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.

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NR508 Week 4 Discussions Latest

Discussion Part One (graded)

Barbara is a married 39-year-old woman with no children, smokes 1 pack/day, and weighs 180 pounds who has scheduled an appointment with you to discuss feelings of anhedonia that she has been experiencing for the past few months. She has a history of depression as a teenager, but has not needed or received therapy for ~20 years. At the appointment, she relays that she has been experiencing chronic fatigue/loss of energy, feelings of worthlessness, appetite disturbances, weight gain, inability to concentrate, psychomotor disturbances, and insomnia.

Please provide a list of differential diagnoses, as well as an indication of your primary diagnosis.
Once this has been completed, please indicate and describe your chosen pharmacological treatment with inclusion of dose and mechanism of action of your chosen prescription.

Discussion Part Two (graded)

Monitoring for efficacy and toxicity of the current drug regimen you prescribed in Part One

Subsequent steps if this patient did not have an adequate response?

Assume you had her on a common, selective serotonin reuptake inhibitor for several months without great response. Explain why the SSRI should be slowly discontinued prior to starting bupropion in Part Three.

Discussion Part Three

You decide to begin the patient on bupropion.

At what dose should she be started on bupropion, and how does bupropion differ from other commonly prescribed antidepressants, such as fluoxetine, venlafaxine, and nortriptyline?
Why would this be the best option for this patient given her symptoms and lifestyle? In your answer, be sure to compare and contrast bupropion with each medication mentioned above (fluoxetine, venlafaxine, and nortriptyline).