MTM 1 Fall 2012 TEST 1 Name______

Case 1 Chief Complaint: My Father is sick and confused History and Physical: VJ is a 78 yo widowed white male and retired dry cleaner. He presents to the clinic with his daughter who he lives with. She reports he has become confused over the last 24 hours. She states a cold has been circulating through the house for the past few days and VJ developed a cough that has gradually gotten worse keeping him awake. His cough started about 3 days ago. She noticed that he has had difficulty breathing over the past day or 2 with a more productive cough clear to the color. He hasn’t had much of a temperature over the past day.

Past Medical History: Smoker X 60 years quit 1 year ago. COPD diagnosed 5 years ago. HTN diagnosed 20 years ago Family History: + HTN, Diabetes, and Cancer Medications: Metoprolol 50 mg BID, HCTZ 12.5 mg QD, Aspirin 81mg QD, DuoNebs 2 puffs QID, Albuterol 1 puff qid as needed Allergies: Erythromycin Vital Signs: BP 118/69, Pulse 80, RR 28, Temp Max 99.2, wt 150 lbs, Ht. 5’10, O2 Sat=89%, PCO2=40%, Ph=7.34, Na=142, K=3.6, Cl=99, CO2=35, BUN=17, SCr=1.3, Glu=89, CBC: wbc=9,700 Segs= 71%, Bands=3%, Urinalysis=(-)Nitrites, (-)Leukocyte Esterase,(-) WBC Chest X-Ray= Upper Right Lobe infiltrates, Clear Left lobe, Clear Right Lower Lobe Sputum: Pending

1. a.) Develop an empiric drug regimen VJ to be sent home with as an outpatient. List the most likely organisms. Include a drug, dose, frequency, and duration and monitoring parameters.(5 pts)

1. b) After 3 days of therapy VJ is brought in to the ER, suffering worsening chest pain, dyspenia, and an increased fever. Gram stains show (+) blood cultures for a Gram Negative Rod. He is being admitted to the hospital into a regular floor bed. Develop an alternative drug regimen for VJ to include drug, dose, frequency, and duration and monitoring parameters. (5 pts) Case Study #2 Chief Complaint: “Mr. A has been breathing very fast over the past few hours and has a fever.” AA is a 68 yo male admitted to the hospital from the local nursing home because very rapid breathing, in and out of cognitive states, confusion, and a fever. He has had a productive cough with sputum production and he has complained of pain in his chest as he breathes. Past Medical History: HTN, Type 2 DM, past UTI 4 weeks ago requiring 3 days hospitalization, Patient has an Indwelling foley catheter, Stroke 2 years ago causing right side paralysis and difficulty swallowing. Family History: + Diabetes, HTN, and Asthma Allergies: Penicillin, Zosyn on last admission caused Nausea and Infusion site rash Admission Labs Vital Signs: BP 91/62 Pulse 119 RR 42 bpm Temp 100.7 PO2=60%, PCO2=50%, PH=7.30, WBC=18,000, Segs=88%, Bands 9%, Na=151, K=5.3, BUN=21, SCr=2.1, Ht. 5’11, wt=165 Chest X-Ray (+) for Right Middle and Right Lower Lobe Infiltrates Respiratory secretions culture(+) for Gram Negative Rods and Gram Positive Cocci Blood Culture (+) for Gram Negative Rods, Urine sample (-) for WBC, (-) Nitrites Currently in the ICU, Intubated and on Ventilator since Admission and IV NS at 150 ml/hr

2. a) Develop an empiric drug regimen for AA . List the most likely organisms. Include a drug, dose, frequency, and duration and monitoring parameters.(5 pts)

2. b) After 5 days of therapy AA’s condition continues to worsen. Provide an alternative drug regimen to cover a potentially resistant Multi Drug Resistant Organism. Include a drug, dose, frequency, and duration and monitoring parameters.(5 pts) Case Study #3

LK is a 59 yo married female who presents to the hospital with a two day history of abdominal pain, tenderness, and right upper quadrant pain, experiencing fever(102), chills, and rigors. She has complained of nausea and vomiting in the past day with a dark urine, and she appears to be jaundiced. Pt hasn’t had a bowel movement in the last 3 days. On Admission to the ER: WBC= 21,000, Segs=82%, Bands=10%, Liver Function Tests=AST=169, ALT=226 CBC=RBC=2100, Hb=9.8, Hct=28, PLT= 215 Vital Signs=BP=107/69, HR=91, RR= 18, Tmax= 103.1, currently 101.7, Urine Culture is normal, Chest X-ray is normal, decreased bowel sounds and motility with abdominal distention.

