Clinical Case Study On Pharmacology

Question

Part A
A1. State the specific treatment indication that will be the focus of this assignment.

[Note: This should only be a single sentence. E.g. “Second line treatment of type 2 diabetes following insufficient control of blood glucose with metformin alone”. Although the case you describe below may potentially include multiple health issues that would need to be addressed in reality, for this assignment you must nominate and focus on only a single specific indication for treatment.]

A2. You will need to demonstrate your ability to make the optimal prescribing decision for treating a specific individual presenting with the nominated indication/issue. Below, concisely summarise the key information (e.g. brief relevant background of presenting situation, current medications, relevant investigations/labs) regarding the specific individual for whom you will develop a pharmacotherapeutic plan.

[Note: Suggested approx. 200 words. Include only the relevant background information that will be important in directing your decisions regarding your prescribing decisions – do not provide a life story. Only summarise background information of the presenting individual - do not describe here any of your analysis of the information or your prescribing/management plan.]

Part B: In this section you must clearly demonstrate your prescribing decision making process – that is, how you would work through the decision to alter to a specific person’s medicines in order to address the specific indication/issue nominated.

B1. State the specific goal(s) of therapy that you wish to achieve for the specific individual with respect to the specific indication/issue nominated. Please include a brief justification of each goal of therapy nominated.

[Notes: The goals of therapy should be sufficiently specific that you (and others) will be able to unambiguously assess subsequently whether the goals have been achieved. The goals of therapy should take into consideration specific circumstances of the individual.]

B2. Describe in depth your prescribing decision making process for deciding upon the medication changes that are optimal for the specific individual in order to address the nominated indication/issue. Your answer should demonstrate your decision making process and form a convincing argument that your eventual decision is the most appropriate option for addressing the indication/issue for the specific individual.

[Notes: The process described should be a logical sequence of steps including identification of the major alternative options and a deep and nuanced consideration of the relative pros and cons of the options with respect to the specific individual. Although non-pharmacological interventions are commonly very important to a therapeutic plan please primarily focus on the pharmacotherapeutic plan (i.e. medicines) in this assignment. Also do not restrict your consideration only to medicines that you will be able to prescribe. Consider all medicines available and choose the medicine that is the best option for the specific individual irrespective of whether you will be able to prescribe it yourself or you will need to refer to another prescriber to do so. This section should describe and discuss your prescribing process and decision – not what someone else has done or would do. ]

B3. Clearly summarise all medication-related changes you will make.

[Notes: This should be a concise list of all the medication-related changes you have finally decided in Part B2 (medicines started or stopped, changes to dose, formulation, route of administration, duration of therapy etc). The changes should be described in sufficient detail that there is no ambiguity regarding what specific changes are to be undertaken.]

References for Part B

Part C: After deciding on the medication-related changes detailed in Part B, you will need to advise and educate the patient with respect to the changes to their medicines. It is assumed that you will provide written information for the patient to read at a later time which will cover a broad range of educational points regarding the medicine changes planned. In person, however, you will prioritise a small number of key specific issues or messages to explain or reinforce – this is the focus of this section (not the long list of written information provided).

What are the TWO most important instructions or warnings that would you prioritise to explain or reinforce when counselling the individual on the medication-related changes you have decided upon? For each specific message nominated, (i) concisely describe the information you would communicate, (ii) provide a short example of the language you would use to communicate the message to the patient, and (iii) clearly explain why it is particularly important that patient particularly understands the message (i.e. why it is prioritised over other information).

[Note: Select only two priority messages/warnings/instructions that you believe are most important to reinforce – do not list a large number of messages. The messages must be specific – for example, telling the person all the potential adverse effects of a medicine is not a single specific message]

References for Part C.

Part D: What is the ONE or TWO most important monitoring plans that you would undertake to follow up on the medication-related changes you have just initiated for this specific individual? Be specific about what you would monitor, how, when and why you would monitor it. Also be clear and specific about how you would use the information gained from the monitoring proposed to alter specific treatment decisions. For each monitoring decision described, clearly explain the rationale.

