Case Study: Closer Look At A Medication Regimen

3539 words - 14 pages

Case Study: Closer Look at a Medication RegimenBackgroundHistoryNB is a 40 year old, 5 foot 7 inch, 148 lbs (67kg) African American female admitted through the emergency department (ED) with loss of consciousness, possibly related to a drug overdose. Subsequently, she was transferred to the medical/surgical floor with a medical diagnosis of renal failure and rhabdomyolysis due to immobility and cocaine. Her histories were ascertained from her boyfriend. Past medical history includes liver disease and renal insufficiency. Past surgical history is unknown. She is allergic to penicillin (PCN), with a reaction of hives.Psychosocially, she lives in an inner-city apartment with her boyfriend and has no children. She has a history of heavy alcohol use and poly-substance abuse, specifically alcohol, heroin, cocaine, and marijuana. There is no use of herbal remedies or tobacco, but occasional use of a multivitamin. The patient's regular medication regimen is unknown, due to the patient's sedation and the boyfriend's ignorance. In addition, a history of present illness was unable to be determined for the same reason. It is suspected that her liver disease stems from chronic alcoholism. Her rhabdomyolysis has been linked to her immobility and cocaine usage.Laboratory resultsHer initial laboratory results included an elevated CPK and tested positive for cocaine, opiates, and benzodiazepines. Whether these results are from prescribed medications or illicit drug use is unknown. Most recently, her laboratory values included: Na2+ = 138; K+ = 4.2; Cl- = 100; CO2 = 28; Ca2+ = 9.8; CPK = 197; BUN = 15; CRE = 1.1; and blood glucose = 105. All of which are within normal levels, with the exception of the CPK and CO2 being slightly high (Myers, 15-21). Numerous medications have been prescribed since her admittance one month ago with the most current ones listed in the Appendix.MedicationsHeparinAlthough the patient was not admitted with any signs of thrombosis, she became increasingly susceptible to their development as her hospital stay prolonged and she remained on bed rest. As a result, an anticoagulant (heparin) is given SQ at 5,000units q 12 hours for the prevention of deep vein thrombi (DVT). This dosage falls within the normal, adult therapeutic range of 5,000units q 8-12 hours for the prophylaxis of thromboembolism (Deglin & Vallerand, 465). It functions on the intrinsic coagulation pathway by combining with antithrombin III to inhibit the conversion of prothrombin to thrombin, and thus inhibiting the clotting of the blood (Abrams, 835).Throughout NB's treatment, it is most important to monitor the laboratory values of active partial thrombin time (aPTT) and hematocrit (Hct) both before and periodically throughout the use of heparin. Blood should be drawn 4-6 h after the injection and the aPTT levels should be maintained at 1.5-2.5 times the control or baseline value (25-35 seconds). Therefore, therapeutic levels should be in the region of 45-70 seconds...

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