Case Study: Prescribed Drugs with CAMs

Mr. X, a 42-year-old male presents to your primary care practice today complaining of low back pain.

History – Mr. X states that he has had chronic low back pain since he had a skiing accident about 10 years ago. Three days ago, he felt a pulling sensation in his lower back after moving some boxes. The pain intensity increased over the subsequent 24 hours and is now steady, aching in nature, at 3-4 out of 10. Mr. X also has Type2 diabetes, which is well controlled on metformin with a HGA1c of 5.6. He has a history of DVT 4 months ago for which he takes Coumadin, INR is WNL. He is followed by a specialist for this problem. He recently started taking two OTC products; kava kava for what he describes as “anxiety” and CoEnzyme Q10 on the advice of a friend.

Social – Mr. X is a smoker, 1 pack per week for 15 years. No alcohol or drug use. He is employed as an accountant and has medical insurance. He is divorced.
PE/ROS – Complains of low back stiffness and pain on movement with occasional spasms related to moving in certain directions. You note he has mild difficulty getting onto the exam table but gait is normal. He denies weakness/numbness/tingling of legs, no radiation, no change in bowel or bladder habits. BMI 27. All range of motion of the back is decreased by 25%. Straight leg lift is negative bilaterally, DTR intact. All other systems WNL.

Medications:

Metformin 1000mg ER one tab daily – Type II Diabetes controlled

Coumadin 5 mg. daily – Hx of DVT – Controlled

Kava Kava 50 mg. tid – Self-medication for anxiety

CoQ10 – 200 mg. daily. – Self-medication for unknown reason

Directions:

1. Provide a diagnosis for the patient and your rationale for the diagnosis
2. Provide a treatment plan specifically for this patient, pharmacologic and non-pharmacologic.
3. Comment on the use of OTC products in relation to Mr. X’s current chronic and acute disease diagnoses and medications. Include drug-drug interactions and side effect profiles.
4. Provide an education plan for Mr. X, make sure to provide principles of therapeutic communication.
5. Do not use patient-facing sources or general nursing texts.


 

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Margo is a 49-year-old divorced woman who works as a bank teller. She tells her primary care provider (PCP) that she feels tired all the time and that she is gaining weight because she has no interest in her usual exercise activities, and that she has been overeating, even though she is often not really hungry. She notices that she has difficulty falling asleep at night and awakens around 4 a.m. most mornings, without her alarm, and cannot go back to sleep even though she still feels tired. She finds little joy in her life but cannot pinpoint any particular concern or event causing this problem. The PCP asks Angela to fill out a Beck’s Depression Scale, which indicates she has moderate depression.

Choose a pharmacologic intervention for Margo.

Provide Margo with written education regarding her prescription. (Include what she should expect when first taking the drug, appropriate activity warnings, when to expect improvement, side effects she may experience, and anything she should report to the provider).


 

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Write a 2- to 3-page paper that addresses the following:

Select one the following factors: genetics, gender, ethnicity, age, or behavior factors.
Reflect on how the factor you selected might influence the patient’s pharmacokinetic and pharmacodynamic processes.
Consider how changes in the pharmacokinetic and pharmacodynamic processes might impact the patient’s recommended drug therapy.
Think about how you might improve the patient’s drug therapy plan based on the pharmacokinetic and pharmacodynamic changes. Reflect on whether you would modify the current drug treatment or provide an alternative treatment option for the patient.

Explain how the factor you selected might influence the pharmacokinetic and pharmacodynamic processes in the patient from the case study you were assigned.
Describe how changes in the processes might impact the patient’s recommended drug therapy. Be specific and provide examples.
Explain how you might improve the patient’s drug therapy plan and explain why you would make these recommended improvements.

*THE FACTOR I SELECTED IS ETHNICITY
CASE STUDY
LM is an 89-year-old female resident of a long-term care facility who has been experiencing multiple falls, some resulting in injuries such as bruising and skin tears. Over the last 6 months, her ambulation status has declined from independent to wheelchair level. She complains of pain in her legs when walking more than short distances across the nursing unit.

