NR508 Week 2 Discussions Latest
NR508 Week 2 Discussions Latest
Discussion Part One (graded)
Cynthia is a 65-year-old African American female who presents to the clinic for a check-up. Her last examination was ~5 years ago. She has no specific, significant, or urgent complaint. She explains that her only issues are thirst, fatigue, and leg numbness and tingling, which is beginning to occur more often. You decide to do a physical exam, as well as draw labs and receive the following results:
| Social history: no smoking or alcohol consumption. |
| Physical examination: |
| GEN: well nourished, slightly obese female |
| VS: BP 180/103 HR 73 RR 13 T 98.4 Weight 90 kg, Height 5’6” |
| HEENT: PERRLA |
| COR: RRR, NMRG |
| CHEST: CTA |
| NEURO: monofilament test shows decreased peripheral sensation |
| EXT: normal |
| Laboratory (fasting): |
| Na 139 mEq/L |
| K 3.8 mEq/L |
| ALT 34 U/L |
| Ca 9.1 mg/dL |
| CL 102 mmol/L |
| HCO3 22 mEq/L |
| AST 39 U/L |
| TP 6 g/dL |
| BUN 33 mg/dL |
| SCr 2.0 mg/dL |
| Alb 4.1 g/dL |
| Cholesterol 254 mg/dL |
| BG 300 mg/dL |
| TSH 0.12 mU/mL |
| UA: SG 1.013 mg/24h, pH 6.5, +++ protein |
What are the major problems in this patient, and what diagnoses do these values indicate?
Additionally, what is your assessment and pharmacological plan for each of these problems including the medication, dose, and mechanism of action?
Discussion Part Two (graded)
Cynthia has been prescribed a plethora of medications. How will you properly monitor each medication for efficacy and toxicity? Are you concerned with any drug-drug interactions? If so, what are they, and what is the mechanism of the interaction?
Discussion Part Three (graded)
Given Cynthia’s increased creatinine and renal deterioration, metformin is probably not optimal in this case. Therefore, upon subsequent visits, you decide to start her on a sulfonylurea. She reappears in your clinic fairly soon thereafter with complaints of shakiness, sweating, chills, clamminess, lightheadedness, and a moderately severe headache.
• What is the diagnosis given these symptoms and the medications she is currently taking from Parts One and Two, and how would you proceed?
• At this point, please also be sure to also provide an accurate summary of Cynthia’s medication plan.
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NR508 Week 3 Discussions Latest
Discussion Part One (graded)
Elliot is a 74 year-old male who presents to your clinic with complaints of frequent nosebleeds (4 in the past week) and several severe bruises scattered variously throughout his anatomy. The patient is also complaining of a runny nose, cough, and head/chest congestion. He has a history of chronic atrial fibrillation and is currently prescribed and taking warfarin. Approximately 3 weeks previously, he started taking over-the-counter cimetidine for heartburn he was experiencing. Below is a list of the patient’s medications, his physical examination, and his laboratory findings:
| Medications | |
| Digoxin 0.25 mg QD | Cimetidine OTC BID |
| Pseudoephedrine SR 120 BID | Warfarin 7 mg QD |
| Allergies: NKDA | |
| Physical Examination | |
| VS: BP: 180/95, HR 75, irregularly irregular, RR 17Weight: 95 kg | HEENT: WNL |
| ABD: + Bowel Sounds | EXT: Bruising on arms and legs |
| NEURO: Alert & Oriented x 3 | GEN: Well developed, well-nourished male |
| ECG: atrial fibrillation | |
| Laboratory | |
| Na 143 mEq/L | K 4.5 mEq/L |
| Cl 99 mmol/L | CO2 25 mEq/L |
| BUN 18 mg/dL | SCr 0.9 mg/dL |
| INR 4.8 | Hct 42% |
| Hbg 15 mg/dL | Digoxin 3.8 ng/ml |
- What problems should be identified in this patient?
- What are the precise mechanisms of action of each drug?
- What do you think is contributing to the patient’s hypertension?
- Are there any drug interactions that you can identify as associated with this current drug regimen, and if so how, mechanistically, are they occurring?
- What is the clinical significance of these interactions?
Discussion Part Two
You have decided to have him stop the pseudoephedrine related to his hypertension, as well as the cimetidine related to its interaction with warfarin. The patient returns for his monthly follow-up appointment, and it is noticed that his blood pressure (195/80) has not come under control. You decide to start him on hydrochlorothiazide.
- Is there a better medication than a thiazide, and if so what dose should you initiate this medication?
- How would you proceed, and how you would monitor for efficacy and toxicity?
Discussion Part Three
He returns a month later complaining of increased fatigue, visual disturbances, weakness, and nausea; however, his ECG is normal.
Based on this information, what is occurring in this patient? Include precise mechanism(s) of how it is occurring.
Additionally, please include any drug interactions associated with any new medications initiated keeping in mind the current regimen.