2.     Stop Aspirin and Ibuprofen (Due to possible GI bleed and poor kidney function)

3.     Start IV fluids (fluid resuscitation of NS for hyponatremia) 

4.      Refer for GI for possible scope.

5.     Begin to taper Metoprolol to discontinue, then once fully discontinued, begin tapering Clonidine until discontinued.

6.     Discontinue Glyburide due to risk of hypoglycemia with combo of metformin

7.     Decrease metformin to 500 mg BID (Due to poor renal function)

8.     Decrease Bupropion to 150 mg TID (450 mg given at once is too high)

2.      Evaluate meds for DM – discontinue glyburide, decrease dose of metformin.

3.      Decrease aspirin to 81mg – evaluate omeprazole use after resolution of GI bleed.

4.      Order colonoscopy.

5.      Start raloxifene for osteoporosis and discontinue alendronate.

6.      Consult nutritionist and obtain thorough social history. 

7.      Change simvastatin dose to 20mg po daily.

1. colonoscopy and endoscopy to see where the blood is coming from  

2. decrease metoprolol in order to take off clonidine to prevent rebound hypertension

3. Fluids -increase pressure/ prevent orthostasis 

4. work up anemia to see if we can find possible cause 

5. stop aspirin due to bleeding until finding cause, decrease to 81 mg PO daily for prevention 

6. D/C glyburide and decrease metformin to 1000 once daily since sugars are slightly low to maintain A1C < 8 due to age 

7. get CMP to look at liver function 

RBC indices: for further details regarding low Hgb. 

Clonidine: Taper off 0.1mg gradually over 1-2 weeks due to possible contribution to recent lightheadedness. 

Metformin: decrease dose to 500mg TID because of poor renal fx. 

Holter Monitor: to assess possible timing/etiology of palpitations. 

Wt bearing Xray of knees: evaluate arthritis advancements. Make PT consult: she’s very independent, so PT to work on strength and mobility. 

Solifenacin: is a strong anticholinergic which may increase confusion and risk for fall. Recommend to switch to Myrbetriq 25mg, take 1 tablet PO daily.

Ibuprofen: patient education for NSAID use. Take Tylenol instead of ibuprofen when experiencing knee pain. Rest, use ice, etc. 

o   Decreasing Aspirin

o   Switching from Ibuprofen to Acetaminophen for arthritis pain 

o   Endoscopy? 

·       Hypotension/orthostasis causing dizziness 

o   Getting rid of Metoprolol

o   Eventually getting rid of Clonidine 

o   Eventually switching from HCTZ and CCB to ACE-I for kidney protection and preventing sodium wasting

·       Possibility of hypoglycemia causing dizziness/near-syncope

o   D/C Glyburide 

o   Decreasing dose of Metformin 

o   At home glucose testing 

·       Poor renal function 

o   U/A to look for proteins, rule out possible UTI

o   Elevated serum creatinine 

1.     Endoscopy R/O stomach or upper GI bleed

2.     Medications – considerations 

a.     D/C glyburide – hypoglycemia 

b.     Educate on NSAID and aspirin use (D/C NSAID and aspirin), consider Tylenol/ice/ heat for arthritis

c.      Start taper of metoprolol followed by taper of clonidine once metoprolol D/C

3.     Red blood cell indices R/O etiologies of anemia

4.     Social work referral to evaluate whether pt is taking all meds for she states that she can’t afford all her medications

2.     D/C aspirin due to potential active bleed; reassess initiation of low dose post bleed

3.     Reevalute hypertension medications (Experiencing orthostatic hypotension, under goal, and on multiple medications [4] – d/c clonidine and d/c metoprolol via taper)

4.     UA (High creat – rule out UTI and analyze kidney function; decrease metformin to 500 mg BID)

5.     D/C Glyburide due to hypoglycemia potentially leading to near syncopal episodes

6.     Holter monitor (Near syncopal episode for complaint of “heart skipping a beat” and normal EKG)

7.     D/C ibuprofen use and consider changing pain management medication to Tylenol PRN due to SCr of 1.3 and possible GI bleed

Orthostatic Hypotension

-       Medication reconciliation: she is not hypertensive even when sitting, yet she’s on a Thiazide, BB, CCB. CCB and BB are not indicated together.

o   Clonidine – vasodilation. 

§  Taper off metoprolol in order to taper of clonidine

o   Glyburide – lipophilic and can stick around to cause hypoglycemia, look at DCing

o   Decrease metformin- 500 mg BID

§  Cost effective 

o   BB and CCB interaction 

§  See how she reacts to removal of metoprolol 

o   Donepezil – dizziness/bradycardia

§  Was her alzheimers dx warranted?

o   Possible discontinuation of Solifenacin

-       Occult Stool Sample: Look for possible cause of slight anemia, as patient is on NSAIDs which can cause GI bleed, and ASA which can increase bleeding risk.

-       Holter Monitor: Monitor possible arrhythmia causing near-syncopal episodes 

-       Further Anemia Studies: obtain Iron studies, retic,

-       Assess DM control: On Metformin, and Glyburide. Sulfonylurea is known to cause hypoglycemia.

-       Add a UA: Assess anemia, kidney function. GFR = 42. CrCl 32

-       OT/PT consult: for updated ADL/iADLs, Assessment for arthritis in her knees

 

F/U: Our suspicion is that this is a polypharmacy problem, and we hope to rule out other possible causes with the following studies. 

-       Assess BP response to DC metoprolol, clonidine 

-       Assess glycemic control in response to Glyburide DC, and reduction of Metformin

-       Assess Holter Monitor findings to r/o cardiac etiology

-       Assess Further Anemia studies, and adjust/DC ASA and NSAID if needed 

-       Assess Occult stool sample to r/u out GI bleed

2.      CT scan po contrast for GI bleed evaluation

3.      Order red blood cell indices 

4.      Taper metoprolol

5.      Once metoprolol d/c, then d/c clonidine

6.      Decrease Aspirin to 81mg po qd

7.      Decrease metformin to 1000mg po qd

8.      d/c omeprazole, hydroclorothiazide, amlodipine, glyburide 

9.       Initiate lisinopril 10mg qd

10.   d/c alendronate, initiate raloxifene 60mg po dq

11.   d/c ibuprofen PRN

12.   Consult to GI for colonoscopy and endoscopy