Clinical Decision-Making and Prescription Management- Guideline-Based Approaches to Patient Scenarios

Clinical Decision-Making and Prescription Management- Guideline-Based Approaches to Patient Scenarios

Case 1

The case presented in the first scenario is about a 35-year-old Mary newly diagnosed with hypothyroidism along with comorbid iron deficiency anemia. Her recent lab results reveal elevated levels of thyroid-stimulating hormone and low levels of ferritin. These findings are suggestive of iron deficiency anemia and hypothyroidism. Her newly diagnosed condition, hypothyroidism, is an endocrine disorder that causes under-secretion of the thyroid hormones mainly thyroxine and triiodothyronine.  Hypothyroidism has a high preference in women and old people but is not limited to the two (Zamwar & Muneshwar, 2023).

To address Mary’s health condition, it is advisable to consider her preexisting health issues and do a comprehensive drug history. This is vital in preventing adverse effects of drug interactions. For instance, in this case, the appropriate drug to prescribe for hypothyroidism is oral levothyroxine 1.6mcg/kg/day (Eghtedari & Correa, 2022). Due to her existing iron deficiency condition and current medication to correct the anemia, close monitoring of the patient is paramount, as well as having baseline data on the interaction of iron, which interferes with the absorption of levothyroxine. These, therefore, require regular assessment of iron levels and subsequent levothyroxine dosage adjustment.

To monitor the response to medication, the level of thyroid-stimulating hormone should be checked after three months to evaluate whether it has dropped to fit within the normal range of 0.4- 5.0mlU/L. To increase the levothyroxine efficacy and achieve a good prognosis in response to the treatment, the patient is asked to take levothyroxine on an empty stomach to optimize its absorption. Secondly, the patient is advised to avoid iron supplements within four hours of levothyroxine. Lastly, the patient should come for follow-up visits for treatment evaluation and risk assessment (Högqvist Tabor et al., 2021).

Case 2

The second case presented about 55-year-old Joe with type II diabetes mellitus and hypertension. His current impression is poor glycemic control, as evidenced by an elevated blood sugar level of 225mg/dl and a decreased level of estimated glomerular filtration of 28, which indicates renal problems.

From the above impression, it is of great essence to prioritize glycemic control as Joe’s first intervention. Type II diabetes mellitus is caused by insufficient insulin secretion or resistance to its action. During the hospital stay, the patient’s glycemic status may be stabilized with soluble insulin. After achieving the normal ranges of blood glucose, the patient should be discharged on metformin where the dose is adjusted in line with the EGFR (Goyal et al., 2023). The impaired renal status of the patient justifies the choice of metformin for glucose control due to its renal safety (Goyal et al., 2023).

For Joe, it is important to stabilize his blood sugars and bring them within normal ranges. Due to his alarming EGFR, it is also important to monitor his fluid input and output. During his hospital stay, I would recommend soluble insulin of six international units (6iu) three times daily, 1000mls of lingers lactate, and 20 mg of glibenclamide once daily (Corsino et al., 2020).

Along with the glycemic control, renal protection is key in this scenario. Due to this reason, a second-line agent such as glibenclamide may be prescribed to solve the renal protection issue. To establish the patient prognosis, it is important to continue monitoring the EGFR and blood pressure and do HbA1c regularly to monitor glycemic control. Lastly, proper patient education about the need to maintain a healthy weight, diet modification, physical exercise, and medication adherence is provided. During the teaching, emphasize the need to do regular follow-ups and blood pressure monitoring as well as blood sugar monitoring (Khardori, 2023b).

Case 3

In this case scenario, Jose is a 55-year-old with a history of diabetes mellitus type II. He presents with poorly managed blood sugar, evidenced by 325mg/dl and HgA1C of 10.6%, which is higher than normal. His current treatment is ideal and does not correspond to his current situation of poor glycemic control. Further patient assessment is necessitated in this scenario; his current presentation is suggestive of non-compliance to medication; other factors linked to his condition may be unhealthy behavior such as alcoholism, lack of exercise, and non-compliance to the diet guidelines (Khardori, 2023a). In addition, the presence of an infection may compromise the anti-hyperglycemic action. This, therefore, warrants more investigations, which may warrant the prescription of antibiotics to treat possible infections (Zhou & Lansang, 2021). Due to his allergic status, other treatments apart from sulfonylureas and sulfonamides should be considered (Alves et al., 2012).

