Family Medicine · Year 3 · from Family Medicine
Case 3: Navigating the Healthcare System
Patient Demographics
- Age: 67 years old
- Sex: Male
- Occupation: Retired factory worker
Chief Complaint
"I'm confused about all my medications and doctors. I just got out of the hospital and don't know what I'm supposed to do."
History of Present Illness
Mr. Harold Washington is a 67-year-old man who was hospitalized 5 days ago for community-acquired pneumonia. He was discharged yesterday with multiple medication changes. He brings a bag with 12 medication bottles and discharge papers from the hospital. His wife is with him and appears overwhelmed.
During hospitalization, his home blood pressure medication (amlodipine) was stopped and replaced with lisinopril. His chronic pain medication was changed from tramadol to acetaminophen. He was started on levofloxacin to complete a 7-day antibiotic course. He was also told to follow up with his cardiologist "soon" but doesn't know how to arrange this.
Medication Reconciliation
Pre-hospitalization medications:
- Amlodipine 10mg daily
- Metformin 1000mg twice daily
- Atorvastatin 40mg daily
- Tramadol 50mg twice daily
- Aspirin 81mg daily
Discharge medications:
- Lisinopril 10mg daily (NEW)
- Metformin 1000mg twice daily
- Atorvastatin 40mg daily
- Acetaminophen 650mg every 6 hours PRN (NEW)
- Aspirin 81mg daily
- Levofloxacin 750mg daily x 3 more days (NEW)
- Guaifenesin as needed (NEW)
Discrepancy identified: Patient still has amlodipine at home and was taking it along with lisinopril, not realizing the switch.
Assessment
- Post-hospitalization transition - High-risk period requiring careful coordination
- Medication discrepancy - Taking both amlodipine and lisinopril (duplicate BP therapy)
- Community-acquired pneumonia - Recovering, completing antibiotics
- Care coordination needed - Multiple specialists, unclear follow-up
Management Plan
Medication Reconciliation:
- Discontinue amlodipine (replaced by lisinopril per hospital team)
- Confirm all other medication changes with patient and wife
- Create updated medication list for patient to carry
Care Coordination:
- Call cardiology office to schedule follow-up appointment
- Ensure pneumonia follow-up chest X-ray in 6 weeks
- Schedule diabetes follow-up in 2-4 weeks for HbA1c
Patient Education:
- Reviewed each medication's purpose with patient and wife
- Provided written medication schedule
- Discussed warning signs requiring immediate attention
Communication:
- Send summary to cardiologist and hospitalist
- Document all care coordination activities
Teaching Points
- Care coordination role: The family physician serves as the "quarterback" coordinating care across settings and specialists.
- Transition of care: The post-hospitalization period is high-risk for adverse events, medication errors, and readmission. A timely PCP follow-up within 7-14 days is essential.
- Health literacy: Patients often don't understand medication changes. Taking time to review the medication list prevents errors.
- Patient-centered medical home: This case demonstrates PCMH functions including care coordination, population health (identifying high-risk transitions), and comprehensive care.