Table 1.

History of medication experience: Medication history was relevant for amitriptyline and gabapentin, both of which were stopped in summer 2011 possibly to reduce fall risk, as well as iron supplements, which the patient had stopped taking on her own. The patient was allergic to acetylsalicylic acid (which caused a rash), possibly allergic to penicillin, and possibly allergic to rofecoxib (the patient said she was unaware of penicillin and rofecoxib allergies).

MEDICATIONREASON FOR USE (IF KNOWN)KNOWLEDGE, EFFICACY, COMPLIANCE, GOALS, SAFETY ASSESSMENTDURATION (IF KNOWN)
5 mg of ramipril every morning
Half a 5-mg amlodipine tablet twice daily
Hypertension
Hypertension
  • BP at GDH in first 4 visits ranging from 92/52 mm Hg to 110/64 mm Hg; 1 episode of orthostatic hypotension (from 110/64 mm Hg lying down to 88/50 mm Hg standing)

  • No dry cough; has some ankle swelling

Many years
Many years
Half a 50-mg metoprolol tablet twice dailyCAD and CABG (remote)
  • Heart rate 56 beats/min at time of assessment

  • Is followed by cardiologist

About 30 y
0.4-mg nitroglycerin patch; 2 on at 9 am and off at 10 pm, rotating siteAngina (remote)
  • If forgets to remove, gets headache and is reminded to remove patch

  • Has difficulty differentiating chest pain and arthritis pain

About 30 y
0.4 mg of nitroglycerin spray as neededAngina (remote)
  • Last used previous summer, does not carry regularly

  • Has difficulty differentiating chest pain and arthritis pain

2.5 y
75 mg of clopidogrel every morningCAD, CABG, possible mild stroke
  • No bruising or bleeding reported

Many years
40 mg of furosemide every morningUnknown
  • Does not know why furosemide started (some ankle edema; sleeps with 2 pillows)

  • Potassium level 4.1 mEq/L (at GDH admission)

Unclear
80 mg of atorvastatin at bedtimeCAD, CABG, possible mild stroke
  • Does not complain of muscle ache

  • Does not drink grapefruit juice

2 y (40 mg for many years previously)
10 mg of escitalopram every morningDepression, possible anxiety
  • Helps with mood; reports previous panic attack when old pharmacy would not refill; worries about stopping suddenly

  • Has nausea after lunch and sleep difficulties

About 6 mo
5 mg of zopiclone at bedtimeInsomnia
  • Sleep not improving (reports going to bed at about 9 pm and waking at midnight with difficulty getting back to sleep)

  • Intends to try nonpharmacologic measures for sleep hygiene

1 y
2, 10-mg tablets of oxazepam at bedtimePossible anxiety
  • Patient thinks it was prescribed for anxiety after open-heart surgery

About 30 y
1000 IU of vitamin D dailyOsteoporosis (midthoracic vertebral compression)
  • Is seen by specialist

  • Vitamin D level 76 nmol/L (at GDH admission)

NA
200 mg of hydroxychloroquine sulfate at supperRheumatoid arthritis
  • Helps with arthritis but does not remove pain completely

  • Is seen by specialist

NA
30 mg of codeine with acetaminophen twice daily as neededPain
  • Pain in left torso and ribs, radiating left hip pain

  • Throbbing pain throughout night; limits sleep, mobility, and function

NA
500 mg of acetaminophen 4 times dailyPain
  • VAS score of 9 out of 10 on admission and 6-7 out of 10 with acetaminophen and codeine in combination and regular acetaminophen

  • Patient states she “could not do without acetaminophen”

NA
40 mg of pantoprazole every morningNausea
  • States it is helpful in reducing nausea

NA
Polyethylene glycol eye drops as neededEye lubrication
  • Uses effectively for dry eyes

NA
  • BP—blood pressure, CABG—coronary artery bypass grafting, CAD—coronary artery disease, GDH—Bruyère Continuing Care Geriatric Day Hospital, NA— not available, VAS—visual analogue scale.