Clinical Pharmacy Question

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Sparda29

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Okay, I have case study and I'm just looking for confirmation about my idea for treatment.

The patient is 66 years old, and is complaining of bad cough, shortness of breath and chest pain. Analysis of the spetum shows presence of bacteria and WBC.

He also has hypertension and diabetes. He is being treated for that with Metformin, Glyburide, and Enalapril.

He is also severely allergic to penicillin

I'm suspecting Streptococcus pneumonaie as the cause and I'm recommending Levofloxacin 500 mg, QD, for 7 days as the empirical treatment plan. If we find that it is a resistant strain, I would proceed to start therapy with Erythromycin or Clindamycin.

Does that sound like a good plan?

Thanks

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Okay, I have case study and I'm just looking for confirmation about my idea for treatment.

The patient is 66 years old, and is complaining of bad cough, shortness of breath and chest pain. Analysis of the spetum shows presence of bacteria and WBC.

He also has hypertension and diabetes. He is being treated for that with Metformin, Glyburide, and Enalapril.

He is also severely allergic to penicillin

I'm suspecting Streptococcus pneumonaie as the cause and I'm recommending Levofloxacin 500 mg, QD, for 7 days as the empirical treatment plan. If we find that it is a resistant strain, I would proceed to start therapy with Erythromycin or Clindamycin.

Does that sound like a good plan?

Thanks

sounds good to me, make sure you monitor the patients glucose levels with levaquin.
 
Sounds like a good plan.

Random question though, what about the chest pain? Is it me, or does it seem kinda wierd he has chest pain with PMH of HTN and DM?
 
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Okay, I have case study and I'm just looking for confirmation about my idea for treatment.

The patient is 66 years old, and is complaining of bad cough, shortness of breath and chest pain. Analysis of the spetum shows presence of bacteria and WBC.

He also has hypertension and diabetes. He is being treated for that with Metformin, Glyburide, and Enalapril.

He is also severely allergic to penicillin

I'm suspecting Streptococcus pneumonaie as the cause and I'm recommending Levofloxacin 500 mg, QD, for 7 days as the empirical treatment plan. If we find that it is a resistant strain, I would proceed to start therapy with Erythromycin or Clindamycin.

Does that sound like a good plan?

Thanks

Nope..not at all actually. Look at the new regimen for CAP using Levaquin, is it 500mg QD X 7 day? Yet you said the Pt is a diabetic? How's the renal clearance?
And you think if Strep Pneumo is resistant to a quinolone, you can cover it with a Macrolide or clinda???

What's one of the major side effects of ACE-I?? And link it with one of the symptoms the patient has. Why does the pt have SOB and how is it related to the Chest Pain?
 
come on, what's a common side effect of ACE-Is?

The patient has severe pcn allergy, what about cephalosporins?

What are his O2 sats?

You say the sputum gram stain shows bacteria - gram + gram - ? That can possibly r/o atypicals.

What is the concern of using glyburide with erythromycin?

Any mention of the chest x-ray?

I like Levaquin 750 mg po QD x 5 days or 500 mg po QD x 10 days.

But if you've got FQ resistance I imagine you already had macrolide resistance on board. You might have to admit the pt.

How do you feel about doxy?
 
I like Levaquin 750 mg po QD x 5 days or 500 mg po QD x 10 days.


How do you feel about doxy?

How does diabetes affect renal fxn and how is Levaquin cleared?

Doxy is ok but not much more cost effective since Zithro went generic..
 
Spicy food. Give the guy a GI cocktail, maybe Rocephin and azithromycin? No idea really


Pneumonia can cause SOB, Decrease in O2 sat.. Tachydardia etc... Tachycardia can lead to ischemia..not necessarily MI.. Get the infection under control...cardio respiratory fxn should improve.
 
Again..we're doing this kid's homework..
 
Well, at least he volunteered his own answer, unlike some other "question" threads I've come across. Perhaps the posts will make sense to me next year.


