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Scenario 1 Sandra is a 52-year-old female with past medical history of hypertension and GERD. Current medications include pantoprazole 40 mg po daily 30 minutes before breakfast and HCTZ 50 mg daily. She smokes 1 pack per day and presents with persistent sadness, anxiety and "empty mood." Her smoking habit has increased the past month as she says it "helps calm her nerves." She denies any history of seizures. How would you treat Sandra? For Sandra's treatment, I would address her mental health concerns, her sadness, anxiety, and increased smoking) and her existing medical conditions which are hypertension and GERD. Based on Sandra's symptoms of persistent sadness, anxiety, and her increased smoking as a coping mechanism, it appears she may be experiencing symptoms of major depressive disorder and/or generalized anxiety disorder (Kennedy & Rizvi, 2022). It would be appropriate to consider pharmacotherapy for her mental health symptoms while also considering her current medications and medical history. What medication would you prescribe (include complete medication order)? Given her symptoms and existing medical conditions, hypertension and GERD, I would prescribe an SSRI (Selective Serotonin Reuptake Inhibitor), which is commonly used for both depression and anxiety. Sertraline (Zoloft) is a good choice as it has a favorable side effect profile and is well-tolerated in many patients (Singh, 2023). Also, a nicotine patch for smoking cessation. New Order Prescription for Zoloft (Sertraline) Dose: 50 mg Route: Oral (PO) Frequency: Take one tablet by mouth once daily in the morning. Special Instructions: Take with food. Start with 25 mg daily for the first 7 days to reduce the risk of side effects, then increase to 50 mg daily. Avoid alcohol. Do not abruptly stop taking this medication without consulting your doctor. Dispense: 30 tablets (30 days supply) Refills: 2 refills Indication: Depression, anxiety disorders (Singh, 2023) Nicotine Transdermal System
Dose : 21 mg patch Route : Transdermal (applied to the skin) Frequency : Apply one patch daily to clean, dry, hairless skin in the upper arm, chest, or back. Special Instructions : Leave the patch on for 24 hours, then remove and replace with a new patch. Rotate application sites to avoid skin irritation. Do not smoke while using the patch. If trouble sleeping occurs, remove the patch before bed. Gradually reduce dose as part of a tapering schedule (e.g., after 6 weeks, reduce to 14 mg, then to 7 mg for 2-4 weeks). Dispense : 28 patches (28 days supply) Refills : 1 refill Indication : Smoking cessation. Patient is to continue their pantoprazole 40 mg po daily 30 minutes before breakfast for GERD and their Hydrochlorothiazide 50 mg po daily for hypertension. What education would you provide to the patient? I would explain that sertraline is used to help manage depression and anxiety symptoms. It may take a few weeks to notice improvement in symptoms, and it's important to take the medication consistently. Also I would discuss potential side effects such as gastrointestinal upset, sleep disturbances, or changes in appetite (Kennedy & Rizvi, 2022). I would encourage her to consider smoking cessation as it can worsen anxiety and depressive symptoms. Offer resources such as counseling or nicotine replacement therapy (Benotwitz & Frairman, 2022). Discuss the importance of regular physical activity, healthy eating, and proper sleep hygiene as adjuncts to medication. Stress the importance of follow-up appointments to monitor her response to the medication and make any necessary adjustments. What labs would you order? CBC (Complete Blood Count): To rule out any underlying causes for mood changes. Liver function tests: Since Sertraline is metabolized through the liver, these tests ensure there are no contraindications. Thyroid function tests (TSH): As thyroid dysfunction can present with mood symptoms, checking TSH levels can help rule out other causes. Basic Metabolic Panel (BMP): To check electrolyte levels, especially since she’s on HCTZ, which can affect potassium and kidney function. Lipids panel: To assess cardiovascular risk, especially with her smoking history. Follow-up appointment in 4-6 weeks to reassess mood, anxiety symptoms, and any side effects from medication. (Moylan et al., 2013)
Dose : 300 mg Route : Oral (PO) Frequency : Take one capsule by mouth at bedtime for 3 days, then increase to 1 capsule twice daily for 3 days, then increase to 1 capsule three times daily thereafter. Special Instructions : Take with or without food. Do not suddenly stop the medication without consulting your doctor. Dispense : 90 capsules (30 days supply) Refills : 2 refills Indication : Neuropathic pain, adjunctive therapy for seizures, or other as indicated. (Yasaei et al., 2024) JR can continue metformin 1000 mg po BID, Synjardy XR 5/1000mg po daily, Tresiba 20 units SC daily and rosuvastatin 10 mg po daily. What would you monitor? I would monitor her glycemic control with HbA1c every 3 months. Also, her blood glucose monitoring logs to assess trends and avoid hypoglycemia (Yasaei et al., 2024). Secondly, I would monitor neuropathy symptoms such as regular follow-up to assess the effectiveness of neuropathy pain management and monitor for side effects from medications. Thirdly, monitor for potential side effects of gabapentin, including sedation, dizziness, or gastrointestinal issues. Regular lipid panel to monitor effectiveness and compliance with rosuvastatin therapy (Badillo & Francis, 2014). Lastly, foot care since JR has neuropathy, he should be advised about proper foot care to prevent ulcers and infections. Regular podiatry evaluations are recommended. References Badillo, R., & Francis, D. (2014). Diagnosis and treatment of gastroesophageal reflux disease. World journal of gastrointestinal pharmacology and therapeutics , 5 (3), 105–112. https://doi.org/10.4292/wjgpt.v5.i3. Feldman, E. L., Callaghan, B. C., Pop-Busui, R., Zochodne, D. W., Wright, D. E., Bennett, D. L., Bril, V., Russell, J. W., & Viswanathan, V. (2019). Diabetic neuropathy. Nature reviews. Disease primers , 5 (1), 42. https://doi.org/10.1038/s41572-019-0097- Yasaei R, Katta S, Patel P, et al. Gabapentin. [Updated 2024 Feb 21]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK493228/
Scenario 3 Zolpidem has a half-life of 3 hours. If a patient takes 10 mg at 10 pm, what will the blood level be at 7 am?
