Boxed Warnings: use with opioids can result in extreme sleepiness, respiratory depression, coma, or death
CI: varies among agents, acute narrow angle glaucoma, sleep apnea, severe respiratory insufficiency, significant liver disease,
warnings: anterograde amnesia, CNS depression, extravasation with IV use, potential for abuse, risk in elderly of falls etc, tolerance, withdrawal symptom,taper off slowly
physiological dependence and tolerance develop with chronic use
SE: somnolence, dizziness, weakness, ataxia, lightheadedness
NOTES: All medications are C-IV
all are on PRN schedule for dosing
to avoid withdrawl symptoms taper slowly, patient is at risk for withdrawl symptoms after taking medication for 10 days of more
History of Present Illness: LY is a 45 year old female who presents to her PCP on August 1st for a follow-up of multiple health problems, including a recent asthma exacerbation. She complains of stress and constantly worrying for the past year. She expresses fear about managing her finances and her health, though there have been no major changes in her life recently to contribute to this. She obtains prescriptions from her PCP, but is often resistant to suggestions and advice from healthcare providers.
Allergies: no known drug allergies
Past Medical History: hypertension, osteoarthritis, allergic rhinitis, asthma, and anxiety
Current Medications (obtained from active prescription bottles on 8/1):
Zestril 10 mg daily
Hydrochlorothiazide 12.5 mg daily
ProAir HFA 2 inhalations Q6H PRN (last two refill dates: 7/29, 6/3)
Protonix 40 mg daily
Prednisone taper 10 mg daily x 4 days, 5 mg daily x 4 days, 2.5 mg x 2 days then stop (on day 5 of treatment)
Ibuprofen 400 mg daily
Zyrtec D 1 tablet BID
Pulmicort Flexhaler 1 inhalation BID
Theophylline 300 mg PO daily
Expired Prescriptions and No Refills:
3/15: Xanax 0.5 mg TID x 30 days. No refills
3/15: Zoloft 50 mg daily. Disp #30. No refills.
4/25: Valium 2 mg BID x 5 days. No refills.
6/1: Lyrica 50 mg TID. Disp #90. No refills
Vitals:
Height: 5'6" Weight: 125 pounds
BP: 152/86 mmHg HR: 95 BPM RR: 13 BPM Temp: 98.5°F Pain: 2/10
Physical Exam:
Neuro: alert and oriented
HEENT: few white plaques on the tongue and inner cheeks
CV: RRR
Abdomen: normal bowel
sounds
Extremities: no edema noted, good reflexes
Labs:
Na (mEq/L) = 139 (135 - 145)
K (mEq/L) = 3.1 (3.5 - 5)
Cl (mEq/L) = 100 (95 - 103)
HCO3 (mEq/L) = 25 (24 - 30)
BUN (mg/dL) = 12 (7 - 20)
SCr (mg/dL) = 0.8 (0.6 - 1.3)
Glucose (mg/dL) = 147 (100 - 125)
TSH (mIU/L) = 0.15 (0.3 - 3)
Ca (mg/dL) = 8.8 (8.5 - 10.5)
Albumin (g/dL) = 3.2 (3.5 - 5)
Theophylline peak level (mcg/mL) = 7
Question
Which of the following may be contributing to LY's
anxiety? (Select ALL that apply.)
Answer
A
Use of a systemic steroid
B
Use of a decongestant
C
Incorrect use or overuse of albuterol
D
Use of theophylline
E
Use of Pulmicort Flexhaler
History of Present Illness: LY is a 45 year old female who presents to her PCP on August 1st for a follow-up of multiple health problems, including a recent asthma exacerbation. She complains of stress and constantly worrying for the past year. She expresses fear about managing her finances and her health, though there have been no major changes in her life recently to contribute to this. She obtains prescriptions from her PCP, but is often resistant to suggestions and advice from healthcare providers.
Allergies: no known drug allergies
Past Medical History: hypertension, osteoarthritis, allergic rhinitis, asthma, and anxiety
Current Medications (obtained from active prescription bottles on 8/1):
Zestril 10
mg daily
Hydrochlorothiazide 12.5 mg daily
ProAir HFA 2 inhalations Q6H PRN (last two refill dates: 7/29, 6/3)
Protonix 40 mg daily
Prednisone taper 10 mg daily x 4 days, 5 mg daily x 4 days, 2.5 mg x 2 days then stop (on day 5 of treatment)
Ibuprofen 400 mg daily
Zyrtec D 1 tablet BID
Pulmicort Flexhaler 1 inhalation BID
Theophylline 300 mg PO daily
Expired Prescriptions and No Refills:
3/15: Xanax 0.5 mg TID x 30 days. No refills
3/15: Zoloft 50 mg daily.