[Note: There may be many parameters that could be monitored while using the medicine(s). However, in this section you must focus on ONE or TWO that you believe are most important to monitor with respect to the medicine and patient in question – do not list a large number of items to monitor. Describe and explain the monitoring decisions specifically and in depth.]

References for Part D.

Answer

Part A- Case Description
A1: Specific treatment indication of the case study
Second line treatment for type 2 diabetes and dyspnea along with a change in medication to metformin and bronchodilators is prescribed for the concerned patient. The involved patient should be provided with medications that tend to control her high blood sugar level. A specified dose of bronchodilators will help her to combat symptoms of dyspnea and chronic obstructive pulmonary disease. In addition to this, she should also be provided with metformin as a controlled drug for elevated blood glucose level. This line of drug therapies and a change in current medication are the main focus points of this assignment.

A2: Summary of the case scenario
The current clinical case study a 60-year-old woman having a 3-year history of type 2 diabetes. In addition to this, the patient also suffers from a chronic obstructive pulmonary disease (COPD) and dyspnea. Her glycosylated hemoglobin measurement was in normal range, 6.8% and physical test results revealed normal blood pressure (130/70 mm Hg). However, she has a slightly elevated pulse rate, 120. Further, test results revealed an absence of cyanosis and bilateral presence of wheezing. She was provided with albuterol medication in order to control her COPD.

The patient has been facing dyspnea while walking and therefore, it is essential to clear her airways. This medication would also ensure proper and effective control of her COPD. On contrary, she was provided with a course of prednisone that has a common side effect of elevating her blood glucose level. Prednisone anti-inflammatory drug has been among this patient in order to deal with airway inflammation. However, this drug seems to cause hyperglycemia and therefore, this drug could become lethal in case of asthma patients. On the 3rd day of medication, her blood glucose level was found out to be 350 mg/dl (normal 70-140 mg/dl). Therefore it is in this clinical case study, this stage of hyperglycemia needs to be controlled by changing her current medication dose.

Part B- Pharmacotherapeutic plan
B1: Specifying goals of therapy required to address the issue
Diabetes is a clinical condition that addresses high level of blood glucose level within the patient's body. In case of Type 2 diabetes, body could not respond to insulin and becomes highly resistant. Therefore, the liver cells fail to absorb glucose that leads to hyperglycemia. Butcher et al. (2018) commented that uncontrolled diabetes could lead to several complications that could impair the body functioning and affect one's physical well being. Since the concerned patient has a previous 3-year old history of type 2 diabetes; therefore proper care needs to be taken. Moorhead et al. (2018) stated that the patient should not consume steroids as this might elevate her blood glucose level. In this clinical case study, her clinicians have recommended her to take prednisone in order to suppress her immune system. Lam, Zhang & Zhao (2018) opined that suppression of immune system of the patient's body will help her to combat with her COPD by clearing her airways. However, this medication has elevated her blood glucose level. Therefore, metformin needs to be taken at this point of condition.

Figure 1: Recommended medications
(Source: Created by the researcher)

An intake of a considerable amount of biguanides like metformin would be beneficial for the affected patient. This medication would help to reduce glucose level in liver. Furthermore, this drug would also help intestines to absorb glucose thereby making body sensitive to insulin. Lee & Halter (2017) stated that most of the COPD medications show an adverse impact on diabetes affected patients. Therefore, a low dose of these bronchodilators is usually recommended in order to treat the prevalent condition. In this case, the patient could be provided with albuterol, however, ipratropium bromide inhalers could also be prescribed in order to treat her condition. Therefore, metformin-ipratropium drug combination needs to be recommended in order to treat her elevated blood glucose level as well as COPD.

