UCLA Medication List Worksheet Dissertation

UCLA Medication List Worksheet Dissertation

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UCLA Medication List Worksheet Dissertation

 

I’m working on a science case study and need an explanation and answer to help me learn.

Case Study

Chief Complaint:

“swelling of tongue and difficulty breathing and swallowing”

History of Present Illness:

77 y o woman in NAD with a h/o CAD, DM2, asthma and HTN on altace for 8 years awoke from sleep around 2:30 am this morning of a sore throat and swelling of tongue. She came immediately to the ED b/c she was having difficulty swallowing and some trouble breathing due to obstruction caused by the swelling. She has never had a similar reaction ever before and she did not have any associated SOB, chest pain, itching, or nausea. She has not noticed any rashes, and has been afebrile. She says that she feels like it is swollen down in her esophagus as well. In the ED she was given 25mg benadryl IV, 125 mg solumedrol IV and pepcid 20 mg IV. This has helped the swelling some but her throat still hurts and it hurts to swallow. Nothing else was able to relieve the pain and nothing make it worse though she has not tried to drink any fluids because of trouble swallowing. She denies any recent travel, recent exposure to unusual plants or animals or other allergens. She has not started any new medications, has not used any new lotions or perfumes and has not eaten any unusual foods. Patient has not taken any of her oral medications today.

Surgical History:

s/p vaginal wall operation for prolapse 2006 s/p Cardiac stent in 1999
s/p hystarectomy in 1970s
s/p kidney stone retrieval 1960s

Medical History:

+CAD w/ Left heart cath in 2005 showing 40% LAD, 50% small D2, 40% RCA and 30% large OM; 2006 TTE showing LVEF 60-65% with diastolic dysfunction, LVH, mild LA dilation
+Hyperlipidemia

+HTN
+DM 2, last A1c 6.7 in 9/2005 +Asthma/COPD
+GERD
+h/o iron deficiency anemia

Social History:

Patient lives in _______ with daughter _____ (919) _______. Patient does all ADLs and IADLs with no/little assistance. She does own finances and drives. Patient has 4 daughters that all live in the area. Patient does not use tobacco, alcohol, illicit drugs.

Family History:

Patient’s Dad died of liver cirrhosis at age 57, mom died of heart attack at age 60. She has 6 siblings who most died of cardiac disease. There is no family history of cancer.

Allergies:

Sulfa drugs – rash
Cipro – rash
Benadryl – causes mild dystonic reaction

Medications:

Theophyline (Uniphyl) 600 mg qhs – bronchodilator by increasing cAMP used for treating asthma

Diltiazem 300 mg qhs – Ca channel blocker used to control hypertension
Simvistatin (Zocor) 20 mg qhs- HMGCo Reductase inhibitor for hypercholesterolemia Ramipril (Altace) 10 mg BID – ACEI for hypertension and diabetes for renal protective

effect
Glipizide 5 mg BID (diabetes) – sulfonylurea for treatment of diabetes
Omecprazole (Prilosec) 20 mg daily (reflux) – PPI for treatment of ulcers Gabapentin (Neurontin) 100 mg qhs – modulates release of neurotransmitters to treat

diabetic neuropathy
Metformin 500 mg qam – biguanide used to treat diabetes
Aspirin 81 mg qam – prophylaxis for MI and TIA
Servant 1puff bid –
Fluticasone (Flovent) 2 puff bid – corticosteroid to treat airways in asthma/copd
xoperex 1.25mg and Ipratropium 2.5 ml nebulized qam – anticholinergic to treat airways

in COPD

Review of Systems:

Constitutional – NAD, has been generally feeling well the last couple of weeks Eyes – no changes in vision, double vision, blurry vision, wears glasses
ENT – No congestion, changes in hearing, does not wear hearing aids Skin/Breast – no rashes

Cardiovascular – No SOB, chest pain, heart palpitations
Pulmonary – hard to get a breath in but not short of breath, no cough
Endocrine – No changes in appetite
Gastro Intestinal – No n/v/d or constipation. Has not eaten because can’t swallow solid

foods.
Genito Urinary – No increased frequency or pain on urination. Some urge incontinence

with history of prolapse.
Musculo Skeletal – no changes in strengths, no joint tenderness or swelling Neurologic – No changes in memory
Psychology – No changes in mood
Heme/Lymph – Denies easy bruising

