Number 1 Post: AF

  A twelve-year-old who is actively having an asthma attack while playing sports. Some manifestations of an asthma attack are, wheezing coughing, trouble breathing and feeling of tightness in the chest (Seattle Children’s Hospital, 2022). An acute attack would warrant the use of inhaled short acting beta2 agonist via a metered dose inhaler such as albuterol (Courtney et al., 2005). For a child that has recurrent chronic problems, it would be helpful to add on systemic corticosteroid, and an inhaled corticosteroid for maintenance therapy such as Pulmicort.

     A 19-year-old is asking for contraceptives. I will obtain a pregnancy test. Ask if there’s any prior history of pregnancies or birth. I Will ask the patient how active they are and maybe current partner status. I ask about history of birth control use. I will assess if the patient uses tobacco. I will talk about family planning with the patient and the pro’s and cons of each method such as a daily pill taken by mouth versus a monthly shot, or even an intrauterine device (IUD) that can last up to ten years (Plan Parenthood, 2022). If the patient asks for medication that may help with acne, I would look for medications that contain both estrogen and progesterone. Yaz, generic name loryna, is a medication the patient would take daily containing (3 mg drospirenone/0.03 mg EE) PO qDay for 21 days, then 1 tablet PO qDay for 7 days). The patient asks what medications can help with osteoporosis. Fosamax is a common medication that is prescribe for persons that may be predisposition to bone loss. Fosamax can be controversial due to the mechanism of unable to break down the bone matrix and therefore causing greater bone mass but not helping with brittle disease. Fosomax works by removing old bone mass, allowing the bone-forming cells (Osteocytes), time to build new bone (John Hopkin’s center, 2012).

      A patient with acute gout attack would need to decrease or stop alcohol beverages especially any beer and beverages that are sweetened with high fructose corn syrup. Oral corticosteroids/corticosteroids as well as nonsteroidal anti-inflammatory drugs are the first line treatment in acute onset of gout. Colchicine is an anti-gout medication that acts as an antiinflammation medication, and it acts as a tubulin disruption. Colchicine is often used in acute flare ups of gout as well as a maintenance medication. Colchicine comes in the brand name of Colcrys, has a mechanism of action that prevents microtubule assembly and thereby disrupts inflammation (HR et al., 2022).

 

Number 2 post: NB

Q1. What treatment should this patient receive to relieve symptoms during an asthma attack?

Asthma is one of the most common childhood diseases, affecting children of all ages. An accurate assessment of the severity of an asthma exacerbation is important to guide clinical decision-making. An exacerbation of asthma can vary in severity from a mild cough and wheeze to severe breathlessness that can be life-threatening.  Appropriate and on-time treatment of an acute asthma exacerbation is lifesaving. The classification of mild asthma includes breathless speech with little exertion, minimal intercostal retraction, moderate wheezing, and an O2 sat 94%. For the treatment of mild asthma, this patient should be prescribed, Salbutamol (albuterol) MDI every 20 mins max: 2 sets (Leung, 2021).

Q2. If the patient's asthma attacks occur more frequently, what changes in therapy might be appropriate?

An Adjunct bronchodilator, along with salbutamol can be added to the medication regimen. Adjunct bronchodilators play an important role in augmenting its effects in children with moderate-to-critical acute asthma exacerbation. Ipratropium bromide is a short-acting anticholinergic. It is indicated for moderate-to-critical asthma exacerbation. It produces a mild bronchodilator effect by blocking the interaction of acetylcholine with muscarinic receptors on bronchial smooth muscle cells whilst also decreasing mucosal edema and secretion (B.T.S.S.I.G. British Guideline for the management of asthma. 2016)

A 19-year-old college student is asking for contraceptives. 

Q3. What will you assess to determine if this patient is a good candidate for contraceptives, and what will you prescribe? (Include brand and generic name, route, frequency, and dose).

Most patients can safely begin using hormonal contraception at any point in their menstrual cycle. An evidence-based, flexible, patient-centered approach to initiating contraception promotes health and enhances patients' reproductive autonomy. IUDs are long-acting, are reversible, and can be used by women of all ages, including adolescents, and by parous and nulliparous women. The Cu-IUD can be inserted at any time if it is reasonably certain that the woman is not pregnant.

Women with known medical problems or other special conditions might need additional examinations or tests before being determined to be appropriate candidates for a particular method of contraception.

