PHRM 311 1 on 1 Patient

📝 Patient Case Presentation Script

1. ID + Chief Complaint

SK is an 87-year-old (DOB Feb 4, 1938) cisgender woman (BMI = 21.8, healthy) admitted on Day 1 with confusion and dehydration secondary to hypoglycemia, following a week-long history of viral symptoms

2. HPI

• She developed malaise, mild sore throat, headache, and poor appetite after a family gathering 3 days prior.

• On the day of admission, she skipped breakfast due to nausea and later became dizzy, unsteady, and confused.

• Husband noted agitation and nonsensical speech → brought her to ED.

In emerg: glucose 2.8 mmol/L, BP 97/60, HR 92. Her glucose is below the 4.0mmol/L cutoff threshold for hypoclycemia, explaining her confusion and hemodynamic instability. She was started on D10W infusion → glucose normalized, vitals stabilized

• Now gradually improving; confusion clearing but still not fully at baseline (per husband).

Relevance: hypoglycemia in a frail older adult is dangerous because it can precipitate falls, delirium, seizures, or even death.

3. PMHx

1. Type 2 Diabetes – A1c 7.7% (reasonable control).

2. Hypertension – baseline ~130/80.

3. Recurrent UTIs – most recent urine culture positive for Klebsiella pneumoniae.

4. CKD Stage 2 – baseline eGFR ~70, dropped to 48–51 with AKI, now improving to 61.

5. GERD

   .

4. Allergies

• Penicillin → rash

5. Medications Prior to Admission

• T2DM: Gliclazide MR 60 mg daily, Metformin 1000 mg BID, Insulin glargine 5 units qHS

• HTN/CKD: Ramipril 5 mg daily, Hydrochlorothiazide 25 mg daily.

• GERD: Pantoprazole 40 mg daily.

• UTI prophylaxis: none; occasional TMP-SMX in the past

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On Admission: Antihyperglycemics were held due to hypoglycemia. Started on sliding-scale insulin aspart TID CC. Supportive meds: acetaminophen, ondansetron (nauesa?)

Ondasetron 4 mg per 2 mL solution (2-4 mL IV q4-6h PRN)

Ondasetron 4 mg PO (1-2 tablets po q4-6h prn)

Acetaminophen 500 mg 1-2 tablets q4h prn

6. Vaccines

Up to date, including COVID and influenza .

7. Social History

• Retired lawyer; lives with husband in Kamloops.

• Drinks 1–2 glasses of wine weekly.

• Never smoked, no cannabis or illicit drugs.

• Walks with husband for exercise

  .

8. Family History

Unknown .

📊 Vital Signs (Days 1–3)

• Blood Pressure (BP):

  • Ranged from 97/60 → 132/78 mmHg.

  • Lowest was 97/60 on Day 2 (supine, 08:00), consistent with her volume depletion/AKI.

  • Since then, pressures have normalized, trending toward her baseline of ~130/80.

  • Relevance: Reflects initial hypotension likely from dehydration and AKI, but improving with fluids and recovery.

• Heart Rate (HR):

  • Range 68–92 bpm.

  • Slightly higher on admission (92 bpm), likely compensatory for hypotension.

  • Stabilized in the mid-70s–80s by Day 2–3.

  • Relevance: No persistent tachycardia or bradycardia; shows hemodynamic stability as BP improved.

• Respiratory Rate (RR):

  • Range 16–20 breaths/min.

  • Steady throughout, no signs of respiratory distress.

  • Relevance: Stable pulmonary status; no evidence of hypoxia or compensatory hyperventilation.

• Temperature:

  • Range 36.7–37.5 °C.

  • Afebrile, with only minor fluctuations.

  • Relevance: Supports absence of systemic infection or sepsis despite positive urine culture.

• Oxygen Saturation (SpO₂):

  • Range 93–97% on room air.

  • Mostly stable at 96–97%; transient dip to 93% (Day 2, evening), but recovered without intervention.

  • Relevance: Overall adequate oxygenation; transient low was not clinically significant.

🔍 10. Review of Systems / Physical Exam Script

CNS:
On Day 1, the patient was confused, oriented only to person (A&O x2), with a GCS of 14. By Day 2, her orientation improved to A&O x3 with a full GCS of 15. Pupils decreased slightly in size from 4 mm to 3 mm but remained equal and briskly reactive throughout.
👉 Relevance: This shows that her confusion was likely secondary to hypoglycemia and dehydration, not a fixed neurological insult. The improving GCS demonstrates recovery, and equal brisk pupils rule out acute intracranial pathology like raised ICP.

HEENT:
On admission, she had sore throat, erythematous tonsils, and dry mucous membranes. By Day 2, oral mucosa improved and there was no evidence of exudate or petechiae.
👉 Relevance: The tonsillar erythema and dry mucous membranes support a recent viral illness and dehydration, both of which likely contributed to poor oral intake and the hypoglycemic event. Importantly, no bacterial features like purulent exudates were noted.

