NR508 Week 5 Discussions Latest

Discussion Part One (graded)

Leroy is a 70 year-old-man, whose wife passed away 5 years ago, and whose 2 children live out-of–state. His neighbor caretaker (Ms. Webb, a middle-aged retired CNA, whom his children hired to provide home care to him 3x/week) brings him to your clinic. He presents with quite severe confusion, incidentally to very minor changes in his environment, which provokes some violence (a symptom which startles Ms. Webb), increasingly impaired judgment, and increasing repetitiousness and inconsistencies in his usual behavior. Upon initial work-up and physical exam, you notice an increased respiratory rate, a slight fever (100°F), and cost vertebral angle tenderness on his right side.

Discussion Part Two (graded)

The patient is diagnosed with a severe urinary tract infection (pyelonephritis), and you decide to prescribe him sulfamethoxazole/trimethoprim (SMX/TMP) beginning with 2 g initially as a loading dose, followed by 1 g as a maintenance dose BID. Over the next couple of weeks, the symptoms associated with his UTI diminish, and his mental status improves. However, Ms. Webb brings him back to your clinic with symptoms, which scare her yet again, and she explains that she thinks he may have a relapse of his UTI. These symptoms include a high fever (103.6°F) and tachypnea, and upon pulmonary examination at your clinic, you hear crackles, and find classic findings of lung consolidation.

What laboratory tests should you order, and what is your primary diagnosis at this point and subsequent steps in his treatment and management?
Once explained, please indicate and describe your chosen pharmacological treatment with inclusion of dose and mechanism of action of your chosen prescription.

Discussion Part Three

Upon receipt of laboratory results, you notice that his eGFR is ~40mL/min, his serum creatinine is 3.0 mg/dl, and his BUN is 50 mg/dl.

How will the medication regimen(s) have to be adjusted given these new laboratory findings, and how should you be monitoring for efficacy and toxicity of this patient’s pharmacological profile with a summary of where this patient currently stands in his medical treatment?

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NR508 Week 6 Discussions Latest

Discussion Part One (graded)

Jonathon is a 56 year-old retired automobile mechanic who has not been to the doctor in approximately 6-7 years. He presents to your office complaining that 3 weeks ago he was awoken with severe pain and inflammation in his knee, which has been consistent since that initial night. Upon physical examination of his knee, it appears swollen and erythematous with periarticular involvement. Upon physical examination and laboratory results you notice the following:

Physical examination:

GEN: well nourished, obese male (310 pounds)

VS: BP 191/112 HR 75 RR 15 T 98.6, HT 5’8”

EXT: Knee joint inflammation

Laboratory (fasting):

Na 139 mEq/L

K 3.8 mEq/L

Ca 9.1 mg/dL

CL 102 mmol/L

HCO3 22 mEq/L

BUN 10 mg/dL

SCr 0.9 mg/dL

Serum Uric Acid 6.5 mg/dL

Alb 4.1 g/dL

Cholesterol 300 mg/dL

UA: pH 6.8, uric acid 250 mg/24h

What problems can be identified in this patient? Please provide a list of differential diagnoses, as well as indication of your primary diagnosis.

What is your pharmacological plan for your primary diagnosis including the medication, dose, and mechanism of action?

Discussion Part Two (graded)

He returns to your clinic for follow-up blood work, and 4 values catch your attention:

AST 430 U/L

ALT 535 U/L

Bilirubin 41 mg/dl

BG 60 mg/dl

He admits to a history of moderate-to-high alcohol intake (>12 drinks/week for >10 years). He is slightly febrile (99.7°F) and has abdominal tenderness. He also admits to taking several, different over-the-counter pain relievers of different brands daily and continuously to combat the pain in his knee, in addition to his prescription(s) in Part One. You decide to run a toxicology lab, and it reveals a blood acetaminophen concentration of 58 µg/mL.

What is the diagnosis at this point in his case? Please explain the mechanism for how this occurs/occurred, and the antidote’s mechanism of action.
What is the subsequent management and treatment for this individual related to the diagnosis in Part One.

Discussion Part Three (graded)

This is your third time seeing this patient, and he reports the NSAID that he has been prescribed is not addressing his pain. He reports his pain is a 10 out of 10, HR 108, talking extremely fast, he is diaphoretic, unshaved, his clothes are a bit wrinkled and he is requesting that you prescribe him Percocet because he doesn’t think Tramadol, that you are considering prescribing, will work.

What are the possible signs of prescription drug abuse?
What should the NP do when a patient has continued to return?