Prescribing Medications for Patient Treatment

SCENARIO : Sarah Johnson – Hypertension in Pregnancy

Problem: Sarah Johnson, a 32-year-old pregnant female at 24 weeks gestation, presents with a history of hypertension, previously treated with Lisinopril, which was discontinued due to pregnancy. Her current blood pressure of 150/95 mmHg indicates uncontrolled hypertension.

Background: Hypertension in pregnancy is a significant risk factor for maternal and fetal complications, including preeclampsia, preterm birth, and fetal growth restriction (Agrawal & Wenger, 2020). ACE inhibitors like Lisinopril are contraindicated in pregnancy due to their teratogenic effects, requiring alternative treatment.

Treatment Goals: The goal is to reduce Sarah’s BP to below 140/90 mmHg, minimizing the risk of complications while maintaining safety for both the mother and fetus (Garovic et al., 2022). Medications that are safe in pregnancy must be selected.

Medication Options: First-line antihypertensive drugs during pregnancy include methyldopa, labetalol, and nifedipine (Conti-Ramsden et al., 2024).

Methyldopa: It acts centrally by inhibiting sympathetic outflow, reducing BP. It is safe in pregnancy but may cause sedation, which can affect patient adherence.

Labetalol: A combined alpha and beta-blocker that reduces BP without significantly affecting uteroplacental blood flow.

Nifedipine (extended-release): A calcium channel blocker that can also be used, especially in cases of severe hypertension.

Given Sarah’s elevated BP, labetalol is preferred for its efficacy and safety profile.

Medication Order:

· Drug: Labetalol 100 mg

· Dose: 100 mg

· Route: Oral

· Frequency: Twice daily (BID)

· Special instructions: Titrate dose upward every 1-2 weeks, as needed, to achieve target BP

· # Dispensed: 30-day supply

· Refills: 1

Monitoring:

· Weekly BP checks to ensure the treatment is effective.

· Monthly blood work to assess kidney function (BUN, creatinine) and electrolytes, particularly potassium, as labetalol may affect renal function.

· Fetal monitoring: Growth ultrasounds should be performed every 4 weeks to assess fetal development, especially if BP control remains challenging.

Patient Education:

· Sarah should be informed about the importance of adhering to the prescribed medication and attending regular prenatal visits.

· Educate her on monitoring for any signs of preeclampsia, such as headaches, visual disturbances, or sudden swelling, which require immediate medical attention.

References

Agrawal, A., & Wenger, N. K. (2020). Hypertension during pregnancy. Current hypertension reports, 22(9), 64.

Conti-Ramsden, F., de Marvao, A., & Chappell, L. C. (2024). Pharmacotherapeutic options for the treatment of hypertension in pregnancy. Expert Opinion on Pharmacotherapy, 25(13), 1739-1758.

Garovic, V. D., Dechend, R., Easterling, T., Karumanchi, S. A., McMurtry Baird, S., Magee, L. A., Rana, S., Vermunt, J. V., & August, P. (2022). Hypertension in pregnancy: diagnosis, blood pressure goals, and pharmacotherapy: a scientific statement from the American Heart Association. Hypertension, 79(2), e21-e41.

SCENARIO 2: Lydia – Gonorrhea and Chlamydia

Problem: Lydia, a 24-year-old female, presents with a 1-week history of vaginal discharge and is diagnosed with gonorrhea. She has a sulfa drug allergy and a history of unprotected sexual activity with a new partner.

Background: Gonorrhea is a sexually transmitted infection (STI) that can lead to problems such as pelvic inflammatory disease (PID), infertility, and chronic pelvic pain if left untreated (Dombrowski, 2021). It often coexists with chlamydia, so treatment should cover both infections.

Treatment for Gonorrhea: According to CDC guidelines, the first-line treatment for gonorrhea is ceftriaxone (Barbee & St. Cyr, 2022). Since Lydia has no contraindications to ceftriaxone (sulfa allergy does not affect its use), this should be administered.

Medication Order:

· Drug: Ceftriaxone 500 mg

· Dose: 500 mg

· Route: Intramuscular (IM) injection

· Frequency: Single dose

· # Dispensed: 1

· Refills: None

Coverage for Chlamydia: As chlamydia often co-occurs with gonorrhea, treatment with doxycycline is recommended. Doxycycline is favored over azithromycin due to its better efficacy in treating rectal chlamydia and minimizing resistance (McAnaney, 2022).