CVS:
Day 1 showed borderline tachycardia with “soft” pressures. By Day 2, her pulse was regular, S1/S2 normal, no murmurs, JVP 1 cm, and no edema.
👉 Relevance: The initial tachycardia and low pressures fit with dehydration/volume depletion. Improvement by Day 2 shows hemodynamic stability after fluids. No murmurs or edema helps rule out acute heart failure or valvular disease contributing to her presentation.

Resp:
Normal depth and rhythm throughout. No cough or adventitious sounds. Lungs clear on auscultation both days.
👉 Relevance: Stable respiratory findings with normal O₂ sats indicate that her confusion was not driven by hypoxia or pulmonary infection. This helps narrow the cause to metabolic factors (hypoglycemia/AKI/UTI).

GI:
On Days 1 and 2, abdomen soft, non-tender, with normal bowels. No pain, no emesis, last bowel movement was brown and formed.
👉 Relevance: Absence of abdominal pathology rules out acute GI causes of confusion (e.g., GI bleed, severe hepatic dysfunction). Stable GI function also supports safe resumption of oral diet as tolerated.

GU:
Urine was pale yellow and clear, with no voiding difficulties or dysuria. However, urinalysis was positive for leukocyte esterase and nitrites, and culture grew Klebsiella pneumoniae.
👉 Relevance: This indicates a urinary tract infection, which in an elderly patient can precipitate or worsen delirium. Treating the infection is important both for symptom resolution and prevention of further AKI.

Endocrine:
Unremarkable exam findings.
👉 Relevance: No evidence of thyroid or adrenal crisis; confirms hypoglycemia is the primary endocrine concern.

MSK/DERM:
Unremarkable.
👉 Relevance: No joint issues or skin lesions contributing to infection or immobility. Important in frail older adults where pressure sores or cellulitis can complicate hospitalizations.

Hematology:
Unremarkable on exam.
👉 Relevance: No signs of bleeding, bruising, or hematologic disorder contributing to her confusion or low sodium.

• .

🧪 11. Labs & Investigations

CBC:

• WBC stable at 9.5 → 9.0 ×10⁹/L.

• Hemoglobin dropped from 125 → 115 g/L.
  👉 Relevance: Stable WBC means no systemic leukocytosis, which makes sepsis less likely. Mild anemia could reflect chronic disease or hemodilution, but no acute bleed.

Electrolytes:

• Sodium consistently low at 130–133 mmol/L.

• Potassium low-normal at 3.3–3.8 mmol/L.
  👉 Relevance: Hyponatremia can worsen confusion and delirium, so this is clinically relevant. Low-normal potassium could reflect diuretic use (HCTZ) and dehydration.

Renal Function:

• Serum creatinine improved from 89 → 78 µmol/L.

• eGFR recovering from 48 → 61 mL/min/1.73m².
  👉 Relevance: This confirms AKI on CKD due to volume depletion, now improving with fluids. Monitoring renal recovery is key for safe reintroduction of metformin and dose adjustments.

Urine ACR:

• Elevated at 22 mg/mmol.
  👉 Relevance: Indicates proteinuria, supporting underlying CKD diagnosis and reinforcing the need for ACE inhibitor (ramipril) for renal protection.

Microbiology:

• Urine culture grew Klebsiella pneumoniae.

• COVID and influenza swabs negative.
  👉 Relevance: Confirms UTI as a contributing factor to delirium and volume depletion. Negative viral swabs rule out influenza/COVID as primary drivers.

Imaging:

• CT Head: No acute intracranial findings.

• CXR: Unremarkable, clear lungs.
  👉 Relevance: Helps rule out stroke, hemorrhage, or pneumonia as alternate causes of confusion. Supports metabolic/infectious etiology instead.

✅ Wrap-up line you can use to close this section:

🩺 12. Medical Problem List (Prioritized – Hypoglycemia First)

1. Hypoglycemia.
   This comes first because it was the immediate, life-threatening issue. Her glucose was 2.8 mmol/L, below the <3.0 mmol/L cutoff for clinically significant hypoglycemia, which explains her confusion and hemodynamic instability. Rapid correction with D10W stabilized her, so addressing prevention of recurrence is the top priority.
   

2. AKI on CKD stage 2. (most likely pre-renal)
   This is next because renal impairment worsens drug clearance and contributes to electrolyte abnormalities. Although her renal function is improving (eGFR up from 48 → 61), AKI on CKD still requires close monitoring, especially with renally cleared drugs like metformin.

   1. Likely pre-renal AKI, given the history of dehydration/poor oral intake and rapid improvement of renal function with fluids.

