{"id":1289,"date":"2023-11-24T15:35:41","date_gmt":"2023-11-24T15:35:41","guid":{"rendered":"https:\/\/kidneydiseaseclinic.net\/blog\/?p=1289"},"modified":"2023-11-24T15:37:41","modified_gmt":"2023-11-24T15:37:41","slug":"case-study-for-clinical-pharmacists","status":"publish","type":"post","link":"https:\/\/kidneydiseaseclinic.net\/blog\/case-study-for-clinical-pharmacists\/","title":{"rendered":"case study for clinical pharmacists"},"content":{"rendered":"\n

Chief Complaint<\/p>\n\n\n\n

Not available.<\/p>\n\n\n\n

HPI<\/p>\n\n\n\n

Martin James is a 73-year-old man who originally presented to the hospital with symptoms of heart failure that culminated in aortic and mitral valve replacement surgery. His surgery was complicated by a 1-hour hypotensive episode, with BP as low as 70\/50. Three days post operation, purulent drainage was noted from the surgical site, and he was subsequently diagnosed with mediastinitis. At that time, the patient was also found to have a Serratia bacteremia (blood cultures \u00d7 4 positive for Serratia marcescens, sensitive to gentamicin, piperacillin, ceftazidime, and ciprofloxacin; resistance was noted to ampicillin). Therapy was initiated with gentamicin and piperacillin. Thus far, he has completed day 25 of a 6-week course of antibiotics. A gradual increase in his BUN and serum creatinine concentration from baseline and signs of volume overload have been noted over the past 7 days<\/p>\n\n\n\n

PMH<\/p>\n\n\n\n

Type 1 DM<\/p>\n\n\n\n

CKD<\/p>\n\n\n\n

Gout<\/p>\n\n\n\n

Osteoarthritis<\/p>\n\n\n\n

HTN<\/p>\n\n\n\n

Atrial fibrillation<\/p>\n\n\n\n

PSH<\/p>\n\n\n\n

Aortic and mitral valve replacement surgery 28 days ago<\/p>\n\n\n\n

FH<\/p>\n\n\n\n

Father had Type 1 DM<\/p>\n\n\n\n

SH<\/p>\n\n\n\n

Denies smoking or alcohol; retired coal miner (11 years ago)<\/p>\n\n\n\n

Current Meds<\/p>\n\n\n\n

Gentamicin 180 mg IVPB Q 48 h (See Table 48-1 for previous<\/p>\n\n\n\n

dosages)<\/p>\n\n\n\n

Ceftazidime 1 g IVPB Q 12 h \u00d7 25 days<\/p>\n\n\n\n

Enalapril 5 mg po once daily<\/p>\n\n\n\n

Colace 100 mg po BID<\/p>\n\n\n\n

Furosemide 80 mg po Q 12 h \u00d7 2 days<\/p>\n\n\n\n

Digoxin 0.25 mg po once daily<\/p>\n\n\n\n

Allopurinol 100 mg po once daily<\/p>\n\n\n\n

Ranitidine 150 mg po Q 12 h<\/p>\n\n\n\n

Meperidine 25 mg IM Q 4\u20136 h PRN pain (started 3 days ago)<\/p>\n\n\n\n

Ibuprofen 400 mg po Q 4\u20136 h PRN pain (started today for joint pain)<\/p>\n\n\n\n

Sliding scale insulin<\/p>\n\n\n\n

* All<\/p>\n\n\n\n

Bactrim (experienced rash about 10 years ago; subsided when drug discontinued)<\/p>\n\n\n\n

*ROS<\/p>\n\n\n\n

Currently complains of trouble breathing, weakness, general malaise, and pain in joints in hands. No fever or chills.<\/p>\n\n\n\n

* Physical Examination<\/p>\n\n\n\n

Gen<\/p>\n\n\n\n

Confused-appearing man in mild distress<\/p>\n\n\n\n

VS<\/p>\n\n\n\n

BP 152\/90, P 80, RR 26, T 37.7\u00b0C; Current Wt 87 kg (admission Wt 73 kg), Ht 5’10”<\/p>\n\n\n\n