A physical exam to assess medical history and blood pressure measurements should be assessed. These measurements are highly effective at detecting contraindications to hormonal contraception. For this patient I would prescribe, Mirena (levonorgestrel-releasing intrauterine system 52 MG, 20 mcg/24 hour.

What is the mechanism of action of the contraceptive you prescribed and the adverse effects?

Levonorgestrel causes thickening of cervical mucus, which inhibits sperm passage through the uterus and sperm survival; In addition, changes to the tubal fluids can impair both sperm and egg motility. Pregnancy may be prevented through several mechanisms. Other mechanisms of action for contraceptives include inhibition of ovulation, from a negative feedback mechanism on the hypothalamus, leading to reduced secretion of follicle-stimulating hormone (FSH) and luteinizing hormone (LH); altering the endometrium, which may affect implantation.

Q4.  The patient states she heard a pill can help her acne. What would you prescribe and your rationale? (Include brand and generic name, dose, route, and frequency). 

Yaz is indicated for the treatment of moderate acne vulgaris in women at least 14 years of age, who have no known contraindications to oral contraceptive therapy and have achieved menarche. Yaz should be used for the treatment of acne only if the patient desires an oral contraceptive for birth control. During the first cycle of Yaz use, instruct the patient to take one light pink Yaz daily, beginning on Day 1 of her menstrual cycle. (The first day of menstruation is Day 1.) She should take one light pink Yaz daily for 24 consecutive days, followed by one white inert tablet daily on Days 25 through 28. Yaz is prescribed as  24 light pink tablets each containing 3 mg drospirenone (DRSP) and 0.02 mg Ethinylestradiol (EE) as betadex clathrate and 4 white inactive tablets. ( RXlist.com, 2021)

Q5. The patient is concerned because her mother and sister developed fractures in their legs and vertebra after menopause. She wants to know what medication and other advice will prevent osteoporosis. You discuss bisphosphonates. How are they used in the prevention and treatment of osteoporosis?

Osteoporotic fractures are associated with increased risk of disability, nursing home placement, total health care costs, and mortality (AAFP, 2018). Osteoporosis risk increases with age, and its impact will increase as the U.S. population ages.

Oral bisphosphonates significantly reduce clinical fracture risk at four years in women with postmenopausal osteoporosis. First-line treatment to prevent fractures consists of fall prevention, smoking cessation, moderation of alcohol intake, and bisphosphonate therapy.

Oral bisphosphonates included alendronate (Fosamax), 5 or 10 mg per day, or etidronate (Didronel), 400 mg per day.

A 48-year-old man has occasional episodes of gout that are painful and debilitating. He requires drugs to treat the symptoms of acute gout attacks and prevent recurrent attacks.

Q6. How would you treat this patient's acute gouty attack? Please list the trade and generic name and the dose of therapy. What is the mechanism of action of your choice of prescription?

Gout is characterized by painful joint inflammation, most commonly in the first metatarsophalangeal joint, resulting from the precipitation of monosodium urate crystals in a joint space. Risk factors include genetics, age, sex, and diet. These factors may contribute to a high serum uric acid level, which is currently defined as a value of at least 6.8 mg per dL (405 μmol per L).

Colchicine (Colcrys) 1.2 mg initially, then 0.6 mg one hour later, then 0.6 to 1.2 mg PO daily. Colchicine modulates multiple pro- and anti-inflammatory pathways associated with gouty arthritis. Colchicine prevents microtubule assembly and thereby disrupts inflammasome activation, microtubule-based inflammatory cell chemotaxis, generation of leukotrienes and cytokines, and phagocytosis (PubMed, 2014).

To achieve rapid and complete resolution of symptoms, treatment of acute gout should commence within 24 hours of symptom onset. Oral corticosteroids, intravenous corticosteroids, NSAIDs, and colchicine are equally effective in treating acute flares of gout. NSAIDs are the first-line treatment. Indomethacin (Indocin) has historically been the preferred choice; however, there is no evidence it is more effective than any other NSAID. Corticosteroids are an appropriate alternative for patients who cannot tolerate NSAIDs.

The US Preventative Task Force, (USPSTF) recommends exercise or physical therapy and vitamin D supplementation to prevent falls in those that are at increased risk of falls. A routine exercise program that consists of weight-bearing resistance and balance training should be recommended. Aerobic exercise programs that do not incorporate strength and balance training should be avoided because of the association with increased fracture risk.

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