Disp #30. No refills.
4/25: Valium 2 mg BID x 5 days. No refills.
6/1: Lyrica 50 mg TID. Disp #90. No refills
Vitals:
Height: 5'6" Weight: 125 pounds
BP: 152/86 mmHg HR: 95 BPM RR: 13 BPM Temp: 98.5°F Pain: 2/10
Physical Exam:
Neuro: alert and oriented
HEENT: few white plaques on the tongue and inner cheeks
CV: RRR
Abdomen: normal bowel sounds
Extremities: no edema noted, good reflexes
Labs:
Na (mEq/L) = 139 (135 - 145)
K (mEq/L) = 3.1 (3.5
- 5)
Cl (mEq/L) = 100 (95 - 103)
HCO3 (mEq/L) = 25 (24 - 30)
BUN (mg/dL) = 12 (7 - 20)
SCr (mg/dL) = 0.8 (0.6 - 1.3)
Glucose (mg/dL) = 147 (100 - 125)
TSH (mIU/L) = 0.15 (0.3 - 3)
Ca (mg/dL) = 8.8 (8.5 - 10.5)
Albumin (g/dL) = 3.2 (3.5 - 5)
Theophylline peak level (mcg/mL) = 7
Question
Based on LY's lab results, what undiagnosed condition does she have that could present with symptoms of anxiety (e.g., tachycardia, shortness of breath, insomnia)?
Answer
A
Hypocalcemia
B
Hypokalemia
C
Hyperthyroidism
D
Hyperglycemia
E
Hypoalbuminemia
History of Present Illness: LY is a 45 year old female who presents to her PCP on August 1st for a follow-up of multiple health problems, including a recent asthma exacerbation. She complains of stress and constantly worrying for the past year. She expresses fear about managing her finances and her health, though there have been no major changes in her life recently to contribute to this. She obtains prescriptions from her PCP, but is often resistant to suggestions and advice from healthcare providers.
Allergies: no known drug allergies
Past Medical History: hypertension, osteoarthritis, allergic rhinitis, asthma, and anxiety
Current Medications (obtained from active prescription bottles on 8/1):
Zestril 10 mg daily
Hydrochlorothiazide 12.5 mg daily
ProAir HFA 2 inhalations Q6H PRN (last two refill dates: 7/29, 6/3)
Protonix 40 mg daily
Prednisone taper 10 mg daily x 4 days, 5 mg daily x 4 days, 2.5 mg x 2 days
then stop (on day 5 of treatment)
Ibuprofen 400 mg daily
Zyrtec D 1 tablet BID
Pulmicort Flexhaler 1 inhalation BID
Theophylline 300 mg PO daily
Expired Prescriptions and No Refills:
3/15: Xanax 0.5 mg TID x 30 days. No refills
3/15: Zoloft 50 mg daily. Disp #30. No refills.
4/25: Valium 2 mg BID x 5 days. No refills.
6/1: Lyrica 50 mg TID. Disp #90. No refills
Vitals:
Height: 5'6" Weight: 125 pounds
BP: 152/86 mmHg HR: 95 BPM RR: 13 BPM Temp: 98.5°F
Pain: 2/10
Physical Exam:
Neuro: alert and oriented
HEENT: few white plaques on the tongue and inner cheeks
CV: RRR
Abdomen: normal bowel sounds
Extremities: no edema noted, good reflexes
Labs:
Na (mEq/L) = 139 (135 - 145)
K (mEq/L) = 3.1 (3.5 - 5)
Cl (mEq/L) = 100 (95 - 103)
HCO3 (mEq/L) = 25 (24 - 30)
BUN (mg/dL) = 12 (7 - 20)
SCr (mg/dL) = 0.8 (0.6 - 1.3)
Glucose (mg/dL) = 147 (100 - 125)
TSH (mIU/L) = 0.15 (0.3 - 3)
Ca (mg/dL) =
8.8 (8.5 - 10.5)
Albumin (g/dL) = 3.2 (3.5 - 5)
Theophylline peak level (mcg/mL) = 7
Question
In reviewing LY's medication history, you find a note from 4/25 that says "Zoloft 50 mg has not improved anxiety, switch to Valium". What is the most likely reason that Zoloft was not effective?
Answer
A
It was used alone, instead of in combination with a benzodiazepine.
B
It was used alone, instead of in combination with buspirone.
C
The duration of use may have
been too short, and the dose too low.
D
The patient was most likely not compliant with the medication.
E
It is not a preferred drug for treatment of anxiety.