Posted: January 9th, 2015

Pharmacology CASE STUDY

Pharmacology CASE STUDY

Order Description

Patient Medication Profile Assignment
Analyze the following case. Create a plan for the patient. Choose an antimicrobial therapy. Utilize The Sanford Guide to Antimicrobial Therapy to make your antimicrobial selection. Write appropriate orders for the patient and be thorough in your writing. Remember, a pharmacist will be reading this.
DC, a sixty-eight-year-old male, presents to the urgent-care clinic after his community pharmacist refers him. He went to his community pharmacy to get an over-the-counter (OTC) cough and cold preparation. He has been feeling weak, short of breath, and feverish with chills; is coughing up yellowish sputum (which has been increasing in both frequency and amount over the past few days); and has had some chest pain, which he describes as stabbing knife-like pain on his right side.
History of present illness: DC had a cold about two weeks ago that has progressively gotten worse and “moved from his head into his chest.”
Past medical history:
• Hypertension X fifteen years
• Right knee surgery after injury skiing eight years ago—has healed and no residual problems
Social history:
• Retired university professor (Biochemistry)
• Married; three adult children (healthy); two grandchildren
• Nonsmoker
• Drinks 1–2 glasses of red wine per day
Family history:
• Mother died of lymphoma at the of age eighty years.
• Father, aged ninety-two, is alive; he had cardiovascular accident (CVA) three years ago (and suffers from hypertension).
• No family members have upper respiratory tract infections (URTI) at the present time.
Medications prior to admission:
• Hydrochlorothiazide 25 mg po daily
• Metoprolol 50 mg po bid
• Sertraline 50 mg po daily
• ASA 325 mg po daily
• Acetaminophen 500 mg po 2 tabs 1-2 X per week for headaches, aches, and pains
Allergies: Amoxicillin—nausea and diarrhea
Immunizations: None in the past ten years
Physical exam: General: Pleasant man, appearing stated age; breathing is labored and patient appears to be in moderate distress
Vital signs: Temp: 102.5 oF; HR: 80 bpm; BP: 125/78 mmHg; RR: 32 bpm; Wt: 195 lbs; Ht: 6’1″
CNS: Alert & Oriented X 3
Head, eyes, ears, nose, and throat (HEENT): PERLA, tympanic membranes intact, mucus membranes red and wet; throat erythematous, no exudates; mild bruits noted on the neck
Pulmonary: Slight splinting on left side with inhalation; crackles and rales in left lower base; O2 saturation: 88 percent
Cardiovascular: PPP, NSR, S1, S2, no S3 or S4
Labs:
• WBC: 18 X 103 cells/mm3
• Neut: 85 percent
• Bands: 6 percent
• Lymph: 8 percent
• HgB: 12 mg/dL
• HCT: 40 percent
• Na+: 140mEq/L
• K+: 4.5 mEq/L
• Cl-: 100 mEq/L
• HCO3-: 24 mEq/L
• BUN: 11 mg/dL
• SCr: 0.6 mg/dL
• Blood glucose: 138 mg/dL
• ABG: pending
Cultures: Blood culture: pending sputum culture; gram stain: < 10 epithelial cells, culture pending
Radiology: CXR: Left lower lobe (LLL) consolidation
Medical problems:
• Community acquired pneumonia
• Hypertension currently controlled
• Measures BP once every two weeks with home BP monitor—always between 120–140/70–80 mmHg; no need to work up on palliative care for advanced disease (PCAD)
Medications:
• Oxygen 2L via nasal prongs
• Acetaminophen 325 mg 2 tabs po q4H p.r.n; temp: 98 oF (Max 4000 mg per twenty-four hours)
• Hydrochlorothiazide 25 mg po daily
• Metoprolol 50 mg po bid
• Sertraline 50 mg po daily
• ASA 325 mg po daily
Provide references with your explanations.
Submit your answers in a Microsoft Word document (maximum of 4 pages).
Submit your document to the W5: Assignment 2 Dropbox by Week 5, Day 4.
Cite any sources using the APA format on a separate page.
Assignment 2 Grading Criteria Maximum Points
Identified correctly and described the risk factors and symptoms contributing to the case. 15
Created an appropriate, committed plan for the patient. 15
Wrote appropriate orders for the patient. 5
Used correct spelling, grammar, and professional vocabulary. Cited all sources using the APA format. 5
Total: 40

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