Therefore, the immediate medical order for this patient would be Lantus insulin 10iu od nocturnal for three days, 500 mg metronidazole iv for five days, three times daily. The two medicines aim to stabilize the glycemic status and clear the possible infection respectively. After the fifth day, administer metformin 500 mg twice daily along with glibenclamide 20mg once daily. Monitor the patient’s fasting blood sugar (Corsino et al., 2020).

Lastly, comprehensive patient education regarding insulin therapy, lifestyle modification, emergency response, and the importance of adherence is given to the patient. Further, in this case, it is important to emphasize regular blood glucose monitoring, increased exercise, and follow-up clinics for monitoring and evaluation.

Case 4

In Jenny’s case, she presents with persistent heartburn and nocturnal symptoms that indicate GERD despite OTC treatment. To manage her GERD symptoms, both pharmacological and non-pharmacological therapies, such as dietary modification, are to be used. The best pharmacological management for the condition is a class of drugs called the proton pump inhibitors like pantoprazole 40mg daily (Mayo Clinic, 2023). To monitor her response, scheduling a regular follow-up to assess the symptoms and check for any adverse effects will be necessitated.

In addition, patient education is important for Jenny since it will help improve symptoms and avoid complications. To include in the patient education are dietary changes, avoiding sleeping immediately after eating, and elevating the head when sleeping. If the woman is on hormone replacement therapy, it is advisable to inform them about the relation of this to their condition (Mohammad Akram Randhawa et al., 2023b). Teaching the patient healthy weight control to avoid obesity, which is a predisposing factor for GERD is also important. Also, as supported by (Mukhtar et al., 2022) emphasizing treatment adherence along with reporting any changes in her symptoms

References

Alves, C., Casqueiro, J., & Casqueiro, J. (2012). Infections in patients with diabetes mellitus: A review of pathogenesis. Indian Journal of Endocrinology and Metabolism, 16(7), 27. https://doi.org/10.4103/2230-8210.94253

Eghtedari, B., & Correa, R. (2022). Levothyroxine. National Library of Medicine; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK539808/

Goyal, R., Jialal, I., & Singhal, M. (2023, June 23). Diabetes mellitus type 2. National Center for Biotechnology Information; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK513253/

Högqvist Tabor, V., Högqvist Tabor, M., Keestra, S., Parrot, J.-E., & Alvergne, A. (2021). Improving the Quality of Life of Patients with an Underactive Thyroid Through mHealth: A Patient-Centered Approach. Women’s Health Reports, 2(1), 182–194. https://doi.org/10.1089/whr.2021.0010

Khardori, R. (2023a). Type 2 Diabetes Mellitus Treatment & Management: Approach Considerations, Pharmacologic Therapy, Management of Glycemia. EMedicine. https://emedicine.medscape.com/article/117853-treatment?form=fpf

Khardori, R. (2023b). Type 2 Diabetes Mellitus: Practice Essentials, Background, Pathophysiology. EMedicine. https://emedicine.medscape.com/article/117853-overview?form=fpf

Mayo Clinic. (2023). Gastroesophageal reflux disease (GERD) – Diagnosis and treatment – Mayo Clinic. Mayoclinic.org. https://www.mayoclinic.org/diseases-conditions/gerd/diagnosis-treatment/drc-20361959

Mukhtar, M., Alzubaidee, M. J., Dwarampudi, R. S., Mathew, S., Bichenapally, S., Khachatryan, V., Muazzam, A., Hamal, C., Velugoti, L. S. D. R., Tabowei, G., Gaddipati, G. N., & Khan, S. (2022). Role of Non-pharmacological Interventions and Weight Loss in the Management of Gastroesophageal Reflux Disease in Obese Individuals: A Systematic Review. Cureus, 14(8). https://doi.org/10.7759/cureus.28637

