[ANSWERED] A 70-year-old woman is in your office complaining of recently having trouble maintaining her balance after taking diazepam (valium). She occasionally takes diazepam when she feels

Written By: Dan Palmer, RN

Edited By: Ethan Green, MSN-FNP

A 70-year-old woman is in your office complaining of recently having trouble maintaining

Week 1: Discussion Question 1

Discussion Prompt

Post your answers to the 6 questions corresponding to this week’s content on primary care medication management. Provide your responses and rationales. Support your rationales with high-level evidence. (See Post Expectations)

A 70-year-old woman is in your office complaining of recently having trouble maintaining her balance after taking diazepam (valium). She occasionally takes diazepam when she feels anxious and has trouble sleeping. She has a 15-year history of taking diazepam.

Q1. Explain the cause of this patient’s difficulty in maintaining her balance?
Q2. Diazepam experiences a significant first-pass effect. What is the first-pass effect, and how can first-pass metabolism be circumvented?

A 75-year-old woman develops symptoms of a cold and buys an over-the-counter cold medication at the grocery store. The medication contains diphenhydramine, acetaminophen, and phenylephrine. She takes the recommended adult dose but soon after taking the medication, she becomes very confused and disoriented.

Q3. What is likely causing the signs of confusion?

A 26-year-old woman who has never been pregnant is seeking preconception care as she is planning to pursue pregnancy in a couple of months. Currently, she has no symptoms to report and on review of body systems, there were no concerns. Her past medical history is significant for a history of rheumatic fever as a child.

She subsequently underwent valve replacement with a mechanical heart valve. She is followed by a cardiologist who has already evaluated her cardiac function and she has received clearance from her cardiologist to pursue pregnancy. Records from her cardiologist include a recent cardiac echocardiography report that reveals a normal ejection fraction indicating normal cardiac function.

She has no alterations in her daily activities related to her heart. She has no other signiﬁcant medical or surgical history. She is a non-smoker, drinks occasionally but has stopped as she is attempting to conceive, and does not use any non-prescription drugs.

Current Medications: Her current medications include only prenatal vitamins, which she has begun in anticipation of pregnancy, and warfarin. She has no known drug allergies.

Vital Signs: On examination, her pulse is 80 beats per minute, blood pressure is 115/70 mm Hg, respiratory rate is 18 breaths per minute, and she is afebrile.

Measurements: Weight = 152 pounds, Height = 5′5 ″, BMI= 25.29

Q4. How is warfarin metabolized? Does warfarin cross the placental barrier?
Q5. Explain the hepatic drug metabolism of children 1 year and older. How do they compare with the hepatic drug metabolism of infants and adults?
Q6. Explain protein binding in the neonate.

Expert Answer and Explanation: Week 1: Discussion Question 1

Question 1

The patient’s difficulty maintaining her balance is due to the side effects of diazepam. Diazepam is a central nervous system depressant that can lead to dizziness, drowsiness, and impaired coordination (Ho et al., 2023). With a 15-year history of taking diazepam, her body may have developed tolerance, requiring higher doses, which can exacerbate these side effects. Additionally, she may be more susceptible to the drug’s sedative effects due to her age (Ho et al., 2023). It is essential to evaluate her medication regimen and consider alternative treatments for her anxiety and sleep issues to improve her balance and overall well-being.

Question 2

The first-pass effect is when the liver metabolizes a significant portion of an orally administered drug before it enters the systemic circulation (Guo & Singh, 2019). This metabolization can reduce the bioavailability of the drug. Circumventing first-pass metabolism requires alternative administration routes, including intravenous injection, sublingual, or transdermal delivery, bypassing the liver and allowing for a more direct entry into the bloodstream to increase the drug’s effectiveness.

Question 3

The woman’s signs of confusion are due to diphenhydramine in the cold medication. This element has a sedative effect and is known to cause drowsiness and confusion, especially in older adults (McKeirnan et al., 2020). Hence, although she uses the correct dosage, her advanced age increases the risk of side effects.