PMH:

HTN
Alzheimer’s disease
Hypothyroidism
Osteoarthritis
Diabetes
MEDICATIONS:

Amlodipine 10 mg QD
Donepezil 10 mg QHS
Levothyroxine 0.88 mg QAM
Celecoxib 200 mg QD
Furosemide 40 mg QAM
Metformin 500mg, 1 BID
Glyburide 5mg, 1 BID
ALLERGIES: NKA

SOCIAL HISTORY:

Widowed with 2 adult children living in town, retired photographer and owner of an art supply store

VITALS: LABS:

Weight: 129 lbs TSH 2.45 Free T4 0.98

Height: 64 inches Na 135, K+ 3.8, Cl 99, CO2 25,

BP: Supine = 177/82 Glucose 101, SCr 0.9, BUN 42

HR: 78 bpm WBC 7.0, RBC 4.5, Hgb 11.9, Hct 34.1

Plt 255

Cr: 1.6 UA: Clear

eGFR: 45 ml/min

PE:

HEENT: Normocephalic, no evidence of trauma, PERRLA, EOMI, Dry mucous membranes
CV: RRR
Respiratory: Clear to auscultation bilaterally
Abdomen: Soft, non-tender, no masses or guarding
G/U: Skin intact, assisted with toileting and personal hygiene by staff
Extremities: Bilateral 2+ edema to lower extremities; skin dry, dark bruising and skin tear to right elbow and forearm
Neuro: Alert and oriented to person only. MMSE 18/30, stable over last 12 months.
PAIN ASSESSMENT:

Faces pain scale: No pain occurs at rest, upon walking, pain is moderate to severe


 

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For the assignment, do the following:

1. Diagnose the child and describe how you arrived at the diagnosis (i.e. how you ruled out other diagnoses).
2. Provide a specific treatment plan for this patient, pharmacologic and/or nonpharmacologic.
3. Provide a communication plan for how the family will be involved in the treatment plan.
4. Provide resources that Mr. Smith could access which would provide information concerning your treatment decisions.
5. Utilize national standards, medical or advanced practice professional sources. Do not use patient-facing sources or general nursing texts to support your diagnosis and treatment.
Case Study:
Mr. Smith brings his 4-year-old son to your primary care office. He states the boy has been ill for three days. Mr. Smith indicates that he would like antibiotics so he can send his son back to pre-school the next day.

History – Child began with sneezing, mild cough, and low grade fever of 100 degrees three days ago. All immunizations UTD. Father reports that the child has had only two incidents of URI and no other illnesses.

Social – non-smoking household. Child attends preschool four mornings a week and is insured through his father’s employment. No other siblings in the household.

PE/ROS -T 99, R 20, P 100. Alert, cooperative, in good spirits, well-hydrated. Mildly erythemic throat, no exudate, tonsils +2. Both ears mild pink tympanic membrane with good movement. Lungs clear bilaterally. All other systems WNL.

Do not consider COVID-19 for this patient diagnosis.


 

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Review the Resources for this module and consider the principles of pharmacokinetics and pharmacodynamics.
Reflect on your experiences, observations, and/or clinical practices from the last 5 years and think about how pharmacokinetic and pharmacodynamic factors altered his or her anticipated response to a drug.
Consider factors that might have influenced the patient’s pharmacokinetic and pharmacodynamic processes, such as genetics (including pharmacogenetics), gender, ethnicity, age, behavior, and/or possible pathophysiological changes due to disease.
Think about a personalized plan of care based on these influencing factors and patient history in your case study.

Post a description of the patient case from your experiences, observations, and/or clinical practice from the last 5 years. Then, describe factors that might have influenced pharmacokinetic and pharmacodynamic processes of the patient you identified. Finally, explain details of the personalized plan of care that you would develop based on influencing factors and patient history in your case. Be specific and provide examples.

RESOURCES
Rosenthal, L. D., & Burchum, J. R. (2021). Lehne’s pharmacotherapeutics for advanced practice nurses and physician assistants (2nd ed.) St. Louis, MO: Elsevier.

