# Clinical Cases: Chronic Disease Management ## Case 1: The Complex Patient with Multiple Comorbidities ### Patient Demographics - **Age:** 63 years old - **Sex:** Male - **Occupation:** Retired electrician ### Chief Complaint "I'm here for my diabetes check-up. I've also been feeling more tired lately." ### History of Present Illness Mr. William Thompson is a 63-year-old man with type 2 diabetes, hypertension, hyperlipidemia, and COPD presenting for routine chronic disease follow-up. His last HbA1c was 8.4% three months ago. He reports increased fatigue over the past month and admits he has been "slipping" on his diet, particularly over the holidays. He occasionally forgets his evening medications. He uses his COPD inhaler "when I need it" but is unsure which one is for daily use versus rescue. He denies chest pain, orthopnea, or leg swelling. ### Current Medications 1. Metformin 1000 mg twice daily 2. Glipizide 10 mg twice daily 3. Lisinopril 20 mg daily 4. Amlodipine 5 mg daily 5. Atorvastatin 40 mg daily 6. Tiotropium inhaler daily 7. Albuterol inhaler PRN 8. Aspirin 81 mg daily ### Past Medical History - Type 2 diabetes (diagnosed 12 years ago) - Hypertension (15 years) - Hyperlipidemia - COPD (former smoker, 30 pack-years, quit 5 years ago) - Osteoarthritis, bilateral knees ### Social History - Former smoker (quit 5 years ago) - Occasional alcohol (1-2 beers on weekends) - Lives with wife - Sedentary lifestyle due to knee pain ### Physical Examination - **Vital Signs:** BP 142/88, HR 78, RR 16, SpO2 95% on RA, BMI 32 - **General:** Overweight, appears fatigued - **HEENT:** Normal - **Cardiovascular:** Regular rate and rhythm, no murmurs, no JVD - **Lungs:** Decreased breath sounds bilaterally, no wheezes - **Abdomen:** Obese, soft, non-tender - **Extremities:** No edema, distal pulses intact - **Feet:** Intact sensation to monofilament, no ulcers, nails thickened ### Clinical Image ![Blood glucose testing](case_01_image.jpg) *Image: Self-monitoring of blood glucose using a glucometer and test strip. Regular glucose monitoring is an essential component of diabetes self-management.* **Image Source:** Wikimedia Commons **Attribution:** David-i98, CC BY-SA 3.0 **URL:** https://commons.wikimedia.org/wiki/File:Blood_Glucose_Testing.JPG ### Laboratory Results - HbA1c: 8.6% (up from 8.4% three months ago) - Fasting glucose: 178 mg/dL - Creatinine: 1.4 mg/dL (eGFR 52) - Potassium: 4.8 mEq/L - LDL cholesterol: 78 mg/dL - Urine albumin/creatinine ratio: 180 mg/g (elevated) ### Chronic Disease Assessment **Diabetes:** - HbA1c 8.6% - Above individualized target of <8.0% (considering age, comorbidities, hypoglycemia risk) - Evidence of diabetic nephropathy (elevated UACR, reduced eGFR) - No retinopathy on last eye exam (1 year ago) - Feet exam: protective sensation intact **Hypertension:** - BP 142/88 - Above target of <130/80 for patient with diabetes and CKD **COPD:** - Stable symptoms - Uncertain about inhaler use - needs education **CKD Stage 3b:** - eGFR 52, albuminuria - Medication review needed for renal dosing ### Assessment and Problem List 1. **Type 2 diabetes, uncontrolled** with diabetic nephropathy 2. **Hypertension, uncontrolled** 3. **CKD Stage 3b** (likely diabetic nephropathy) 4. **COPD** - stable, needs inhaler education 5. **Medication non-adherence** - forgetting evening doses 6. **Hyperlipidemia** - at goal on current therapy ### Management Plan - Applying the Chronic Care Model **1. Self-Management Support:** - Discussed barriers to adherence - identifies evening busyness as issue - Action plan: Set phone alarm for 7 PM as medication reminder - Provided written medication schedule - Reinforce diet goals: carbohydrate counting, portion control - Confidence assessment: Patient rates 7/10 for taking meds with alarm **2. Decision Support - Evidence-Based Treatment Adjustments:** *Diabetes:* - Continue metformin 1000 mg twice daily (renal-safe at eGFR 52) - Discontinue glipizide (hypoglycemia risk, not kidney protective) - ADD empagliflozin 10 mg daily (SGLT2 inhibitor) - Benefits: Cardiovascular protection, renal protection, weight neutral - Counsel on genital yeast infection risk, volume depletion - Target HbA1c: <8.0% given comorbidities *Hypertension:* - Already