NSG6005 Advanced Pharmacology
Week 1 Discussion
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?
NSG6005 Advanced Pharmacology
Week 2 Discussion
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 medication/treatment?
NSG6005 Advanced Pharmacology
Week 3 Discussion
Mr. JD is a 24-year-old who presents to Urgent Care with a 2-week history of cough and congestion. He says it started out as a "normal cold" and it will not go away. He has a productive cough for green mucous and has green nasal discharge. He says he has had a low-grade temperature for the past 2 days. John reports an intermittent frontal headache with this cold. He is otherwise healthy, with no known allergies.
In his assessment it is found that his vital signs are stable, temperature is 99.9 degrees F, tympanic membranes (TMs) are clear bilaterally, pharynx is erythematous with no exudate; there is greenish postnasal drainage; turbinates are swollen and red; frontal sinus tenderness; no cervical adenopathy, and lungs are clear bilaterally.
Is there any additional subjective or objective information you need for this client? Explain.
Would you treat Mr. JDs cold? Why or why not?
What would you prescribe and for how many days? Include the class of the medication, mechanism of action, route, the half-life; how it is metabolized in and eliminated from the body; and contraindications and black box warnings.
Would this treatment vary if Mr. JD was a 10 year-old 78 lb child? Include the class of the medication, mechanism of action, dosing, route, the half-life; how it is metabolized in and eliminated from the body; and contraindications and black box warnings
What health maintenance or preventive education is important for this client based on your choice medication/treatment?
NSG6005 Advanced Pharmacology
Week 4 Discussion
Respiratory Case Study
For this question, please read the following case study and then respond to the questions noted below
Johnathan, age 7, presents to the office with symptoms of worsening cough and wheezing for the past 24 hours. He is accompanied by his mother, who is a good historian. She reports that her son started having symptoms of a viral upper respiratory infection 2 to 3 days ago, beginning with a runny nose, low-grade fever of 101.0 degrees F orally, and loose cough. Wheezing started on the day before the visit, so Johnathan 's mother started administering albuterol metered-dose inhaler (MDI) two puffs before bed and then two puffs at around 2 AM. The cough and wheezing appear worse today, according to the mother. He had difficulty taking deep-enough breaths to inhale this morning's dose of albuterol, even using the spacer.
Johnathan has been a patient at the clinic since birth and is up to date on his immunizations. His growth and development have been normal, and he is generally healthy except for mild intermittent asthma. This is his first asthma exacerbation of the school year, and his mother expresses a concern about sending him to school with an inhaler.
Johnathan is afebrile with a respiratory rate of 36 and a tight cough every 1 or 2 minutes. He weighs 45 pounds (20.5 kgs.). The examination is all within normal limits except for his breath sounds. He has diffused expiratory wheezes and mild retractions. Pulse oximetry readings have been 93% of oxygen saturation.
What are the appropriate pharmacological therapies to be prescribed for Johnathan?
What information is necessary to provide to Johnathan and his mother regarding asthma exacerbation?
What is an appropriate clinical assessment tool to be use with Johnathan?
What are the classification of asthma?
How would you as the NP address his mother's concern regarding providing an inhaler at school?
What is an appropriate plan of care for Johnathan?
NSG6005 Advanced Pharmacology
Week 5 Discussion
DQ1 Mr. EBR is a 74-year-old retired Hispanic gentleman with known coronary artery disease (CAD), who presents to your clinic with substernal chest pain for the past 3 months. It is not positional; it reliably occurs with exertion, approximately one to two times daily, and is relieved with rest, or one or two sublingual nitroglycerin (NTG) tabs. It is similar in quality, but is much less severe, than the chest pain that occurred with his previous inferior myocardial infarction (MI) 3 years ago. Until the past 3 months, he has felt well.
The chest pain is accompanied by diaphoresis and nausea, but no shortness of breath (SOB) or palpitations. He does not vomit. He denies orthopnea, paroxysmal nocturnal dyspnea (PND), syncope, presyncope, dizziness, lightheadedness, and symptoms of stroke or transient ischemic attack (TIA). An echocardiogram done after his MI demonstrated a preserved left ventricular ejection fraction (LVEF). Other medical problems include well-controlled type 2 diabetes mellitus (DM), well-controlled hypertension (HTN), and hyperlipidemia, with low-density lipoprotein (LDL) at goal. He also has stage 3 chronic kidney disease (CKD) and diabetic neuropathy. He no longer smokes and does not use alcohol or recreational drugs. His daily medications include: Atenolol 25 mg PO bid, Lisinopril 20 mg PO bid, aspirin 81 mg PO daily, Simvastatin 80 mg PO each evening, and metformin 500 mg PO bid.