Chapter 1, “Prescriptive Authority” (pp. 1–3)
Chapter 2, “Rational Drug Selection and Prescription Writing” (pp. 4–7)
Chapter 3, “Promoting Positive Outcomes of Drug Therapy” (pp. 8–12)
Chapter 4, “Pharmacokinetics, Pharmacodynamics, and Drug Interactions” (pp. 13–33)
Chapter 5, “Adverse Drug Reactions and Medication Errors” (pp. 34–42)
Chapter 6, “Individual Variation in Drug Response” (pp. 43–45)
American Geriatrics Society 2019 Beers Criteria Update Expert Panel. (2019). American Geriatrics Society 2019 updated AGS Beers criteria for potentially inappropriate medication use in older adults. Journal of the American Geriatrics Society, 67(4), 674–694. doi:10.1111/jgs.15767

American Geriatrics Society 2019 updated AGS Beers criteria for potentially inappropriate medication use in older adults by American Geriatrics Society, in Journal of the American Geriatrics Society, Vol. 67/Issue 4. Copyright 2019 by Blackwell Publishing. Reprinted by permission of Blackwell Publishing via the Copyright Clearance Center.

This article is an update to the Beers Criteria, which includes lists of potentially inappropriate medications to be avoided in older adults as well as newly added criteria that lists select drugs that should be avoided or have their dose adjusted based on the individual’s kidney function and select drug-drug interactions documented to be associated with harms in older adults.


 

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In this assignment, assuming you prescribe Dilantin, RX (Brand) and Phenytoin, RX (Generic) for your patient, how would you minimize cost or assist the patient in getting the medication at the lowest cost possible. What resources are available to reduce drug costs? Find at least 2 resources for free or reduced cost medications.


 

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Your patient is a 23-year-old female. She presents with coughing and wheezing which she stated started about three weeks ago. She is currently 25 weeks pregnant. Her last prenatal visit was one month ago in another state. She has an appointment with the prenatal care provider next week, however her respiratory symptoms brought her to your office today.

History – Chickenpox as a child. Asthma as a child, diagnosed at age 8 for which she used a SABA when needed. She has not had the need to use an inhaler since she was 19. She takes only her prenatal vitamin. No other acute or chronic problems. She advises you that she is up to date on all immunizations except she has not had a flu shot (it is October).
Social – Non-smoker, no drug use. She relocated to your state two weeks ago to get away from an abusive domestic situation. She has no support network in this area and has not yet found employment. She has no medical insurance.

HPA – Non-productive cough x 3 weeks. Wheezing audible from across the room. She states it is like this all day and wakes her from sleep every night. She reports that she is fatigued even in the morning. No other complaints.

PE/ROS – Pt appears disheveled but clean. Wheezing in all lung fields. T 98, P 82 regular, R 28 no stridor. FH 130 regular. The remainder of the exam is WNL.

02 98% and FEV 70%

Directions:

1.Construct a narrative document.
2.Diagnose the patient based on the above findings and provide your rationale for how you arrived at the diagnosis.
3.Develop a treatment plan specifically for this patient, pharmacologic and non-pharmacologic. ( 3 pharmacologic and 3 non-pharmacologic)
4.Describe community resources (using your community) currently available in your state/city to support this patient. (3 resources)
5.Provide a communication plan that you will use to ensure the patient is an active participant in the treatment plan. Refer to therapeutic communication concepts.
Utilize national standards, and medical or advanced practice professional sources. Do not use patient-facing sources or general nursing texts.
6.Use references to support your concepts. Utilize correct APA formatting (7th edition) and mechanics of professional communication.


 

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Part 1

Choose a drug that is used for the GI system. Write a legal prescription for the drug for a fictitious patient. You are the provider. Be sure your prescription includes all legally correct patient information, provider information, medication information as well as any special instructions to the pharmacist. Your writing Assignment should include all the legal elements of a prescription.

Part 2

Write an essay to describe the pharmacokinetics and pharmacodynamics of the drug as well as specific patient education about the chosen drug.


 

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Therapeutic communication is important to ensure patients are part of treatment planning. Provide discussion of the following:

1, How would you evaluate a patient’s ability to understand your instruction and their current knowledge base about their problem? What characteristics of the patient would be helpful?
2, How would you be certain that the patient understands your medication instruction?
3, What methods of therapeutic communication would be useful in advanced practice?


 

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How do you think you will use knowledge of pharmacology differently as an advanced practice nurse than you do as an RN?