Skin<\/p>\n\n\n\n

Normal skin turgor<\/p>\n\n\n\n

\"\"<\/figure>\n\n\n\n

HEENT<\/p>\n\n\n\n

PERRLA, EOMI, poor dentition<\/p>\n\n\n\n

Neck\/Lymph Nodes<\/p>\n\n\n\n

(+) JVD<\/p>\n\n\n\n

Chest<\/p>\n\n\n\n

Basilar crackles, inspiratory wheezes<\/p>\n\n\n\n

CV<\/p>\n\n\n\n

S1, S2 normal, no S3, irregular rhythm<\/p>\n\n\n\n

Abd<\/p>\n\n\n\n

Soft, nontender, (+) BS, (\u2013) HSM<\/p>\n\n\n\n

Genit\/Rect<\/p>\n\n\n\n

(\u2013) Masses<\/p>\n\n\n\n

MS\/Ext<\/p>\n\n\n\n

2+ Ankle\/sacral edema<\/p>\n\n\n\n

Neuro<\/p>\n\n\n\n

A & O to person and place, but not to time<\/p>\n\n\n\n

\ufffd Labs (Current)<\/p>\n\n\n\n

\"\"<\/figure>\n\n\n\n

* UA<\/p>\n\n\n\n

Color, yellow; character, hazy; glucose (\u2013); ketones (\u2013); SG 1.010; pH 5.0; protein 30 mg\/dL; coarse granular casts 5\u201310\/lpf; WBC 0\u20133\/hpf; RBC 0\u20132\/hpf; no bacteria; nitrite (\u2013); osmolality 325 mOsm; urinary sodium 45 mEq\/L; creatinine 33 mg\/dL, FENA = 3.2%.<\/p>\n\n\n\n

* Repeat Blood Cultures Today<\/p>\n\n\n\n

Negative.<\/p>\n\n\n\n

* Fluid Intake\/Output and Daily Weights<\/p>\n\n\n\n

\"\"<\/figure>\n\n\n\n

*Assessment<\/p>\n\n\n\n

Acute kidney injury with extracellular fluid expansion<\/p>\n\n\n\n

QUESTIONS<\/p>\n\n\n\n

Problem Identification<\/p>\n\n\n\n

1.a. Create a list of the patient\u2019s drug therapy problems.<\/p>\n\n\n\n

1.b. What information (signs, symptoms, laboratory values) indicates the presence or severity of the patient\u2019s problem(s)?<\/p>\n\n\n\n

1.c. Based on the patient\u2019s estimated creatinine clearance and clinical presentation, do any of his medications require dosage adjustment? If so, what adjustment would you recommend?<\/p>\n\n\n\n

1.d. What additional laboratory information would assist in the assessment of this patient?<\/p>\n\n\n\n

1.e. When assessing fractional excretion of sodium (FENA), what influence do previous dosages of furosemide have on interpretation of the results?<\/p>\n\n\n\n

1.f. Could any of the patient\u2019s problems have been caused by drug therapy?<\/p>\n\n\n\n

1.g. What risk factors did the patient have for gentamicin-induced acute kidney injury?<\/p>\n\n\n\n

1.h. What therapeutic interventions could have been initiated to decrease the likelihood of developing drug-induced acute kidney injury?<\/p>\n\n\n\n

Desired Outcome<\/p>\n\n\n\n

2. What are the goals of pharmacotherapy in this case?<\/p>\n\n\n\n

Therapeutic Alternatives<\/p>\n\n\n\n

3.a. What nondrug therapies might be useful for this patient?<\/p>\n\n\n\n

3.b. What feasible pharmacotherapeutic alternatives are available for treating acute kidney injury in this patient?<\/p>\n\n\n\n

Optimal Plan<\/p>\n\n\n\n

4. What drugs, dosage forms, doses, schedules, and duration of therapy are best for this patient?<\/p>\n\n\n\n

Outcome Evaluation<\/p>\n\n\n\n

5. What clinical and laboratory parameters are necessary to evaluate therapy for achievement of the desired therapeutic outcomes and to detect or prevent adverse effects?<\/p>\n\n\n\n

Patient Education<\/p>\n\n\n\n

6. What information should be provided to the patient to enhance compliance, ensure successful therapy, and minimize adverse effects?<\/p>\n","protected":false},"excerpt":{"rendered":"

Chief Complaint Not available. HPI Martin James is a 73-year-old man who originally presented to the hospital with symptoms of heart failure that culminated in aortic and mitral valve replacement surgery. His surgery was complicated by a 1-hour hypotensive episode, with BP as low as 70\/50. Three days post operation, purulent drainage was noted from […]<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"closed","ping_status":"","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[1],"tags":[],"class_list":["post-1289","post","type-post","status-publish","format-standard","hentry","category-med"],"_links":{"self":[{"href":"https:\/\/kidneydiseaseclinic.net\/blog\/wp-json\/wp\/v2\/posts\/1289","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/kidneydiseaseclinic.net\/blog\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/kidneydiseaseclinic.net\/blog\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/kidneydiseaseclinic.net\/blog\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/kidneydiseaseclinic.net\/blog\/wp-json\/wp\/v2\/comments?post=1289"}],"version-history":[{"count":3,"href":"https:\/\/kidneydiseaseclinic.net\/blog\/wp-json\/wp\/v2\/posts\/1289\/revisions"}],"predecessor-version":[{"id":1296,"href":"https:\/\/kidneydiseaseclinic.net\/blog\/wp-json\/wp\/v2\/posts\/1289\/revisions\/1296"}],"wp:attachment":[{"href":"https:\/\/kidneydiseaseclinic.net\/blog\/wp-json\/wp\/v2\/media?parent=1289"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/kidneydiseaseclinic.net\/blog\/wp-json\/wp\/v2\/categories?post=1289"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/kidneydiseaseclinic.net\/blog\/wp-json\/wp\/v2\/tags?post=1289"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}