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SCENARIO 1
Mary Mite is a 21-year-old female who presents to your clinic with a one-week history of rash that you diagnose as scabies. There are skin lesions on the back, abdomen, groin, hands and feet, and arms and legs. Mary states her roommate also has similar symptoms.
SCENARIO 2
18-month-old Lucie May presents to your clinic with acute onset of R ear pain last night, following a 5-day viral URI. This is her 3rd otitis media diagnosis in the last 4 months. Both previous times were treated with amoxicillin with resolution, but it seems like she is sick again pretty quick after the last diagnosis of OM 3 weeks ago.
SCENARIO 3
Jane Rebel is a 25-year-old female who presents to your clinic with an abscess and cellulitis of her left deltoid x 3 day?s duration. Admits to having similar skin infections several times in last year, but she can?t remember what medication was prescribed. She does remember that the first time, she was given a prescription that didn?t work, and they gave her something else, which did make the skin infection go away.
Exam: Alert female, somewhat disheveled and unkept in appearance, left deltoid with pointing, fluctuant abscess, measuring 3 cm in diameter with surrounding cellulitis measuring 4 inches in diameter, mild left axillary lymphadenopathy, no streaking
Critical-Thinking Questions (30 pts)
1. Why have you selected this medication in this situation? Justify your selection over alternatives. What class of medication are you choosing and why? Tell me why you chose this med and not others, and include the pharmacodynamic action of the med you are choosing versus the other options. Include either a research article or evidenced based guideline that supports your decision-making and selection process. Give rationale and reference your information.
2. List 3-5 instructional points you would include in educating the patient/parents. Note: There are probably many things you could include in your instruction but do not exceed 5 points. Select the most important points relative to this medication and this case. Don?t just copy and paste into this section. Make it meaningful to this patient.
3. What are the potential side effects and/or adverse drug reactions and how should they be managed? What would you expect that your patient might experience, and what are your worst case scenarios? If these occur, what would you want your patient to do?
4. What are potential drug interactions for this patient and what would you education and management be? (Note: This answer may be none.) Don?t just copy and paste drug interactions into this area. What is applicable for this patient?
5. Did you prescribe a generic or a brand/trade name? Is there a generic version of this medication available? If so, what is it called? Is there a brand/trade version of this medication? What is an example of this, if so? What is your rationale for prescribing or not prescribing a generic preparation?
6. What is the cost of this medication? How does it compare to other options available for this patient? Is the medication as you prescribe it on the $4 lists available at area stores?
7. How would you monitor the efficacy of this medication? Specifically, when would you expect this medication to work? When would you want to see this patient again? Are there lab tests or other information that you would need to gather to see if this medication is efficacious? How do you know the medication is efficacious?
8. What are alternative treatment plans should this option fail? Specifically address what medication, how and when you would use it.
9. How would this treatment be changed if the patient is pregnant? Specifically, what category in pregnancy is this medication? How would you approach this medication with a pregnant patient?
10. Include at least three references, including one Internet resource URL, and at least one research article with a very brief explanation of what was used from the site. References must be in APA format.
WORK TO BE EDIT.
Mary Mite is a 21-year-old female who presents to your clinic with a one-week history of rash that you diagnose as scabies. There are skin lesions on the back, abdomen, groin, hands and feet, and arms and legs. Mary states her roommate also has similar symptoms.
DOB: November 10
Current Meds: Denies
Allergies: Denies
PMH: Denies
Exam: Alert female, nontoxic
CV: S1S2, no murmur
Lungs: CTA, easy and unlabored on room air
Vitals: T 37.1C HR 72 BP 118/74 RR 18 Sat 98%
Why have you selected this medication in this situation?
I chose the First-choice treatment which is permethrin. is a synthetic pyrethrin derivative scabicide which kills mites and eggs. Permethrin is superior to topical lindane or oral ivermectin in reducing treatment failures and in decreasing itch. Permethrin may be used safely in pregnant women and pediatric patients.
List 3-5 instructional points you would include in educating the patient/parents.
1. at night apply thin, uniform layer to ALL skin surfaces (entire trunk and extremities) from neck to toes (including soles of feet), all skin folds, and brush under fingernails and toenails
2. avoid contact with eyes and mucous membranes
3. remove cream after 8-14 hours by bathing or showering
4. People who are in close contact with the infected person, such as members of the same household, should also be checked for scabies
5. To avoid giving scabies to another person or getting it again, clothing and bed linens that have been in contact with your skin less than 2 days before treatment should be machine-washed with hot water and dried in a hot dryer for 20 minutes, dry cleaned, or removed from body contact for 72 hours.
What are the potential side effects and/or adverse drug reactions.
Skin irritation, including itching, swelling, and redness, may occur with scabies and temporarily worsen after treatment with permethrin. Mild burning or stinging may also occur. If any of these effects persist or worsen, give me a call as soon as possible. Many people using this medication do not have serious side effects.A very serious allergic reaction to this drug is rare. However, seek immediate medical attention if you notice any symptoms of a serious allergic reaction, including: rash, itching/swelling (especially of the face/tongue/throat), severe dizziness, trouble breathing.
