ANSWER
Situation 1: Sandra’s Chronic Depression, Anxiety, and Increasing Smoking Issue: Sandra, a 52-year-old woman, exhibits increased smoking, anxiety, and ongoing unhappiness. She is now on HCTZ and pantoprazole for her history of GERD and hypertension. She now smokes more frequently and utilizes cigarettes as a coping mechanism for her anxieties. These symptoms are compatible with either generalized anxiety disorder (GAD) or major depressive disorder (MDD), which can co-occur in people who smoke.
Treatment: Sandra’s anxiety and despair should be addressed first because of her symptoms and smoking behaviors. For both depression and anxiety, a selective serotonin reuptake inhibitor (SSRI) is advised as the initial course of treatment. Sertraline (Zoloft), an SSRI that is proven to be beneficial for both disorders, is what I would recommend.
Prescription:
Sertraline (Zoloft) is the drug.
Dosage: 25 mg per day for the first week, followed by a 50 mg dose per day, depending on tolerability.
Path: Oral (po)
Regularity: Every day
Particular Guidelines: Take in the morning or evening, with or without food, to reduce the possibility of sleeplessness adverse effects. Keep an eye out for adverse effects include mood swings, irritability, and sexual dysfunction. Check in after two weeks to see if the symptoms have improved.
# 30 pills were dispensed (one month’s supply).
Two refills
Given her increased smoking habit, Sandra should also be given the opportunity to get smoking cessation counseling and perhaps even a prescription for a smoking cessation medication such as Varenicline (Chantix).
A prescription for quitting smoking:
Varenicline (Chantix) is the drug.
The recommended dosage is 0.5 mg per day for the first three days, followed by 0.5 mg BID for the next four days, and then 1 mg BID.
Path: Oral (po)
Often: Twice a day
Special Instructions: One week prior to the desired cessation date, start taking. Talk about possible adverse effects like mood swings and nausea. Keep an eye out for neuropsychiatric signs.
# 30 pills were dispensed (one month’s supply).
No refills
Learning: Inform Sandra of the value of routine follow-up for her smoking cessation and sadness. Describe how SSRIs are likely to ease symptoms, which usually takes 4-6 weeks. To support her mental health, offer resources for organizations that help people quit smoking and promote physical activity.
Labs: In light of Sandra’s HCTZ use and hypertension, I would suggest the following tests:
Electrolyte monitoring using a basic metabolic panel (BMP) (particularly potassium and sodium, because of the usage of HCTZ)
Liver function tests (LFTs) to track possible sertraline interactions
Using a complete blood count (CBC) to check for any irregularities linked to long-term SSRI usage
Test for thyroid-stimulating hormone (TSH), since symptoms of depression might be mistaken for thyroid dysfunction
Scenario 2: JR: Leg pain, tingling, and numbness
Problem: JR exhibits signs of exhaustion, numbness, tingling in the legs, discomfort, and balance problems. He is currently taking rosuvastatin for cardiovascular health and metformin, Synjardy XR, and Tresiba for type 2 diabetes. These signs point to the possibility of diabetic neuropathy.
Diabetic neuropathy is the working diagnosis, most likely brought on by his chronic diabetes and the resulting peripheral nerve damage. A typical consequence of poorly managed diabetes is diabetic neuropathy, which is characterized by numbness, tingling, and pain in the extremities.
therapy: Optimizing blood sugar regulation, managing pain, and maybe using drugs like gabapentin or pregabalin to relieve nerve pain are all part of the therapy of diabetic neuropathy.
Prescription:
Medication: Gabapentin
Dosage: 100 mg three times day; depending on tolerance, titrate to 300 mg three times daily.
Path: Oral (po)
Often: three times a day
Special Instructions: To reduce adverse effects including sedation and vertigo, start with a low dose and titrate up. Keep an eye out for behavioral or emotional shifts.
# 90 pills were dispensed (one month’s supply).
Two refills
Extra Administration:
Make sure JR’s blood glucose levels are tightly controlled by modifying his existing prescription regimen (maybe adding another drug, like liraglutide or empagliflozin, or increasing the dosage of Tresiba).
Changes in Lifestyle: To enhance general glucose regulation and cardiovascular health, promote weight loss, quitting smoking, and increasing physical activity.
Observing:
Keep an eye on your blood sugar, A1C, and kidney function (since high dosages of metformin can harm your kidneys).
Assess how well gabapentin works to reduce the symptoms of neuropathy.
Check for any adverse effects, such as gabapentin-induced sleepiness or dizziness.
Scenario 3: Antidepressants with Zolpidem for Depression and Sleep Issues: A situation where a patient takes zolpidem for sleeplessness is presented in the question. Because of its three-hour half-life, zolpidem has a significantly lower blood concentration in the morning, which is crucial for safety, especially in older patients who might have more severe side effects.
Zolpidem Blood Levels: Because zolpidem has a brief half-life, if 10 mg is taken at 10 pm and taken by 7 am (9 hours later), the drug’s blood level will probably be quite low. With a three-hour half-life, the drug would have been digested and removed after around three half-lives (9 hours), bringing the blood concentration down to very low levels.