Medication Order:

· Drug: Doxycycline 100 mg

· Dose: 100 mg

· Route: Oral

· Frequency: Twice daily (BID) for 7 days

· # Dispensed: 14 tablets

· Refills: None

Patient Education:

· Lydia should abstain from sexual activity for at least 7 days after completing treatment to prevent reinfection.

· She should ensure her partner receives treatment, as untreated partners can lead to reinfection.

· Education on safe sex practices, such as the consistent use of condoms, is necessary to prevent future STIs.

Follow-Up:

· Lydia should return to the clinic for retesting in 3 months, as reinfection rates for gonorrhea and chlamydia can be high.

· Encourage her to contact the clinic if she experiences persistent symptoms, suggesting possible treatment failure or reinfection.

References

Barbee, L. A., & St. Cyr, S. B. (2022). Management of Neisseria gonorrhoeae in the United States: Summary of evidence from the development of the 2020 gonorrhea treatment recommendations and the 2021 Centers for Disease Control and Prevention sexually transmitted infection treatment guidelines. Clinical Infectious Diseases, 74(Supplement_2), S95-S111.

Dombrowski, J. C. (2021). Chlamydia and gonorrhea. Annals of Internal Medicine, 174(10), ITC145-ITC160.

McAnaney, C. (2022). Doxycycline preferred for the treatment of Chlamydia. American Family Physician, 106(5), 485-485.

SCENARIO 3: Edgar – Bacterial Conjunctivitis

Problem: Edgar, a 6-year-old boy, presents with bacterial conjunctivitis, manifesting as redness, swelling, and yellow discharge in his right eye. He is allergic to sulfa drugs, amoxicillin, and penicillin.

Background: Bacterial conjunctivitis is typically caused by Staphylococcus aureus, Streptococcus pneumoniae, or Haemophilus influenzae (Hu et al., 2021). Treatment with topical antibiotics is effective, with erythromycin ointment being a safe choice given Edgar’s allergies.

Treatment Plan:

· Drug: Erythromycin 0.5% ophthalmic ointment

· Dose: Apply a 1 cm ribbon

· Route: Topical (to the affected eye)

· Frequency: Four times daily (QID) for 7 days

· # Dispensed: 1 tube

· Refills: None

Patient Education:

· Edgar’s mother should be informed that bacterial conjunctivitis, often called “pink eye,” is contagious (Mahoney et al., 2023). Hand hygiene is crucial to prevent the spread to others, especially if Edgar is in school or daycare.

· Use a separate towel for Edgar to prevent transmission within the household.

· Edgar should stay home from school for at least 24 hours after initiating treatment or until symptoms improve significantly.

· Encourage Edgar not to rub his eyes, as this can worsen irritation and increase the spread of infection.

Follow-Up:

If symptoms do not improve within 3 days, Edgar should return to the clinic for further evaluation to rule out resistant organisms or complications like corneal involvement.

Mother’s question: Bacterial conjunctivitis is commonly referred to as “pink eye,” but “pink eye” can also refer to viral or allergic conjunctivitis (Ponsetto & Ponsetto, 2023).

References

Hu, Y.-L., Lee, P.-I., Hsueh, P.-R., Lu, C.-Y., Chang, L.-Y., Huang, L.-M., Chang, T.-H., & Chen, J.-M. (2021). Predominant role of Haemophilus influenzae in the association of conjunctivitis, acute otitis media and acute bacterial paranasal sinusitis in children. Scientific Reports, 11(1), 11.

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.

Ponsetto, J., & Ponsetto, M. (2023). Differentiating acute conjunctivitis presentations in children. J Urgent Care Med, 18(1), 15-20.

SCENARIO 4: JT – Acute Otitis Media

Problem: JT, a 3-year-old male weighing 15 kg, was diagnosed with acute otitis media (AOM). The first-line treatment is amoxicillin, but there is a concern for a potential allergic reaction if a rash develops.

Background: AOM is a common infection in young children caused by Streptococcus pneumoniae, Haemophilus influenzae, or Moraxella catarrhalis (Orders, 2023). The typical treatment is high-dose amoxicillin due to its effectiveness against these organisms.