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NRP507 Advanced Pharmacology

Week 3 Assignment

Patient Case Study: Diabetes Mellitus, Hypertension, Hyperlipidemia

This week you gained insight into diabetes, hypertension, and hyperlipidemia, and now it is time to apply your knowledge to complete a case study focused on a patient returning to review his labs.

As clinicians, it is essential to be aware of the two main evidence-based guidelines, the American Diabetes Association® (ADA) and the American Association of Clinical Endocrinologists® (AACE), to help you manage patients.

For this assignment, use the ADA evidence-based guidelines to answer the questions within the case study.

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Case Study: Diabetes Mellitus,

Hypertension, Hyperlipidemia

Complete the case study by answering the questions associated with the scenario.

DOB: 2/14/72

George Garcia, a 48-year-old Hispanic male, presents for his 3-month follow-up type-2 diabetes mellitus (T2DM) lab review. He is a long-term patient in your practice. He works as an interstate truck driver, so he admits he doesn’t get a chance to exercise, eats a lot of fast food, and drinks 3 cups of coffee and 2 beers/day. He was diagnosed with T2DM 2 years ago and has maxed out on his metformin, refused to start a statin for “fearing the side effects” despite our discussions at each office visit. He has been taking his meds as prescribed and needs refills on everything. His blood pressure was suboptimal at his last visit 3 months ago and his lisinopril was increased from 20mg to 40mg, and he complains of constant throat clearing and an annoying dry cough. He complained of a mild cough in the past and always attributed it to allergies but states this is not allergies. He verbalizes he wishes he had some ideas on how he could make some health changes but finds it hard with his job. He feels sluggish and has decided he wants to try that medicine for cholesterol we discussed in the past.

ROS is negative except for his dry cough

The exam is normal except has frequent dry hacky cough during the visit

ASCVD 10-year risk assessment is >15%.

Eye exam: Current: no retinopathy

Foot exam: Current: sensation intact to monofilament

PMH: HTN, T2DM, Erectile dysfunction.

FH: Father: T2DM, MI

 Mother: T2DM, obesity

 Sisters x 2: Obesity

Meds:

metformin XR 1000mg 2 tab with dinner

lisinopril 40mg 1-tab daily

Viagra® 100mg 1-tab prn

Allergies: NKDA

VS: BP 142/90 P 82 R 20 BMI 28

CBC: Normal

Case Study DM_HTN_HLP

NRP/507 v5

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CMP: glucose: 116

 GFR: 110

 Creatinine: 0.9

 BUN: 10

 K: 4.0

 LFTs: all normal urinary albumin-to-creatinine ratio normal

A1C: 7.5

Lipids: TC: 235

Trigs: 190

HDL: 32

LDL: 180

VLDL: 23

Part I: Hypertension (HTN)

Analysis of Blood Pressure Control

Using the most current ADA EBP guidelines, answer the following questions.

1. Using the information provided in the scenario, synthesize George’s overall social and medical history, clinical symptoms, and clinical assessment, and provide an analysis of his blood pressure control.

Plan of Care and Prescription Writing

2. Which medication would you use to treat him? Explain your rationale. Include the medication class, side effects, and any precautions or black box warnings in your explanation.

3. Using the Rx template provided, type the blood pressure prescription you have chosen to treat George’s blood pressure. Make sure to include all elements. Excellence in Health Care, LLC.

4. Outline 2 of the most common side effects of the medication you just prescribed, monitoring for appropriate follow-up labs and office visit, including time frames on both.

5. Discuss 5 specific, relevant, and realistic dietary interventions you would suggest to positively impact George’s blood pressure. One intervention needs to incorporate a complementary herb or supplement. Provide a rationale for each intervention using evidence-based support. (Use the National Institutes of Health Herbs at a Glance page to search for and locate evidence-based support for a complementary herb or supplement.)

Part II: Diabetes Mellitus (DM)

Using the most current ADA EBP guidelines, answer the following questions.

Analysis of Blood Sugar Control

1. Based on the information provided within the scenario, synthesize George’s overall social and medical history, clinical symptoms, and clinical assessment, and provide an analysis of whether his blood sugars are under control.

Plan of Care and Prescription Writing

2. Which medication changes would you make to treat him and explain your rationale? Include the medication class, side effects, and any precautions or black box warnings in your explanation.

3. Using the Rx templates, type the prescription(s) you have chosen to treat George’s blood sugar.

4. Outline your follow-up plan for labs and office visit, including time frames on both. List each lab and provide rationale.

5. Discuss 5 lifestyle interventions and explain specifically how they can impact George’s glycemic control.

Part III: Hyperlipidemia (HLP)

Analysis of Lipid Control

Using the most current ADA EBP guidelines, answer the following questions.