Physical Examination:

Vitals: Temp 35.9

Pulse 76
O2 98% RA RR 20
BP 159/111

General – NAD, sitting up in bed, well groomed and in nightgown
Eyes – PERRLA, EOM intact
ENT – Large swollen tounge and cheek on left side, tounge was large and obscured the view of the posterior oropharynx
Neck – No noticeable or palpable swelling, redness or rash around throat or on face Lymph Nodes – No lymphadenopathy
Cardiovascular – RRR no m/r/g, no JVD, no carotid bruits
Lungs – Clear to auscltation, no use of acessory muscles, no crackles or wheezes.
Skin – No rashes, skin warm and dry, no erythematous areas
Breast –
Psychiatry –
Abdomen – Normal bowel sounds, abdomen soft and nontender
Genito Urinary – Genital exam not performed since complaints not related.
Rectal – Rectal exam not performed since no symptoms indicated blood loss. Extremeties – No edema, cyanosis or clubbing
Musculo Skeletal – 5/5 strength, normal range of motion, no swollen or erythematous

joints.
Neurological – Alert and oriented x 3, CN 2-12 grossly intact.

Pertinent Diagnostic Tests:

Na 140 K 4.5
Cl 109 Co2 23 BUN 29 Cr 1.0 Ca 9.9 Mg 1.4 Phos 3.6

PTT 26.7

WBC 9.9 Hgb 10.0 Hct 30.3 Plt 373

EKG – no signs of ischemia

Assessment and Plan:

77 yo woman presents with significant angioedema in left side of tongue and inner cheek. Possible causes of angioedema include allergic anaphylaxis reaction, drug induced, allergic contact dermatitis, viral infection, drug induced, or a C1 inhibitor deficiency disorder acquired or hereditary. Laryngeal edema can also be caused by tonsillitis, peritonsilar abscess or pharyngeal foreign body.

It is unlikely that the patient has edema caused by abscess or tonsillitis since she does not have any associated fever or other signs of infection and the sudden onset of her swelling also argues against this. It is not likely a foreign body since ENT did not find anything when they scoped her.

It is unlikely that it is caused by a mast cell mediated etiologigy that increases vascular permeability through mast cell degranulation and release of inflammatory mediators include allergic angioedema, autoimmune mast cell release and direct mast cell release caused by medications such as opiates and radiocontrast media. It is not likely this type of reaction because these etiologies are associated with urticaria and pruritis, which the patient did not have. Also the patient did not have any exposure to a new pet, food, lotion or any other allergen or medication that could cause an allergic type reaction. The patient also does not have any history of autoimmune disease or any reaction similar to this in the past

It is more likely that the etiology is kinin-related where angioedema results from generation of bradykinin and complement-derived mediators that increase vascular permeability since there is no urticaria or pruritis. The most likely cause is the Altace (ACEI) that the patient has been taking caused an increase in bradykinin since it decreases angiotensin 2 which degrades bradykinin. Bradykinin can then interact with vascular receptors increasing vasodilation, vascular permeability, increased cGMP and release of nitric oxide. This reaction occurs in .1-7% of patients treated with an ACEI and it typically involves the mouth, lips, tounge, larynx, pharynx and sublottic tissues. Half of these cases usually occur within a week of starting the ACEI but can occur years later. This is a class specific reaction not a drug specific and ARBs can cause the same reaction even though these drugs don’t effect the kinin metabolism. 50% of patients with angioedema due to an ARB also had an ACEI induced angioedema (Cicardi, M, Zingale, LC, Bergamschini L, Agostoni, A. Angioedema associated with agniotensin-converting enzyme inhibitor use: outcome after switching to a different treatment. Arch Intern Med 2004; 164:910). Deficiency of C1 inhibitor can cause angioedema since levels of complement are reduced and cause increased bradykinin. This can be due to lack of C1 INH or adequate amounts of nonfunctional C1 INH. Other causes of angioedema include aspirin and NSAIDs since inhibition of cox and enzyme pathyway increases formation of pro-inflammatory leukotrienes.

