Case Study

Mr. Jeremy Levy is an 89-year-old cis-gendered man with a past medical history of uncontrolled hypertension, a myocardial infarction with the placements of two stents, high cholesterol, diabetes, and gastroesophageal reflux disease. He has currently been prescribed a variety of medications, including lasix, amlodipine, metformin, sitagliptin, aspirin, pantoprazole and rosuvastatin. His primary care provider has connected with his cardiologist and endocrinologist and discovered that he has missed appointments with them. In the times that he has shown up to his appointments his blood pressure and point-of-care blood glucose have consistently been elevated and when asked whether he was taking his medications as prescribed Mr. Levy responded, “There are too many to keep track of” and admitted that he took the blood pressure medications but not every day.

Today Mr. Levy shows up to the clinic hoping to be seen by the primary care provider, although he has no scheduled appointment. You are the nurse completing Jeremey’s intake forms, he states that he is feeling weak and drowsy for the past three days with muscle cramps in his arms and legs, and some intermittent abdominal pain. You document his presenting concerns and assess his vital signs noting BP 93/59 and HR 115 bpm. You noticed the A-72994 tattoo on his arm and try to be friendly and state, “Cool tattoo” and instruct Mr. Levy to wait while you speak with the primary care provider to determine if he can be seen and he interrupts you and states firmly “well am I going to be seen or not? Don’t waste my time”. You repeat yourself and ask him again to wait while you speak with the primary care provider. You inform the doctor of Mr. Levy’s presenting signs and symptoms. The doctor agrees to assess Mr. Levy right away and instructs you to arrange for a transfer via ambulance to the emergency department. As you wait with Mr. Levy, you discover he has recently travelled and forgotten his medications and then decided to double up on his medications two days ago.

The ambulance arrives and transports Mr. Levy to the nearest emergency in which he is brought into the subacute area after being triaged. Mr. Levy is then assessed by the emergency physician who also reads the note that was sent by Mr. Levy’s family doctor. Mr. Levy is then ordered to have blood work including a blood glucose level, electrocardiogram and Normal Saline 0.9% 1L IV bolus. The emergency doctor diagnosed Mr. Levy with mild hyperglycemia and severe electrolyte imbalance presumably due to the double dosing of his medications. He is then ordered electrolyte replacement of his potassium, magnesium, and calcium.

Mr. Levy is given a referral to be assessed by the pharmacist, endocrinologist, diabetic nurse educator and nutritionist. When the doctor explained the extreme seriousness of the situation to Mr. Levy, he was then agreeable to meeting other members of the healthcare team. After each team member’s individual assessment, the team collectively agreed that Mr. Levy has difficulty with his medication regimen. The interprofessional team discussed changes needed to address his current medical issues and decided to admit him to the hospital. Mr. Levy was apprehensive about being admitted to the hospital and he decided to contact his two daughters for assistance. One daughter informs you, “Papa is a holocaust survivor so he is often fearful of being admitted to the hospital.” As he informs both of his daughters of the situation, they meet with their father and the healthcare team to collectively generate a plan to support Mr. Levy once he is discharged home.