That is true!
 
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Definitely need to consider renal function before dosing Levaquin, especially in an elderly patient with DM.

Is the OP a 1st year but already having to answer these kinds of clinical questions?
 
Again..we're doing this kid's homework..

Have to run, but OP (along with what Z was saying): pull this up and see what you think...

Dunbar LM, Wunderink RG, Habib MP, et al. High-dose, short-course levofloxacin for community-acquired pneumonia: a new treatment paradigm. Clin Infect Dis. 2003 Sep 15;37(6):752-60.

I'm just surprised the "double coverage" topic didn't come up!
 
Have to run, but OP (along with what Z was saying): pull this up and see what you think...

Dunbar LM, Wunderink RG, Habib MP, et al. High-dose, short-course levofloxacin for community-acquired pneumonia: a new treatment paradigm. Clin Infect Dis. 2003 Sep 15;37(6):752-60.

I'm just surprised the "double coverage" topic didn't come up!

You work for Ortho McNeil now??? Pushing tha 750mg dosing regimen??????

Why double cover? Levo covers both atypical and typicals.

Unless pt is from a nursing home...then it's a different story.
 
But you do it so freaking well! Also, maybe this will stick in someone's head during real life.


In a strange way, Pharmacy God has found a way for me to pay back all those years I didn't do my own homework.. To my classmates who did my dirty work, I thank you.. :smuggrin:
 
You work for Ortho McNeil now??? Pushing tha 750mg dosing regimen??????

Why double cover? Levo covers both atypical and typicals.

Unless pt is from a nursing home...then it's a different story.

I'm not pushing double coverage! I just meant I'm surprised it didn't come up. Everyone's brainwashed nowadays to think it's always necessary...without understanding why you're doing it to begin with. So I was just impressed it didn't come up right away!
 
I'm not pushing double coverage! I just meant I'm surprised it didn't come up. Everyone's brainwashed nowadays to think it's always necessary...without understanding why you're doing it to begin with. So I was just impressed it didn't come up right away!

It only came up because you brought it up!!!
 
I don't mean to be a stupid P1 but...
It could be TB.

Of course, the course of treatment for TB would be quite rigorous. I guess you could start on the other drugs, and at the same time do TB tests.
 
I don't mean to be a stupid P1 but...
It could be TB.

Of course, the course of treatment for TB would be quite rigorous. I guess you could start on the other drugs, and at the same time do TB tests.


:smuggrin::smuggrin::smuggrin: I mean...I understand your fascination with Bacillus and all...but...

doubt it..
 
How does diabetes affect renal fxn and how is Levaquin cleared?

Doxy is ok but not much more cost effective since Zithro went generic..

we like doxy in NM because it's effective against our atypicals. We don't really see Legionella, but we've got Y.pestis!
 
Let me qualify why I don't think it's TB...

The OP lists some diagnostic tests.. Sputum culture, "blood work for MI" etc.. of course those could be done fairly rapidly, so can TB skin test..

Granted, it may take extra day or 2 for TB skin test to show, I think that data should be available if done..
 
another argument for CXR.
 
we like doxy in NM because it's effective against our atypicals. We don't really see Legionella, but we've got Y.pestis!

yeah? Y.pestis?? No way!!
 
we like doxy in NM because it's effective against our atypicals. We don't really see Legionella, but we've got Y.pestis!

That's so MMWR! Do you detect it with CXR, PCR, or just sputum culture gram stain?
 
no mention of CXR results. No documentation means it wasn't done.

But yeah, we have y.pestis AND Hanta virus. y.pestis is easy, unless you're already losing limbs. Hanta requires ECMO for a couple days.
 
That's so MMWR! Do you detect it with CXR, PCR, or just sputum culture gram stain?

CXR to confirm the diagnosis of pneumonia... Sputum culture is gram stained then identified then sensitivity tested.. this helps to change the empiric therapy to streamline the therapy to correct abx.
 
no mention of CXR results. No documentation means it wasn't done.

