A case of cough

History

Your next patient is a florid, plump, forthright woman of 52 years, who is complaining of an irritating cough for the last week or two. She works as a waitress or bartender, and is married with three children. The cough is non-productive and is disturbing her sleep. She admits to getting breathless on climbing stairs, but she is familiar with the symptom and is merely asking for a repeat prescription of her regular cough medicine. The computer records only date back 6 years, so you ask the receptionist to find her old Lloyd George paper records, and in the meantime examine her.

Examination 

You note her being overweight, almost obese: she weighs 14 stone (90 kg) and is 5 feet 8 inches tall (175 cm), giving her a body mass index of almost 30. You also note her nicotine-stained fingers: she smokes about 20 cigarettes a day, less now, since the ban on smoking at work. Her throat is slightly inflamed. She has a scattering of coarse rhonchi, but no rales. You guess that she may have a mild exacerbation of chronic obstructive airways disease. Her peak flow rate is certainly reduced (300 L/minute).
The records now reveal that she has been prescribed variously simple linctus, ipecacuanha with morphine linctus and pholcodine linctus by one of your predecessors in the practice. 

Questions
• What treatment might you rationally advise?
• What other advice might you offer her?
• What further investigation is appropriate? 

Pharmaceutical Calculations:Naplex

For solutions and suspensions, it is often necessary to calculate a volume needed to administer a certain medication dose. For example, what if a resident has the following prescription

How to Study for the NAPLEX

Successful completion of the North American Pharmacist Licensure Examination (NAPLEX) is required by anyone wishing to practice pharmacy in the United States. The NAPLEX is a 185-question test, administered in multiple-choice format and including both stand-alone questions and questions based on scenarios provided on the test. The NAPLEX is a computer-based test and is "adaptive," meaning that your answer to each question determines the question that the computer asks next. A correct answer generates a question that is more difficult; an incorrect answer produces an easier question. There are various ways to prepare for the test and numerous study resources available.

MCQs: Gastrointestinal Drugs

ANSWER THE QUESTIONS BELOW.

Case Discussion – Community-Acquired Pneumonia

TG is a 68 y.o. patient admitted to the hospital after complaining of a “severe cold with difficulty breathing”.  A brief note accompanies the patient to the floor, where he is examined by the medical intern who writes the following note:

CASE-Itchy rash on his leg

NJ is a 33-year-old man who comes to the pharmacy complaining of an itchy rash on his leg. He was working in the yard and thinks he came in contact with poison ivy. NJ says that when this has happened in the past, he has always treated it with a topical cream, but he cannot remember its name. He also mentions that his 1-year-old daughter was outside playing while he was doing yard work, and she has a little bit of a rash on her leg as well. He wants to purchase something that would be safe and effective for both of them. What would you recommend?

Answer
NJ should be counseled that when he comes in contact with poison ivy, it is important to wash the exposed area with soap and water. The quicker he washes off the exposed area, the less severe his reaction will be. For itching, you can recommend that NJ use a topical hydrocortisone cream, which can provide relief. Nonprescription oral antihistamines can also be prescribed to assist with the itching. However, it is recommended to avoid topical creams that contain antihistamines (diphenhydramine), anesthetics (benzocaine), and antibiotics (neomycin, polymycin). They generally can cause more harm than benefit. NJ’s daughter would not qualify for self-treatment because she is younger than 2 years, so she should be referred to a physician for evaluation. The Handbook of Nonprescription Drugs: An Interactive Approach to Self-Care provides the following parameters for selftreatment in a case such as NJ and his daughter: “Exclusions for self-treatment include less than 2 years of age, dermatitis present >2 weeks, involvement of 20% of the body surface area, presence of numerous bullae, extreme itching, swelling of the body or extremities, swollen eyes or eyelids swollen shut, discomfort in genitalia from itching, signs of infection, failure to self manage after 7 days, low tolerance for pain, or impairment of daily activities.”¹

References
1. Contact dermatitis. In: Krinsky DL, Berardi RR, Ferreri SP, et al, eds. Handbook of Nonprescription Drugs: An Interactive Approach to Self-Care. 17th ed. Washington, DC: American Pharmacists Association; 2011:650.

Case-Allergic conjunctivitis

GR is a 28-year-old man who comes to the pharmacy in April complaining of itchy eyes. He explains that his eyes have been itchy for the past few weeks. He says they have been tearing more than usual as well. GR is not on any medications and has no medical conditions. Upon questioning, he says that he has been affected by seasonal allergies over the past few years. GR owns a lawn cutting company and is outside for most of his day. He has taken loratadine 10 mg in the past, but only when he had systemic symptoms. At this time, he has no other symptoms besides his itchy eyes. What would you recommend for GR?