Other possibilities in the differential of causes of swelling include cellulitis, autoimmune conditions including SLE, polymyositis, dermatomyositis and sjorgren’s syndrome. Hypothyroidism can cuase puffiness of face and lips, hyperthyroidism can cause an infiltrative dermopathy, superior vena cava syndrome and tumors can cause venous engorgement and swelling. It is not likely one of these etiologies since the patient is on

an ACEI and the swelling is restricted only to her tongue and throat typical of ACEI angioedema.

Plan:

++Swollen tongue:

– Give patient corticosteroid to decrease inflammation and to protect against relapse after initial improvement. 4 days of Dexamethasone 10 mg IV tid.

– Give patient antihistamine to block inflammation as well. 4 days of Diphenhydramine 25 mg bid.

– ENT consult to rule out abscess or foreign object

– Check C1 and C4 levels that would be decreased if the patient had C1 inhibitory complement deficiency

– TSH level to check for hypo/hyper thyroid

– Hold all oral home meds and keep patient NPO until airway swelling is reduced and patient can swallow easily ++Asthma/COPD

– continue albuterol and ipratropium nebs prn

– resume theophylline when patient can take oral meds ++DM

– Not on oral home meds

– Patient is on corticosteroids that increase blood glucose levels, so put patient on sliding scale normal insulin to adjust for high sugars

– Resume neurontin for neuropathy when oral meds can be taken ++HTN

– Continue patient’s BP control with Diltiazem drip 5mg/hour

– HOLD altace (ACEI) that is most likely the cause of angioedema

– Consider an alternative HTN medication to replace the ACEI. Can’t use a HCTZ because of sulfa allergy. Also has asthma/COPD picture so beta blocker may not work well either. ++CAD s/p PCI in 1999
– Resume simvastatin and aspirin when patient is able to take oral meds ++GERD
– famotidine when oral meds are resumed

 

—-Complete the following for each med listed below: (sources should be used for Mechanism of action Onset of action and Nursing considerations specific to this patient but may use one source for all)

Medications (with APA citations)

Class/

Purpose

Route

Frequency

Dose (& range) If out of range, why?

Mechanism of action Onset of action

Common side effects

Nursing considerations specific to this patient

Medications:

Theophyline (Uniphyl) 600 mg qhs – bronchodilator by increasing cAMP used for treating asthma

Diltiazem 300 mg qhs – Ca channel blocker used to control hypertension

Simvistatin (Zocor) 20 mg qhs- HMGCo Reductase inhibitor for hypercholesterolemia

Ramipril (Altace) 10 mg BID – ACEI for hypertension and diabetes for renal protective effect

Glipizide 5 mg BID (diabetes) – sulfonylurea for treatment of diabetes

Omecprazole (Prilosec) 20 mg daily (reflux) – PPI for treatment of ulcers

Gabapentin (Neurontin) 100 mg qhs – modulates release of neurotransmitters to treat diabetic neuropathy

Metformin 500 mg qam – biguanide used to treat diabetes

Aspirin 81 mg qam – prophylaxis for MI and TIA

Servant 1puff bid –

Fluticasone (Flovent) 2 puff bid – corticosteroid to treat airways in asthma/copd

xoperex 1.25mg and Ipratropium 2.5 ml nebulized qam – anticholinergic to treat airways in COPD

(Allergies of patient: Sulfa drugs – rash Cipro – rash Benadryl – causes mild dystonic reaction)