Question 4

Warfarin metabolism occurs primarily in the liver through the action of the cytochrome P450 enzyme system. It is a racemic mixture of R and S enantiomers, with the S-enantiomer being more potent and metabolized by CYP2C9 (Cheng et al., 2022). Warfarin does cross the placental barrier. Therefore, its use during pregnancy increases the risk of fetal exposure, potentially leading to birth defects, especially if used during the first trimester (Cheng et al., 2022). Given the woman’s desire to conceive, it is crucial to consider alternative anticoagulation therapies.

Question 5

Hepatic drug metabolism in children aged one year and older is similar to that of adults compared to infants. Infants lack fully developed hepatic drug-metabolizing enzymes, making drug metabolism less efficient (Van Groen et al., 2021). As children grow and develop, the activity of drug-metabolizing enzymes in the liver, particularly the cytochrome P450 system, mature and approach adult levels (Van Groen et al., 2021).

This maturation leads to a more efficient and effective metabolism of drugs in children aged one or older. However, the specific maturation rate can vary for different enzymes and drugs. Therefore, dosing adjustments and considerations based on age and weight are still necessary to ensure safe and effective drug therapy in pediatric patients.

Question 6

Protein binding in the neonate refers to how drugs and other substances in their bloodstream attach to proteins, primarily albumin, affecting their distribution and effectiveness. Neonates have lower albumin levels, making them more susceptible to drug interactions and potential toxicity (Leroux et al., 2019). This reduced protein binding capacity can lead to higher concentrations of free, unbound drugs in their system, increasing the need for careful dosing and monitoring in newborns.

References

Cheng, S., Flora, D. R., Rettie, A. E., Brundage, R. C., & Tracy, T. S. (2022). Pharmacokinetic modeling of warfarin І–model-based analysis of warfarin enantiomers with a target mediated drug disposition model reveals CYP2C9 genotype-dependent drug-drug interactions of s-warfarin. Drug Metabolism and Disposition, 50(9), 1287–1301. https://doi.org/10.1124/dmd.122.000876

Guo, Y. G., & Singh, A. P. (2019). Emerging strategies for enhancing buccal and sublingual administration of nutraceuticals and pharamaceuticals. Journal of Drug Delivery Science and Technology, 52, 440–451. https://doi.org/10.1016/j.jddst.2019.05.014

Ho, T. T., Noble, M., Tran, B. A., Sunjic, K., Gupta, S. V., Turgeon, J., & Crutchley, R. D. (2023). Clinical impact of the CYP2C19 gene on diazepam for the management of alcohol withdrawal syndrome. Journal of Personalized Medicine, 13(2), Article 285. https://doi.org/10.3390/jpm13020285

Leroux, S., van den Anker, J. N., Smits, A., Pfister, M., & Allegaert, K. (2019). Maturational changes in vancomycin protein binding affect vancomycin dosing in neonates. British Journal of Clinical Pharmacology, 85(5), 865–867. https://doi.org/10.1111/bcp.13899

McKeirnan, K. C., Frazier, K. R., & Yabusaki, A. A. (2020). Patient fall risk caused by unintended diphenhydramine use. The Senior Care Pharmacist, 35(3), 113–119. https://doi.org/10.4140/TCP.n.2020.113

van Groen, B. D., Nicolaï, J., Kuik, A. C., Van Cruchten, S., van Peer, E., Smits, A., Schmidt, S., de Wildt, S. N., Allegaert, K., De Schaepdrijver, L., Annaert, P., & Badée, J. (2021). Ontogeny of hepatic transporters and drug-metabolizing enzymes in humans and in nonclinical species. Pharmacological Reviews, 73(2), 597–678. https://doi.org/10.1124/pharmrev.120.000071

Week 1: Discussion Question 2

Discussion Prompt

Post your answers to the 6 questions corresponding to this week’s content prescribing privileges for APRN in your state. Provide your responses and rationales. Support your rationales with high-level evidence. (See Post Expectations)

Post the link to your state requirement for completion of the pharmacology course.
Discuss your state requirements and scope of practice for APRN’s in your state.
Discuss the process on how to obtain an NPI number.
Discuss CEU requirements for your state for APRN certification renewal.
What information is required by your state to be on your prescription pad when prescribing controlled substances?
Discuss considerations for prescribing (non-controlled substances) when using telemedicine.