B2: Changes in medication
The patient was initially provided with albuterol along with prednisone in order to treat her COPD. However, she has a history of type 2 diabetes and therefore, this drug combination has elevated her blood glucose level. The clinician has not considered her blood glucose level and should not have prescribed her with steroids. Fried & Carlton (2018) commented that application of steroids in case of diabetic patients seem to aggravate her condition. Therefore, she should not have prescribed with prednisone. She should be provided with metformin as this helps in controlling blood glucose level. This is the first line of treatment however, the doctor has considered that her blood glucose level is in normal range. Therefore, metformin needs to be provided to her in order to treat her prevailing condition. This drug seems to lower the elevated blood glucose level and help in making body cells hypersensitive to insulin. Lam, Zhang & Zhao (2018) stated that in case of type-2 diabetes, the patient's body fails to absorb glucose due to insulin-insensitivity. Thus, metformin is recommended to combat her present elevated blood glucose level.

In addition to metformin, bronchodilators also need to be used in order to clear her air passages. Ipratropium bromide could be preferred as the most effective drug in order to treat COPD. This beta-agonist drug helps to dilate air passages thereby allowing proper intake of air. Fried & Carlton (2018) commented that lungs have anticholinergic receptors and therefore, this drug binds with these receptors thereby facilitating dilation of bronchi. This dilation of bronchi further facilitates proper inhalation and exhalation thereby promoting proper health profile of COPD affected patients. Therefore, it can be said in the clinical case study that a combination of metformin and ipratropium bromide will be effective in treating her condition.

B3: Summary of medication changes
The concerned patient was initially provided with albuterol and prednisone in order to treat her COPD. Furthermore, it has been observed that she even suffered from dyspnea due to her prevalent condition. Therefore, she was provided with steroids in order to minimize her wheezing and dyspnea. Moorhead et al. (2018)) stated that in case of type 2 diabetes patients, it is essential to clinically monitor and check the patient's condition and her blood glucose level. The clinician should not have recommended her with steroid drug as this could adverse her condition. Therefore, it is essential at this point to control her elevated blood glucose level. It was observed that on the 3rd day of consuming prednisone, her blood glucose level was about 350 mg/dl. Therefore, it is required to lower her blood glucose level by recommending a right dose of drug.

Metformin oral dose Initially, metformin alone needs to be taken about 1000 mg/day. This dose of drug would help to minimize or lower the elevated blood glucose level. Butcher et al. (2018) stated that metformin has insulin-sensitizing effect and therefore, it works at a cellular level. They help to suppress glucose production that occurs in liver. Suppression of glucose production in liver cells increases insulin sensitivity within the body. This enhances peripheral uptake of glucose by inducing GLUT4 factor. The action of GLUT 4 causes suppression of fatty acid oxidation thereby facilitating glucose absorption. Metformin treatment increases binding of insulin with glucose thereby controlling the blood glucose level. Therefore, it can be said in this clinical case study that a high dose of metformin needs to be administered among this patient in order to control her high level of glucose.

Insulin therapy : Insulin therapy helps in controlling blood glucose level and therefore, this needs to be administered among the affected patient. Fried & Carlton (2018) stated that in this particular patient. Her blood glucose level is found out to be 350 mg/dl and therefore, she needs insulin therapy. Lam, Zhang & Zhao (2018) opined that in case of any patient with type 2 diabetes, they should be provided with insulin therapy followed by metformin. 2 or more injections of insulin is required in order to treat her condition. However, one of the most common outcomes of regular intake of insulin is hypoglycemia. Furthermore, lipoatrophy and lipohypertrophy are other cutaneous complications that might arise among this patient on insulin therapy. Therefore, it is observed in this clinical case study that the duty of clinicians to administer a proper dose of insulin in order to treat her condition.

