Case Study Week 4

Scenario 1: Asthma Management

JG, a 37-year-old male, presents with asthma symptoms, including frequent albuterol use and nocturnal cough. His current therapy includes salmeterol, albuterol, prednisone, and antihistamines. The frequent use of albuterol and nighttime symptoms classify his asthma as poorly controlled. Salmeterol, a long-acting beta-agonist (LABA), should not be used as monotherapy because it increases the risk of severe exacerbations without an inhaled corticosteroid (ICS): Case Study Week 4.

Updated Treatment Plan

• Discontinue salmeterol.
• Initiate Budesonide/Formoterol (Symbicort) 160/4.5 mcg, 2 inhalations BID. Dispense 1 inhaler (30 days supply), refills: 2.
• Continue Albuterol 90 mcg MDI PRN: 2 puffs every 4-6 hours as needed (Johnson et al., 2022).
• Taper prednisone gradually over 1 week.

Rationale: Adding an ICS (Budesonide) improves asthma control by reducing inflammation. Combining it with LABA (Formoterol) improves symptom management. Prednisone taper minimizes systemic steroid side effects, such as weight gain, hyperglycemia, and immune suppression (Katsaounou et al., 2019).

Patient Education
Teach inhaler techniques, emphasizing daily use of Symbicort and PRN use of albuterol. Monitor peak flow readings, symptom frequency, and oral hygiene (ICS can cause thrush). Consistently avoidance of known asthma triggers, including allergens and smoke exposure. Follow-up in 4 weeks is necessary to assess improvement (Al-Moamary et al., 2021).

References

Al-Moamary, M., Alhaider, S., Alangari, A., Idrees, M., Zeitouni, M., Al Ghobain, M., Alanazi, A., Al-Harbi, A., Yousef, A., Alorainy, H., & Al-Hajjaj, M. (2021). The Saudi Initiative for Asthma – 2021 Update: Guidelines for the diagnosis and management of asthma in adults and children. Annals of Thoracic Medicine, 16(1), 4. https://doi.org/10.4103/atm.atm_697_20

Johnson, D. B., Merrell, B. J., & Bounds, C. G. (2022). Albuterol. PubMed; StatPearls Publishing. https://pubmed.ncbi.nlm.nih.gov/29489143/

Katsaounou, P., Buhl, R., Brusselle, G., Pfister, P., Martínez, R., Wahn, U., & Bousquet, J. (2019). Omalizumab as alternative to chronic use of oral corticosteroids in severe asthma. Respiratory Medicine, 150(47), 51–62. https://doi.org/10.1016/j.rmed.2019.02.003

Scenario 2: Type II Diabetes With CKD

KH, a 48-year-old male, presents with A1C 7.5% and stage 4 CKD (eGFR 28). Metformin, though first-line for T2DM, is inappropriate in severe CKD due to the risk of lactic acidosis. A DPP-4 inhibitor, such as Sitagliptin, is ideal because it is safe and renally dosed.

Updated Treatment Plan

• Initiate Sitagliptin (Januvia) 25 mg PO once daily. Dispense 30 tablets (30 days supply), refills: 2 (Olvera Lopez et al., 2020).
• Continue Lisinopril 10 mg PO daily for hypertension and renal protection (Shubrook et al., 2021).

Rationale: Sitagliptin improves glycemic control without hypoglycemia or worsening kidney function. The goal is to achieve A1C <7% while avoiding complications related to poor renal function (American Diabetes Association Professional Practice Committee, 2021).

Patient Education

Educate on self-monitoring blood glucose, the importance of medication adherence, and a low-protein, low-sodium diet to preserve kidney function. Emphasize recognizing symptoms like fatigue or swelling, which may indicate worsening CKD. Monitor renal function and A1C every 3 months to ensure efficacy (Shubrook et al., 2021).

Monitoring Effectiveness

• Glycemic control: Check A1C every 3 months with a target of <7%, per ADA guidelines.
• Renal function: Assess serum creatinine, eGFR, and potassium levels every 3-6 months to evaluate kidney status and monitor for potential hyperkalemia from Lisinopril.
• Blood pressure: Monitor regularly to ensure it stays below 140/90 mmHg to minimize further kidney damage.