3. a) Develop an empiric drug regimen for LK . List the most likely organisms. Include a drug, dose, frequency, and duration and monitoring parameters.(5 pts)

3. b) After 2 days of therapy LKs blood cultures come back positive for Anaerobes she is slowly improving, but the Dr would like to change her therapy for more aggressive coverage. List the most likely organisms. Provide an alternative drug regimen to cover the anaerobes. Include a drug, dose, frequency, and duration and monitoring parameters.(5 pts) Case Study #4 GN is a 34 yo woman who presents to the clinic with a 3 day history of urinary frequency and dysuria. Over the past day she has experienced nausea, vomiting and flank pain. On month before she received a 3 day course of cephalexin 500mg TID for 3 days for an E. Coli UTI. Six weeks prior to that course she received a single dose of Amoxicillin for UTI like symptoms. This is her 3rd UTI in 3 months. She has a history Type 2 DM, which is poorly controlled HbA1c= 8.5, HTN, and a history of leg clots. Vital Signs= Tmax= 102.5, HR=86, BP=131/92, RR=18 Lab: wbc=12,000, segs 72%, bands 6%, Urine=(+) Nitrites and Leukocytes, 500 WBC/CFU

4. a) Develop an empiric drug regimen for GN . List the most likely organisms. Include a drug, dose, frequency, and duration and monitoring parameters.(5 pts)

4. b) 12 months later GN is in the 1st trimester of her second pregnancy, again she has developed a UTI. Develop a drug regimen for GN including drug, dose, duration, and patient monitoring parameters. (5 pts) Case Study #5 DG a 60 yo male experienced his first UTI at age 40, with symptoms of frequency, dysuria, nocturia, pain, fever, and chills. No flank pain was present. He has recently been diagnosed with acute prostatitis with a positive Gram Negative Rod urine culture. Allergies to Penicillins.

5. a) What is one of the most likely pathogens causing the UTI?(5pts)

5. b) Develop a drug regimen for DG’s complication. Include the dose, route, duration of therapy and any monitoring parameters of therapy.(5pts)

5. c) After initiating antibiotic therapy, DG develops an allergic reaction to therapy. Provide an alternative to DG’s therapy, Include the dose, route, duration of therapy and monitoring parameters.(5pts) Case Study #6 YO is a 23 yo college student who presents to the clinic with genital itching and vesicles on her vulva. She is sexually active with her partner who has a history of herpes. Her partner doesn’t always use condoms when they have sex. Allergies: Fluroquinolones and Sulfas

6. a) Develop a drug regimen for YO. Include drug, dose, duration of therapy and any monitoring parameters.(3pts)

6. b) After 9 months YO returns to the clinic being troubled with recurrences, she has had 5 to date. Recommend an alternate therapy regimen to include drug, dose, duration of therapy, and monitoring parameters.(2 pts)

2 years later YO reports to the ER with severe abdominal pain, fever, dysuria, and a vaginal discharge. She has been sexually active with multiple partners. Tmax=101.5, WBC= 14,000.

6. c) What a likely cause of YO’s complication?(2pts)

6. d) Develop a drug regimen for YO. Include drug, dose, duration of therapy and any monitoring parameters.(5pts)

6. e) Include an alternate therapy regimen to YO’s initial treatment regimen to cover all possible potential infections that YO may have?(3pts)

Case #7 A 45 year old patient presents to the ER with severe foul smelling diarrhea. In his records, you notice that he was prescribed clindamycin a week ago. After labs, it showed the patient had a WBC count of 16,000 and a temp of 101.5. What would you start the patient on? Provide the drug, dose frequency, and duration and monitoring parameters?(5 pts)

7. b) Provide the directions for making oral vancomycin from the IV reconstituted powder form. Include the dose of the vial to be used, volume of diluent to reconstitute the vial, and final concentration along with the patient’s dose in mg/ml at each dose.(2 pts)

7. c) Which of the following is usually used to treat traveler’s diarrhea, but is now being tested in the treatment of C. Diff?(3pts)