   2. Risk factors: age > 74, female sex, baseline CKD, T2DM, hypertension, diuretic + ACEi use.

1. Confusion – multifactorial.
   I placed confusion second because although it was the chief complaint, it is more of a symptom of underlying causes. Here, it likely resulted from hypoglycemia, AKI, dehydration, and infection. I recognize it’s important clinically because delirium in older adults carries risks of falls and morbidity.

1. UTI (Klebsiella).
   Fourth priority, because infection is another contributor to delirium and dehydration. It requires treatment to prevent progression to sepsis.

1. Type 2 Diabetes Mellitus.
   Fifth, because while it is chronic, it directly links to her hypoglycemia risk. A1c of 7.7% suggests control is “reasonable,” but her regimen (insulin + sulfonylurea) is too intensive for her age/frailty. This makes optimization of long-term diabetes management very relevant.

1. Hypertension.
   This follows, as her BP is currently stable on ramipril and hydrochlorothiazide. It’s important for long-term cardiovascular and renal protection, but it wasn’t driving her acute presentation.

1. GERD.
   Last, because it’s stable on pantoprazole and not clinically significant in this admission.

PRECEPTORS’ VERSION OF THE LIST

1. Hypoglycemia + T2DM

2. AKI

3. HTN (Was a little hypotensive on admission + concerns of antihypertensives)

4. CKD

5. UTI

6. GERD

13. Drug Therapy Problem List

Safety

• Hypoglycemia risk: Both insulin glargine and gliclazide significantly increase hypoglycemia risk in older adults. This was the precipitating cause of admission and needs de-intensification.

• Hyponatremia risk with HCTZ: Sodium persistently low (130–133 mmol/L). Hydrochlorothiazide likely contributing and should be reassessed.

• Electrolyte disturbances with Ramipril + HCTZ in CKD: Combination increases risk of hyperkalemia (ramipril) and hyponatremia/hypokalemia (HCTZ). Close monitoring is required.

Efficacy

• Diabetes regimen too intensive for age/frailty: Combination of metformin + sulfonylurea (gliclazide) + insulin glargine is aggressive for an 87-year-old with CKD and recurrent hypoglycemia. Her A1c of 7.7% is already within individualized targets for older adults (7.1–8.5% depending on comorbidity/frailty). Maintaining current triple therapy increases harm without clear benefit.

• CKD progression prevention: Patient is already on ramipril (ACEi, reno-protective). Current guidelines would also support initiation of an SGLT2 inhibitor (if renal function permits). Example: Empagliflozin 10 mg PO daily; reassess renal function at 1–3 months. This would reduce CKD progression and lower CV risk, though it would need to be withheld during AKI (per SADMANS).

Necessity

• Ondansetron: Ordered PRN IV/PO but the patient has not reported nausea → medication may not be necessary at this time.

• SADMANS medications during AKI: In the setting of AKI, nephrotoxic or renally cleared drugs (e.g., sulfonylureas, ACEi, diuretics, metformin, ARBs, NSAIDs, SGLT2i) should be temporarily held to reduce risk of worsening renal function. Ondansetron, acetaminophen, and pantoprazole remain appropriate.

Adherence

• Insulin glargine: Patient dislikes nightly injection (“does not like the poke before bed”), which could impair adherence. Simplifying regimen (e.g., deprescribing glargine if glycemic control is acceptable without it) may improve adherence and quality of life.

• Complex diabetes regimen: Sliding scale in hospital + basal insulin + oral agents can be confusing, especially in an older adult with recent delirium.

Unmet Needs

• UTI prophylaxis: History of recurrent UTIs, most recently Klebsiella. Consider whether prophylaxis (e.g., nitrofurantoin low-dose, vaginal estrogen if appropriate, or non-pharmacologic hydration strategies) is indicated.

• CKD optimization: As above, initiation of an SGLT2 inhibitor once AKI resolves could provide renal and CV protection.

• Vaccinations: Patient is up to date on influenza and COVID; ensure pneumococcal vaccination status confirmed for CKD.

• Lifestyle/education: Counseling on sick-day management (“SADMANS” list) to reduce risk of medication-related AKI in future.

14. Goals of Therapy

• Resolve confusion & hypoglycemia.

• Prevent recurrence of severe hypoglycemia.

• Treat and clear UTI.

• Preserve renal function.

• Maintain BP within safe range.

• Optimize diabetes regimen for safety/quality of life.

• Provide education on hypoglycemia prevention, insulin use, hydration

  Patient Work Up General Outline…

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💊 14. Recommendations to Address DTPs

1. Hypoglycemia risk from intensive diabetes regimen

• DTP: Patient on metformin + gliclazide (sulfonylurea) + insulin glargine → regimen too intensive for frail 87 y/o with CKD, causing severe hypoglycemia.

