Sarah Johnson is a 32-year-old pregnant female at 24 weeks gestation.

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SCENARIO 1

Sarah Johnson is a 32-year-old pregnant female at 24 weeks gestation. PMH consists of hypertension x 3 years and acne treated with isotretinoin and spironolactone 50 mg po daily. She denies smoking and alcohol but drinks 3 cups of coffee per day. Lisinopril 10mg daily was discontinued due to pregnancy. She presents for a routine prenatal visit. Labs include Hgb 12.8, HCT 39.9, K 4.7, glucose 78, BUN 12, Cr 0.78. Her blood pressure is 150/95 mmHg, measured twice with a 5-minute interval. What treatment plan would you implement for Sarah? How would you treat her hypertension (include a complete medication order)? How would you monitor drug therapy and what is her goal blood pressure?

SCENARIO 2

Lydia is a 24-year-old single female presenting with vaginal discharge for 1 week. She is sexually active and has had unprotected sex with a new male partner for the last month. Her gonorrhea culture is positive. This patient is allergic to sulfa drugs. What is the first line treatment for this patient? What other organism should you consider covering and why? What medication would you prescribe to cover this organism (include complete medication orders)? How long should Lydia abstain from sexual activity to prevent reinfection? What patient education would you provide?

SCENARIO 3

Edgar is a 6-year-old boy seen in the clinic today. His mother states he woke up this morning with his right eye red and swollen with a crusty yellow discharge. He has been diagnosed with bacterial conjunctivitis of the right eye. The mother asks if this is the same as pink eye? Edgar is allergic to sulfa drugs, amoxicillin and penicillin. His current medications include montelukast 10mg chewable tablet qhs. What treatment plan would you implement for Edgar (include complete medication orders)? What education would you provide to the patients mother regarding his treatment?

SCENARIO 4

JT is a 3-year-old male that was seen 3 days ago for acute otitis media. He weights 15 kg. Utilizing the dosage calculator in Medscape, write a prescription for liquid amoxicillin. If the patient develops a rash and is presumed to have an allergy, what alternative antibiotic would you prescribe to treat his acute otitis media? What education would you provide his mother during this visit?

 

 

Sample Solution

Scenario 1: Sarah Johnson

Treatment Plan:

  • Hypertension Management:

    • Medication: Due to pregnancy, lisinopril is contraindicated. Labetalol is a safe and effective alternative for gestational hypertension.

      • Order: Labetalol 100mg PO BID, titrate to goal BP.

  • Monitoring:

    • Blood Pressure: Monitor BP daily at home and at every prenatal visit.

    • Fetal Monitoring: Ultrasound monitoring for fetal growth and well-being is crucial.

    • Lab Tests: Repeat labs (Hgb, HCT, K, BUN, Cr) as needed to monitor renal function and electrolytes.

  • Goal Blood Pressure: Aim for a systolic blood pressure less than 140mmHg and a diastolic blood pressure less than 90mmHg.

Education:

  • Lifestyle Modifications: Encourage dietary modifications, including low-sodium intake, and regular exercise.

  • Stress Management: Discuss techniques for stress reduction.

  • Caffeine Reduction: Advise her to decrease caffeine intake.

  • Follow-up: Schedule regular follow-up appointments to monitor BP and fetal well-being.

Rationale:

  • Labetalol is preferred in pregnancy due to its beta-blocking and alpha-blocking effects, helping control both systolic and diastolic BP.

  • Frequent monitoring is crucial to ensure adequate BP control and fetal safety.

  • Lifestyle modifications and caffeine reduction can aid in BP management.

Scenario 2: Lydia

First-Line Treatment:

  • Cefixime: Cefixime is a safe and effective treatment for gonorrhea in patients allergic to sulfa drugs.

    • Order: Cefixime 400mg PO single dose.

  • Co-infection Coverage:

    • Chlamydia Trachomatis: Chlamydia is a common co-infection with gonorrhea. It is crucial to cover this organism to prevent complications.

    • Medication: Azithromycin is the preferred treatment for chlamydia.

      • Order: Azithromycin 1g PO single dose.

Abstinence Period:

  • 7 days: Lydia should abstain from sexual activity for 7 days to prevent reinfection and ensure effective treatment.

Patient Education:

  • Symptoms: Explain common symptoms of gonorrhea and chlamydia.

  • Treatment: Discuss the importance of taking all prescribed medications as directed.

  • Partner Notification: Emphasize the importance of partner notification and treatment to prevent further transmission.

  • Safe Sex Practices: Encourage safe sex practices, including consistent condom use.

  • Follow-Up: Schedule a follow-up appointment to ensure treatment effectiveness and discuss any concerns.

Rationale:

  • Cefixime is a safe alternative for patients allergic to sulfa drugs.

  • Azithromycin effectively treats chlamydia, a common co-infection with gonorrhea.

  • A 7-day abstinence period allows for proper treatment and prevents reinfection.

  • Patient education is critical to ensure compliance and prevent further transmission.

Scenario 3: Edgar

Treatment Plan:

  • Ophthalmic Medication: Due to allergies, erythromycin ophthalmic ointment is a safe and effective treatment for bacterial conjunctivitis.

    • Order: Erythromycin ophthalmic ointment 0.5% to the right eye TID x 7 days.

Patient Education:

  • Contagiousness: Explain that bacterial conjunctivitis is highly contagious and emphasize the importance of handwashing.

  • Hygiene: Instruct the mother on proper eye cleaning techniques and the importance of separate towels for Edgar.

  • Avoid Sharing: Advise the mother to avoid sharing towels, washcloths, and eye makeup with Edgar.

  • Medication Application: Demonstrate the correct method of applying ophthalmic ointment.

  • Symptoms: Explain that it’s common to experience redness, itching, and discharge, but that these symptoms should improve with treatment.

  • Follow-up: Schedule a follow-up appointment if symptoms persist or worsen.

Rationale:

  • Erythromycin ophthalmic ointment is safe for patients with penicillin and amoxicillin allergies.

  • Good hygiene practices are essential to prevent further transmission.

  • Proper medication application and follow-up ensure effective treatment.

Scenario 4: JT

Amoxicillin Prescription:

  • Dosage: Using the Medscape dosage calculator for amoxicillin, the recommended dosage for JT (15kg) is 40mg/kg/day divided BID. This translates to 600mg per day, divided into 300mg every 12 hours.

  • Order: Amoxicillin oral suspension 300mg PO BID x 10 days.

  • Instructions: Shake well before each dose.

Alternative Antibiotic:

  • If rash develops: Assuming a presumed allergy, switch to a macrolide antibiotic.

    • Order: Azithromycin 10mg/kg PO once a day for 3 days.

Patient Education:

  • Symptoms: Explain common symptoms of otitis media.

  • Treatment: Instruct the mother on proper medication administration.

  • Pain Relief: Discuss over-the-counter pain relievers such as acetaminophen or ibuprofen (as appropriate) for pain management.

  • Follow-Up: Schedule a follow-up appointment if symptoms persist or worsen.

Rationale:

  • The Medscape dosage calculator provides an accurate and safe dosage based on JT’s weight.

  • Azithromycin is a safe alternative for patients with penicillin allergies.

  • Pain management and follow-up are crucial for effective treatment.

Important Note: These recommendations are for educational purposes only. Always consult with a healthcare professional for specific medical advice.

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