on ACE inhibitor (appropriate for diabetic nephropathy) - Increase lisinopril 20 mg to 40 mg daily - Continue amlodipine 5 mg - Target BP: <130/80 **3. Delivery System Design:** - Scheduled diabetes educator visit for carbohydrate counting review - Scheduled respiratory therapist visit for inhaler technique - Care coordinator to call in 2 weeks to check on medication adherence **4. Clinical Information Systems:** - Added to diabetes registry for population health management - Set reminder for repeat HbA1c in 3 months - Set reminder for annual eye exam - Set reminder for recheck of creatinine/potassium in 1-2 weeks (after ACE inhibitor increase) ### SMART Goal Setting with Patient **Patient goal:** "I want to have more energy and feel better" **Collaborative SMART goals:** 1. "I will take my medications every evening by setting a 7 PM phone alarm, 7 days per week, for the next 3 months" - Confidence: 8/10 2. "I will check my blood sugar before breakfast 3 days per week and record the numbers in my log" - Confidence: 7/10 3. "I will walk for 15 minutes after dinner, 3 days per week" - Confidence: 6/10 (modified from initial 30 minutes due to knee pain) ### Follow-Up Plan - Phone check-in by care coordinator: 2 weeks - Labs (Cr, K+): 2 weeks (after lisinopril increase) - Office visit: 6 weeks - HbA1c: 3 months - Annual comprehensive diabetes visit: Review all complications, referrals ### Teaching Points 1. **Chronic Care Model:** This case demonstrates all six elements - self-management support, decision support, delivery system design, clinical information systems, community resources, and health system organization. 2. **SMART goals:** Patient-centered goals should be Specific, Measurable, Achievable, Relevant, and Time-bound. Adjusting the walking goal from 30 to 15 minutes maintained achievability. 3. **Evidence-based medication changes:** Adding an SGLT2 inhibitor provides cardio-renal protection beyond glucose lowering. Discontinuing the sulfonylurea reduces hypoglycemia risk. 4. **Care coordination:** Team-based care with diabetes educators, care coordinators, and respiratory therapists extends the physician's impact. --- ## Case 2: Medication Non-Adherence ### Patient Demographics - **Age:** 54 years old - **Sex:** Female - **Occupation:** Hotel housekeeper ### Chief Complaint "I'm here to refill my blood pressure medicine." ### History of Present Illness Ms. Rosa Martinez is a 54-year-old woman presenting for medication refill. She was diagnosed with hypertension 2 years ago and started on lisinopril. Her pharmacy records show her last refill was 6 weeks ago for a 30-day supply. When asked directly, she admits she "sometimes forgets" to take her medicine. She says, "I feel fine, so I don't think I need it every day." She also mentions she stopped her cholesterol medicine (atorvastatin) because it was "making my muscles hurt." ### Current Medications (prescribed) - Lisinopril 10 mg daily - Atorvastatin 20 mg daily (patient reports not taking) ### Vital Signs - BP 162/98 (repeated: 158/94) - HR 82 - BMI 29 ### Adherence Assessment **Non-judgmental questioning approach:** "Many people find it hard to take medications every day. There's no wrong answer here - I just want to understand so I can help. How has it been for you with your blood pressure medicine?" **Patient response:** "Honestly, I probably only take it a few times a week. I feel fine without it, and I'm worried about side effects." **Pharmacy refill records:** Last 12 months - Expected refills: 12 - Actual refills: 6 - Medication Possession Ratio: 50% ### Identifying Barriers to Adherence | Barrier Category | Patient's Specific Barriers | |------------------|----------------------------| | **Medication-related** | Side effect concern (statin - muscle aches); Multiple daily doses challenging | | **Condition-related** | Asymptomatic disease - "I feel fine" | | **Patient-related** | Forgetfulness; Belief that medication not needed if asymptomatic | | **Health system** | English is second language; Health literacy concerns | | **Cost** | Denies cost concerns (has insurance) | ### Assessment 1. **Hypertension, uncontrolled** due to medication non-adherence 2. **Hyperlipidemia** - statin discontinued