What are your expectations of your advanced practice role, specifically as a prescriber?

What do you think the role of standards of care are in the prescribing process?


 

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Gami is a 48-year-old who you discover when completing a health history is taking cinnamon to treat Type II Diabetes. She is specifically using cassia, Cinnamon. You also discover that she is taking Ginseng to assist with memory. Her prescribed medications are Aricept and Coumadin.

Ms. GM is a 48-year-old who presents to your clinic to establish care. During the health history, you learn that she has a history of Type II Diabetes. When asked about prescription and non-traditional medications, she reports being prescribed Aricept, Coumadin, Cassia cinnamon for Type II Diabetes and Ginseng for memory.

Is there any additional subjective or objective information you need for this client? Explain.
What would be your position on the Ms. GMs use of alternative supplements for her diabetes and memory? Explain and include contraindications, if any.
Are there any additional test/assessments you would complete for this patient given this list of medications? Explain.
How might your treatment plan, in terms of medications, differ for this patient? Include the class of the medication, mechanism of action, route, the half-life; how it is metabolized in and eliminated from the body; contraindications, and black box warnings.
What health maintenance or preventive education is important for this client based on your choice of medication/treatment?


 

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Discussion Question 1

For these questions, please read the following case study and then respond to the questions noted below.

Ms. BD is a 33-year-old G2P1 African-American female who presents to your clinic today complaining of unusual fatigue, nausea, and vomiting for the last five days. She has a medical history of chronic hypertension (HTN) that was diagnosed shortly after her first pregnancy two years ago and GERD. MS. BD’s blood pressure is controlled on Lisinopril-Hydrochlorothiazide 20/12.5mg by mouth twice a day, and GERD controlled on Bismuth Subsalicylate 262mg by mouth every 6 hours as needed. During the interview, you learn that she is single, sexually active, has one partner and that her menses is ten days late. She performed a home pregnancy the three days after missing her menstrual cycle, and the results were inconclusive. She states she feels terrible and needs relief. She has no other medical problems, symptoms, or concerns.

Assessment: Physical examination is unremarkable. BP128/68, HR is 74, Urine human chorionic gonadotropin (HCG) positive, beta HCG sent, potassium 4.2, blood
urea nitrogen (BUN) 14, creatinine is 0.6, Alanine aminotransferase (ALT) 29, White blood cells (WBCs) 6.5, hemoglobin (Hgb) 12.8, hematocrit (Hct) 39, and platelets 330,000.

List the additional questions you would need to ask this patient. Explain.
What is the safety profile of Lisinopril-hydrochlorothiazide and bismuth subsalicylate in pregnant women? What are the possible complications to the pregnant woman and her fetus?
What is the importance of assessing laboratory values when prescribing medications? How might the laboratory values, in this case, impact your treatment plan?
Would you make any changes to Ms. BD’s blood pressure and GERD medications? Explain. If yes, what would you prescribe? Discuss the medications safety in pregnancy, mechanism of action, route, the half-life; how it is metabolized in and eliminated from the body; and contraindications and black box warnings.
How does ethnopharmacology apply to this patient if she were NOT pregnant? Explain.
What health maintenance or preventive education do you provide in this client case based on your choice of medications/treatment?
Would you treat this patient or refer her? Explain. If you refer, where would you refer this patient?


 

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Explore weight loss management and treatments that are used today
Discuss the prevalence of obesity in US among children
Describe medications/foods that contribute to weight gain
Explain indications for pharmacologic therapy
Create an educational handout that can be used for improving patient’s knowledge of alternative medication and treatments


 

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The Central Nervous System (CNS) is a complicated network that controls behaviors and is adaptive to environment.

Select a medication class that is used to treat seizure disorder
Choose three medications within the class
Provide each drugs’ mechanism of action, indication, absorption, distribution, and metabolism in a separate section for each drug selected


 

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Explain the mechanism of action of a “biologic drug”
Identify two advantages and two disadvantages of using this medication for chronic disease states
Provide a patient case and drug treatment plan to support it


 

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1. Provide patient educational material to assist with adherence to treatment and/or non-pharmacologic management of Benign Prostatic Hyperplasia and provide 1 reference article less than 5 years old.

