NURS 602: Pharmacologic Applications Essay Assignment Paper

NURS 602: Pharmacologic Applications Essay Assignment Paper

NURS 602: Pharmacologic Applications Essay Assignment Paper

CASE SUMMARY:

MT is a 68 year-old black female who presents to you for an outpatient follow-up appointment. She is known to you from prior visits (and the last case study). She has a history of diabetes, hypertension, atrial fibrillation, and TIA. She has had weight gain and worsening diabetes. Her weight gain is due to lack of energy and inability to exercise. Her medications have been stable, with no recent changes, except switching from pantoprazole to famotidine about 9 mos. ago. Her diabetes was previously well controlled on metformin alone, but her fasting glucose and hemoglobin A1C (Hgb_A1C) have gradually worsened. Despite attempts with dieting, she has not been able to lose weight. You have referred her to a dietician in the past, and she feels like she has all the information she needs regarding appropriate diet. She is compliant with her medications and lab work. Today, she presents with no major complaints, other than generalized tiredness. She does monitor her blood pressure and occasionally her glucose at home and knows that it is not at “goal”. She has “good” prescription insurance coverage, so cost is not a “major” issue.

Social History: 20 PPD history of smoking (quit 22 years ago); minimal exercise (aside from occasional walks in the neighborhood several times a week); she is a retired retail worker. Drinks a glass of wine occasionally (1-2 times per month) when visiting with friends.

Family History: father died at age 74 from an MI; mother alive with a history of diabetes, Alzheimer’s dementia, and colon cancer

Past Medical History: HTN; atrial fibrillation (diagnosed 8 years ago); TIA (7 years ago); diabetes; GERD, osteoarthritis

Pharmacologic Applications

 Medication History:

Hydrochlorothiazide 50 mg PO once daily

Enalapril (Vaostec) 20 mg PO once daily

Metformin (Glucophage) 1000 mg PO BID

Apixiban (Eliquis) 5 mg PO BID

Atorvastatin (Lipitor) 40 mg PO once daily

Famotidine 20 mg PO BID

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Acetaminophen (Tylenol) 500 mg PO PRN joint pain

 Vaccine History: received influenza vaccine in October 2020. All other vaccines are up to date. She is on a waiting list to receive the COVID-19 vaccine.

 Allergies: NKDA

 Physical Examination: VS: BP 129/78 (las visit 130/77 mm Hg)

HR 66                RR 18               Temp. 37

Ht. 64 in.           Wt. 169 lbs.

Remainder of physical exam normal 

Lab Results:                    Fasting lipid profile: Total: 176 LDL 90  HDL 50  Triglycerides 180

Fasting glucose: 145  HgbA1c: 7.9

Electrolytes: NA 138     K 4.1   CL 100    CO2 22                                                               BUN 17   Scr 1.0   Ca++ 8.8

CBC: WNL                        LFTs: WNL                                          TSH: WNL                                          UA: 1+ protein (otherwise normal)

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CASE QUESTIONS (provide appropriate evidence-based references as applicable):                                

1. Based upon current guidelines, what would be the goals for treating MT’s diabetes (be specific in goals that are evidence based and can be measured, not limited to just laboratory goals)? (3 points)

2. Based upon current guidelines, what is the first-line agent used in treating most patients with Type 2 diabetes? When would this medication NOT be indicated (or when would it be contraindicated)? (2 points)

3. After reviewing MT’s lab results, you determine that her regimen is not adequate and decide to initiate combination therapy (i.e. to add a medication(s) to the current regimen). What medication(s) would be most appropriate to initiate and why? (be sure to include drug(s), dose, frequency, and rationale for choosing this regimen over other medications) (4 points)

4. How would you monitor this/these medication(s) (particularly focusing on response to therapy, progression towards her goals, and the potential for adverse effects)? Be specific on what you would monitor, how you would monitor it, including the frequency of monitoring? (4 points)

5. What information would you tell MT about her new medication(s) and how to take it/them (be specific on all counseling points and what to look out for/how to monitor at home)? (3 points)

6. MT is diagnosed with cholecystitis and is undergoing a cholecystectomy. She is referred to you prior to her gallbladder surgery. What recommendations do you have for her diabetes medications around the time of her surgery? (her apixaban will need held, but you do not need to worry about this for the purpose of this case study) (3 points).

After her surgery, she has developed some complications, including acute renal failure and diagnosed with heart failure (HFrEF), with an ejection fraction of less than 45%. Her renal function has improved, and her serum creatinine is now stabilized at 2.2 mg/dl (assumed to be her new baseline). Her weight is 76 kg. Her enalapril and hydrochlorothiazide have been discontinued. She has been started on sacubitril/valsartan (Entresto) 24/26 mg PO BID, furosemide (Lasix) 20 mg PO once daily (as need), and amlodipine 5 mg PO once daily. You are seeing her today to determine the best course of action in treating her diabetes based on these recent changes.

7. What changes to her diabetes medications do you recommend if any? Please provide rationale. If you start any new medications, include specific medication(s) to start, how to transition, dose, frequency and route. Be specific with your recommendations (4 points).

8. How would you monitor this/these medication(s) (particularly focusing on response to therapy, progression towards her goals, and the potential for adverse effects)? Be specific on what you would monitor, how you would monitor it, and the frequency of monitoring? What information would you tell MT about these changes(s) in her diabetes medication regimen including how to use/take any additional/new medications added? (4 points)

9. Within a few months of starting the regimen above, MT develops significant side effects and must discontinue this therapy. She has exhausted ALL options for ORAL medications (either not effective or are contraindicated due to comorbidities or intolerance) and you have started her on insulin glargine 10 units subcutaneously once daily. She has been compliant with home glucose monitoring and her numbers are listed below. You would like to titrate her regimen to meet glucose goals. You intend on initiating basal/bolus insulin therapy (be specific to the type, dose and frequency of the insulin(s) you choose). Her current weight is 76 kg. (Note that you would need to use just insulin therapy in MT to treat her diabetes) (3 points)

Here are her current capillary glucose readings over the past 3 days*:

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NURS 602: Pharmacologic Applications Essay Assignment Paper

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