I do not need a title page. I only need a reply to each of the following postings. Each reply must be 7 sentences long with 2 references each. The main textbook for this course is:
Rosenthal, L. D., & Burchum, J. R. (2021). Lehneâ€™s pharmacotherapeutics for advanced practice nurses and physician assistants (2nd ed.) St. Louis, MO: Elsevier.
Reply to your colleagues: Provide recommendations for alternative drug treatments to address the patientâ€™s pathophysiology. Be specific and provide examples.
(Maurise) Posting 1:
A 46-year-old, 230lb woman with a family history of breast cancer. She is up to date on yearly mammograms. She has a history of HTN. She complains of hot flushing, night sweats, and genitourinary symptoms. She had felt well until one month ago, and she presented to her gynecologist for her annual Gyn examination to discuss her symptoms. She has a history of ASCUS about five years ago on her pap; other than that, Pap smears have been normal. Home medications are Norvasc 10mg qd and HCTZ 25mg qd. She has regular monthly menstrual cycles, and her LMP was 1 month ago.
According to McCance & Huether (2019), menopause is the cessation of ovulation and mense caused by ovarian failure, and it is a normal developmental event making the end of reproduction. The onset of menopause is between forty to sixty years old. The symptoms of menopause include temperature, hot flashes, perspiring at night, headaches, vaginal atrophy, frequent urinary tract infections, cold hands and feet, forgetfulness, inability to concentrate, aggressiveness, anger, and depression (Consumer’s Medical Journal, 2004). Based on the patient presenting symptoms, we can formulate a menopause diagnosis. McCance & Huether (2019) report that during this period, the body undergoes many changes called vasomotor flushes that affect the cardiac and the skeletal system. Roberts & Hickey (2016) agree that vasomotor symptoms (VMS), “hot flushes” or “night sweats,” are normal during the menopause transition and affect around 80% of women. The mechanisms of vasomotor symptoms are poorly understood. However, they reflect disturbances of the hypothalamic thermoregulatory system after estrogen exposure and withdrawal.
Before starting the treatment regimen, we need to perform a pregnancy test since the patient is still of childbearing age and she still has a period, ordering labs test such as a complete blood count (CBC), electrolytes level, etc. Then, we will consider the therapy we will initiate based on health history. The patient’s height is five feet and four inches. she weighs two hundred and thirty pounds which categorizes her as obese. We should consider hypertension and family of breast cancer as well. According to Roberts & Hickey (2016), hormonal therapy is contraindicated in patients with liver disease, breast cancer, and known high inherited risk, and this patient falls in the category of high risk. Also, hormone therapy increases blood pressure, drug-to-drug interaction, cardiovascular disease, and ovarian cancer.
Therefore, We will manage the symptoms by adding a Selective Serotonin Reuptake Inhibitor (SSRI) moderate dose of Citalopram 10 mg daily to reduce hot flashes symptoms by 50% (Koch, 2016) while the patient will continue to take her previous meds. The Citalopram may be titrated upward depending on the reported symptoms after a month.
We will provide education on the signs and symptoms of menopause, the side effects of the new medication, and the importance of developing healthy diet habits and exercise weight loss that will surely improve the patient’s health outcomes.
(Okon) Posting 2:
The function of prescribing medications for patients is ordinarily a â€œprivilege and a burdenâ€ (Rosenthal & Burchum, 2021) and requires good clinical judgement and detailed consideration. But prescribing medications for patients with complex comorbidities is much more complicated and onerous for two reasons: First, the need to avoid the risks due from polypharmacy namely drug-to-drug interactions and adverse drug reactions. Second, the high prevalence of treatment conflicts. Polypharmacy presents a real danger for patients with multiple comorbidities because, being managed by different specialists, patients may use many drugs that interact and potentiate the effect of one or more others, or cause very serious adverse reactions. There is also the problem of treatment conflict arising when treatment of one condition results in the worsening of another condition (Caughey et al., 2017). The challenge of reconciling competing priorities between global health outcomes and disease-specific outcomes in patients with complex comorbid conditions requires critical decision-making skills. A comprehensive analysis of the patientâ€™s health need is necessary to determine the type treatment.
