Patient Presentation Chief Complaint “My father has been coughing and wheezing for several days.

Patient Presentation Chief Complaint “My father has been coughing and wheezing for several days. He has been staying with my brother for the past month, but he didn’t even take my father to the doctor, let alone start him on antibiotics.” HPI Kathryn Comeaux appears distraught and hurried as she brings her father, Cole Comeaux, into the primary care clinic. She states that her father, a 63-year-old widower, has been complaining of a productive, purulent cough, wheezing, and rhinorrhea for the past 5 days. Upon questioning the patient, Mr. Comeaux denies that he has had any fever, chills, or myalgia. He also insists that the only problem he has now is the cough, and the wheezing and rhinorrhea have almost stopped. He states that, besides having “children who constantly bicker with each other,” he is almost completely free of problems and is “feeling much better than before, thank you very much.” PMH Hypertension x 10 years Diabetes x 5 years Hyperlipidemia x 2 years FH The patient’s wife passed away at age 60 (6 months ago) due to a stroke, and his father and mother both lived to be in their 90s and died of “natural causes.” He was vaccinated for pneumonia last year. SH Mr. Comeaux’s children, both divorced, have taken turns letting him live with them after the death of their mother, since he has no gainful employment and could not keep up with his house mortgage. He used to write children’s books, including the Boudreaux’s Bayou Adventures series, but his last meaningful project was over a decade ago. He spends most of his time reading and smoking Barrington cigarettes (1 ppd x 30 years). Also, he admits that he would like to quit before he starts having any chronic lung problems. He tried quitting 1 year ago and was smokefree for 2 days, but he could not tolerate the itchiness that the nicotine patches caused. Once he stopped using the patches, he started smoking again. He denies any alcohol use. This month is his daughter’s turn to serve as caretaker, but she is distressed that she will have to send him to a senior daycare center during the day while she starts her new job as a waitress at a local restaurant that serves Cajun cuisine. She is also upset because she thinks that her brother has not been taking care of their father well, since he did not take Mr. Comeaux to the doctor, let alone start him on antibiotics. Meds Lisinopril 40 mg daily Metformin 1,000 mg BID Simvastatin 20 mg daily Note: This is patient’s current list over the past 6 months. He is unsure what he took in the past because his wife used to take care of his medication responsibilities. All NKDA ROS No fever, chills, myalgia, chest pain, or shortness of breath; no nausea, vomiting, or diarrhea Physical Examination Gen Well-developed, overweight male in NAD; overall demeanor seems slightly disheartened, but he is communicative and clean and well-shaven in appearance VS BP 142/92 mm Hg, P 84, RR 17, T 37°C; Wt 78 kg, Ht 5’6” HEENT PERRLA, conjunctivae clear, TMs intact. No epistaxis or nasal discharge. No sinus swelling or tenderness, and mucous membranes are moist. There are no oropharyngeal lesions. Wears dentures. Neck Supple without adenopathy or thyromegaly Chest (–) rhonchi, rales, increased fremitus, wheezing, or egophony Heart RRR without MRG Abd Soft, nontender, (+) BS Ext Pulses 2+ throughout Neuro A & O x 3; 2+ reflexes throughout, 5/5 strength; CN II–XII intact Labs Na 140 mEq/L FPG 104 mg/dL WBC 4.9 x 103/mm3 Fasting Lipid Profile (from outpatient visit 1 month ago): K 4.5 mEq/L A1C 6.4% Segs 55% Cl 102 mEq/L Hgb 14 g/dL Bands 3% HCO3 24 mEq/L Hct 45% Lymphs 33% T. chol 150 mg/dL BUN 14 mg/dL RBC 5.0 x 106/mm3 Monos 6% TG 145 mg/dL SCr 0.9 mg/dL Plt 250 x 103/mm3 Eos 2% LDL 69 mg/dL Basos 1% HDL 52 mg/dL Sputum culture No pathogens isolated Assessment A 63-year-old man with presumed acute bronchitis that is likely viral in origin (+) smoking history; patient currently expressing desire to quit Diabetes and dyslipidemia—well controlled on current medication regimen Family/caregiver issues that should be further explored and addressed Questions Problem Identification 1.a. Create a list of the patient’s drug therapy problems. 1.b. What information (signs, symptoms, laboratory values) indicates the presence or severity of acute bronchitis? 1.c. Could any of the patient’s symptoms have been caused by drug therapy?

1.d. What additional information must be considered before deciding whether antimicrobial therapy is indicated? Desired Outcome

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2. What are the goals of pharmacotherapy in this case? Therapeutic Alternatives

3.a. What nondrug therapies might be useful for this patient? 3.b. What feasible pharmacotherapeutic alternatives are available for treatment of uncomplicated acute bronchitis? 3.c. What are the most likely alternatives for the uncontrolled hypertension and smoking cessation attempt? 3.d. What psychosocial considerations are applicable to this patient? Optimal Plan

4.a. What drugs, dosage form, dose, schedule, and duration of therapy are best to alleviate this patient’s symptoms of acute bronchitis? 4.b. What medication and dosage should be recommended for this patient’s elevated blood pressure and smoking cessation plan? Outcome Evaluation

5. What clinical and laboratory parameters are necessary to evaluate the therapy for achievement of the desired outcome and to detect or prevent adverse effects