Mr. EBR's physical examination includes the following: height 68 inches, weight 185 lb, Blood pressure (BP) 126/78, heart rate (HR) 64, Respiratory rate (RR) 16, and temperature 98.6°F orally. He is alert and oriented, and in no apparent distress (NAD). His neck is without jugular venous distention (JVD) or carotid bruits. Lungs are clear to auscultation bilaterally. Cardiovascular: normal S1 & S2, RRR, without rubs, murmurs or gallops. Abdomen has active bowel tones and is soft, nontender, and nondistended (NTND). Extremities are without clubbing, cyanosis, or edema. Distal pedal pulses are 2+ bilaterally
What would you add to the current treatment plan? Why?
Would you discontinue any of the currently prescribed medication? Why or why not?
How does the diagnosis stage 3 chronic kidney disease affect your choices?
Why is the patient prescribed more than one antihypertensive?
What is the benefit of the aspirin therapy in this patient?
DQ2 List three classes of drugs affecting the Hematopoietic System. List the mechanism of action for each class of drug. Choose one medication from the three classes and discuss what disorder the drug is used to treat? How often the medication is given? What labs should get monitored while the patient is taking this medication? Your response should be at least 350 words.
NSG6005 Advanced Pharmacology
Week 6 Discussion
DQ1 Mike is a 46-year-old who presents with a complaint of "heartburn" for 3 months. He describes the pain as burning and it is located in the epigastric area. The pain improves after he takes an antacid or drinks milk. He has been taking either over-the-counter (OTC) famotidine or ranitidine off and on for the past 2 months and he still has recurring epigastric pain. He has lost 6 lb since his last visit.
Assessment
His examination is unremarkable. His blood pressure (BP) is 118/72. Laboratory values are normal complete blood count (CBC) and a positive serum Helicobacter pylori test.
What would you prescribe initially?
How long would you prescribe these medications?
What other possible meds could you prescribe to assist with the side effects from the medications prescribed?
How would the treatment vary if the patient has GERD instead?
DQ2 List differential diagnosis that would help confirm GERD while ruling out other diagnosis. Which medication is the best medication for treatment of GERD and why? What labs or other diagnostic tests that are used to confirm GERD? Your response should be at least 350 words.
NSG6005 Advanced Pharmacology
Week 7 Discussion
DQ1 Tom, a 26-year-old runner, came into the office today complaining of constant pain in the right ankle. While running his usual route, he accidentally stepped on a branch lying in his path, twisting his ankle inward. He denies hearing a "pop." He was able to walk, or limp, the remaining ¼ mile back to his home, where he immediately elevated and iced the ankle for 30 minutes. He took two acetaminophen 325 mg, showered and dressed for work, and drove to his place of employment. He continued to experience significant pain in the ankle, worse when walking. His foot became swollen. Since his job in a sporting goods store requires that he be on his feet most of the day, he was unable to continue his normal workday, and made a same-day appointment to be seen. He has no chronic diseases, takes no medication, and denies recent use of NSAIDs, as aspirin and ibuprofen cause him to have gastritis. He sprained the ankle last year, but was able to manage that injury at home.
Assessment
A 26-year-old, otherwise healthy male presents limping into the examination room, holding his right shoe in his hand. He grimaces with partial weight-bearing of the affected foot. He has local ecchymosis and 1+ edema over the anterolateral ligaments of the right ankle. Capillary refill, pulses, and sensation of the foot and toes are intact. There is no lateral or anterior instability of the joint or tendons. X-ray of the ankle and foot are negative for fracture or dislocation. He has a grade I lateral ankle sprain.
What pain relieving medications would you prescribe? Defend your choice.
How would you prescribe them?
What side effects should you educate the patient about?
Does the age of the patient influence what your choice?
DQ2 What organs are damaged mostly by taking NSAIDS? What patient education would you provide to someone taking NSAIDS? What organ is damaged by taking too much aspirin? What patient education should you provide to a patient taking Aspirin? List 3 diagnosis for which you would administer NSAIDS. List 3 diagnosis for which you would administer Aspirin. What labs or diagnostic tests would you perform for a patient who has consumed too much Aspirin and NSAIDS. Your response should be at least 350 words.
NSG6005 Advanced Pharmacology
Week 8 Discussion
Margaret is a 40-year-old white female in for her annual examination. She states she has been under increased stress in her life for the past few months. She and her husband are currently separated and considering divorce. Her teenaged sons are acting out and she is working extra hours to make ends meet. Secondary to the increased stress she has started smoking again, "about a pack per day" and states "I know that I am not eating right."
