## Scenario 1
### Problem Explanation
Jamie, a 38-year-old homeless individual with bipolar disorder, is experiencing an acute psychotic episode. He has a history of long-term lithium use and was recently started on imipramine 75 mg daily. The acute psychotic episode suggests that his current medication regimen may not be effectively managing his bipolar disorder and could potentially be exacerbated by the imipramine.
### Treatment Plan
1. **Lithium Continuation**:
– Lithium is effective in managing bipolar disorder. However, its therapeutic levels need to be closely monitored.
– **Order**: Continue lithium and check serum lithium levels immediately.
2. **Discontinue Imipramine**:
– Imipramine, a tricyclic antidepressant, can potentially exacerbate manic or psychotic symptoms in bipolar patients.
– **Order**: Discontinue imipramine.
3. **Initiate Antipsychotic Medication**:
– Given Jamie’s acute psychotic episode, initiating an antipsychotic medication is appropriate.
– **Prescription**:
– Drug: Risperidone
– Dose: 2 mg
– Route: Orally
– Frequency: Twice daily
– Special Instructions: Start with 2 mg twice daily, can be increased based on response and tolerability.
– # Dispensed: 30 days supply
– Refills: 1 refill
4. **Monitor Therapy**:
– Regular monitoring of lithium levels, kidney function (serum creatinine), thyroid function (TSH), and psychiatric symptoms.
– Follow up in one week for symptom assessment and lithium level check.
### Prescription for Pharmacy
1. **Risperidone 2 mg**
– Take one tablet by mouth twice daily.
– Dispense 60 tablets.
– 1 refill.
– Special Instructions: Monitor for side effects and therapeutic response.
### Sources
– American Psychiatric Association. (2013). Practice guideline for the treatment of patients with bipolar disorder (second edition). *American Journal of Psychiatry, 160*(4), 1-50.
– Post, R. M., & Leverich, G. S. (2008). Treatment of bipolar depression. *Journal of Clinical Psychiatry, 69*(11), e18.
– Malhi, G. S., Gessler, D., & Outhred, T. (2017). The use of lithium for the treatment of bipolar disorder: Recommendations from clinical practice guidelines. *Journal of Affective Disorders, 217*, 266-280.
## Scenario 2
### Problem Explanation
AH, a 68-year-old woman with rheumatoid arthritis (RA), has been taking meloxicam for two years. She has other significant medical conditions, including Crohn’s disease and well-controlled type 2 diabetes. Her RA pain has worsened, indicating that her current treatment may no longer be sufficient.
### Treatment Plan
1. **Assess Disease Activity**:
– Evaluate the current disease activity and the severity of symptoms.
2. **Adjust Current NSAID Therapy**:
– Meloxicam is an NSAID used to reduce inflammation and pain in RA. Consider increasing the dose or switching to another NSAID if no contraindications are present.
– **Prescription**:
– Drug: Meloxicam
– Dose: Increase to 15 mg
– Route: Orally
– Frequency: Daily
– # Dispensed: 30 days supply
– Refills: 2 refills
3. **Add Disease-Modifying Antirheumatic Drug (DMARD)**:
– Consider adding a DMARD if not already prescribed. Methotrexate is commonly used.
– **Prescription**:
– Drug: Methotrexate
– Dose: 15 mg
– Route: Orally
– Frequency: Once weekly
– Special Instructions: Take with folic acid to reduce side effects.
– # Dispensed: 4 weeks supply
– Refills: 3 refills
4. **Monitor Therapy**:
– Regular follow-ups to monitor response to treatment and side effects.
– Routine blood tests (CBC, liver function tests) to monitor for methotrexate toxicity.
### Prescription for Pharmacy
1. **Meloxicam 15 mg**
– Take one tablet by mouth daily.
– Dispense 30 tablets.
– 2 refills.
2. **Methotrexate 15 mg**
– Take one tablet by mouth once weekly.
– Dispense 4 tablets.
– 3 refills.
– Special Instructions: Take with folic acid.
### Sources
– Singh, J. A., Saag, K. G., Bridges, S. L., Akl, E. A., Bannuru, R. R., Sullivan, M. C., … & McAlindon, T. (2016). 2015 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. *Arthritis & Rheumatology, 68*(1), 1-26.
– Smolen, J. S., Landewé, R., Bijlsma, J., Burmester, G., Dougados, M., Kerschbaumer, A., … & van Vollenhoven, R. (2017). EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2016 update. *Annals of the Rheumatic Diseases, 76*(6), 960-977.
– Alamanos, Y., & Drosos, A. A. (2005). Epidemiology of adult rheumatoid arthritis. *Autoimmunity Reviews, 4*(3), 130-136.
## Scenario 3
### Problem Explanation
Sheila, a 26-year-old with a history of head injury and tonic-clonic seizures, presents with symptoms suggestive of phenytoin toxicity (funny eye movements, feeling uncoordinated, blurred vision, lethargy). Her current medications include Ritalin, Dilantin (phenytoin), Paxil, and Lasix. Her lab results show a low serum albumin level which affects the interpretation of her Dilantin level.