But yeah, we have y.pestis AND Hanta virus. y.pestis is easy, unless you're already losing limbs. Hanta requires ECMO for a couple days.

Maybe the student forgot to mention it... or it's pending...or the CXR got lost between radiology and ER...

Alright..no documentation means it wasn't done.. but how can you not do a CXR on a patient with +sputum culture who is hacking away.. probably due to another reason..
 
no mention of CXR results. No documentation means it wasn't done.

But yeah, we have y.pestis AND Hanta virus. y.pestis is easy, unless you're already losing limbs. Hanta requires ECMO for a couple days.

We have Hanta in PA now too-mostly the vector is mice in hunting camps-scary.
 
That's so MMWR! Do you detect it with CXR, PCR, or just sputum culture gram stain?

I used to work at the state vet lab - we used fluorescent antibodies from abscesses or blood smears, as well as culture - it grows pretty quickly in blood.

They would also do serology for plague and tularemia (often show up together) and get titers, but that tends to be more after the fact.

I've never seen it as a pna, but it always comes up when we discuss preferred abx for atypicals.
 
Can't be CF.... the pt is too old..

Hey, I've seen them in their 40s...

I really don't see why you wouldn't do a CXR. The only thing I can really think of is like super severe kyphosis where physical deformity would make it incredibly difficult to interpret.
 
Jeez this thread multiplied like bacteria in immunosuppressed patient. :laugh:

The chest x-ray showed a consolidation in the left lower lobe.

I never said that the pneumonia was a resistant strain. I guess I did screw up with the renal clearance on the Levaquin. I did also ask the two pharmacists that I work with about it, and both of them said the Levaquin should be fine as long as the patient monitors his blood glucose levels.

TB is easy to rule out because the patient has never been to an endemic region and because this case study was given in a packet about CAP.
 
Jeez this thread multiplied like bacteria in immunosuppressed patient. :laugh:

The chest x-ray showed a consolidation in the left lower lobe.

I never said that the pneumonia was a resistant strain. I guess I did screw up with the renal clearance on the Levaquin. I did also ask the two pharmacists that I work with about it, and both of them said the Levaquin should be fine as long as the patient monitors his blood glucose levels.

TB is easy to rule out because the patient has never been to an endemic region and because this case study was given in a packet about CAP.

Who knows where this old guy has been hanging out, you hang around scummy downtown area with some homeless fellows, you could get yourself some TB, not likely but people will surprise you.
 
TB is easy to rule out because the patient has never been to an endemic region and because this case study was given in a packet about CAP.

Dude, everywhere is "endemic" to TB. Old, immunocompromised guy coughs in the air as you walk past him into a store - you may have just been exposed to TB. You'll keep it down, no worries, until something happens. Whether that simply means getting old, or HIV.
 
Thread hijacking.....


Which of the following is most effective BC (assume perfect use)?
-condom with spermicide
-minipill
-Lunelle
-patch, ortho evra
-combined ee and progestin
 
Hey, I've seen them in their 40s...

I really don't see why you wouldn't do a CXR. The only thing I can really think of is like super severe kyphosis where physical deformity would make it incredibly difficult to interpret.


I told you there was a CXR yet the OP didn't think it important enough to mention it!

Z - 1
NJ - 0

:smuggrin:
 
Well, to be honest the lecture for this assignment isn't for another 2 weeks, and the assignment isn't due for 3 weeks, I just figured that I'd get a head start on it.

So going through the packet with information about CAP, there was a picture showing the difference between a healthy lung and an infected lung, however, when I looked at the case study(single sheet of paper), there was no picture of the lung and all it stated next to Chest X-Ray was LLL Consolidation.
 
what would be significant if it had been RLL consolidation?
 
What I want to know is how in the world are you doing these cases studies if you're in the Class of 2012.

Or maybe I went to the wrong school?
 
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