Margaret has been on the "pill" for almost 20 years and has always liked the method. She states the she has heard that smoking and taking the pill are not good, and she is worried about that. "I really do not need birth control since I am separated but just in case I probably need something." She states that she has been in a mutually monogamous relationship (as far as she knows) since her marriage 18 years ago. She denies a new partner since her separation. Menarche was at 11 years, her cycles when on the pill are regular and very light. Her menstrual period should start tomorrow as she just finished her active pills. She denies a personal history of abnormal Pap smears, gynecological issues, hypertension (HTN), or diabetes. She is G2P2002, and her pregnancies were full term and uncomplicated at ages 24 and 26. Family history is significant for both parents with HTN and mom has type 2 diabetes. Her paternal grandfather died at age 64 years from type 2 diabetes, HTN, and coronary artery disease. Her other grandparents died in their late 70s early 80s and she is unaware of any medical issues.
Assessment:
Margaret's examination finds her height 5'5", weight 172 lb (up 10 lb. from last year), current body mass index (BMI 28.6), and blood pressure (BP) 148/88. Head, eyes, ears, nose, and throat (HEENT) are grossly within normal limits (WNL). No thyromegaly or lymphadenopathy. Heart rate is regular and rhythm is without murmurs, thrills, or rubs. Lungs are clear to auscultation in all lobes. Breasts are without masses, nipple discharge, asymmetry, or lymphadenopathy; self breast examination techniques and frequency reviewed during examination. Abdomen is soft, nontender, with no masses or hepatosplenomegaly; bowel sounds present in all four quadrants. Pelvic examination reveals normal vulva and negative Bartholin's and Skene's glands; vagina is pink, rugated, with minimal white nonodorous discharge; cervix is pink, multiparous os. Pap smear collected during speculum examination was normal. Bimanual examination reveals a retoverted, firm, mobile, nonenlarged, nontender uterus with negative cervical motion tenderness; adnexa nontender; and ovaries palpable bilaterally, mobile, without masses. Lower extremities were without edema or varicosities.
1. What options are appropriate for this patient?
2. What contraceptive options are contraindicated?
3. What type of patient education is indicated?
4. Given that she has a normal pelvic exam, does that change would that influence your decision?
NSG6005 Advanced Pharmacology
Week 9 Discussion
Angela is a 54-year-old married woman with three adult children. She has been the office
manager of a small law firm for 20 years and has enjoyed her work until this past year. She has
rheumatoid arthritis with minimal impairment that has been managed well with NSAIDs. She has
been taking conjugated estrogens for 8 years and decided to stop taking them because of her
concern of their risks without sufficient medical benefit. She has tolerated the discontinuation
without difficulty.
Assessment:
At her annual medical checkup appointment, she told her primary care provider that she seemed
to be tired all the time, and she was gaining weight because she had no interest in her usual
exercise activities and had been overeating, not from appetite but out of boredom. She denied
that she and her husband have had marital difficulties beyond the ordinary and she was pleased
with the achievements of her children. She noticed 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. Although she denies suicidal feelings, she does not feel that there is meaning to her life:
“My husband and kids would go on fine if I died and probably wouldn’t miss me that much.”
The primary care provider asks Angela to fill out a Beck’s Depression Scale, which
indicated she has moderate depression.
1. What medication would you first prescribe to this patient?
2. She comes back in 2 weeks and states she has not noticed and change in her mood since starting on the medication. What would be your response?
3. What are the possible problems with the medication you prescribed?
4. How long should you continue the treatment regimen?
NSG6005 Advanced Pharmacology
Week 10 Discussion
DQ1 What would you do first prior to prescribing any medication?
What are the various schedules of medications for controlled substances?
Would you prescribe a long or short acting narcotic? Why or why not?
DQ2 What other non narcotic medication options can you offer to this patient?
What patient education is needed with them?
What would you do if the patient and his wife tell you that none of them work for him?
DQ3 You are concerned that this patient may have a substance abuse problem.
What screening testing is available for you to use that is reliable and valid?
What strategies would you suggest for this patient if he was found to have a problem?
What type of referrals would you make?
DQ4 After some investigating, you find that Howard actually is seeing a pain specialist who has given him epidural injections, and prescribes medication for him.
How does that impact any intervention that you may consider?
What other pharmacological options could you offer him?
What nonpharmacological options could you suggest?
DQ5 After seeing Howard and performing the appropriate screening tools, and a urine drug screen, he admits to you that he does have a problem with opioids due to his back injury. He states he has been admitted to an inpatient detox and twenty-eight day rehabilitation unit previously and was able to quit using for 3 months, but relapsed due to his pain. He states for the last 6 months he has been unable to get opioids from physicians since there is a record of him being prescribed a large amount over a short period of time. Due to this, he has started buying heroin from an acquaintance who he went to high school with. His wife is very tearful and states she is concerned that eventually Howard will end up killing himself.
What type of substance abuse programs would be most appropriate for him?
What requirements are there for a nurse practitioner to prescribe a medication to treat opioid addiction?
What are the requirements for a patient who is enrolled in a medication assisted opioid treatment program?