Answer

GR is experiencing allergic conjunctivitis. The treatment goal for allergic conjunctivitis is removal or avoidance of the allergen. Because his job requires him to be outdoors, it would be difficult for GR to avoid the allergen; therefore, symptomatic relief is recommended. It is usually recommended that patients with allergic conjunctivitis be treated first-line with ocular lubricants. If symptoms continue, GR could then switch to an antihistamine/ mast cell stabilizer product. There are currently 2 such products on the market, Zaditor (Novartis) and Alaway (Bausch Lomb). Either can be recommended for use twice daily. If symptoms persist, you can suggest adding loratadine 10 mg as a second regimen.

PharmD cases:Verify the suitability of drug

Verify the suitability of your P-drug

A         Active substance and dosage form

B         Standard dosage schedule

C         Standard duration of treatment

PharmD cases:Is the standard duration of treatment suitable for this patient?

Many doctors not only prescribe too much of a drug for too long, but also frequently too little of a drug for too long, but also frequently too little of a drug for too short a period. In one study about 10% of  patients on benzodiazepines received them for a year or longer. Another study  showed that 16% of outpatients with cancer still suffered from pain because doctors we afraid to prescribe morphine for a long period. They mistook tolerance for addiction. The duration of the treatment and the quality of drugs prescribed should also be effective and safe for the individual patient.

Case JS, a 3-year-old child weighing 16 kg, was recently hospitalized for acute appendicitis.

Case JS, a 3-year-old child weighing 16 kg, was recently hospitalized for acute appendicitis. Upon discharge, the physician instructed JS’s mother to purchase OTC acetaminophen and to administer 7.5 mL (1.5 teaspoonfuls) 4 times per day for post-appendectomy pain. What can the hospital pharmacist add to the instructions?

Answer
An estimated 12% of children younger than 11 years of age take acetaminophen in any given week.¹ This OTC antipyretic/ analgesic is first-line therapy for pain and fever in children at a dose of 10 to 15 mg/ kg every 4 to 6 hours as needed (maximum: 5 doses per 24- hour period).^2,3 Commercially available acetaminophen has historically been supplied in 2 formulations: 1) concentrated acetaminophen 80 mg/0.8 mL, and 2) acetaminophen elixir 160 mg/5 mL.^1,3 

Without specific instructions, JS’s mother might inadvertently administer a significantly higher dose than intended. If she purchased the 80 mg/0.8 mL rather than the 160 mg/5 mL concentration and gave 1.5 teaspoonfuls, she would administer her child a 3-fold overdose by giving 750 mg rather than the intended 240 mg dose.

Acetaminophen-associated medication errors are commonly reported to result from improper administration of concentrated acetaminophen drops instead of less concentrated acetaminophen elixirs, in addition to confusion with units of measure (ie, teaspoonfuls vs dropperfuls).^4-7

A pharmaceutical industry–wide initiative began in mid-2011 in response to a 2009 FDA Advisory Committee recommendation for standardization of acetaminophen concentrations for children less than 12 years of age.1,8-11 Commercially available acetaminophen products will be converted to 1 standardized concentration: 160 mg/5 mL. Additionally, age-appropriate, accurate administration devices with a standardized unit of measure (mL) will be included with all medication packages. These changes are specifically aimed at improving patient safety by decreasing acetaminophen- associated medication errors.
While the transition to 1 standardized strength will ultimately lead to improved patient safety, during the period of transition both formulations continue to be on pharmacy shelves and in homes. Pharmacists are uniquely positioned to safely shepherd this change and to provide appropriate education to providers and caregivers alike. By maintaining awareness of the concentrations of products, appropriate administration devices, and effective provider/caregiver education, pharmacists play an important role in promoting safe medication practices for children and reducing pediatric medication errors.

PharmD case:HYPERTENSION

Pharmd Case:
A 65-year-old man presents to your hypertension clinic with a past medical history of type 2 diabetes and hypertension. Vital signs in clinic today are blood pressure 134/80 mm Hg, heart rate 78 bpm. Current medications include Metformin 1000 mg twice daily, Levemir 40 units daily, Novolog 10 units before each meal, lisinopril 40 mg daily, and simvastatin 40 mg daily. At the last visit, his lisinopril was increased due to BP of 140/85 mm Hg and his A1C was 7.2%. 

Case on Medication Error: Right Drug, Wrong Route

A 40-year-old female was brought into the ER for shortness of breath and rash following ingestion of seafood. On presentation, she was found to have edema of the throat with a mild stridor upon inspiration. Her temperature was 98.7°F

PharmD Case :MRSA Endocarditis

Case
JM is a 46-year-old man with a history of actively abusing cocaine intravenously who presented with methicillin-resistant Staphylococcus aureus (MRSA) endocarditis (vegetation on tricuspid valve per TEE). After 7 days of IV vancomycin therapy (with troughs in the 15 to 20 mcg/mL range), JM’s blood cultures remain positive for MRSA, and the microbiology laboratory reports a vancomycin minimum inhibitory concentration (MIC) of 2 mcg/mL. What treatment options are available for this patient?