What are the potential drug interactions for this patient.
There has been no drug interaction reported about permethrin.
Did you prescribe a generic or a brand/trade name?
I prescribed the generic brand permethrin 5% and the brand name is elimite. By prescribing the generic brand this give the patient the option of purchasing a brand name or a generic brand, which is the best bet is to go with the generic product. And also it is cost effective.
What is the cost of this medication?
The cost of permethrin 5% cream 60 gram is $26.00 compare to Elimite 5% cream of 60 gram which cost 71.00. This medication in not available on the $4.00 list.
How would you monitor the efficacy of this medication?
The efficacy of this patient will be on a follow up visit in 2 weeks, if there is no improvement in patient condition or if symptoms persist longer than 1-2 weeks or if live mites are still present I will retreat patient.
Should this option fail, what are the alternative treatment plans?
If treatment failed, I will prescribe Lindane because FDA approved as second-line therapy for scabies in patients cannot tolerate or have failed first-line treatment with safer medications. Will teach patient of prolong use of lidane, due to neurologic toxicity, seizures and death reported following repeat or prolonged application of lindane.
How would this treatment be changed if the patient is pregnant?
Permethrin topical has been assigned to pregnancy category B by the FDA. Animal studies have revealed no evidence of impaired fertility or harm to the fetus. There are no controlled data in human pregnancy. Permethrin topical is only recommended for use during pregnancy when benefit outweighs risk. I will prescribe this medication to a pregnant patient, with a close monitoring.
References
18-month-old Lucie May presents to your clinic with acute onset of R ear pain last night, following a 5-day viral URI. This is her 3rd otitis media diagnosis in the last 4 months. Both previous times were treated with amoxicillin with resolution, but it seems like she is sick again pretty quick after the last diagnosis of OM 3 weeks ago.
Exam: Awake, cranky but consolable, alert, no acute distress, nontoxic in appearance, well hydrated
PMHx: NSVD, no complications with pregnancy or birth, urinary tract infection 6 months ago, normal VCUG workup
Meds: Tylenol and Motrin prn
Allergies: Ceftin (rash)
Social: Lives with parents, daycare 5 days a week, father smokes, not in house
DOB: September 6
Vitals: HR 100 RR 24 Sat 98% RA T 38.5C Wt: 28 lbs.
Why have you selected this medication in this situation?
I will prescribe another antibiotics, Amoxicillin/clavulanate 90mg per kg per day since this child has been treated with amoxicillin twice with resolution, and sick again in 3 weeks with recurrent otitis media. may be considered as second-line antimicrobial agents if high-dose amoxicillin proves ineffective. High-dose amoxicillin-clavulanate has been found to be highly efficacious. I will not use any anthihistamines or dicongestants as it is not recommended for a child with acute otitis media. Although Cefdinir is also considered another first choice of treatment, I cannot use Cefdinir since patient is allegic to ceftin.
List 3-5 instructional points you would include in educating the patient/parents.
1. A follow-up examination is recommended after completion of therapy, usually 3 to 4 weeks after initial diagnosis or when symptoms recur, whichever comes first.
2. Minimizing risk factors, such as exposure to cigarette smoke, supine pacifier use, and supine bottle feeding, is helpful in preventing recurrence of AOM.
3. Take medication with food and plenty of water to minimize the potential gastrointestinal intolerance.
4. Keep liquid medication in the refrigerator, tightly closed, and throw away any unused medication after 10 days. Do not freeze.
5. Take this medication for the entire length of prescribed by Doctor. Do not stop using this medication even if the patient feels better.
6. Advise patients that skipping doses or not completing the full course of therapy may decrease effectiveness and increase the likelihood that bacteria will develop resistance and will not be treatable with amoxicillin and clavulanate or other antibacterials in the future.
What are the potential side effects and/or adverse drug reactions.
Amoxicillin and clavulanic acid may cause side effects. ?If your child shows signs of very bad dizziness or passes out. If your child has trouble breathing. If your child has a very bad upset stomach or is throwing up. If your child is not able to eat. If your child has very loose stools (diarrhea), even after drug is stopped. If your child has any bruising or bleeding. If your child has dark urine or yellow skin or eyes. If your child is feeling very tired or weak.
What are the potential drug interactions for this patient.
Since this patient is not on any other medication there is no potential drug interaction, I will advice the parent not to combine this medication with any over the counter without consulting me first.
Did you prescribe a generic or a brand/trade name?
I prescribed the generic brand for this drug with the exact form. The brand names are Augumentin, Amoclan.
What is the cost of this medication?
Amoxicillin/clavulanate 125mg/5mg suspension cost $27.32, and it is not available in the $4.00 list in the area store.
How would you monitor the efficacy of this medication?
A telephone follow up call will be made within 48 to 72 hours for symptoms relieve. If there is no improvement with the symptoms with the initial treatment, patient will be screen more for a different antibiotics.
Should this option fail, what are the alternative treatment plans?