Zamwar, U. M., & Muneshwar, K. N. (2023). Epidemiology, Types, Causes, Clinical Presentation, Diagnosis, and Treatment of Hypothyroidism. Cureus, 15(9), e46241. https://doi.org/10.7759/cureus.46241

Corsino, L., Dhatariya, K., & Umpierrez, G. (2020, October). Management of Diabetes and Hyperglycemia in Hospitalized Patients. Nih.gov; MDText.com, Inc. https://www.ncbi.nlm.nih.gov/books/NBK279093/

Zhou, K., & Lansang, M. C. (2021). Diabetes Mellitus and Infections (K. R. Feingold, B. Anawalt, A. Boyce, G. Chrousos, W. W. de Herder, K. Dhatariya, K. Dungan, A. Grossman, J. M. Hershman, J. Hofland, S. Kalra, G. Kaltsas, C. Koch, P. Kopp, M. Korbonits, C. S. Kovacs, W. Kuohung, B. Laferrère, E. A. McGee, & R. McLachlan, Eds.). PubMed; MDText.com, Inc. https://www.ncbi.nlm.nih.gov/books/NBK569326/

Mohammad Akram Randhawa, Sadia Azam Khan, None Aqsa Naseer, & Muhammad Tariq Baqai. (2023b). Non-pharmacological approach for the management of gastroesophageal reflux disease. Pakistan Journal of Medical Sciences, 40(3). https://doi.org/10.12669/

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Directions: For each of the scenarios below, answer the questions below using clinical practice guidelines where applicable. Explain the problem and explain how you would address the problem. If prescribing a new drug, write out a complete medication order just as you would if you were completing a prescription. Use at least 3 sources for each scenario and cite sources using APA format.

Clinical Decision-Making and Prescription Management- Guideline-Based Approaches to Patient Scenarios

Mary is a 35-year-old woman who has been diagnosed with hypothyroidism. Her labs today show a TSH of 20, MCV 78, MCHD 26, Ferritin 9, and IBC 418. She has a history of iron deficiency anemia for 2 months. Current medications include Kelp tablets daily, ibuprofen 400 mg daily as needed, and ethinyl estradiol/norgestrel one tablet daily. What medication would you start this patient on for her hypothyroidism? How would you monitor this patient’s response to the medication? What education would you provide regarding her medications and their interactions?

Joe is a 48-year-old male diagnosed with Type II Diabetes Mellitus a year ago. He has controlled his blood glucose through dietary changes. He has hypertension and is currently on Lisinopril 20 mg PO daily. He has no known allergies. His lab work includes these results: fasting BG is 225 mg/dL; HgA1C = 7.5%. The Basic Metabolic Profile (BMP) is normal except for a Cr of 2.0 and eGRF of 28. What treatment plan would you implement for Joe? What medications would you prescribe and how would you monitor them? What education would you provide regarding his treatment plan?

Jose is a 55-year-old truck driver being evaluated for his commercial driver’s license. He has a known history of diabetes mellitus type II. Current medications include Metformin 1000 mg Bid, and Glipizide 20 mg PO daily. Diltiazem 120 mg po BID. He is allergic to sulfa. Lab results show a fasting blood glucose of 325 mg/dL, HgA1C = 10.6%. The basic metabolic Profile is normal. What treatment plan would you implement for Jose? What medications would you prescribe and how would you monitor them? What education would you provide regarding his treatment plan?

Jenny is a 63-year-old woman with complaints of heartburn 4 to 5 times a week over the past 3 months. Her symptoms are worse at night after going to bed. Her heartburn is worse, and she coughs a lot at night. She has tried OTC Prevacid 24 hours once daily for the past 2 weeks. This has helped the symptoms some, but she is still bothered by them. Current medications include Diltiazem CD 120 mg PO once daily, Hydrochlorothiazide 25 mg PO once daily, Metformin 500 mg PO twice daily, Aspirin 81 mg PO daily, Fluticasone/salmeterol DPI 100 mcg/50 mcg one inhalation twice daily. Your working diagnosis for this patient is GERD. What treatment plan would you implement for Jenny? What medications would you prescribe and how would you monitor them? What education would you provide regarding her treatment plan?