GP Comprehensive Medication Assessment

Patient Name: Arthur Pendelton Date of Birth: 14/05/1948 Date of Consultation: 24/10/2023 Medical Record Number: 482-910-38

Medication Review

Reason for Review

• Polypharmacy review post-recent fall and postural dizziness; optimization of T2DM and HTN regimen.

Current Medications

• perindopril (Coversyl®) - 5 mg PO, OD
• amlodipine (Norvasc®) - 10 mg PO, OD
• metformin (Diabex®) - 1,000 mg PO, BD
• gliclazide MR (Diamicron®) - 60 mg PO, OD
• atorvastatin (Lipitor®) - 40 mg PO, nocte
• meloxicam (Mobic®) - 15 mg PO, OD PRN

Patient's Medication Adherence

• Compliance: Good overall, utilizes a pharmacy-packed Webster-pak. Occasional missed evening metformin dose.
• Challenges: Difficulty opening standard medication bottles due to hand OA; large tablet size of metformin causes mild dysphagia.

Clinical Review

• Effectiveness: BP 115/68 mmHg sitting, 98/60 mmHg standing (symptomatic postural drop). HbA1c 6.4% (tight control for age). OA knee pain moderately controlled.
• Side Effects: Postural dizziness and bilateral ankle oedema secondary to amlodipine 10 mg. Mild GI upset with metformin.
• Interactions: Meloxicam + perindopril + metformin increases risk of AKI ("double whammy" + biguanide) and blunts antihypertensive effect. Gliclazide contributing to potential hypoglycaemic episodes given tight HbA1c.

Patient's Concerns

• Reported Issues: Worried about having another fall due to lightheadedness when standing. Frustrated by swollen ankles making footwear tight.
• Patient's Goals: Maintain independence at home, reduce daily pill burden, and resolve dizziness and ankle swelling.

Recommendations

1. Medication Adjustment: Cease meloxicam 15 mg PO OD immediately (renal/CV risk). Reduce amlodipine from 10 mg to 5 mg PO OD to address postural hypotension and pedal oedema. Cease gliclazide MR 60 mg PO OD to prevent hypoglycaemia. Switch metformin to XR formulation 1,000 mg PO nocte to improve GI tolerance and adherence. Commence paracetamol (Panadol Osteo®) 1,330 mg PO TID for OA pain.
2. Further Investigations: Fasting bloods in 2 weeks: FBE, UEC, eGFR, LFTs. Home blood pressure monitoring (sitting and standing) BD for 1 week.
3. Patient Education: Educated on risks of NSAIDs with current kidney function and BP meds. Advised on postural hypotension management (slow transitions, hydration). Discussed hypoglycaemia recognition. Pharmacy notified to update Webster-pak.

Follow-Up Plan

• Next Review Date: 07/11/2023
• Additional Appointments: Referral for Home Medicines Review (HMR) with accredited pharmacist; physiotherapy referral for falls prevention and balance training.

Signature

Dr. Sarah Jenkins General Practitioner, FRACGP Bayside Family Medical Centre, (03) 9555 4321

Date: 24/10/2023