Clinical Pharmacy Case Scenario

A 63 year old male admitted to hospital with augmented breathlessness. He is smoker and his BMI is 31 kg/m2 Presenting Complaint: augmented breathlessness History of Present Complaint: last 7 days – increasing SOB, lethargy Past Medical History: Heart failure 2 Heart attacks (2015 and 2017)- coronary bypass in 2015 Drug History: Aspirin 75mg OD, Simvastatin 80mg OD, Bisoprolol 1.25mg OD, Ramipril 2.5mg OD, Furosemide 20mg OD On examination: Chest oedema • Wheeze • Arrhythmias (ECG and heart sounds indicate Atrial fibrillation) • Blood pressure 141/90 mmHg • Heart rate 84bpm • O2 saturation 86% Blood results on admission: Na 128 mmol/L K 3.5 mmol/L Cr 67 micromol/L Ur 3.9 mmol/L Hb 11.2 g/dL Possible diagnosis: worsening heart failure, with severe oedema Management plan: • Continuous furosemide infusion 10mg/hour • Add-in spironolactone (25mg daily, to be reviewed upwards as necessary) • Load the patient on digoxin (500micrograms STAT, followed by 62.5micrograms daily) • Start oxygen therapy at 2L/min November 2018 QUESTIONS 1. How would you comment patient’s results? 2. What is the class of drugs and what is the rationale of their use? 3. You are worried about the effect of loop diuretics on sodium levels. During the ward round a doctor shared that he read about tolvaptan in the use of heart failure and he suggested the dose of 15 mg twice daily for 5 days. Based on patient’s background, and the evidence/literature found for and against the use of tolvaptan in this case, would you recommend the use of tolvaptan? Please give your rationale. 4. Comment on the pharmaceutical care for this patient, based on the patient’s history. What else would you suggest optimising this patient’s medications and why? 5. What other advice would you give to this patient?                                                                                                                                      

Sample Solution