Case Study 1 Special Populations
I. Women as Patients
History
In general, women live longer than men. Consider the following factors and identify the potential impact on the pharmacological regimen for an 85-year-old, widowed, Social Security-dependent female with arthritis in her hands and impaired eyesight due to cataracts. She needs to walk with cane due to chronic bursitis in her left hip. She lives in a two story home, but has moved into a first floor “den” as her sleeping room to avoid climbing the stairs. She no longer drives but is adept at catching the bus, which stops a half block from her house. She has been active in her church, but only attends about two Sundays a month, avoiding the coldest and rainiest weather because the bus schedule is not always reliable on the weekends. She takes the bus to the grocery store, buying only the essentials she absolutely needs due to the bus ride. She has no living children, but has a niece who lives in town and calls her from time to time. The niece has three active children who come with her when she visits once a month.
1. What social determinants of health are in play here and what can you help to plan/coordinate as her nurse practitioner (NP)? List 6 determinants of health.
2. How can the NP address poverty/decreased income?
II. Men as Patients
Complaint Inability to urinate with associated severe lower abdominal pain for 36 hours
History
Mr. Smith is a 51-year-old white male who presents with lower abdominal pain and inability to urinate. He is also complaining of anorexia, nausea, and vomiting over the past 3 days. He has no fever, chills, or night sweats. About 9 months ago, he noticed some decrease in his force of stream. This has progressed, and he currently has daytime frequency of four to five times and nocturia of four to five times. He reports postvoid dribbling. He has no history of urinary tract infections. He is otherwise healthy. Assessment Upon physical examination, he is afebrile, with heart rate 112, respiratory rate 22, and blood pressure 142/94. He has a markedly tender, tense, and distended lower abdomen. Rectal examination reveals a large, smooth, nontender prostate, measuring 4 cm in width. Laboratory results are as follows: serum creatinine 3.2 mg/dL (normal is 0.7 to 1.3), potassium 5.9 mEq/dL (normal is 3.3 to 5.1), and blood urea nitrogen 32 mg/dL (normal is 6 to 19). He is diagnosed with acute renal failure secondary to outflow obstruction.
1. What would be the plan of care for a male with outflow obstruction due to enlarged prostate?
III. Pediatric Patients
Complaint “Can I take antibiotics while breastfeeding?”
History
A 25-year-old female who is breastfeeding a 4-week-old infant has developed mastitis and is asking if the antibiotic she was prescribed is safe for her infant who is fully breastfed. She has been prescribed amoxicillin/clavulanate (Augmentin) to take for 10 days. Assessment Examination was deferred. The infant is nursing every 2 to 3 hours and gaining weight well.
1. How would you educate this lactating patient regarding antibiotic use?
2. What medications are absolutely contraindicated in breastfed infants?
IV. Transgendered Clients
History
A 25-year-old birth-gender male presents to their primary care provider stating they would like to transition to transfeminine. The patient has been dressing as a female for over a year, seeing a therapist, and has a strong support group of transgender friends. The patient is requesting estrogen therapy to feminize their features.
1. What medications can be prescribed to this patient?
2. What adverse effects could the patient receiving gender-affirming hormone therapy receive?
V. Geriatric Patients
History
The graduate students in pharmacology class are trying to help a fellow student with a question that came up in clinic. Her patient is a 75-year-old woman who has been a member of the practice for over 20 years. She takes great interest in her medication plan. She is now questioning things as they currently stand and over the past few years because she is getting more side effects (such as being sleepy during the day) and her doses have had to be changed after several long years of consistent dosing for her Digoxin. During her time with the clinic she has gained 45 pounds over the years, most in the last 5. She has become very dependent upon using Prilosec for her persistent heartburn in the past 3 years. She no longer exercises at the YMCA as she used to because of transportation issues. She readily admits she has “gone to a flabby resemblance of her prior self” in a short period of time. Your peer’s preceptor wants her to differentiate between the impacts of normal aging and any pathophysiological changes linked with specific disease processes that older patients frequently have. There are severe common changes most aging patients have that impact the use of medications and require considerations when adjusting medications. She has reviewed several pharmacokinetic and pharmacodynamic principles and want you to validate her thinking.
1. She believes her patient’s percentage of fat to lean body mass change with lack of exercise and general increased fat stores are a key to the answer. Do you agree? Provide a rational for your response.
2. Your classmate also knows that there are alterations in the CYP450 cytochrome system in aging. What can you offer to help her answer the preceptor’s request?
3. You bring to your classmate’s attention there is also a percentage of water to fat and lean body mass with an overall decreased water percentage to take into consideration. What insights might she have offered?
4. You do know the evidence is uncertain about the pharmacokinetic impact of long term gastric acid altering medications like Prilosec. You do remember there is also something about “getting older” and stomach acid. What is the possible relationship to changes in medications your patient is having?
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