Week 1: Osmosis Assignment

Assignment Prompt

Once you have finished the Osmosis playlists, you need to take a screen capture of the level of completion (the amount of the playlists you viewed from your account. Please ensure that you include your account name in the screenshot.

Week 2: Discussion Question 1

Discussion Prompt

You are a new FNP in a restricted state and have your DEA license, and state furnishing for schedule II-V controlled substances. You are working at a busy family practice group, and you have a patient, ML, that is establishing care for the first time with your practice and comes to you with the following scenario:

ML is a 54 y.o. Hispanic female with hx of chronic shoulder and back pain that began 10 years ago when she was in a boating accident.
She lives in both US and Mexico, making regular visits across the border. Lately, she has stayed in the US due to Covid border crossing constraints, living with her daughter’s family.
She had rotator cuff surgery in 2011 and reports to you that due to a long operation and poor positioning, she has suffered from not only pain, but also chronic numbness and tingling in her R shoulder.
As “la abuela” (grandma), she is the primary caregiver of the children and homemaker for her family. Her pain is exacerbated with housework, and especially with the prolonged carrying of her grandchildren; one of which is 10 m.o.
Currently, her med list is as follows
- Losartan 50 mg BID for HTN
- Gabapentin 300 mg po BID for pain
- Atorvastatin 40 mg daily for cholesterol
- Diazepam 5 mg po up to TID prn pain
- Norco 5/325 mg – takes up to two, sometimes up to 4-5x a day, prn pain
She is a smoker, only smokes outside the house, and drinks 2-3 cans of beer on the weekends, but more on family celebrations.
She denies recreational drugs and denies past overdoses.
She has recently moved to CA more permanently to stay to take care of children during Covid/school closures.
She asks you to refill all her meds for 6 months, like her doctor in Mexico did, so she doesn’t have to make another co-pay and come back and see you so often. It’s hard for her to get an appointment, and with Covid, her daughter has to take off of work to watch the kids so that she can come to you by bus (since there is only one family car).
Here VS are 135/75, 80, 97.5, 20 and PE unremarkable other than R shoulder exam with pain with ROM, but full ROM, no tenderness, otherwise normal, back exam including SLR are normal/neg

In 600 or fewer words, but a minimum of 250, please describe your approach with this patient. In your response, include the following:

What concerns do you have about her current regimen, and what alternatives will you discuss and offer? What other screenings might you apply? What are your own ethical standards on this case that you might consider in addition to legal standards?
Provide a sample of an appropriate pain contract that would suit this patient and address her specific safety concerns (cite it and attach the actual contract you found – you do not have to make your own – there are plenty online).
Include your steps to ensure safe prescribing. Include the registry you will search prior to any prescribing; name the CA registry, and if you are in a different state, you should name that registry also.
If you were to keep her current list, what are the laws surrounding refills and the amounts you are allowed to dispense with the schedule II and III medications in the state of CA? In your own state?
Which medications on her list may you call into the pharmacy, and which would you need a written script or electronic order? What are some elements required to include on the prescription form (paper or electronic signature) for the scheduled medications?
After you prescribe, how, when, and where would you (or your staff) go about making a report of your scheduled prescription in the state registry so that other prescribers and pharmacies could be aware?
In restricted states, APRN prescribers must follow a standardized procedure or protocol for furnishing schedule II and III controlled substances with a patient-specific approach. Please outline the minimum required components of a protocol. You may outline this in bullet form. Alternatively, you may find an appropriate protocol, clinical guideline, or standardized procedure from a literature search and attach it in lieu of outlining your own protocol.

Week 2: Discussion Question 2

Discussion Prompt

Post your answers to the 7 questions corresponding to this week’s content prescribing privilege for APRN in your state. Provide your responses and rationales. Support your rationales with high-level evidence. (See Post Expectations)

What are the requirements for an APRN to obtain a controlled substance certificate in your state?
Discuss your state requirements and scope of practice for APRN’s in your state when prescribing controlled substances.
Discuss the process of how to obtain a DEA number.
Discuss CEU requirements for your state for APRN certification renewal for controlled substance prescribing.
What information is required by your state to be on your prescription pad?
Discuss considerations for prescribing when using telemedicine when prescribing controlled substances.
Do you need more than one DEA number, if so, when do you need another number?

