Question: What additions/subtractions/titrations to the pt’s medication regimen would you recommend?
CC: Heartburn, my pills aren’t helping anymore
HPI: 75 year old Native American female presents to the family practice clinic for routine visit. Pt reports that over the last 3 weeks she has had increasing heartburn about one hour after eating and also some regurgitation and trouble swallowing food. This occurs nearly every day. c/o food getting stuck behind her breastbone. This is a new problem. She has been using antacids daily in addition to histamine-2-blockers to achieve relief. Despite sleeping with 3 pillows, pt has been experiencing frequent nocturnal wakings due to pain. Reports nighttime coughing and c/o fatigue. Denies SOB, hoarse voice, nausea, vomiting, constipation, diarrhea, abdominal pain, urinary difficulty, blood per rectum or in stool.
PmHx: GERD x 7 years, HTN x 15 years, alcoholic cirrhosis x 2 years, hiatal hernia
SocHx: Pt is widowed, lives alone, daughter lives in same town and checks on her regularly and takes her grocery shopping. She is a retired teacher and volleyball coach. Enjoys cooking, traveling, gourmet dining, and playing cards. Drinks 5 cups of coffee daily, 6 beers with shots per week with history of heavier consumption, 55 pack year smoking history, currently smokes ¾ ppd. Denies illicit drugs.
Meds: Verapamil SR 120 mg PO daily
HCTZ 25 mg PO daily
OTC antacids
Famotidine 20 mg PO daily at bedtime
Allergies: Citrus fruits and juices (upset stomach), erythromycin (unknown symptoms)
Vital Signs: T=97.9 HR=75, regular BP=155/90 Resp=18 Ht=5’8” Wt=195 lbs
Physical Exam: no abnormalities
Labs:
|
Na |
138 |
Hgb |
13 |
AST |
21 |
|
K |
3.8 |
Hct |
39 |
ALT |
24 |
|
BUN |
18 |
WBC |
8.7 |
Alk Phos |
55 |
|
Creatinine |
1.3 |
|
|
|
|
|
Glucose |
136 |
|
|
|
|
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