriptions to be written.
She is a 63 year old woman with a history of insulin dependent type 2 Diabetes Mellitus, hypertension,
hyperlipidemia who presented to the ER 4 days ago with pneumonia. She had respiratory distress and
was admitted to the ICU and placed on BIPAP. Her pneumonia was treated with moxifloxacin and she
was given esomeprazole for GI prophylaxis. She was transferred to the floor on hospital day #3. Upon
interview, she was noted to be depressed and Lexapro was started. Her diabetes has been well
controlled since admission on an insulin glargine/insulin aspart regimen. Her blood pressure has been
well controlled on irbesartan and amlodipine, and her cholesterol is well below goal on atorvastatin.
You evaluate her. She is breathing comfortably on room air. She has a good mood, and states she is
ready to go home, but just needs her prescriptions. She reminds you that she doesn’t have health
insurance.
Task: You want to impress your new attending by demonstrating cost conscious care. Please evaluate
the regimen below and recommend any changes you deem appropriate. The team that saves the
patient the most money while still effectively treating each of her medical problems wins the
competition.
Current Medications:
Moxifloxacin 400mg daily x6 days
Esomeprazole 40 mg daily
Lexapro 20mg daily
Insulin Glargine 20 units QHS
Insulin Aspart 8 units TIDAC
Irbesartan 150mg daily
Amlodipine 10mg daily
Atorvastatin 20mg daily
Patient #5 (Inpatient)
History of Present Illness
A 50 year old man with a history of COPD was admitted to the hospital with a COPD exacerbation. He
was treated with IV solumedrol and nebulizers and greatly improved over the next 3 days. You round
with your team and the decision is made to discharge him home. Please evaluate his current medication
list and recommend any changes that you deem appropriate. He has Alabama Medicaid prescription
coverage.
Past Medical History:
Type 1 Diabetes Mellitus
COPD (FEV1 40% predicted)
Hypertension
Please evaluate the regimen below and recommend any changes you deem appropriate. The team that
saves the patient the most money while still effectively treating each of her medical problems wins the
competition.
Current Medications:
Prednisone taper over 2 weeks
Symbicort 160/4.5mcg (2 puffs BID)
Spiriva Handihaler 18 mcg/cap per day
Proair rescue inhaler Q2 hrs prn SOB
Lantus 14 units QHS
Aspart 5 units TIDAC
Lisinopril 20 mg daily
Hydrochlorothiazide 25mg daily
Instructions to Preceptor:
The goal of this session is to teach cost-effective management of common ambulatory conditions.
Divide the trainees into several small groups (3-6 participants per group)
Give each group 15 minutes to review the history, physical exam, and laboratory results and write the
prescriptions for the patient (medication, frequency, and dosing). Use of smartphones and other
resources are allowed.
Then have each group report their prescriptions for the patient and write them on a board to compare.
For each team, review the medications they have chosen and whether they are appropriate for the
patient. Then discuss various mechanisms for obtaining medication cost. Calculate the monthly bill for
each patient.
The team that effective treats each problem with the lowest total monthly bill wins.
Pharmacy Resources
Smartphone Apps:
Epocrates
GoodRx
Lowestmed
Specific Pharmacy’s:
http://i.walmartimages.com/i/if/hmp/fusion/customer_list.pdf
http://www.target.com/pharmacy/generics-condition
http://www.publix.com/pharmacy/Free-Medications.do
Publix free antibiotics: Amoxicillin, Ampicillin, Cephalexin, Trimethoprim-Sulfamethoxazole,
Ciprofloxacin, Penicillin VK, Doxycycline
Alabama Medicaid:
http://www.medicaid.alabama.gov/
programs pharmacy Services/DME Preferred Drug List PDL reference tool
Costco Price Checker:
http://www2.costco.com/Pharmacy/DrugInformation.aspx?p=1
Consumer Reports
http://www.consumerreports.org/health/best-buy-drugs/index.htm
http://www.lowestmed.com