Patient counseling: Chronic Pain Management ???

Case
ST is a 54-year-old woman with chronic neck pain related to severe cervical stenosis. Over the past several months, she has undergone unsuccessful trials with various long-acting opioids. Her pain clinic physician is now interested in pursuing a trial of methadone. What information should be ascertained prior to

[Answer] Alzheimer’s Disease case

JY is a 75-year-old man who was diagnosed with mild Alzheimer’s disease (AD) 1 week ago with a Mini Mental Status Exam (MMSE) score of 19. His wife, PY, comes to the pharmacy with her husband’s prescription for donepezil (Aricept), but she believes the doctor made a mistake. She recalls seeing an advertisement for a medication named memantine (Namenda) for use in the treatment of AD. PY asks the pharmacist why the doctor wrote a prescription for donepezil and not memantine.

How should the pharmacist respond to PY?

Answer: Case One The treatment of AD is based on a patient’s stage of cognitive decline. Various mental status examinations, such as the MMSE, are used in practice to diagnose and monitor a patient’s disease course. The MMSE is an 11-item test with a maximum score of 30 that quantifies a patient’s orientation, registration, attention, calculation, recall, and language. Mild cognitive decline is classified by an MMSE score of >18, moderate cognitive decline as a score of 10 to 18, and severe cognitive decline as a score of <10.

Medications used to treat the cognitive symptoms of AD include the cholinesterase inhibitors donepezil, rivastigmine (Exelon), and galantamine (Razadyne), and the N-methyl-D-aspartate receptor antagonist memantine. Donepezil is FDA-approved to treat all stages of AD, rivastigmine and galantamine are approved to treat mild to moderate stages, and memantine is approved to treat moderate to severe stages. Current treatment guidelines recommend that cholinesterase inhibitors be offered to patients with mild to moderate AD.

The pharmacist should reassure PY that donepezil is an appropriate medication considering her husband’s MMSE score, the drug’s approved indication, and AD treatment guidelines.

what is the next Step in management ?

A 40-year-old male smoker presents with a history of chronic cough. Hehas had symptoms of an upper respiratory illness for a few months since
visiting family in Arizona. Physical exam

Student, 5-day history of cough, low-grade fever, sore throat, and coryza

A 26-year-old female student presents with a 5-day history of cough, low-grade fever (temperature 37.6 C), sore throat, and coryza.
On exam, there is mild conjunctivitis and pharyngitis. Tympanic membranes are inflamed, and one bullous lesion is seen. Chest exam shows few basilar rales.

Laboratory findings are as follows:
Hct: 38
WBC: 12,000/μL
Lymphocytes: 50%
Mean corpuscular volume (MCV): 83 nL
Reticulocytes: 3% of red cells
CXR: bilateral patchy lower lobe infiltrates

The sputum Gram stain is likely to show

a. Gram-positive diplococci
b. Tiny gram-negative coccobacilli
c. White blood cells without organisms
d. Acid-fast bacilli

This patient is likely to have

a. High titers of adenovirus
b. High titers of IgM cold agglutinins
c. A positive silver methenamine stain
d. A positive blood culture for Streptococcus pneumoniae

Treatment of choice is

a. Erythromycin
b. Supportive therapy
c. Trimethoprim-sulfamethoxazole
d. Cefuroxime

A worried woman came to your office with mental disrepairs.

A worried woman 47 years old came to your office with mental disrepairs. There is no deficits on neurologic exam but she dont know where she is and what time is. Physical examination shows high temperature, respiration 27/min, pulse is 130, TA:100/65 mmHg. She has bronchial breath in auscultation. You confirm the diagnosis pneumonia from chest radiography.

Where do you put this patient status?

a. Bacteremia
b. SIRS
c. Sepsis
d. Shock
e. Hypotension due to sepsis

A patient female 24 year old came to you with cough, fever and sore throat

A patient female 24 year old came to you with cough, fever and sore throat. She has 4 days with these symptoms when she was to the grandmother'village. We see the tympanic membrane that is inflamated with some lessions on it. We see even a little conjunctivitis.
Laboratory exams are :
Hct: 33
WBC: 11,000/μL
Reticulocytes: 4%
Chest x-ray shows bilateral infiltrates

What will you choose to take the better infection control?

a. Erythromycin
b. Trimethoprim-sulfamethoxazole
c. Cefuroxime
d. Ciprofloxacine
e. Amoxicillin/clavulanate

A patient suffer of chronic obstructive lung disease for about 10 years

A patient 53 year old suffer of chronic obstructive lung disease for about 10 years. He recently develops an episode of aching in the distal extremities in both wrists.There is a 10-lb weight loss. The skin over the wrists is warm and erythematous. Plain film is shows periosteal thickening.

What should you do?

a. Start ciprofloxacin
b. Chest x-ray
c. Aspirate both wrists
d. Begin gold therapy