Replacing prednisone with Ipratropium bromide: Prednisone seems to elevate blood glucose level and therefore, this need to be discontinued immediately. Butcher et al. (2018) stated that a proper dose of ipratropium bromide needs to be taken in order to prevent any drug-drug interaction. Lam, Zhang & Zhao (2018) recommended that a lower dose of ipratropium bromide helps to control COPD and lower instance of dyspnea without interacting with metformin. Therefore, in this case, she is required to be provided with 250 micrograms of ipratropium bromide drug to control her situation. However, a higher dose of drug could aggravate her condition and impact her physical well being.

Part C- Patient education
Instructions or messages provided to the patient regarding changed medication: It is essential to educate the involved patient regarding the changed medication. This would further help the patient to recover from her condition. Bharucha et al. (2015) commented that a detailed analysis of her changed medication needs to be provided to her in written format. Verbal communication could confuse the patient regarding her medication and this could affect her physical condition, Therefore, it is essential to convey warning or messages in a clear and concise manner. The following are the messages that need to be provided to the patient in order to make her understand regarding the changed and modified medications.

Instruction to the concerned patient regarding the dose timings: It is essential that the patient has detailed information regarding her timings of medications. There are some medications that need to be taken along with foods while other drugs need to be consumed at different timings. Kamdar & Patel (2017) opined that it is essential for the patient to be provided with proper timings regarding their medication. Most of the clinicians prescribe to take insulin 15 minutes before intake of food. This would help in proper absorption of glucose that is essential in case of hyperglycemic patients. This time management is essential and needs to be informed to the patients for effective intake of insulin therapy. Intake of insulin after food intake would have no impact on body and therefore, patient needs to be informed regarding this time management (American Diabetes Association, 2018). Furthermore, proper use of language is also essential for easy accessibility by the patients, the clinicians need to use her own native language so that she could understand the information.

Metformin should not be consumed on an empty stomach as this might impact her health. It is usually recommended to take metformin twice daily along with meal. Tieu et al. (2016) commented that metformin if consumed on empty stomach, could affect the gastrointestinal tract thereby leading to diarrhoea. Similarly, a single dosage of 3 ml of ipratropium bromide vial is recommended 4 times per day with the help of nebulizer. Therefore, it can be said that the concerned patient should be provided with proper and appropriate information regarding drug timings. This would help the patient to receive effective results and prevent drug toxicity.

Patient education regarding the adverse impact of medication: Apart from drug timings, it is also necessary for the patients to gain information regarding the adverse impact or side effects of the prescribed drugs. Ishikawa-Takata & Ohta (2017) stated that it is essential for every patient to understand the efficacy of their recommended drugs. In this case, along with metformin, she could not take any form of steroid drugs. This would result in a drug-drug interaction that could affect her physical well being. Furthermore, the clinician should use such language that she could understand easily. Lee et al. (2016) commented that use of proper and appropriate language is necessary and essential for any patient.

Every patient has right to understand and gain information regarding the importance or significance of the prescribed medication, similarly, in this case, she should be provided with information and knowledge regarding benefits and adverse impacts of any drugs. Furthermore, she should also be provided with information related to the potential side effects of any use of drugs. Metformin should be taken initially at a high dose and consumed along with meal (American Diabetes Association, 2018). This information regarding dose timings and its harmful impact need to be provided to the patient in order to improve her physical well being. She should analyse and understand the potential side effects that might happen due to inappropriate drug timings. Therefore, pros and cons of every medication should be provided with inappropriate language to the involved patient for achieving effective benefits.

Part D- Monitoring plans
Essential monitoring plans that is required during medication-related changes: Proper monitoring of the patient needs to be promoted in case of any altered medication. During altering any prescribed medications, it is necessary for the healthcare practitioner to analyse efficacy rate of those medications. Furthermore, it has also been observed that regular monitoring of medications would allow this clinician to track down any adverse impact on health. In case any medication has an adverse side effect on the health profile of the patient, then it could be changed or the dose could be reduced in order to secure their health. Inzucchi et al. (2015) opined that medications should be administered among patients base on the condition of their patients. Therefore, in case of diabetic patients, severe adverse impact could be observed and therefore, medications should be done depending upon the health. Furthermore, it has also been observed that diabetes may adverse the health condition of COPD patients. They tend to suffer more from wheezing and dyspnea. Therefore, it is observed in this clinical case study that the essential for these clinicians to monitor the efficacy rate of these medications while administering among patients. Some of the monitoring plans and test that need to be performed are summarized as follows-