If Amoxicillin/clavulanate failed to reduce symptoms withing 48-72 hours, azithromycin a 5 days course Z-pack will be given orally. 20mg per kg once a day.
How would this treatment be changed if the patient is pregnant?
Amoxicillin-clavulanate has been assigned to pregnancy category B by the FDA. Animal studies failed to reveal any evidence of teratogenicity. There are no controlled data in human pregnancies. I will prescribe this medication to a pregnant patient.
Jane Rebel is a 25-year-old female who presents to your clinic with an abscess and cellulitis of her left deltoid x 3 day?s duration. Admits to having similar skin infections several times in last year, but she can?t remember what medication was prescribed. She does remember that the first time, she was given a prescription that didn?t work, and they gave her something else, which did make the skin infection go away.
Exam: Alert female, somewhat disheveled and unkept in appearance, left deltoid with pointing, fluctuant abscess, measuring 3 cm in diameter with surrounding cellulitis measuring 4 inches in diameter, mild left axillary lymphadenopathy, no streaking
HEENT: Unremarkable
CV: S1S2, no murmur
Lungs: CTA easy and unlabored on room air
Abd: Soft, nontender, and nondistended
Vitals: T 38.2C HR 78 BP 108/74 RR 18 Sat 98%
DOB: January 3
Current Meds: Denies
Allergies: Denies
PMH: Denies
Why have you selected this medication in this situation?
Cellulitis is a spreading, acute inflammation of the dermis and subcutaneous tissue, sometimes involving muscle, it Covers the most common bacteria that cause cellulitis There is considerable overlap in presentation between various skin and soft tissue infections, and many have a cellulitic component. Hallmarks are erythema, edema, tenderness, and warmth. Common causes are Group A ?-hemolytic streptococci (Streptococcus pyogenes) Staphylococcus aureus, Haemophilus influenzae (decreasing in frequency), Group B, C, D, or G ?-hemolytic streptococci. I will treat the cellulitis with Cephalexin 500 mg orally every 6 hours for 7 days, because this is an option for no purulent cellulitis. Since the cellulitis does not present with prulent. Surposing the cellulities has purulent (or signs of systemic toxicity) I could have treat with the use antibiotics effective against MRSA, either as outpatient or inpatient.
List 3-5 instructional points you would include in educating the patient/parents.
1. Instruct patient to complete full course of therapy.
2. Advise patient to take with food or milk if GI distress occurs.
3. Remind patient to check body temperature daily. Advise patient to notify health care provider immediately if fever persists for more than a few days or if high fever (more than 102?F) or shaking chills are noted.
4. Advise patient to maintain normal fluid intake while using this medication.
5. Instruct patient to report the following symptoms to me as soon as possible: diarrhea, hives, muscle or joint pain, nausea, skin rash, vomiting.
What are the potential side effects and/or adverse drug reactions and how should they be managed?
All medicines may cause side effects, but many people have no, or minor, side effects. Check with your doctor if any of these most COMMON side effects persist or become bothersome when using Cephalexin: Diarrhea; dizziness; headache; indigestion; joint pain; stomach pain; tiredness. Seek medical attention right away if any of these SEVERE side effects occur when using Cephalexin: Severe allergic reactions (rash; hives; itching; difficulty breathing; tightness in the chest; swelling of the mouth, face, lips, or tongue); agitation; confusion; dark urine; decreased urination; fever; hallucinations; red, swollen, or blistered skin; seizures; severe or bloody diarrhea; severe stomach pain or cramps; severe tiredness; unusual bruising or bleeding; unusual vaginal pain, odor, or discharge; yellowing of the eyes or skin.
What are potential drug interactions for this patient and what would you education and management be?
Since this patient is not on any other medication there is no potential drug interaction, I will advise the parent not to combine this medication with any over the counter without consulting me first. There is no food interaction with this drug reported.
Did you prescribe a generic or a brand/trade name?
I prescribed the generic name for this drug which is Cephalexin, the brand name are Keflex, Panixine. I prescribed the generic of this drug because it is cost effective, and it also give the pharmacy to dispense a wider range of drugs, rather that limiting to one which may be out of stock.
What is the cost of this medication?
Cephalexin for 28 capsule cost $26.75, and it is available on the $4.00 list at the area pharmacy store.
How would you monitor the efficacy of this medication?
The efficacy of this treatment will be monitored by resolution of the cellulitis, signs and symptoms of the infection. Check that the cellulitis has not spread. Skin will be examined 24 to 48 hours after patient initiates therapy. Patient will be monitor closely, by monitoring the white blood cell, culture, and sensitivity.
What are alternative treatments plans should this option fail?
If symptoms does not improve within 5 days, Hospitalization and intravenous antibiotics
Search for complications, alternate diagnoses; consider resistant organisms
Surgical debridement may be necessary.
How would this treatment be changed if the patient is pregnant?
FDA pregnancy category B. Cephalexin is not expected to be harmful to an unborn baby. I will treat the pregnant patient this same way, with close observation.
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