Case Study part 3 37 year old Tran comes in for sick visit. He has not been doin

Question

Case Study part 3

37 year old Tran comes in for sick visit. He has not been doing well lately. He injured his back several years ago at work and suffers from chronic back pain and depression. He is feeling depressed, his pain is out of control (the vicodin is no longer working) and is not taking his taking blood pressure medications. He feels shaky and is complaining of epigastric pain. He tried an antidepressant after the back injury, but stopped taking it after a few months.

PMH

Chronic back pain

HTN

Depression

Medications

NKDA

Motrin 800 mg 3 times per day

Aspirin 325 mg daily

Vicodin 10/325 mg tabs every 4 hours (since the injury)

Tenormin 50 mg 2 times per day (5-years)

Gabapentin 100mg po 3 times per day (chronic pain)

Exam findings

200/106, 122, 98.0, 16. Mild tremors on exam noted in upper extremities. Lungs CTA, RRR s1 & s2 no MRG. Abdomen soft, tenderness in the epigastric area on palpation. An EKG is completed which shows normal intervals with a normal sinus rhythm, but evidence of ischemia consistent with developing heart disease.

1. Why do you think the vicodin is no longer working? Is this an expected event? Are there any other concerns about the amount of vicodin Tran is taking?

The patient history on Tran reveals to us that he has been taking Vicodin at the listed dose for “several years”; sine the injury.

2. What medication might be the trigger for the upper extremity tremors?

3. What medications are likely contributing to the epigastric pain and why?

4. Based on his EKG and blood pressure reading what does Tran need to know about NSAID use?

5. Tran is started on the following medications today. Pepcid 40 mg 2 times per day, and an SSRI at starting dose (paxil 20 mg QD), Fentanyl patches. The Motrin and Vicodin were discontinued. Briefly describe what Tran needs to know about each of these medications. Be specific about what the transition from oral pain medications to long-acting patches. Be specific about what to expect when starting an SSRI.

6. How does gabapentin work to treat chronic pain?

Terms to apply: tolerance, steady state, withdrawal, physical versus psychological dependence, sympathetic nervous system response, selective versus non-selective drugs

On Trans return visit 3 weeks later, his BP is still elevated despite medication compliance. His symptoms of depression are improving, but not resolved. He complains of daytime sleepiness. The decision is made to increase the Paxil dose and add HCTZ 12.5 mg daily for blood pressure management. He has transitioned well to the Fentanyl patches.

1. When would you advise Tran to take the Paxil? Does increasing the dose make sense?

2. What teaching does Tran need about HCTZ?

Terms to apply: titration to response,

38 year old Angela has a seizure disorder. She is currently taking Tegretol, Valporic Acid & Dilantin. She has not had a seizure in many years. She brought to the ED for evaluation of tremors, ataxia and confusion. Her vital signs are: 90/50, 130, 99.6, 22.

1. What labs do you anticipate drawing?

2. What IV fluid would you anticipate hanging?

3. What is the normal therapeutic range for the drugs she taking?

4. What drug is mostly likely causing her symptoms?

5. The doctors tell her they want to wean her off of her some of her anti-seizure medications because she has not had a seizure in years. Is this consistent with evidence-based practice guidelines?

Terms to apply: toxicity,

Both 8 month old Sophie and 3 year old Michael are diagnosed with conjunctivitis and external otitis media. Both children will need to be treated.

1. What is true about the absorption of topical local medications?

2. Cortisporin otic and Ofloxacin are treatment options for the OE infection. Are they safe for use in the children's age groups?

3. Can eye drops be used in the ear? Can ear drops be used in the eye? Why?

Terms to apply: physiologic tissue differences affecting absorption,PH

Explanation / Answer

1). Vicodin is a combination of acetaminophen and hydrocodone, which acts through the opioid receptors. The acetaminophen do not cause tolerance as it acts by inhibiting the cyclooxygenase enzyme. While the hydrocodone can cause tolerance by the downregulation of opioid receptors upon regular usage. Due to the regular intake of Vicodin, it is not working, some beneficial effects can be obtained if the dose is increased.

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