UCLA Medication List Worksheet Dissertation

RUBRIC QUALITY OF RESPONSE NO RESPONSE POOR / UNSATISFACTORY SATISFACTORY GOOD EXCELLENT Content (worth a maximum of 50% of the total points) Zero points:  Student failed to submit the final paper. 20 points out of 50:  The essay illustrates poor understanding of the relevant material by failing to address or incorrectly addressing the relevant content; failing to identify or inaccurately explaining/defining key concepts/ideas; ignoring or incorrectly explaining key points/claims and the reasoning behind them; and/or incorrectly or inappropriately using terminology; and elements of the response are lacking. 30 points out of 50:  The essay illustrates a rudimentary understanding of the relevant material by mentioning but not full explaining the relevant content; identifying some of the key concepts/ideas though failing to fully or accurately explain many of them; using terminology, though sometimes inaccurately or inappropriately; and/or incorporating some key claims/points but failing to explain the reasoning behind them or doing so inaccurately.  Elements of the required response may also be lacking. 40 points out of 50:  The essay illustrates solid understanding of the relevant material by correctly addressing most of the relevant content; identifying and explaining most of the key concepts/ideas; using correct terminology; explaining the reasoning behind most of the key points/claims; and/or where necessary or useful, substantiating some points with accurate examples.  The answer is complete. 50 points:  The essay illustrates exemplary understanding of the relevant material by thoroughly and correctly addressing the relevant content; identifying and explaining all of the key concepts/ideas; using correct terminology explaining the reasoning behind key points/claims and substantiating, as necessary/useful, points with several accurate and illuminating examples.  No aspects of the required answer are missing. Use of Sources (worth a maximum of 20% of the total points). Zero points:  Student failed to include citations and/or references. Or the student failed to submit a final paper. 5 out 20 points:  Sources are seldom cited to support statements and/or format of citations are not recognizable as APA 6th Edition format. There are major errors in the formation of the references and citations. And/or there is a major reliance on highly questionable. The Student fails to provide an adequate synthesis of research collected for the paper. 10 out 20 points:  References to scholarly sources are occasionally given; many statements seem unsubstantiated.  Frequent errors in APA 6th Edition format, leaving the reader confused about the source of the information. There are significant errors of the formation in the references and citations. And/or there is a significant use of highly questionable sources. 15 out 20 points:  Credible Scholarly sources are used effectively support claims and are, for the most part, clear and fairly represented.  APA 6th Edition is used with only a few minor errors.  There are minor errors in reference and/or citations. And/or there is some use of questionable sources. 20 points:  Credible scholarly sources are used to give compelling evidence to support claims and are clearly and fairly represented.  APA 6th Edition format is used accurately and consistently. The student uses above the maximum required references in the development of the assignment. Grammar (worth maximum of 20% of total points) Zero points:  Student failed to submit the final paper. 5 points out of 20:  The paper does not communicate ideas/points clearly due to inappropriate use of terminology and vague language; thoughts and sentences are disjointed or incomprehensible; organization lacking; and/or numerous grammatical, spelling/punctuation errors  10 points out 20:  The paper is often unclear and difficult to follow due to some inappropriate terminology and/or vague language; ideas may be fragmented, wandering and/or repetitive; poor organization; and/or some grammatical, spelling, punctuation errors 15 points out of 20:  The paper is mostly clear as a result of appropriate use of terminology and minimal vagueness; no tangents and no repetition; fairly good organization; almost perfect grammar, spelling, punctuation, and word usage. 20 points:  The paper is clear, concise, and a pleasure to read as a result of appropriate and precise use of terminology; total coherence of thoughts and presentation and logical organization; and the essay is error free. Structure of the Paper (worth 10% of total points) Zero points:  Student failed to submit the final paper. 3 points out of 10: Student needs to develop better formatting skills. The paper omits significant structural elements required for and APA 6th edition paper. Formatting of the paper has major flaws. The paper does not conform to APA 6th edition requirements whatsoever. 5 points out of 10: Appearance of final paper demonstrates the student’s limited ability to format the paper. There are significant errors in formatting and/or the total omission of major components of an APA 6th edition paper. They can include the omission of the cover page, abstract, and page numbers. Additionally the page has major formatting issues with spacing or paragraph formation. Font size might not conform to size requirements.  The student also significantly writes too large or too short of and paper 7 points out of 10: Research paper presents an above-average use of formatting skills. The paper has slight errors within the paper. This can include small errors or omissions with the cover page, abstract, page number, and headers. There could be also slight formatting issues with the document spacing or the font Additionally the paper might slightly exceed or undershoot the specific number of required written pages for the assignment. 10 points: Student provides a high-caliber, formatted paper. This includes an APA 6th edition cover page, abstract, page number, headers and is double spaced in 12’ Times Roman Font. Additionally, the paper conforms to the specific number of required written pages and neither goes over or under the specified length of the paper.

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