AC 1 blood test to check blood glucose level : In case of diabetes patients, blood test needs to be performed in order to estimate her serum glucose level. Umegaki (2015) commented that proper estimation of this blood glucose will overall help the clinicians to prescribe effective medications. Farrar (2016) commented that a higher dose of metformin is initially recommended to patients with diabetes. However, blood test results will further guide this clinician to recommend next dose of drugs. Furthermore, diabetic patients are also recommended to take insulin dose and therefore, high dose insulin injections might harm the involved patient and make her more hypoglycemic. In this AC1 test, blood glucose level needs to be monitored. This monitoring is essential in order to prevent further lowering of blood glucose level due to prolonged use of medications. The clinician will carry out AC1 test in order to confirm blood glucose level.

Blood glucose level should be monitored after 3 months of medication. Since the patient was not provided with metformin therapy adverse drug impact might happen. Therefore, it is essential to monitor her blood glucose level after 3 months of consumption. In case, she suffers from side effects then the clinician will guide her to cease this application of drug. The normal blood glucose level is 70-140 mg/dl and this level need to be monitored by the clinician. In case this blood glucose level falls below 70 mg/dl then it will affect the physical condition of the patient (Clinical Diabetes, 2018). Therefore, it can be said that this monitoring of blood glucose level is essential and prerequisite in case of diabetic patients. Their serum glucose level should be kept within the range in order to ensure proper health status of the patient. Therefore, it can be said that regular monitoring of the blood glucose level is essential in case of this patient. A regular check of this blood glucose level would allow the clinician to alter their medication depending upon her blood glucose level. Therefore, it can be said that this monitoring of blood glucose is highly essential and effective to cater effective health profile of this patient.

PFT test in order to monitor COPD: Pulmonary Function Test (PFT) is essential in case of COPD affected patients. Inzucchi et al. (2015) opined that this test help in proper evaluation of the patient's condition. It has been observed that bronchodilation is necessary among these COPD affected patients. Therefore, proper dose of medications like beta-agonists needs to be administered among these patients. Umegaki (2015) commented that pulmonary function test would help in monitoring the lung volume as well as lung capacity. Furthermore, this test will also help the clinician to analyse the rate of flow of air within bronchi of the affected patients. Based on the clinical results, medications are provided to these patients that improve their condition (Clinical Diabetes, 2018). Similarly, in this case of the patient, her lung volume and capacity need to be monitored by the clinician. It has been observed that she suffered from persistent dyspnea and thus, she has been recommended to take ipratropium bromide. This is one of the effective drugs that help in combating her prevalent situation.

This parameter needs to be tested with the help of physical examination and need to be monitored after 4 months of continuing with this modified drug. In case of altered drug use, it is essential for every clinician to mark the efficacy of their drugs. In this case, a changed and modified drug has been administered within the patient and therefore, it is essential to test its efficacy. In case drug has any adverse impact then it could be monitored by questioning the patient (Clinical Diabetes, 2018). She will face some side effects and this need to be monitored by her clinician. Thus, it can be said that this sort of monitoring is beneficial and necessary in case of diabetes patients. Furthermore, this monitoring is also essential for COPD affected patients. Regular and continuous monitoring is essential for every patient to understand the efficiency of drugs. Therefore, it can be said that regular and effective monitoring of this patient is essential in order to ensure proper effectiveness of drugs. In case of drug alteration, the patient's clinical tests and regular surveillance is essential to cater effective health profile. Clinical case study assignments are being prepared by our nursing assignment help experts from top universities which let us to provide you a reliable university assignment help service.

Reference List
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