2. Respond to this classmate’s post and provide 1 reference article

(Post from classmate) Benign prostatic hyperplasia (BPH) is a disease that is manifested by symptoms such as poor urinary flow, urgency, nocturia, incomplete voiding and dribbling (Ababneh et al., 2019). Typically, the treatment goal of BPH is to reduce the severity of the patient’s symptoms and prevent long-term complications. Adherence to patient medications has a significant role in reducing the severity of symptoms and improving one’s clinical outcomes. The clinician’s role in this instance is to provide adequate and thorough education to the patient regarding treatment options, their risks and benefits, and duration of treatment. It has been shown that, with verbal communication only, patients only retain about 20% of the information taught (Sare et al., 2020). Improvement of treatment adherence and clinical outcomes can occur when using both verbal and written material to ensure higher education retention rates. This written material would be better accessed through the Internet, such as a website or application, rather than brochures and pamphlets can be easily lost during traveling or in the home. One factor to be cognoscente of when creating educational material is to ensure it has high readability. On average, an American is able to read at a level of a seventh to eight grade student (Sare et al., 2020). The clinician needs to be mindful of the educational status and cognitive status of their client when providing material for treatment adherence.


 

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1. Provide patient educational material to assist with adherence to treatment and/or non-pharmacologic management of Benign Prostatic Hyperplasia and provide 1 reference article less than 5 years old.

2. Respond to this classmate’s post and provide 1 reference article

(Post from classmate) Benign prostatic hyperplasia (BPH) is a disease that is manifested by symptoms such as poor urinary flow, urgency, nocturia, incomplete voiding and dribbling (Ababneh et al., 2019). Typically, the treatment goal of BPH is to reduce the severity of the patient’s symptoms and prevent long-term complications. Adherence to patient medications has a significant role in reducing the severity of symptoms and improving one’s clinical outcomes. The clinician’s role in this instance is to provide adequate and thorough education to the patient regarding treatment options, their risks and benefits, and duration of treatment. It has been shown that, with verbal communication only, patients only retain about 20% of the information taught (Sare et al., 2020). Improvement of treatment adherence and clinical outcomes can occur when using both verbal and written material to ensure higher education retention rates. This written material would be better accessed through the Internet, such as a website or application, rather than brochures and pamphlets can be easily lost during traveling or in the home. One factor to be cognoscente of when creating educational material is to ensure it has high readability. On average, an American is able to read at a level of a seventh to eight grade student (Sare et al., 2020). The clinician needs to be mindful of the educational status and cognitive status of their client when providing material for treatment adherence.


 

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Download the LDL-C Manager app by the American College of Cardiology – the URL is: https://www.acc.org/LDLCmanager

For the initial post provide data that correlates with the following case:

52 y/o African American male with ST-elevation myocardial infarction (STEMI) 6 months ago

Strong fam hx of heart disease

Patient went to cardiac rehab for the first 3 months after his MI but has just been going to the gym to ride the bike two to three times a week now. He denies unilateral weakness, numbness/tingling, or changes in vision. He denies CP and only has SOB if he really pedals hard on the bike for longer than 15 minutes. He denies changes in bowel or urinary habits. He denies any lower extremity edema.

MEDICATION LIST:

Carvedilol 25mg po bid

Atorvastatin 80mg po qd

aspirin 81mg po qd

Plogridolel 75 mg PO once daily

Lisinopril 40 mg po qd

Clothalidone 25mg po qd

BP 136/85, P 64, RR 18, T 38.2°C; Wt 102.3 kg, Ht 6′0″

Total Cholesterol 190; HDL 40; LDL 121; triglycerides 145

PE: normal heart, lung and abdomen. Liver enzymes WNL

Calculated patient risk of a cardiovascular event
What are the patients CV risk factors (consider med list)
Change at least one data parameter (LDL, HDL, smoking cessation, et. al) and provide the new CV risk calculation
Discuss what resources were most helpful in this tool – Lowering LDL-C booklet – and how it can be used in the clinic setting


 

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Your responses should be a minimum of 250 words, scholarly written, APA formatted, and referenced. A minimum of 4 references are required (other than your text).


 

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