- 10 mg at 10 pm
- 5 mg at 1 am (3 hours later)
- 2.5 mg at 4 am (3 hours later)
- 1.25 mg at 7 am (3 hours later) So, at 7 am, the patient would have approximately 1.25 mg of Zolpidem left in their system (Bouchette et al., 2024). Do elderly patients need a smaller dosage of zolpidem? Elderly patients often require a smaller dosage of Zolpidem. This is because the drug is metabolized more slowly in older adults, which can lead to higher blood levels of the drug and increased risk of side effects. The recommended starting dose for elderly patients is 5 mg for immediate-release tablets and 6.25 mg for extended-release tablets (Bouchette et al., 2024). Name 3 antidepressants/antipsychotics you might prescribe for patients with co-existing depression and insomnia (include complete medication orders) and include patient monitoring.
- Mirtazapine (Remeron) : Dose: 15 mg Route: Oral (PO) Frequency: Take one tablet by mouth at bedtime. Special Instructions: Take with or without food. Start with 15 mg orally at bedtime. May cause drowsiness; avoid driving or operating machinery after taking. Start with 15 mg at bedtime, may increase to 30 mg after 1–2 weeks if needed. Do not abruptly discontinue without consulting your doctor. Dispense: 30 tablets (30 days supply) Refills: 2 refills Indication: Depression, insomnia, or appetite stimulation. Monitor for side effects such as weight gain and sedation. Regularly assess depression symptoms and sleep quality. (Jilani et al., 2023)
(Maan et al., 2023) References Bouchette D, Akhondi H, Patel P, et al. Zolpidem. [Updated 2024 Feb 29]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK442008/ Jilani TN, Gibbons JR, Faizy RM, et al. Mirtazapine. [Updated 2023 Aug 28]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK519059/ Maan JS, Ershadi M, Khan I, et al. Quetiapine. [Updated 2023 Aug 28]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK459145/ Shin JJ, Saadabadi A. Trazodone. [Updated 2024 Feb 29]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470560/ Scenario 4 A mother brings her 7-year-old son David into the clinic today stating that he is increasingly getting into trouble at school. He “fidgets and frequently leaves his seat, does not listen to his teacher, talks excessively and interrupts other classmates.” What would you prescribe for David? David's symptoms, as described by his mother, suggest a possible diagnosis of Attention- Deficit/Hyperactivity Disorder (ADHD). In children, the most common treatment for ADHD includes behavioral therapy, medications, or a combination of both (Drechsler et al., 2020). For medication, stimulant medications like methylphenidate or amphetamine-based medications are typically first-line treatments. Non-stimulant options, such as atomoxetine, guanfacine, or clonidine, are alternatives for children who may not tolerate stimulants well or for whom stimulants are not effective. How common is it for a parent and child to both have ADHD? ADHD has a strong genetic component. Research suggests that a child with ADHD is more likely to have a parent with ADHD, and estimates of heritability range from 70% to 80% (Drechsler et al., 2020). This makes it relatively common for both a parent and a child to have the disorder. How are symptoms and treatment of ADHD different between children and adults? Children with ADHD often present with hyperactivity, impulsivity (e.g., interrupting others, fidgeting), and inattention (e.g., trouble following instructions, losing things). These behaviors
tend to be more external and disruptive (Drechsler et al., 2020. For children behavioral therapy is emphasized, especially for young children. Stimulants are the most common medication. Adults with ADHD often have issues with organization, time management, procrastination, emotional regulation, and maintaining focus on long-term tasks. Hyperactivity may be less visible but manifests as inner restlessness. Treatment for adults are medications, particularly stimulants, are also commonly used (Williams et al., 2023). Adults may benefit more from cognitive-behavioral therapy (CBT) to manage time, focus, and emotional regulation. What would you prescribe for David’s 40-year-old mother with ADHD? I would prescribe Ritalin because it can significantly enhance quality of life for adults struggling with ADHD by improving focus, organization, and energy levels, enabling the mother to better manage her responsibilities and reduce stress (Williams et al., 2023). Methylphenidate (Ritalin) 10 mg immediate-release tablets Dose : 10 mg Route : Oral (PO) Frequency : Take one tablet by mouth twice daily (morning and early afternoon). Special Instructions : Take 30 minutes before meals. Avoid taking later in the day to prevent insomnia. Do not abruptly discontinue without consulting your doctor. Dose adjustments may be made every week depending on response. Dispense : 60 tablets (30 days supply) Refills : 0 refills (since methylphenidate is a controlled substance, refills typically require a new prescription). Indication : Attention Deficit Hyperactivity Disorder (ADHD). (Verghese, 2023) References Drechsler, R., Brem, S., Brandeis, D., Grünblatt, E., Berger, G., & Walitza, S. (2020). ADHD: current concepts and treatments in children and adolescents. Neuropediatrics , 51 (05), 315–335. https://doi.org/10.1055/s-0040- Williams, O. C., Prasad, S., McCrary, A., Jordan, E., Sachdeva, V., Deva, S., Kumar, H., Mehta, J., Neupane, P., & Gupta, A. (2023). Adult ADHD: a comprehensive review. Annals of Medicine and Surgery , Publish Ahead of Print. https://doi.org/10.1097/ms9.