• Recommendation:

  • Deprescribe gliclazide. Sulfonylureas are high risk in older adults due to long duration of action and hypoglycemia.

  • Reassess insulin glargine dose: consider lowering or discontinuing depending on home BG trend and A1c. (PROBABLY DISCONTINUE ; BETTER OPTIONS AVAILABLE, insuline has such a quick impact on blood glucose levels that esp in elderly population puts them at risk for hypoglycemia, not T1DM, not required for insulin)

  • Continue metformin if eGFR remains >45 (safe, low risk of hypoglycemia).

• Thought process: Prioritize safety → prevent future severe hypoglycemia. Targets for frail elderly: A1c 7.1–8.5% (vs <7% in younger patients). She’s already at 7.7%, so de-intensification makes sense.

2. Hyponatremia likely due to hydrochlorothiazide (Na 130–133 mmol/L)

• DTP: HCTZ contributing to hyponatremia and electrolyte instability.

• ALSO MAY BE RAISING BLOOD GLUCOSE LEVELS

• Recommendation:

  • Hold hydrochlorothiazide and reassess sodium after discontinuation.

  • If additional antihypertensive needed, consider calcium channel blocker (e.g., amlodipine 2.5–5 mg daily) which is neutral on electrolytes (FIRST LINE IN ACEI/ARB add on DHP CCB (low dose amlodipine) > Thiazide diuretic) DM BP target <130/80-140/90

• Thought process: In elderly patients, thiazide diuretics often cause hyponatremia and increase falls/confusion risk. Safety > BP benefit, especially since her BP is stable on ramipril alone.

3. Renal protection in CKD stage 2

• DTP: Currently only on ramipril; could benefit from an SGLT2 inhibitor.

• Recommendation:

  • Start empagliflozin 10 mg PO daily once AKI has resolved and renal function stable (eGFR >45).

  • Monitor renal function, electrolytes, and risk of genital infections.

• Thought process: SGLT2 inhibitors slow CKD progression and reduce CV events. But must avoid during AKI (part of SADMANS) and restart once stable.

4. AKI management (pre-renal, improving)

• DTP: Risk of nephrotoxic medications worsening AKI.

• Recommendation:

  • Continue fluids, monitor renal recovery.

  • Avoid NSAIDs completely.

  • Temporarily hold SADMANS meds during AKI (ACEi, diuretic, metformin, insulin if needed). Resume cautiously once renal function stable.

• Thought process: Correct volume depletion (pre-renal), minimize nephrotoxic exposures, and prevent progression to intrinsic damage.

5. Ondansetron PRN without indication

• DTP: Ordered routinely but no current nausea.

• Recommendation: Keep PRN but reassess daily for necessity → discontinue if unused.

• Thought process: Low-risk medication but avoid unnecessary prescribing to reduce pill burden.

6. UTI (Klebsiella, recurrent)

• DTP: Infection confirmed, recurrent pattern, no prophylaxis strategy.

• Recommendation:

  • Treat acute episode based on culture sensitivities (e.g., ceftriaxone IV or appropriate oral agent).

  • After recovery, evaluate prophylaxis options if recurrences continue:

    • Nitrofurantoin 50–100 mg PO HS (if eGFR >30).

    • Non-pharm: hydration, voiding post-intercourse, vaginal estrogen if postmenopausal.

• Thought process: Prevent further UTI episodes, which can trigger delirium and AKI in elderly.

7. Adherence issue – nightly insulin dislike

• DTP: Patient reports disliking bedtime insulin injections → adherence barrier.

• Recommendation:

  • If A1c stable after deprescribing gliclazide, consider discontinuing insulin glargine altogether.

  • If basal insulin needed, consider once-daily degludec (long-acting, flexible dosing) to improve adherence.

• Thought process: Simplifying regimen increases adherence, reduces hypoglycemia risk, and aligns with patient preference.

8. Unmet need – sick-day education (SADMANS)

• DTP: Patient unaware of medication adjustments during illness.

• Recommendation: Provide education on holding SADMANS meds (sulfonylureas, ACEi, diuretics, metformin, ARBs, NSAIDs, SGLT2i) during dehydration/acute illness.

• Thought process: Prevents repeat AKI and hypoglycemia in future viral illnesses.

17. Monitoring Plan

Efficacy:

• Monitor mental status daily until discharge.

• Monitor BG (QID), aiming 5–12 mmol/L.

• Repeat urine culture post-treatment.

Safety:

• Watch for recurrent hypoglycemia (sweating, confusion, dizziness).

• Monitor Na, K, SCr, eGFR (daily in hospital, then weekly until stable).

• Monitor for adverse effects of antibiotics (rash, GI upset).

• Assess for orthostatic hypotension on antihypertensives