due to side effects 3. **Medication non-adherence** - 50% adherence rate ### Management Plan - Addressing Adherence **1. Education (Health Literacy Appropriate):** - Used teach-back method with Spanish interpreter - Explained: "High blood pressure is called a 'silent killer' because you can feel perfectly fine but it's still damaging your heart, kidneys, and brain. Taking the medicine prevents heart attacks and strokes even when you feel well." - Visual aid: Showed pictures of healthy vs. damaged blood vessels **2. Simplify Regimen:** - Changed from lisinopril to amlodipine/losartan combination pill (single daily dose) - This addresses both BP control and the statin issue by using a different class **3. Address Statin Side Effects:** - Discussed that muscle aches with statins are common but often improve - Options discussed: - Try a different statin (rosuvastatin has lower myalgia rates) - Try lower dose - Try every-other-day dosing - Patient elected to try rosuvastatin 5 mg daily **4. Practical Adherence Strategies:** - Pill organizer provided - Linked medication to daily routine: "Take with morning coffee" - Involved family: Husband will remind her - Spanish-language medication information sheet provided **5. Motivational Interviewing:** - Explored importance: "On a scale of 1-10, how important is preventing a stroke to you?" - Patient: "10, my mother had a stroke" - Explored confidence: "How confident are you that you can take this pill every day?" - Patient: "Maybe 6" - Problem-solving: "What would help you feel more confident?" - Patient: "If my husband reminds me and I keep it by the coffee pot" - Re-assessed confidence: "Now?" - Patient: "8" **6. Follow-Up Plan:** - Return in 4 weeks for BP recheck - Phone call in 1 week by staff to check on adherence - Repeat lipid panel in 6 weeks ### Follow-Up (4 weeks) - BP: 138/86 (improved) - Reports taking medication "almost every day" - Pill count consistent with good adherence - No muscle aches on rosuvastatin ### Teaching Points 1. **Non-judgmental assessment:** Opening with "Many people find it hard..." normalizes the struggle and encourages honesty. 2. **Identify specific barriers:** Adherence is not a single problem. Each patient has unique barriers requiring tailored solutions. 3. **Simplify regimens:** Every additional daily dose decreases adherence. Combination pills and once-daily dosing improve adherence. 4. **Motivational interviewing:** Exploring importance and confidence, then problem-solving specific barriers, is more effective than lecturing. 5. **Asymptomatic disease:** Patients with conditions like hypertension often struggle to take medication for something they can't feel. Education and regular monitoring are essential. --- ## Case 3: Deprescribing in an Elderly Patient ### Patient Demographics - **Age:** 82 years old - **Sex:** Female - **Living Situation:** Lives alone, daughter checks daily ### Chief Complaint "My daughter brought me in. She's worried I've been confused and falling." ### History of Present Illness Mrs. Helen O'Brien is an 82-year-old woman brought by her daughter who reports her mother has been increasingly confused over the past 3 months and has fallen twice in the past month (no injuries). She has been less active and complains of "dizziness when I stand up." Her daughter also notes she seems more sleepy than usual. Review of the medication list reveals she is on 14 medications prescribed by multiple providers. ### Current Medications 1. Metoprolol 50 mg twice daily (hypertension) 2. Lisinopril 10 mg daily (hypertension) 3. Furosemide 40 mg daily (leg swelling) 4. Potassium chloride 20 mEq daily 5. Atorvastatin 40 mg daily (cholesterol) 6. Aspirin 81 mg daily (primary prevention) 7. Omeprazole 20 mg daily (acid reflux - taking for 5+ years) 8. Oxybutynin 5 mg twice daily (overactive bladder) 9. Diphenhydramine 25 mg at bedtime (sleep) 10. Diazepam 5 mg at bedtime (anxiety/sleep) 11. Gabapentin 300 mg three times daily (neuropathic pain) 12. Tramadol 50 mg twice daily (back pain) 13. Acetaminophen 650 mg four times daily 14. Vitamin D 1000 units daily ### Physical Examination - **Vital Signs:** - Supine: BP 118/68, HR 58 - Standing (1 min): BP 96/60, HR 62 (orthostatic