Ms Miles HMR Case Scenario

Ms Miles HMR Case Scenario

Information from patient interview
Whilst at the patient’s home the following information is obtained:

•       Ms Miles is a pleasant frail lady who has been experiencing some mild nausea over the previous few months.  She said she will often miss breakfast because she wakes feeling nauseous, the nausea is persistent through the day though she manages a little lunch and a reasonable dinner.  She has been chewing a few Mylanta 2go tablets through the morning though admits they do not help much    

•       She demonstrates use of her inhaler devices and you note she has good technique with both.  She has noticed that over the previous few months she is using a few more of her ‘when necessary’ doses of Symbicort (uses an extra dose most days compared to not having to do this at all before).  She suspects this is just due to changes in weather and more pollution in the air.  She replaces her Handihaler device each month with a new one

•       About 5 months ago she had what she thought was just a fainting attack at a friend’s house.  Her friend insisted she go to hospital where they did tests and confirmed a ‘mini stroke’.  She was discharged on a baby aspirin dose every day, though she was not sure why as she has no pain.  She had noticed she started to bruise more easily and read that aspirin can cause this so she cut them back to every second day

•       She has taken an antidepressant for a couple of years now and says her mood is pretty good generally, she has the occasional low day but doesn’t everybody.  She admits she does seem to be a bit anxious and on edge at times lately.

•       She has always enjoyed a few cigarettes each day.  She says they settle her nerves, and she only has about 5 a day and does not inhale deeply (just little puffs).  This way they will not do her harm

•       She lives in a little duplex unit that she loves.  Her only complaint is that the neighbours have a small dog that will occasionally bark in the early hours of the morning, and she is a light sleeper and wakes easily.  This probably happens about once a week and when she wakes it is hard to get back to sleep.  This is when she will use her sleeping tablet which works well  (The doctor said using it only once a week is good and that she won’t get addicted)

•       Ms Miles has a pretty normal diet she says though as mentioned above her appetite is not the best at the moment.  Currently black tea is all she feels like for breakfast, some fruit salad for lunch, a cup of tea in the afternoon, and meat and vege for dinner with another black tea and a sweet biscuit before bed

•       She had another little fall recently and shows you a small skin tear on her arm that occurred when she hit the floor, there is a small scab but no redness or swelling, it is not painful, she asks what kind of antiseptic is the best to use to help healing

•       Ms Miles takes her bone tablet religiously every Sunday, as soon as she wakes up (has taken for at least 6-7 years following a fall with wrist fracture). 

HMR case – Part 2 further information gathered 

Current medications according to patient
Medication Dose (according to patient) Purpose/comments (according to patient)
Telmisartan 40 mg One with dinner Blood pressure
Aspirin 100 mg One second daily at dinner Causes bruising
Alendronate 70 mg One each Sunday Bones
Spiriva Handihaler 18 mcg One daily Asthma
Escitalopram 20 mg One nocte For her mood
Temazepam 10 mg One prn (about 1/week) To get back to sleep
Mylanta 2go tablets Chews one prn for nausea Has 2-3 / day
Symbicort TH 200/6 mcg One bd and prn (uses an extra dose most days now) Asthma
Additional test results/information from GP
Contact with the GP reveals previous pathology (see below), this is all that is available at this time.  A brief discussion with the GP reveals he increased her escitalopram dose following her hospital discharge, in anticipation of the stress such an event would have on her.

8 months ago

•       TSH  3 (0.4-4.00 mU/L)

•       T4   14 (11-25 pmol/L)

•       Ferritin   115  (15-200 mcg/L)

•       Iron   20 (7.0-27.0 µmol/L)


Consider the patient needs or concerns, medication-related problems and medication management issues. 

 Part 2 A

Based on the information provided, identify potential and actual medication-related and disease-related problems, and patient concerns. Suggest how these could be addressed and/or monitored.

 Part 2B

Write a letter or report to the referring GP, outlining your key findings for this patient and your suggestions or recommendations.


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