Post your answers to the 6 questions corresponding to this week’s content on primary care medication management. Provide your responses and rationales. Support your rationales with high-level evidence. (See Post Expectations)

A 70-year-old woman is in your office complaining of recently having trouble maintaining her balance after taking diazepam (valium). She occasionally takes diazepam when she feels anxious and has trouble sleeping. She has a 15-year history of taking diazepam.

Q1. Explain the cause of this patient’s difficulty in maintaining her balance?

Q2. Diazepam experiences a significant first-pass effect. What is the first-pass effect, and how can first-pass metabolism be circumvented?

A 75-year-old woman develops symptoms of a cold and buys an over-the-counter cold medication at the grocery store. The medication contains diphenhydramine, acetaminophen, and phenylephrine. She takes the recommended adult dose but soon after taking the medication she becomes very confused and disoriented.

Q3. What is likely causing the signs of confusion?

A 26-year-old woman who has never been pregnant is seeking preconception care as she is planning to pursue pregnancy in a couple of months. Currently, she has no symptoms to report and on review of body systems, there were no concerns. Her past medical history is significant for a history of rheumatic fever as a child. She subsequently underwent valve replacement with a mechanical heart valve. She is followed by a cardiologist who has already evaluated her cardiac function and she has received clearance from her cardiologist to pursue pregnancy. Records from her cardiologist include a recent cardiac echocardiography report that reveals a normal ejection fraction indicating normal cardiac function.

She has no alterations in her daily activities related to her heart. She has no other significant medical or surgical history. She is a non-smoker, drinks occasionally but has stopped as she is attempting to conceive, and does not use any non-prescription drugs.

Current Medications: Her current medications include only prenatal vitamins, which she has begun in anticipation of pregnancy, and warfarin. She has no known drug allergies.

Vital Signs: On examination, her pulse is 80 beats per minute, blood pressure is 115/70 mm Hg, respiratory rate is 18 breaths per minute, and she is afebrile.

Measurements: Weight = 152 pounds, Height = 5′5 ″, BMI= 25.29

Q4. How is warfarin metabolized? Does warfarin cross the placental barrier?

Q5. Explain the hepatic drug metabolism of children 1 year and older. How do they compare with the hepatic drug metabolism of infants and adults?

Q6. Explain protein binding in the neonate.

Case Study TB

Maria is a 42-year-old single mother living in New York City with her three sons. She immigrated to New York from Peru two years ago. About six months after she arrived, she began developing night sweats and unexplained fevers. Most recently, she has developed a persistent, worsening cough. Her illegal status has made her hesitant to seek medical treatment, but a neighbor told her that the local community clinic would see her and would not check her residency status.

Screening at the clinic included a questionnairethat addressed some of the problems she was experiencing. The nurse explained to Maria that she might have TB. The physician treating Maria performed a complete physical exam and discussed her questionnaire responses with her, including her response that in Peru, she lived with her grandfather who she believes may have died from TB.

Physical exam findings showed abnormal lung sounds in Maria’s upper lobes bilaterally. The physician found cervical and axial lymphadenopathy. Maria was asked to leave sputum samples to be tested for mycobacterium tuberculosis. A PPD was placed with instructions for Maria to return in two days to have it read. When Maria returned two days later, the result showed a 10 mm raised, red reactive site. Maria was also screened for HIV at the time of initial exam because it is often found in patients with TB. In this case, she tested negative for HIV. Her sputum culture tested positive for M. tuberculosis.

The physician explained that given the findings on the chest x-ray and the clinical findings on exam, he believed that she had reactivation TB. The physician informed Maria that he planned to start her on a four-drug regimen of isoniazid, rifampin, pyrazinamide, and ethambutol (Myambutol) for two months. The physician then explained that a “continuation phase” would follow, which would consist of isoniazid and a rifamycin (rifampin, rifabutin [Mycobutin], or rifapentine [Priftin]) that is administered daily for four to seven months. He also informed her that he would start her treatment at the hospital, where she would stay for least two days because she was still considered contagious. Following the hospital stay, Maria would need to come to the clinic for observed medication administration and to assure compliance.

Two months passed and Maria continued about her day-to-day life including going to the clinic for her medication. She attempted to work full time and to take care of her three sons. She found that her night sweats had become a nightly occurrence, and her cough had become productive with blood along with intense coughing spells. Maria was compliant with the drug regimen but called the clinic because her symptoms were worsening. Maria was scheduled for a visit the very next day.

The follow up chest x-ray showed no improvement, and it was determined that Maria was exhibiting signs of multidrug-resistant TB. Because multidrug-resistant and extensively drug-resistant tuberculosis requires at least 18 to 24 months of therapy, depending on the patient’s response to treatment, the physician decided to extend her therapy to 18 months, beyond the 4 to 7 month time period he had projected. He also stopped the ethambutol and started moxifloxacin. Thoracic surgery for resection of lung lesions is often considered as adjunctive therapy, and this was discussed with Maria at the time of the exam.

Maria was devastated to learn about her multidrug resistant TB because she needed to work. Fortunately, the clinic was able to fund Maria’s drugs at a discounted rate. Nonetheless, the entire situation has put Maria under stress to the point that it is unclear how she will meet this challenge and adequately handle her health crisis.

Conduct an evidence-based literature search to identify the most recent standards of care/treatment modalities from peer-reviewed articles and professional association guidelines (www.guideline.gov (Links to an external site.) ). These articles and guidelines can be referenced, but not directly copied into the clinical case presentation. Cite a minimum of three resources.

What is the transmission and pathophysiology of TB?

What are the clinical manifestations?

After considering this scenario, what are the primary identified medical concerns for this patient?

What are the primary psychosocial concerns?

What are the implications of the treatment regimen, as far as likelihood of compliance and outcomes? Search the Internet to research rates of patient compliance in treatment of TB, as well as drug resistant TB.

Identify the role of the community clinic in assisting patients, particularly undocumented patients, in covering the cost of TB treatment. What resources exist for TB treatment in community health centers around the United States? Compare the cost for treatment between, subsidized as it would be for a community health center, and unsubsidized.

What are the implications of TB for critical care and advanced practice nurses?