hypotension) - **General:** Appears drowsy, slow to respond - **Mental Status:** Alert but processing slowly, MMSE 22/30 (mild impairment) - **Cardiovascular:** Bradycardic, regular rhythm - **Neurologic:** Unsteady gait, decreased lower extremity strength ### Assessment 1. **Polypharmacy** with 14 medications 2. **Medication-related adverse effects likely:** - Confusion: diphenhydramine, oxybutynin, diazepam, tramadol - Falls/orthostatic hypotension: diazepam, metoprolol, furosemide, tramadol, gabapentin - Sedation: diphenhydramine, diazepam, tramadol, gabapentin - Bradycardia: metoprolol 3. **Orthostatic hypotension** - symptomatic 4. **Cognitive impairment** - likely multifactorial (medications vs. early dementia) ### Beers Criteria Medications Identified | Medication | Beers Concern | Recommendation | |------------|---------------|----------------| | Diphenhydramine | Highly anticholinergic, cognitive impairment, falls | **STOP** | | Oxybutynin | Highly anticholinergic, cognitive impairment | **STOP** | | Diazepam | Sedation, falls, cognitive impairment | **TAPER and STOP** | | Tramadol | CNS depression, falls, especially with benzos | **TAPER and STOP** | ### Deprescribing Plan **Immediate Changes (High Priority):** 1. **STOP diphenhydramine** - Replace with sleep hygiene counseling, consider melatonin 3mg at bedtime if needed 2. **STOP oxybutynin** - Behavioral measures for overactive bladder (timed voiding, fluid management) **Gradual Tapers (To Prevent Withdrawal):** 3. **TAPER diazepam** - Reduce by 25% per week over 4 weeks to discontinue 4. **TAPER tramadol** - Reduce by 25% every 5-7 days; switch to scheduled acetaminophen **Reassess and Consider Discontinuing:** 5. **Aspirin** - Primary prevention in 82-year-old with fall risk: risks > benefits - Discussed with patient and daughter; agreed to stop 6. **Omeprazole** - On > 5 years, original indication unclear - Plan: Taper to every other day x 2 weeks, then stop. Use PRN antacid if needed. 7. **Atorvastatin** - Consider benefit at age 82 with limited life expectancy - Patient prefers to continue - respect this preference **Adjust for Orthostatic Hypotension:** 8. **Reduce furosemide** 40 mg to 20 mg (reassess need for diuretic) 9. **Reduce metoprolol** 50 mg BID to 25 mg BID (address bradycardia) **Continue:** - Lisinopril 10 mg (monitor BP) - Potassium (adjusted with furosemide change) - Gabapentin (continue for now, reassess after other changes) - Acetaminophen (scheduled for pain) - Vitamin D ### Communication with Patient and Family - Explained concerns about medication burden and side effects - Used the word "deprescribing" - "We're going to carefully remove some medications that may be causing more harm than good at your age" - Provided written schedule showing medications to stop, taper, and continue - Ensured daughter understands the plan ### Safety Monitoring - Recheck orthostatic BP in 1 week - Monitor for diazepam withdrawal (anxiety, insomnia) - Monitor cognitive function after medication changes - Fall prevention: home safety evaluation, PT referral ### Follow-Up - Phone call: 3 days (check for problems) - Office visit: 2 weeks - Reassess cognition: 6 weeks (after medication changes complete) ### Outcome (6-Week Follow-Up) - Medications reduced from 14 to 9 - No longer orthostatic - MMSE improved to 26/30 - No falls in past 6 weeks - Patient feels "more like myself" - Daughter: "She's so much more alert" ### Teaching Points 1. **Polypharmacy is not just a number:** The harm comes from specific high-risk medications and drug-drug interactions, not simply the medication count. 2. **Beers Criteria:** A practical tool for identifying potentially inappropriate medications in older adults. Not absolute prohibitions, but prompts for critical review. 3. **Deprescribing is a process:** Some medications can be stopped immediately; others require gradual tapers. Communication and monitoring are essential. 4. **Reversible causes of cognitive impairment:** Always consider medications before attributing cognitive changes to dementia. Anticholinergic burden is a major contributor. 5. **Goals of care:** In an 82-year-old, quality of life and symptom management may take priority over aggressive disease prevention.