Elderly Patients: Because of their slower metabolisms and heightened sensitivity to sedatives, elderly patients usually require lower doses of zolpidem. For older adults, a starting dose of 5 mg at bedtime is advised.
Antidepressants and antipsychotics for depression and insomnia that coexist:
Medication: 50 mg of trazodone before bed
Method: Oral
Frequency: Every day before bed
Special Instructions: To reduce gastrointestinal adverse effects, take with food. Keep an eye out for priapism, orthostatic hypotension, and sleepiness.
# 30 pills were dispensed (one month’s supply).
Two refills
Medication: 15 mg of mirtazapine before bed
Method: Oral
Frequency: Every day before bed
Special Instructions: Keep an eye out for weight gain and increased hunger.
# 30 pills were dispensed (one month’s supply).
Two refills
Medication: 10 mg of doxepin before bed
Method: Oral
Frequency: Every day before bed
Special Instructions: Keep an eye out for cognitive impairment, anticholinergic effects, and drowsiness.
# 30 pills were dispensed (one month’s supply).
Two refills
Monitoring: Keep an eye out for adverse effects such as severe sedation or drowsiness the next day, changes in weight while taking mirtazapine, and problems with eating.
SCENARIO 4: ADHD in a 7-Year-Old and Adult Parent Issue: David, a 7-year-old, displays indicators of ADHD, such as hyperactivity, impulsivity, and inattention. ADHD runs in families, and his mother has a history of it as well.
David’s prescription:
Methylphenidate (Concerta): 18 mg per day, morning; oral route
Regularity: Every day
Special Instructions: Keep an eye out for possible growth delays, sleeplessness, and appetite suppression.
# 30 pills were dispensed (one month’s supply).
Two refills
The medication David’s mother is taking:
Medication: 20 mg of amphetamine salts (Adderall XR) each day; dosage: oral
Frequency: Mornings once a day
Special Instructions: Keep an eye out for appetite loss, sleeplessness, and cardiovascular side effects.
# 30 capsules (1 month’s supply) were dispensed.
Two refills
Disparities in ADHD Treatment: Behavior control and stimulant drugs like methylphenidate are the mainstays of treating ADHD in youngsters. Non-stimulants like atomoxetine and drugs like Adderall XR are more frequently utilized for adults. Organization, time management, and maintaining focus on adult tasks are common challenges for adults with ADHD.
Citations
(2013) American Psychiatric Association. The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders. Psychiatric Publishing, America.
(2020) MedlinePlus. Zolpidem. Medicine’s National Library. A692025.html https://medlineplus.gov/druginfo/meds
Food and Drug Administration, United States. (2020). methylphenidate. The FDA’s website
QUESTION
To Prepare:
· Be sure to thoroughly answer ALL questions.
· Explain the problem and discuss how you would address the problem.
· When recommending medications, write out a complete prescription for each medication. What order would you send to a pharmacy? Include drug, dose, route, frequency, special instructions, # dispensed (days supply), refills, etc. Also state if you would continue, discontinue or taper the patient’s current medications.
· Answer questions using your required learning resources, clinical practice guidelines, Medscape and JNC 8.
· Include at least three references (WITHIN PAST FIVE YEARS) to support each scenario and cite them in APA format. Please include in-text citations. You do not need an introduction or conclusion paragraph.
WEEK 7 ASSIGNMENT-do all FOUR SCENARIOS
SCENARIO 1
Sandra is a 52-year-old female with past medical history of hypertension and GERD. Current medications include pantoprazole 40 mg po daily 30 minutes before breakfast and HCTZ 50 mg daily. She smokes 1 pack per day and presents with persistent sadness, anxiety and “empty mood.” Her smoking habit has increased the past month as she says it “helps calm her nerves.” She denies any history of seizures. How would you treat Sandra? What medication would you prescribe (include complete medication order)? What education would you provide to the patient? What labs would you order?
SCENARIO 2
Patient JR is experiencing symptoms of pain, numbness and tingling in his legs. He states he sometimes has trouble keeping his balance and feels easily fatigued. He is currently on metformin 1000 mg po BID, Synjardy XR 5/1000mg po daily, Tresiba 20 units SC daily and rosuvastatin 10 mg po daily. What is your working diagnosis? How would you treat JR and improve his treatment? What would you monitor?
SCENARIO 3
Zolpidem has a half-life of 3 hours. If a patient takes 10 mg at 10 pm, what will the blood level be at 7 am? Do elderly patients need a smaller dosage of zolpidem? Name 3 antidepressants/antipsychotics you might prescribe for patients with co-existing depression and insomnia (include complete medication orders) and include patient monitoring.
SCENARIO 4
A mother brings her 7-year-old son David into the clinic today stating that he is increasingly getting into trouble at school. He “fidgets and frequently leaves his seat, does not listen to his teacher, talks excessively and interrupts other classmates.” What would you prescribe for David? How common is it for a parent and child to both have ADHD? How are symptoms and treatment of ADHD different between children and adults? What would you prescribe for David’s 40-year-old mother with ADHD?