Patient Health Needs
In the category of patient health needs in case study 1, continuing treatment and care for HHâ€™s community acquired pneumonia (CAP) ranks first. His laboratory results still show presence of infective agent. For instance, culture from bronchial alveolar lavage shows heavy growth of S. pneumoniae, CXR shows RLL infiltrate, WBC is 16.6 still above 11.0 considered (Mank & Brown, 2022), and patient is still febrile with a temperature of 100.9 â°F. All these indicate the need for continued antibiotic therapy.
Another area of need is respiratory given patientâ€™s history of COPD. The patientâ€™s O2 saturation and respiratory rate are at borderline low and high respectively and an abnormal HCO3 of 30 with normal range between 22-26 meq/L (Castro et al., 2022). Hypertension treatment is another area of need to continue receiving attention, especially under stressful situation such as infection and hospitalization. On day 3 after admission, patientâ€™s blood pressure of 136/70 still remains above normal levels. Diabetes care is very important because blood sugar is also affected by stress. Patientâ€™s last glucose level of 143 is still high and needs continued attention. Although there is no lab result for lipid panel, the patient needs care to manage his cholesterol given his history of HLD. In addition, because of his history of diabetes, and hypertension, he is at risk for metabolic syndrome with HLD and atherosclerosis as clusters in the syndrome (NIH, 2022).
Thus, the patientâ€™s health needs include managing infection, COPD, HTN, diabetes, and hyperlipidemia.
Culture and Sensitivity Results
It is important to consider the culture and sensitivity result in prescribing the right type of antibiotics to treat patientâ€™s CAP and to know alternatives given patients allergy to penicillin. The positive culture of S. pneumoniae was susceptible to penicillin, ceftriaxone, vancomycin, and levofloxacin, but resistant to erythromycin and tetracycline. The antibiotic with the lowest minimum inhibitory concentration (MIC) – the lowest concentration of antibiotic needed to inhibit the growth of an organism (Giuliano et al, 2019) of 0.123, is Vancomycin. These will affect the antibiotic treatment course I will choose to address CAP.
Treatment to Address Complex Health Needs
On admission of patient with severe infection and no lab result to identify infecting organism, empiric antibiotic therapy is necessary (Rosenthal & Burchum, 2021). However, after identifying S. pneumoniae, and determining drug sensitivity, I will assess clinical stability of patient including resolution of vital sign abnormalities, normal cognitive function, ability to eat and then switch to organism-specific antimicrobial therapy guided by antibiotic sensitivity antibiotic. Based on the result of patients C & S, I will not choose erythromycin and tetracycline because they are resistant to infecting agent. I will also avoid penicillin and ceftriaxone because patient is allergic to penicillin and by implication to cephalosporins such as ceftriaxone. Out of the remaining medications, I will choose vancomycin. Although vancomycin is not a first line treatment for CAP caused by S. pneumoniae, Rosenthal and Burchum (2021), list it as an alternative therapy. This is appropriate given the fact that other antibiotics tested either do not feature as first line and alternative treatment or have higher MIC than vancomycin e.g., levofloxacin MIC of â‰¤ 0.5.
In treating COPD, with short-acting Î²-agonists (SABAs), I will avoid the use of Î²-blockers, diuretics, digitalis, and monoamine oxidase inhibitors (MAOIs) for patientâ€™s HTN because beta-blockers can decrease the effectiveness of SABAs and produce severe bronchospasm (Ajimura et al., 2018). Also, SABAs are steroids that can exacerbate hyperglycemia and should be monitored and used short term.
For diabetes, I will not use Metformin because of its rare but serious side effect of lactic acidosis especially given patientâ€™s electrolyte imbalance.
Supportive care will include monitoring oxygen saturation with the aim of maintaining SaOâ‚‚ above 92%. Assessing nutritional needs as patient is not tolerating oral intake due to nausea and vomiting. I will treat this initially with ondansetron and then consider switching vancomycin to oral instead of IV.
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