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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? The primary concern is managing her hypertension during pregnancy safely. Given her blood pressure of 150/95 mmHg, treatment is necessary to reduce the risk of complications like preeclampsia. Since she is 24 weeks pregnant, it is important to choose antihypertensive medications that are safe for both her and the baby. I would discontinue spironolactone is contraindicated during pregnancy, especially after the first trimester, due to its anti-androgenic effects and potential for fetal harm (Garovic et al., 2021). I would encourage Sarah to adopt lifestyle changes such as reducing caffeine intake, since she reports drinking 3 cups of coffee per day. Also engaging in regular physical activity, as tolerated and incorporating a balanced diet low in sodium. I would monitor her weight to avoid excessive weight gain during pregnancy (Abalos et al., 2018). Sarah should be encouraged to monitor her blood pressure at home, keeping a log of her readings. Regular follow-up visits should be scheduled to assess blood pressure control, typically every 1-2 weeks. Routine lab tests (such as renal function and electrolytes) should be done every month, and closer monitoring of fetal development may be warranted, including growth scans or non-stress tests if clinically indicated (Garovic et al., 2021). Regular assessment of her weight, and monitoring for signs of preeclampsia (e.g., headache, visual changes, epigastric pain, and swelling). How would you treat her hypertension (include a complete medication order)? Labetalol is considered a first-line agent for treating hypertension in pregnancy due to its safety profile and effectiveness (Bej & Das, 2022). New Medication Order Drug: Labetalol 100 mg Route: Oral Frequency: Twice daily (BID) Special Instructions: Take with food to minimize gastrointestinal side effects. Dispensed: 60 (30-day supply) Refills: 1 refill (for 60 days total coverage) (Bej & Das, 2022)
How would you monitor drug therapy and what is her goal blood pressure? I would monitor her blood pressure with weekly monitoring initially, either at home or in the clinic, aiming for a blood pressure goal of <140/90 mmHg (Abalos et al., 2018). I would monitor electrolytes and renal function with potassium, BUN, and creatinine in 2-4 weeks to ensure there is no worsening renal function, particularly since labetalol can affect these parameters (Garovic et al., 2021). Goal Blood Pressure The goal blood pressure in pregnancy is <140/90 mmHg to reduce the risk of pre-eclampsia and other hypertensive complications without compromising uteroplacental blood flow (Garovic et al., 2021). This treatment approach prioritizes the safety of both mother and baby while ensuring effective management of her blood pressure. By implementing a comprehensive treatment plan and closely monitoring Sarah's condition, the healthcare provider can effectively manage her hypertension and reduce the risk of complications during pregnancy (Abalos et al., 2018). References Abalos, E., Duley, L., Steyn, D. W., & Gialdini, C. (2018). Antihypertensive drug therapy for mild to moderate hypertension during pregnancy. Cochrane Library , 2018 (10). https://doi.org/10.1002/14651858.cd002252.pub Bej, P., & Das, S. (2022). Effect of labetalol for treating patients with pregnancy-induced hypertension: A systematic review. Journal of the Practice of Cardiovascular Sciences, 8(3), 144–151. https://doi.org/10.4103/jpcs.jpcs_69_ Garovic, V. D., Dechend, R., Easterling, T., Karumanchi, S. A., Baird, S. M., Magee, L. A., Rana, S., Vermunt, J. V., & August, P. (2021b). Hypertension in Pregnancy: diagnosis, blood pressure goals, and pharmacotherapy: A scientific statement from the American Heart Association. Hypertension , 79 (2). https://doi.org/10.1161/hyp. 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? First-line treatment for gonorrhea in a patient allergic to sulfa drugs is Ceftriaxone which is a single intramuscular dose of 500 mg ceftriaxone is the preferred treatment for uncomplicated gonorrhea (St Cyr et al., 2020). What other organism should you consider covering and why? Chlamydia trachomatis is often coinfected with gonorrhea, so it's important to treat both infections simultaneously (Springer & Salen, 2023).
