C3.2 R5: Perform and document a “Best Possible Medication History (BPMH)”

ID: 24 yo female with atypical Angelman syndrome with uncontrolled status epilepticus

HPI: On Feb 25, had seizures on a school trip that did not resolve with use of PRN Lorazepam. Admitted to Squamish hospital then transferred to VGH as LOC was decreasing and seizing q2-3 min (~40 sec per episode). admitted to NICU, given 8mg total ativan, 2mg midazolam, dilantin load x1, valproic acid, levetiracetam titrated up. Phenobarbital bolus was given and then LOC continued to decrease and obstruction. Patient required intubation for airway protection and was brought to ICU.

Anti-epileptics and medications PTA was not clear. Most of Med Rec was verified with: “Per Pharmanet”. Patient also had a fairly recent hospital admission for uncontrolled status epilepticus in Dec 2016, making it difficult to interpret what is current on Pharmanet.

Patient is unable to speak due to her Angelman’s syndrome. Parents were very involved in her care, kept a list of her medications and were able to answer questions. The following is verified by her parents.

Medical Conditions Medications PTA
  1. Focal dyscognitive tonic seizures (characteristics of seizures has been evolving as she has aged)
  2. Acid reflex
  3. Slow GI motility
  4. Neuropathic pain due to scoliosis
  5. Induce amenorrhea
  6. Chronic constipation
All oral medications were taken via G-tube

  1. Topiramate 125mg PO BID
  2. Clobazam 20mg PO AM, 30mg PO HS
  3. Levetiracetam 250mg PO AM, 500mg PO HS (since Jan 17/2017)
    Patient has been managed fairly well on TPM and Clobazam previously but now thought to be no longer effective. Plan with epileptologist is to wean off TPM and Clobazam after appropriate titration of LEV. 
  4. Lorazepam 2-4mg SL PRN (after 2nd clustered seizure)
    Had to use it 3 times in the last month, but parents feel that it is not effective as seizures have generally persisted despite use. Has not used midazolam PTA although filled on P’net 
  5. Lansoprazole Fastab PO BID
  6. Domperidone 10mg (2mL) PO TID
  7. Gabapentin 200mg (2mLs) PO TID
    (Indication purely for neuropathic pain)
  8. Acetaminophen 480mg (15mL) PO Q4H PRN for pain (usually needs 2 times/week)
  9. Loestrin 21 po daily
  10. Microlax (1-2 enemas twice weeky)
  11. Calcium with vitamin D (unaware of dose)

No other non-prescription or alternative medications


Reflections
:

  • Even if there is a personal medication list provided, it is important to still verify each medication (dose, route, regimen) and indication. This is especially important for any medications that are currently being titrated up or down. Upon interview with the parents, we were able to identify one discrepancy on the list regarding her anti-epileptics.
  • For medications that have multiple indications, it is important to confirm the intended indication of the medication with the patient and/or caregivers. For example, gabapentin was prescribed purely for her neuropathic pain and not for her seizures. The neurology team had initially considered discontinuing the gabapentin but I was able to let them know it was meant for her pain and gabapentin was continued.
  • I had checked previous consultations on CareConnect after verifying the medications with her parents and found that there were some discrepancies between the consults and my interview. For instance, parents were not aware of the use of phenytoin (filled on Pharmanet) prior to this hospital admission but the most recent consult note stated that it was initiated in Dec 2016 but the plan was to titrate down and discontinue. For patients with more complex histories, medication histories and hospital admissions, it would be important for me to gather as much information from previous admissions and other specialists following them prior to the interview. This would allow me to point out any discrepancies and clarify it with them during a single interview session.
  • When doing medication reconciliations – especially for complex medication histories, I should proactively document on the chart to ensure that the health care team and other specialty teams are aware of the patient’s history.
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