References

American Diabetes Association Professional Practice Committee. (2021). 13. older adults: Standards of medical care in diabetes—2022. Diabetes Care, 45(Supplement_1), S195–S207. https://doi.org/10.2337/dc22-s013

Olvera Lopez, E., Parmar, M., Pendela, V. S., & Terrell, J. M. (2020). Lisinopril. PubMed; StatPearls Publishing. https://pubmed.ncbi.nlm.nih.gov/29489196/

Shubrook, J. H., Neumiller, J. J., & Wright, E. (2021). Management of chronic kidney disease in type 2 diabetes: screening, diagnosis and treatment goals and recommendations. Postgraduate Medicine, 23(47). https://doi.org/10.1080/00325481.2021.2009726

Scenario 3: Early-Onset Alzheimer’s Disease

AT, a 63-year-old female, presents with early-onset Alzheimer’s Disease and low vitamin D (24 ng/mL).

Updated Treatment Plan

• Donepezil (Aricept) 5 mg PO once daily at bedtime. Dispense 30 tablets (30 days supply), refills: 2.
• Vitamin D3 2000 IU PO daily. Dispense 60 capsules (30 days supply) (National Institutes of Health, 2024).

Rationale: Donepezil, a cholinesterase inhibitor, slows cognitive decline in mild-to-moderate Alzheimer’s Disease by increasing acetylcholine availability in the brain. Correcting vitamin D deficiency supports cognitive function, mood stabilization, and bone health (National Institute on Aging, 2023).

Monitoring Effectiveness

• Cognitive function: Monitor for changes in memory, attention, and daily functioning every 3-6 months.
• Side effects of Donepezil: Watch for nausea, diarrhea, or bradycardia.
• Vitamin D levels: Recheck in 8-12 weeks to ensure adequacy.

Patient Education

Explain that Donepezil improves symptoms but does not cure Alzheimer’s. Reinforce medication adherence and encourage mental stimulation activities, regular physical exercise, and social engagement to slow cognitive decline (Wilken et al., 2023).

References

National Institute on Aging. (2023). Alzheimer’s disease fact sheet. National Institute on Aging; National Institutes of Health. https://www.nia.nih.gov/health/alzheimers-and-dementia/alzheimers-disease-fact-sheet

National Institutes of Health. (2024, July 26). Vitamin D. National Institutes of Health. https://ods.od.nih.gov/factsheets/VitaminD-HealthProfessional/

Wilken, B., Zaman, M., & Asai, Y. (2023). Patient education in atopic dermatitis: a scoping review. Allergy, Asthma & Clinical Immunology, 19(1). https://doi.org/10.1186/s13223-023-00844-w

Scenario 4: Gerd Management

HM, a 42-year-old female, presents with GERD, worsened at night, alongside asthma, diabetes, and hypertension. She uses PRN famotidine, which can be discontinued in favor of a proton pump inhibitor (PPI).

Updated Treatment Plan:

• Pantoprazole 40 mg PO once daily, 30 minutes before breakfast. Dispense 30 tablets (30 days supply), refills: 2 (Nguyen et al., 2022).
• Discontinue PRN famotidine.

Rationale: PPIs are first-line for GERD management as they significantly reduce gastric acid production. They are more effective than H2 blockers for healing esophagitis and controlling nighttime symptoms (Ahmed & Clarke, 2023).

Can a Patient Take an H2 Blocker and PPI Together?

H2 blockers (like famotidine) and PPIs (like pantoprazole) are generally not used together routinely. They work via different mechanisms, but combining them can diminish PPI efficacy. In rare cases of refractory GERD or nocturnal acid breakthrough, short-term dual therapy may be appropriate under medical supervision.

Patient Education

Recommend dietary changes: Avoid late-night meals, caffeine, alcohol, spicy, and fatty foods, all of which exacerbate reflux symptoms. Encourage weight loss if applicable and elevate the head of the bed to prevent nocturnal acid reflux. Follow up in 4 weeks to assess symptom control and treatment adherence (Herdiana, 2023).

