The Patient with Complex Problems (Case 3)

Published on 24/06/2015 by admin

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Last modified 24/06/2015

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The Patient with Complex Problems (Case 3)

William D. Surkis MD

Case: The patient is a 62-year-old woman with a past medical history of hypertension, gastroesophageal reflux, atrial fibrillation (not on anticoagulation because of medication nonadherence), end-stage renal disease on hemodialysis, nonischemic cardiomyopathy with ejection fraction of 40%, status post (S/P) automatic implantable defibrillator placement, and aspirin allergy who presents for a follow-up appointment one week after hospital discharge. The only information you have is in a short notation that was made at the time the appointment was given: “Had TIA [transient ischemic attack] at Elsewhere General Hospital.” Discharge paperwork is unavailable. The patient’s chief complaint was recorded by the appointment secretary as: “I had a stroke, and now I can’t pay for the pills they gave me.”

The Patient with Complex Issues: A Problem List


S/P automatic implantable defibrillator placement

Gastroesophageal reflux

Atrial fibrillation

Allergy to aspirin

Medication nonadherence

Nonischemic cardiomyopathy

End-stage renal disease (on hemodialysis)

S/P sigmoid colectomy for diverticulitis


Speaking Intelligently

Encountering a patient with so many active medical conditions is anxiety provoking. Under such circumstances I try to remember to (1) breathe deeply, (2) convey warmth and reassurance, (3) confirm current symptoms, and (4) gather information.

Always begin a visit by conveying warmth (“How are you? We haven’t seen you in a while and I heard you’ve been through a lot!”) and reassurance (“We will straighten out the issues with your medications”).

Confirm the patient’s current symptoms: Is she having any active symptoms at this time? If this were the case, the goal of the appointment would immediately shift to focus on her acute medical problems.

Gather information. If your patient’s recent care took place at an outside hospital that is not associated with your practice, have the patient fill out the appropriate forms to release her medical information to your office. With time in short supply during a primary-care visit, the three most helpful pieces of paperwork to obtain would be (1) a copy of her hospital history and physical, (2) her recent discharge summary, and (3) her discharge paperwork and/or medication reconciliation form. These forms should allow you to confirm the details of her hospitalization, obtain information on tests and lab findings during hospitalization, and ensure that she leaves your visit on the correct medications. A call can also be made to the patient’s pharmacy to obtain a list of the most recently prescribed medications.

I generally avoid trusting patient descriptions of medications (e.g., “the little, round brown pill”). If unidentified pills are brought in by the patient, they can be identified using free online resources such as the “Pill Identifier” ( Many emergency departments have access to electronic medical records and may be able to confirm or deny critical medications if other sources are closed or unavailable.

The number of patients with complex problems being seen today is significant. As we do a better job of saving lives during acute illness, we create more chronically ill patients, with an ever-increasing number of illnesses, who can be on many medications. It is important to ensure that adequate systems are in place in hospitals to complete proper medication reconciliation, and to communicate discharge medications and patient plans of care with primary-care physicians.


Clinical Thinking

• This is a worrisome patient. She has a complex medical history and recent new issues.

• When confronted with such a situation, my general thought process is to isolate my highest priorities of concern:

She has had a recent hospitalization for a serious issue (stroke or TIA) without accurate knowledge of her medications.

For financial reasons, she has not been taking the antiplatelet agent (clopidogrel), which was apparently prescribed. After the first TIA, 10% to 20% of patients will have a stroke within 90 days, and in 50% of patients, this stroke will take place 24–48 hours after the TIA.

Obtaining paperwork from the hospital and pharmacy is always a priority.

I now put myself in the mindset to decipher the details of her hospitalization. (See details in history taking below.)


• Sort out acute matters first:

What changes may have brought her to her appointment today?