Oh, How I Miss SOAP Notes

My friend, another pharmacist, called me today to ask a favor. She was wondering if the medications a patient is taking are contributing to some symptoms the patient is having: hearing loss, vision changes, and unexplained weight loss. My friend didn’t have time to do a thorough review of the medications, so she asked me to do it (because I have lots of time).

She started reading the list of medications to me.

Amitriptyline
Furosemide
Klor-Con
Fosamax
Atarax
Levothyroxine
Oxycodone
Vitamin D
Pangestyme
Warfarin
Lidocaine Viscous
Aldara
Zyrtec
Folic Acid
B12
Centrum
Senokot
Prilosec
Claritin

Off the top of my head, the only one I could think of that causes ototoxicity is furosemide. The dose wasn’t high, either (40mg). Without seeing labs, I couldn’t assess the patient’s renal function. But it still seemed unlikely that the loop diuretic was doing it. Other hearing problems can be caused by accumulation of salicylates. This is always a possibility I consider because patients often don’t read labels on OTC medications. She could be taking Exedrin for headaches, using Bengay for muscle pain, taking Pepto-Bismol for diarrhea, and using Alka-Seltzer for a hangover. I don’t know, but that’s a lot of salicylates. It’s always good to ask, especially if the hearing problem is ringing in the ears.

As for changes in vision, I looked at the medication list and thought: anticholinergic overload? Her prescription medications include a TCA and 3 antihistamines (although the hydroxyzine HCl has the greatest anticholinergic potential of the three). If she was taking any OTC antihistamines (Benadryl, Unisom, Tylenol PM, Bonine, Dramamine, NyQuil) on top of her prescriptions, she likely WAS overloaded with anticholinergics. Vision problems are common with excess anticholinergic use. She was also obviously constipated (using Senokot), which is a side effect of anticholinergics.

Or the patient just may be showing some signs of age. Hearing loss and vision changes tend to happen when you get old.

The unexplained weight loss and inability to gain weight are the most troublesome of her symptoms. Any time I hear “unexplained weight loss,” I have to think about cancer. Assuming that her doctor has done everything in his/her power to rule that out, other reasons for weight loss must be considered.

The patient is on levothyroxine. Again, without labs, I don’t know the patient’s TSH. Has the doctor ordered a free T4? Sometimes TSH isn’t a perfect indicator of levothyroxine levels; her pituitary gland may not be functioning properly (not reducing TSH production in response to elevated thyroid hormone function).

Why is she on Pangestyme? As it’s just a capsule full of digestive enzymes, I don’t see much harm in it. But why is she taking it? Is there an anatomical or gastrointestinal reason for her inability to gain weight?

There are a million different potential causes of unexplained weight loss. With the information I have about the patient today, this is about the best I can do.

To help her gain weight, I told the other pharmacist to talk to her doctor about possibly switching her hydroxyzine to cyproheptadine. It is an antihistaminergic/antiserotonergic agent that has been shown to promote weight gain in patients with AIDS-associated wasting, cachexia, and cystic fibrosis. It should also help with allergy symptoms. If overload of anticholinergics is indeed a causative factor for her vision problems, this would need to be evaluated. Like hydroxyzine, cyproheptadine has moderate anticholinergic activity.

I communicated my thoughts on her medications and symptoms with my friend, the other pharmacist. It’s up to her now to talk to the patient and doctor.

I have to thank my pharmacy professors for taking the time in case studies to do this sort of exercise with me. In school, our case studies were complete packages of information (labs, history, etc). In the real world, I never get a complete profile. But I do the best I can with the limited information I have available to me. I feel thankful that I have the opportunity, even if only occasionally, to use my pharmaceutical knowledge. It reminds me of why I went to pharmacy school.

On days when I can make some recommendations and have the potential to make a difference in a patient’s health, I love my job.