1. Based on the information provided within the scenario, synthesize George’s overall social and medical history, clinical symptoms, and clinical assessment, and provide an analysis of whether his lipids are under control.

2. Differentiate the mechanism of action between a hydrophilic statin and a lipophilic statin and provide an example of each. How is this information helpful to you as a clinician and specifically in treating George?

Plan of Care and Prescription Writing

3. Which medication would you use to treat George? Explain your rationale including the medication class, side effects, any precautions, or black box warnings in your explanation.

4. Using the Rx template, type the prescription you have chosen to treat George’s abnormal lipids.

 Excellence in Health Care, LLC.

Monitoring, Follow-up, and Patient Education

5. Outline monitoring for appropriate follow-up labs and office visit, including time frames on both.

6. Patient education is always essential and important. In this case, what imperative piece of information regarding a potential side effect of this lipid medication would you impart to George?

 

NRP507 Advanced Pharmacology

Week 5 Assignment

Patient Case Study: Asthma

Based on the knowledge you have gained up to this point, it is time to apply your skills to determine the proper treatment plan for a patient presenting with asthma exacerbation.

CASE STUDY:

Asthma

Complete the case study by answering the questions associated with the scenario.

DOB: 2/3/1984

Nancy Smith, a 35-year-old female, presents with an asthma exacerbation. She was diagnosed with asthma at age 20 and

has been only using an albuterol inhaler p.r.n. (when necessary). She has been seen in urgent care a few times over the past year (most recently 4 months ago) and was given a prescription for an inhaled steroid (this one she never filled), albuterol inhaler, and oral steroids. Her asthma symptoms flared again 2 weeks ago, and she has been using her albuterol 3-4 times/day. She reports that she is very short of breath when climbing stairs or when walking to the mailbox. She has had nighttime coughing spells every day during the past week and has had to prop herself up on pillows to breathe. She indicates that she has had similar previous flares in the past and she “just wants more albuterol and steroid pills.”

Meds:

Proair HFA

Claritin prn

Spirometry: FEV1: 58%

FEV1/FVC ratio: 69%

Pulse ox: 93% on RA

Analysis of Asthma Stage

Refer to the most current UpToDate® evidence based guidelines (EBG) for asthma located in the University Library to answer the following questions:

1. Synthesize the patient’s overall social and medical history, clinical symptoms, and clinical assessment to classify her asthma using EBG. Which of the 4 categories (intermittent, persistent mild, persistent – moderate, persistent – severe) does she fall under? Explain your justification.

2. From a pathophysiological perspective, what is the danger with her current treatment plan execution regarding her SABA use? Explain your answer.

Plan of Care and Prescription Writing

1. What is your evidence-based medication treatment plan? Please do NOT use the Alternative treatment plan listed in the guidelines for this case study. Based on your analysis, write a minimum of 3 prescriptions the patient will need using the templates provided. One prescription needs to include a steroid burst.

Excellence in Health Care, LLC.

DEA #

Name Date

DOB

Rx:

Sig:

Qty:

RF:

Signature

Dispense as Written Substitution Permissible

Excellence in Health Care, LLC.

DEA #

Name Date

DOB

Rx:

Sig:

Qty:

RF:

Signature

Dispense as Written Substitution Permissible

Excellence in Health Care, LLC.

DEA #

Name Date

DOB

Rx:

Sig:

Qty:

RF:

Signature

Dispense as Written Substitution Permissible

Mechanism of Action, Monitoring, and Patient Education

1. Explain the mechanism of action of each medication you are prescribing and how it addresses the patient’s asthma exacerbation. When would you see her back for a follow-up appointment?

2. Outline appropriate monitoring for drug side effects, laboratory monitoring with rationale, and follow-up.

3. Discuss the specific, realistic patient education you would provide and how you would tailor your information to Nancy to facilitate treatment adherence and understanding.

 

NRP507 Advanced Pharmacology

Week 6 Assignment

Patient Case Study: Migraine

Assignment Content

Karen Myers a 35-year old, who was recently promoted to CEO of a marketing company, presents to the FNP for c/o increasing migraines. She does not have a migraine today but has a past medical history (PMH) of migraines since her early 20s and was able to manage them effectively with OTC Excedrin® Migraine, however, it is no longer effective. Her job requires her to be “at the top of her game,” and she expresses frustration since she has missed work a few times over the past month due to the migraines when she had to retreat to her dark, quiet bedroom and try to sleep it off. She describes a scintillating scotoma aura she has always experienced with her migraines. The evolution of her migraines has not changed, and she describes it as always unilateral, starting in her occipital scalp and migrating retro-orbitally. 

ROS: GI: c/o mild nausea with migraines but has never vomited, Neuro: See HPI; Denies red flags. — PMH: Migraines — Meds: Excedrin Migraine prn — Allergies: NKDA — VS: 124/74, P 72, R 16 — BMI 24

Question 1Which of the following is most appropriate to prescribe first line for Karen?