Week 2: Osmosis Assignment

Assignment Prompt

Week 3: Discussion Question – Case Study

Discussion Prompt

Mrs. Lyons is a 57-year-old African American female who recently developed headaches and had an elevated blood pressure reading at her work health fair. Her blood pressure was taken at the health fair, and the reading was 168/99. She has returned to the drugstore three times to take her blood pressure. The readings have been: 145/90, 150/89, 140/88. At the health fair, she was told her BMI is elevated. Her cholesterol levels were also done at the health fair, and the results were: total cholesterol level of 250, LDL 138, HDL 48, and Triglycerides 170.

She has not been to see a primary care provider in over 5 years. At her last office visit, which was 5 years ago, her blood pressure was (135/95). Her LDL and triglycerides were also elevated at that time. The patient was supposed to monitor her blood pressure at home and trial diet and lifestyle changes. She was supposed to return for a follow-up with her blood pressure log and for a recheck of her labs. She, unfortunately, did not do this.

Today in the clinic, her vital signs are:
BP 146/92, HR 90, Temp 98.4, RR 12, O2 98%, Height 5’5, Weight 220 lbs, BMI 36.6

She is not currently taking any medications. She has NKDA. Family history: her brother and sister both have been diagnosed with hypertension and DM. Diagnoses for the patient are HTN, Obesity, and Hyperlipidemia.

Q1. Please briefly discuss the first-line treatment recommendations from JNC8, and the AHA/ACC for a patient with no other major comorbidities.

Q2. What are the recommended medications to start this specific patient on? Please provide the drug class, generic & trade name, and initial starting dose.

Q3. Please discuss the mechanism of action of each of the drugs you listed.

Q4. Please discuss the side effect profile of each medication you listed.

Q5. Are there any interactions between any of the medications you prescribed?

Q6. What other non-pharmacological interventions would be suggested?

Week 3: APEA QBank Quiz

Assignment Prompt

This week, please complete the following QBank quiz:

Principles of pharmacology
Cardiology
Hematology

Please submit a screenshot of your question completion categories (separately if more than one category is due) and the screenshot must show that you have an 84% in either tutor or exam mode. Quiz scores will be averaged if there is more than one Qbank assigned for the week. Scores below 84% will be scored a zero. You cannot retake the quizzes once the due date has passed.

Week 4: Discussion Question 1

Discussion Prompt

Post your answers to the 5 questions corresponding to this week’s content on primary care medication management. Provide your responses and rationales. Support your rationales with high-level evidence. (See Post Expectations)

Eric Johnson is a 21-year-old Caucasian male in his senior year of college. The patient has a history of seasonal allergies. He does not remember what his allergist told him to take for his allergies in the past. He wants to know what he can take. He presents to the clinic today with complaints of a stuffy nose, shortness of breath, a fever TMAX 102 at home, and a productive cough.

He also notes that over the past few months, he has also noticed a watery discharge and burning when he urinates. He does admit to having unprotected intercourse last month. He undergoes rapid testing and a chest x-ray while in the clinic. His diagnoses are pneumonia, chlamydia, and seasonal allergies.

Clinic Vital Signs: BP 125/75, HR 116, Temp 102.5, O2 94%. He has no known drug allergies.

Q1. What are the recommended medications to start this specific patient on? Please provide the drug class, generic & trade name, and the initial starting dose.
Q2. Please discuss the mechanism of action of each of the drugs you listed.
Q3. Please discuss the side effect profile of each medication you listed.
Q4. Are there any interactions between any of the medications you prescribed?
Q5. What other non-pharmacological interventions would be suggested?

Week 4: Discussion Question 2

Discussion Prompt

Part 1:
Choose a condition from the following case studies: (Week 4 Case Studies). You may work in small groups of up to 3 students if desired.

Part 2: Answer the following questions

Discuss what are the potential treatments for this child’s diagnosis
What antibiotic/s should be given for this patient’s diagnosis?
How long should you prescribe the chosen antibiotic?
What teaching would you give this child’s parents on the prescription?
Write out a correct prescription for the antibiotic you are going to prescribe for this patient. (Be sure to include all elements needed for a correct prescription)

Week 4: Osmosis Assignment

Assignment Prompt

Week 5: Discussion Question 1 – Case Study

Discussion Prompt

An obese patient, age 45, comes to your office. She recently moved from another state three weeks ago and told you that her FNP diagnosed her with type 2 diabetes mellitus. She is currently not on any medicine for her diabetes, and she wishes to avoid insulin, if possible. She is a non-smoker. Her blood pressure is 138/74 mmHg.