### Diagnosis and Supporting Lab Values
– The symptoms suggest phenytoin toxicity, potentially due to hypoalbuminemia affecting phenytoin binding.
– Calculated corrected phenytoin level using the formula: Corrected Phenytoin Level = Measured Total Phenytoin Level / ((0.2 x Albumin) + 0.1)
– Corrected Phenytoin Level = 11 / ((0.2 x 2) + 0.1) = 11 / 0.5 = 22 mcg/mL (indicating toxicity)
### Treatment Plan
1. **Adjust Phenytoin Dosage**:
– Reduce phenytoin dose due to toxicity.
– **Prescription**:
– Drug: Phenytoin (Dilantin)
– Dose: Reduce to 200 mg
– Route: Orally
– Frequency: Twice daily
– # Dispensed: 30 days supply
– Refills: 2 refills
2. **Monitor Serum Phenytoin Levels**:
– Recheck phenytoin levels in 1 week and monitor for symptom resolution.
3. **Address Hypoalbuminemia**:
– Evaluate and manage the underlying cause of hypoalbuminemia.
### Prescription for Pharmacy
1. **Phenytoin (Dilantin) 200 mg**
– Take one capsule by mouth twice daily.
– Dispense 60 capsules.
– 2 refills.
– Special Instructions: Monitor serum phenytoin levels weekly.
### Sources
– Patsalos, P. N., Berry, D. J., Bourgeois, B. F., Cloyd, J. C., Glauser, T. A., Johannessen, S. I., … & Tomson, T. (2008). Antiepileptic drugs—best practice guidelines for therapeutic drug monitoring: a position paper by the subcommission on therapeutic drug monitoring, ILAE Commission on Therapeutic Strategies. *Epilepsia, 49*(7), 1239-1276.
– Bauer, L. A. (2008). Applied clinical pharmacokinetics (2nd ed.). McGraw-Hill Medical.
– Perucca, E. (2006). Clinically relevant drug interactions with antiepileptic drugs. *British Journal of Clinical Pharmacology, 61*(3), 246-255.
## Scenario 4
### Problem Explanation
Xavi, a 44-year-old man, presents with severe low back pain following a motor vehicle accident 10 days ago. He rates his pain as 8 out of 10 and was prescribed Lortab (hydrocodone/acetaminophen) 5/325 mg in the ER. He requests a refill, stating the medication provides only minimal relief.
### Treatment Plan
1. **Evaluate Pain Management**:
– Assess pain severity and the effectiveness of the current medication.
2. **Adjust Pain Medication**:
– Consider increasing the dose or changing to a more potent pain management regimen while ensuring safe use.
– **Prescription**:
– Drug: Hydrocodone/Acetaminophen (Norco) 10/325 mg
– Dose: 10/325 mg
– Route: Orally
– Frequency: Every 6 hours as needed for pain
– # Dispensed: 30 tablets (5 days supply)
– Refills: No refills
– Special Instructions: Do not exceed 4 grams of acetaminophen
Directions: For each scenario below, answer the questions below using your required learning resources, clinical practice guidelines, and medscape. Explain the problem and explain how you would address the problem. When recommending medications, write out a complete prescription for each medication. What order would you send to a pharmacy? Include drug, dose, route, frequency, special instructions, # dispensed (days supply), refills, etc. Also, state if you would continue, discontinue or taper the patient’s current medications. Use at least 3 sources for each scenario and cite sources using APA format.
SCENARIO 1
Jamie is a 38-year-old homeless bipolar patient who presents with an acute psychotic episode. He tells you that he has been on lithium for years and was recently started on imipramine 75 mg daily by someone at a free clinic. What treatment plan would you develop for Jamie? How would you monitor therapy?
SCENARIO 2
A 68-year-old woman AH has a history of rheumatoid arthritis and has been taking meloxicam 15 mg po daily for 2 years. Other pertinent past medical history includes occasional incontinence, Crohn’s disease with frequent exacerbations, and well-controlled diabetes type 2. Recently, her arthritis pain has been much worse, and she is requesting additional medication for her rheumatoid arthritis. What treatment plan would you develop for AH? How would you monitor therapy?
SCENARIO 3
Sheila is a 26-year-old with history of head injury and tonic clonic seizures. She is seen today with complaints of “funny” eye movements, feeling uncoordinated, blurred vision, and feeling lethargic. Her current medications include Ritalin 10 mg po BID, Dilantin 300 mg po BID, Paxil 20 mg po daily, Lasix 20 po daily Lab Values from today Dilantin level of 11 Albumin 2 WBC 9.9 Plt 177 Na 141 K 4.2 Hg 13.2. What do you think is causing the patient’s symptoms? What lab values and calculated corrected medication level support your diagnosis? What is your treatment plan for this patient?
SCENARIO 4
Xavi is a 44-year-old man with complaints of low back pain following a motor vehicle accident. The accident occurred 10 days ago. He rates his pain 8 out of 10. He was prescribed Lortab 5 / 325 in the ER. He is requesting a refill of the Lortab today and indicates it just barely makes him comfortable. What treatment plan would you implement for Xavi? What days supply would you prescribe?
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