Tramadol 50 mg tab, sig: 2 tabs at the onset of her migraine and repeat every 4 hours until migraine resolved

Propranolol hydrochloride LA 80 mg cap, sig: 1 cap daily

Rizatriptan 5-10 mg tab, sig: 1 tab at onset of migraine; may repeat dose every 2 hours x2

Magnesium 400 mg tab, sig: 1 tab daily

Question 2

The mechanism of action of serotonin receptor agonists is:

Vasodilation by inhibiting the release of vasoactive peptides and blocking pain pathways in the brainstem, thereby inhibiting dural nociception.

Inhibition of prostaglandin synthesis and have a central analgesic mechanism of action

Modulation of neurotransmitters and appears to affect the central serotonin receptor function

Inhibition of vasospasm of the cerebral arteries and preventing cerebral hypoxia during migraine attacks

Question 3

In a follow-up 3 weeks later, Karen reports success with using the triptan prescribed. She expressed concern over side effects she experienced shortly after taking a dose. Which of the following concerns you the most?

Warming sensation

Drowsiness

Chest tightness

Transient visual loss

Question 4

Which of the following is an unlikely risk factor contributing to Karen’s increased migraine frequency?

Work stress

Jet lag

Dark chocolate and aspartame

Acupuncture

Question 5

You determine Karen is overusing her abortive migraine treatment and want to initiate a prophylactic medication (in addition to abortive treatment). Which of the following medications is most favorable considering the concerns she verbalized above?

Topiramate

Verapamil

Amitriptyline

Candesartan

Botulinum toxin

 

NRP507 Advanced Pharmacology

Week 7 Assignment

Patient Case Study: Musculoskeletal/Pain

Assignment Content

This week you explored both the musculoskeletal system and pain management. In this assignment, focus on developing the proper treatment plans for two patients presenting with severe pain related to gout and osteoarthritis.

Gout

Read the following scenario to answer questions 1-3:

Marco Aquino, a 41-year-old male from the Philippines, presents with severe pain in his right first MTP joint that started 2 days ago. He suspects it is his “gout flaring up” again because of overindulging in seafood and beer, which he admits. He describes similar episodes of severe pain in the same toe over the past couple of years to the degree he couldn’t walk. He didn’t see a provider but achieved resolution of the pain after a few weeks of ice, rest, and taking an herbal medication from the Philippines. He works as a forklift driver and can’t miss work. He is asking what he can take to achieve more rapid relief of his symptoms. He takes no other medications and has no known allergies. His labs are all normal. 

Question 1

All of the following are appropriate medication options to prescribe for George’s acute gout attack except for which of the following?

Indomethacin

Prednisone

Colchicine

Probenecid

Question 2

Marco has agreed to take allopurinol, a xanthine oxidase inhibitor daily. Educating Marco about titration of the medication to a therapeutic dose is important. The goal is to treat to a serum uric acid level of what?

The “normal” uric acid level outlined by the laboratory conducting the testing

Less than 6mg/dL

Less than 8mg/dL

There is no specific uric acid level treatment goal; only need to achieve resolution of symptoms.

Question 3

Which of the following labs is the least important to monitor while Marco is on anti-gout medications?

Liver function

Renal function

CBC

Uric acid

Question 4

Which of the following is the most appropriate treatment for Tracie at this point?

Scheduled dosing of acetaminophen in combination with topical capsaicin

Scheduled dosing of oral NSAIDs with mild opioid for breakthrough pain

Topical NSAID pain relief with mild opioid for breakthrough pain

PRN dosing of acetaminophen

Question 5

Tracie asks about alternative treatments. All of the following are true except:

Systematic reviews done on glucosamine revealed a significant reduction in knee pain.

Topical NSAID pain reliever is generally considered a safer alternative to oral therapy; however, it still requires liver function monitoring.

Beneficial interventions include stretching, yoga, acupuncture, weight reduction, and gradual conditioning of major muscle groups.

Injection options include steroids, hyaluronate, and viscous solutions.

Question 6

Tracie returns 1 year later and she indicates her daily pain is now 7/10 despite using acetaminophen, NSAIDS, topical medications, physical therapy, massage, ice, and rest. She is currently using ibuprofen 800mg TID with food, capsaicin topical to her knee, and adds acetaminophen prn. The pain interferes with her quality of life and sleep. She plans to have a total knee replacement done, but her surgery is scheduled 2 months out. She is requesting stronger pain medicine until she can get her surgery done. According to the World Health Organization “pain ladder,” which is the most appropriate medication to add for Tracie?

Ketoprofen

Oxycodone

Tramadol

MS Contin®

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