Labs from 3-weeks ago was hemoglobin A1C = 8.4%; total cholesterol = 260 mg/dL, triglycerides = 290 mg/dL, HDL = 49 mg/dL, LDL = 170 mg/dL (calculated 10-year ASCVD risk = 6.2%). You discuss current treatment goal recommendations endorsed by the ADA regarding glycemic control, blood pressure control, and lipid management. She agrees to start any medications you recommend with lifestyle modification and a DASH diet to treat hypertension.

Q1. Which classes of diabetes medications are either weight neutral or cause weight loss? Please give one (1) example of a drug’s generic and trade name in that class.

Q2. Based on the current guidelines of the ADA, it would be appropriate to treat her with monotherapy since the patient is hesitant to take any injections. What agent would you recommend? Please provide the trade name, generic name, the dose you would start the patient with frequency, and route.

Q3. What are the contraindications of your selected diabetic therapy?

The patient returns to your office six months later, complaining of fatigue for the past two months, constipation, and heavy, irregular menses. Upon examination, you note that her skin is dry, and her fingernails are brittle. You suspect she has hypothyroidism.

Q4. What lab workup should you obtain? What sort of results will you see in patients who have hypothyroidism and hyperthyroidism?

Q5. What is the treatment of choice for hypothyroidism? What is the mechanism of action? Please provide the initial dose, trade, and generic name of the drug, route, and frequency.

Q6. What are the adverse effects, and what important teaching will you provide this patient on thyroid replacement therapy?

Week 5: APEA QBank Quiz

Assignment Prompt

This week, please complete the following QBank quiz:

Gastrointestinal
Endocrine
Men’s health
Urology

Week 6: Discussion Question 1

Discussion Prompt

Mrs. William, a 75-year-old patient is with her daughter for a follow-up visit. At her previous office visit, her daughter expressed concerns about her mother’s increasing forgetfulness. You send Mrs. William for neuropsychiatric testing. She is diagnosed with mild dementia, and the patient and family would like to discuss treatment options.

Q1. Name a drug for each of the two classes of medication that is currently available for the treatment of dementia, and their adverse effects. (Trade and generic names).
Q2. Mrs. William’s daughter is concerned about the behavioral disturbances that can be associated with progressive dementia. Discuss at least two disturbances associated with progressive dementia and their treatment recommendations. Please provide one medication, trade and generic name for each of the behavioral disturbances you list.

Mr. Lacy is a 65-year-old man diagnosed with Parkinson’s disease (PD) five years ago. His disease has progressed over the years, and it is recommended that he be treated with levodopa.

Q3. What is levodopa, and how is it used in the treatment of Parkinson’s disease? What are the adverse effects of levodopa that might be expected in this patient?
Q4. What drug is most commonly combined with levodopa and why?
Q5. What other drugs can be used for the treatment of PD?

A 50-year-old man has developed depression after the death of his wife. He is prescribed venlafaxine (Effexor XR) 75 mg PO once a day.

Q6. How does venlafaxine differ from tricyclic antidepressants (TCAs)? What adverse effects might this patient expect with venlafaxine?

Week 6: Discussion Question 2

Discussion Prompt

What is the 340b Pricing Program?

Access these websites for more information: Fact Sheet: The 340B Drug Pricing Program and 340B Drug Pricing Program. Access this part of the website and enter the name of your state and city or town, and see a list of contracted 340b pharmacies. If you live in a small town and there are no 340b pharmacies, choose a town in a surrounding area.

For those of you who live in metro areas, look at the number of 340b pharmacies available. Then, select 2-3 small rural towns and see if there are any 340b pharmacies there.The point of this is to see where the closest 340b pharmacy is in rural areas and to learn about 340b pharmacies.