Monitoring Effectiveness:

• Symptom relief: Assess improvement within 2-4 weeks.
• Side effects: Watch for headache, diarrhea, or nutrient malabsorption (e.g., magnesium, vitamin B12) with prolonged PPI use.

References

Ahmed, A., & Clarke, J. O. (2023). Proton Pump Inhibitors (PPI). PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK557385/

Herdiana, Y. (2023). Functional Food in Relation to Gastroesophageal Reflux Disease (GERD). Nutrients, 15(16), 3583. https://doi.org/10.3390/nu15163583

Nguyen, K., Dersnah, G. D., & Ahlawat, R. (2022, July 11). Famotidine. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK534778/

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To Prepare:

• Review assignment rubric and case studies. Be sure to thoroughly answer ALL
• Explain the problem and discuss how you would address the problem.
• When recommending medications, write out a complete prescription for each medication. What order would you send to a pharmacy? Include drug, dose, route, frequency, special instructions, # dispensed (days supply), refills, etc. Also state if you would continue, discontinue or taper the patient’s current medications.
• Answer questions using your required learning resources, clinical practice guidelines, Medscape and JNC 8.
• Include at least three references to support each scenario and cite them in APA format. Please include in-text citations. You do not need an introduction or conclusion paragraph.

Cases (answer all four)

• SCENARIO 1
  • JG is a 37-year-old male presenting with wheezing and shortness of breath. During his visit today, he reports having to use his albuterol 3 days per week over the past month. He reports being awakened by a cough six nights during the last month. His current medications include: salmeterol 50 mcg inhaler BID, albuterol MDI two puffs q4-6 hr PRN shortness of breath, prednisone 20mg qam, loratadine 10 mg daily, diphenhydramine 50 mg qhs prn. How would you step up asthma therapy for this patient (include complete medication order)?
    What medication changes would you make? What drug classification is salmeterol? Can it be used as monotherapy? What patient teaching and monitoring would you provide regarding the updated drug therapy plan?
• SCENARIO 2
  • KH is a 48-year-old male diagnosed with type II diabetes 1 year ago. He has controlled his blood glucose through dietary changes. He has hypertension and is currently on lisinopril 10 mg po daily. He has no known allergies.
    His lab work today includes: fasting BG is 175 mg/dL; HgA1C = 7.5%. Basic Metabolic Profile (BMP) is normal except for Cr 1.8 and eGRF 28. What treatment plan would you implement for KH (include complete medication order)? What education would you provide regarding his treatment plan? How would you monitor the effectiveness of this plan? What is the goal A1C?
    

    Case Study Week 4

• SCENARIO 3
  • AT is a 63-year-old female that presents to the clinic today with early-onset Alzheimer’s Disease. What would you prescribe? Consider her labs and provide an updated drug therapy plan. Include complete medication orders. How would you monitor drug therapy?
    Labs: TSH 3.9 mU/L, vitamin D 24 ng/mL, B12 450 pg/mL, Hb 12.5 g/dL, blood glucose = 100 mg/dL, HgA1C = 5.4% Medications include: insulin glargine 20 units once daily qhs, insulin lispro 6 units before each meal (adjusting based on carbohydrate intake)
• SCENARIO 4
  • HM is a 42 year-year-old female seeking evaluation for feelings of fullness, bloating and acid reflux with symptoms worse at night. HM eats fast food once a day and consumes 2 cups of coffee a day. She drinks alcohol socially on weekends. PMH includes asthma, diabetes and hypertension.
    Her blood pressure today is 142/85. Current medications include prn famotidine, prn albuterol, Pulmicort Flexhaler 90 mcg 2 inhalations twice daily, cetirizine 10 mg daily, bisoprolol 5 mg po daily and metformin 1000 mg po daily with food. How would you improve her drug therapy plan? What changes would you make (include complete medication orders)?
    What information would you provide to the patient at her visit? Can a patient take a H2 blocker and PPI at the same time?