Inform her that her sexual partner(s) should also be tested and treated. Explain the potential for reinfection and the need for future testing. Provide information on safe sex practices, including condom use. Educate Lydia about the signs and symptoms of gonorrhea and chlamydia, such as abnormal discharge, pain during urination, or abdominal pain. Encourage Lydia to return for a follow-up visit in 7 days to ensure the infection has cleared. (Springer & Salen, 2023) References Springer, C., & Salen, P. (2023, April 17). Gonorrhea. StatPearls - NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK558903/ Yonke, N., Aragón, M., & Phillips, J. K. (2022). Chlamydial and Gonococcal Infections: Screening, Diagnosis, and Treatment. American family physician , 105 (4), 388–396. St Cyr, S., Barbee, L., Workowski, K. A., Bachmann, L. H., Pham, C., Schlanger, K., Torrone, E., Weinstock, H., Kersh, E. N., & Thorpe, P. (2020). Update to CDC’s Treatment Guidelines for gonococcal Infection, 2020. MMWR Morbidity and Mortality Weekly Report , 69 (50), 1911–1916. https://doi.org/10.15585/mmwr.mm6950a 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)? Given Edgar's allergies, a topical antibiotic would be appropriate. Tobramycin ophthalmic solution is a good choice (Blumenthal et al., 2018). Medication Order Tobramycin ophthalmic solution 0.3%: Dose: 1-2 drops in the affected eye every 4 hours Route: Topical
Frequency: 4 times daily Special instructions: Wash hands before and after applying. Avoid touching the tip of the dropper to the eye. # dispensed: 1 bottle (10 mL) Refills: As needed (Medscape, n.d.) Continue the montelukast can be continued as it is not directly related to the conjunctivitis and is likely prescribed for another condition (Mahoney et al., 2023). What education would you provide to the patient’s mother regarding his treatment? Emphasize the importance of handwashing to prevent the spread of infection. Advise against rubbing or touching the affected eye. Inform the mother that Edgar should not share towels, washcloths, or pillows with others. Ensure that the full course of the medication is completed, even symptoms improve. If symptoms do not improve or worsen, recommend a follow-up visit. Explain that bacterial conjunctivitis is contagious and can spread to other family members. Encourage good hygiene practices for everyone in the household. (Mahoney et al., 2023) By following this treatment plan and providing appropriate education, Edgar's bacterial conjunctivitis should resolve and prevent further spread (Mahoney et al., 2023) References Blumenthal, K. G., Peter, J. G., Trubiano, J. A., & Phillips, E. J. (2018). Antibiotic allergy. The Lancet , 393 (10167), 183–198. https://doi.org/10.1016/s0140-6736(18)32218- Mahoney, M. J., Bekibele, R., Notermann, S. L., Reuter, T. G., & Borman-Shoap, E. C. (2023). Pediatric Conjunctivitis: A review of clinical manifestations, diagnosis, and management. Children , 10 (5), 808. https://doi.org/10.3390/children Tobrex, Tobramycin Ophth (tobramycin ophthalmic) dosing, indications, interactions, adverse effects, and more. (n.d.). https://reference.medscape.com/drug/tobrex-tobramycin- ophthalmic-
Instruct the mother on how to correctly administer the medication, including using the provided dosing device. Emphasize the importance of completing the entire course of antibiotics, even if symptoms improve. Discuss over-the-counter pain relievers, such as acetaminophen, that can be used to alleviate pain and fever. Advise the mother to schedule a follow-up visit if symptoms do not improve or worsen after the prescribed treatment. Discuss strategies to prevent future ear infections, such as avoiding secondhand smoke and ensuring adequate immunizations. If a rash or other allergic reaction occurs, explain the importance of notifying the healthcare provider immediately. (Danishyar & Ashurst, 2023) References Amoxil (amoxicillin) dosing, indications, interactions, adverse effects, and more. (n.d.). https://reference.medscape.com/drug/amoxil-amoxicillin- Danishyar A, Ashurst JV. Acute Otitis Media. [Updated 2023 Apr 15]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470332/ Syrogiannopoulos, G., Goumas, P., Haliotis, F., Lygatsikas, C., Spyropoulos, C., & Beratis, N. (1992). Cefuroxime axetil in the treatment of acute otitis media in children. Journal of Chemotherapy , 4 (4), 221–224. https://doi.org/10.1080/1120009x.1992.