Access Letter to Sec. Becerra Urging Him to Stop Six Drug Companies That Are Denying 340B Discounts and HHS Moves to nix 340B insulin, EpiPen Discount Rule, Cites Health Center Burden to read the information regarding infighting between Big Pharma and hospitals over 340b pricing. Both of these articles highlight the importance of staying abreast of what is happening with trying to put the brakes on drug pricing and maintaining this valuable program.

When the term “community health center is used in these articles, it refers to an entity defined by HRSA to serve under- and uninsured populations. These are federally-qualified health centers (FQHCs) such as Great Salt Plains or Mary Mahoney down around OKC. In your discussion, answer the following questions:

What did you learn from the question post links that you did not know?
Did you find any 340b pharmacies around your home?
Do you know anyone who accesses 340b drugs?
What are some other ways that can help patients save money on prescriptions?
List two websites where you can find drug pricing or help patients receive discount drug pricing at the pharmacy.

Week 6: Osmosis Assignment

Assignment Prompt

Week 6 Assignment: SCOPE of Pain Podcast and Quiz

SCOPE (Safer/Competent Opioid Prescribing Education) of Pain is a six series of 15 to 20-minute podcasts for continuing medical education/continuing education offered by Boston University School of Medicine. These activities will take you approximately two hours to complete. This online activity must be taken sequentially.

They are designed in a case study format to help you safely and effectively manage patients with acute or chronic pain, when appropriate, with opioid analgesics. The podcasts are free of charge and compliant with the Opioid Analgesic REMS education requirements issued by the US Food and Drug Administration.

Please click on this link to access the podcasts. You are required to create a free account to proceed with the online module. The registration process is self-explanatory; please check off RN to receive CME credits. You will receive a certificate with your name upon successfully passing the post-test with 70% or better. Please upload a screenshot or the certificate in the Opioid Assignment section provided to receive 20 points.

Students who have finished these SCOPE of Pain podcasts and earned a certificate in a prior attempt at this course should reach out to their instructor for directions for an alternative assignment.

After the completion of the podcasts, you will learn to:

1. Apply regulatory and best practices to optimize safety when prescribing opioids for acute pain

2. Develop an evidence-based treatment plan when opioid analgesics are indicated for chronic pain

3. Assess pain and identify individuals at risk for opioid overdose and develop an appropriate treatment plan

4. Understand the role of minimizing opioid-related harms through patient education and safe prescribing practices.

5. Monitor and implement harm reduction strategies for patients with opioid use disorder

6. Assess patients on opioids for adverse effects and when and how to taper off opioids safely

Week 7: Discussion Question 1 – Case Study

Discussion Prompt

A 12-year-old boy has occasional episodes of mild asthma while playing soccer with his friends.

Q1. What treatment should this patient receive to relieve symptoms during an asthma attack?
Q2. If the patient’s asthma attacks occur more frequently, what changes in therapy might be appropriate?

A 19-year-old college student is asking for contraceptives.

Q3. What will you assess to determine if this patient is a good candidate for contraceptives, and what will you prescribe? (Include brand and generic name, route, frequency, and dose). What is the mechanism of action of the contraceptive you prescribed and the adverse effects?
Q4. The patient states she heard a pill can help her acne. What would you prescribe and what is your rationale? (Include brand and generic name, dose, route, and frequency).
Q5. The patient is concerned because her mother and sister developed fractures in their legs and vertebra after menopause. She wants to know what medication and other advice will prevent osteoporosis. You discuss bisphosphonates. How are they used in the prevention and treatment of osteoporosis?

A 48-year-old man has occasional episodes of gout that are painful and debilitating. He requires drugs to treat the symptoms of acute gout attacks and prevent recurrent attacks.

Q6. How would you treat this patient’s acute gout attack? Please list the trade and generic name and the dose of therapy. What is the mechanism of action of your choice of prescription?

Week 7: APEA QBank Quiz

Assignment Prompt

This week, please complete the following QBank quiz:

Respiratory
ENT
Neurology
Orthopedics

Week 7: Osmosis Assignment

Assignment Prompt

Week 7: Assignment – Pharmacology Case Study Presentation

Assignment Prompt

For this case study, you will create an engaging, 20-minute recorded presentation on condition management, that encompasses pharmacological and non-pharmacological utilizing evidence-based guidelines within the last five years. Pick one of the following cases:

Sherri is 48-year-old African American female with hypertension on Lisinopril 40mg with reports of the systolic blood pressure consistently over 160 in the last three weeks. Today in the clinic, the patient is 162/90 and she reports taking her medication daily. Her Heart rate is 72, Temperature 98.4, Respirations 16 and Oxygen Saturation 98%.

She comes to the office because she has had a sore throat for several days and stuffy nose, which was found to be strep negative. She has no fever or cough. What should you recommend for her sore throat and stuffy nose and why? What precautions should you give her regarding over-the-counter medication because of her medical history and why? Discuss the medications that you will prescribe and/or recommend. Include patient education for the visit, as well. Include diagnostics and work-up, as deemed appropriate for the clinical guidelines.

Hailey, a 32-year-old Hispanic female has a 13-year history of asthma. For the past two-months, she has been using albuterol every day. Previously, she had been using the inhaler every 3 to 4 months. She is in the office for a refill. What further information is needed to treat this patient and why? What is her asthma classification? Which clinical guidelines should you refer to for her medication management and why? Discuss the medications that you will prescribe and/or recommend. Include patient education for the visit, as well. Include diagnostics and work-up, as deemed appropriate for the clinical guidelines.

Shaon is a 41-year-old African American male with a history of hypertension and hypertriglyceridemia. Current medications include: ezetimibe 10 mg daily, niacin SR 1,000 mg at bedtime and HCTZ/lisinopril 25/20 mg daily. He complains of lack of energy, core weight gain, and a decrease in erections. Labs reveal: testosterone 180 ng/dL (193–836 ng/dL) with normal TSH/thyroxine, FSH, LH, and PSA. Is this patient a candidate for testosterone therapy? Why or why not? Which, if any, of his medications are contributing to his symptoms? Discuss the medications that you will prescribe and/or recommend. Include patient education for the visit, as well. Include diagnostics and work-up, as deemed appropriate for the clinical guidelines.

The presentation should include an overview of the health problem identified, an in-depth review of the associated epidemiology, anatomy and physiology, clinical manifestations/symptoms, diagnostics/work-up, and an overview of treatment methodologies, including pharmacological and non-pharmacological management; in addition, include patient education. If your scenario has specific questions. You can use a slide in your presentation to address the questions.

Your presentation should be prepared in PowerPoint and recorded with voice over narration (.PPT or .PPTX file) and in APA Format. The PowerPoint should have a conclusion slide to summarize the points of the presentation, title slide and reference slide. Illustrations should be used. A minimum of 4 scholarly references are required.

Week 8: Discussion Question 1

Discussion Prompt

A healthy 2-month-old child was brought to your clinic by her parents. The child is a full-term infant with no concerns. Her exam is normal, and she received her Hep B #1 in the nursery.

Q1. What vaccines does she get? What combinations are available at your clinic?
Q2. The child returns at 12 months after completing her primary series of vaccines at 2, 4, and 6 months of age. Her vaccines are right on schedule, her parents have no concerns, she is developing normally, and her exam is normal. What vaccines can she get today?
Q3. Which groups of patients are at higher risk for pneumococcal disease, and need PPSV23 early starting at 2-years old?

A 25-year-old woman comes to your office asking for oral contraceptive refills. She stated that she was feeling depressed and heard about St. John’s wort used in depression which she started taking a week ago.

Q4. How might concomitant administration of St. John’s wort affect the efficacy of drugs this patient is taking such as the oral contraceptives? Discuss another example of a possible drug interaction that might occur with St. John’s wort?

The 25-year-old woman stated that her 4-year-old child has been coughing and sounds congested. She wants to know if echinacea might help her child.

Q5. What is echinacea used for and how is it taken?
Q6. Is it safe for this mother to give her child echinacea?

Week 8: Discussion Question 2

Discussion Prompt

Post your answers to the 6 questions corresponding to this week’s content on vaccinations. Provide your responses and rationales. Support your rationales with high-level evidence. (See Post Expectations)

A new mother presents to the clinic with her 6-month-old infant for a wellness visit. When taking the vaccine history you find that the child has had no immunizations. The mother is afraid that the immunizations will cause autism.