Chapter 11 – Assignment

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  1. Read the Case Study 11-2: Go to the Hospital and Come Back with Four More Medications in Chapter 11 of the textbook.
  2. Once you have read the Case Study thoroughly, answer the following questions:
    1. What does the administration of antibiotics have to do with a Clostridium difficile (C. diff infection) infection?
    2. List all the inappropriate medications prescribed for K.L. and describe the reason why they are inappropriate.
    3. What kind of treatment regimen is utilized for a patient with a C. diff infection?
    4. Do any of these treatments regimens raise suspicion as being inappropriate for K.L.?
    5. List the therapy and if contraindicated, give a reason why it is inappropriate.
  3. Your paper should be:
    • One (1) page or more.
    • Use factual information from the textbook and/or appropriate articles and websites.
    • Cite your sources – type references according to the APA Style Guide.

Case Study 11-2: Go to the Hospital and Come Back with Four More Medications

K. L. is an 84-year-old man who was sent to the hospital for treatment of possible urinary tract infection (UTI) and dizziness with fever. He has lived in assisted living at SHV assisted living facility for the past 4 years. K. L.’s hospital course was complicated by aggressive antibiotic treatment resulting in a Clostridium difficile infection and diarrhea. Geriatric Nurse Practitioner B. G. checked on K. L. the first day after he returned from the hospital. B. G. compared her chart records to the new posthospital discharge records and found several discrepancies and inappropriate medication changes:

  • Ht = 6 ft 1 in, Wt = 178 lb, BP = 125/65, RR = 18, HR = 72
  • PMH: DM2, HTN, OsteoArthritis, CAD, Afib, chronic UTI (colonization)
  • Labs: CMP within normal limits (WNL) except for creatinine 1.8, BUN = 32, glucose 72; K = 3.0
  • CBC WNL; Lipid panel TC = 70, LDL = 127, HDL = 65
From ALF to ED Hospital DC summary Current in ALF chart Assessment and de-prescribing by GNP
Metoprolol XL 25 mg daily Metoprolol XL 25 mg daily Metoprolol XL 25 mg daily
Digoxin 0.125 mg every other day Amiodarone 200 mg twice daily Amiodarone 200 mg twice daily Cardio consult placed him on amiodarone, purposefully avoided in the past, will switch back to digoxin every other day (Bahr, Lackner, & Pacala, 2008) DC amidarone.
Warfarin 3 mg daily Warfarin 3 mg daily Warfarin 3 mg daily
Lisinopril 20 mg daily Lisinopril 20 mg daily Lisinopril 20 mg daily
Amlodipine 5 mg daily Amlodipine 10 mg daily Amlodipine 10 mg daily Amlodipine dose increased by hospitalist targeting BP = 120/80; too low for K.L. due to orthostasis and age. Decrease to 5 mg.
Metformin 500 mg BID Metformin 500 mg BID Metformin 500 mg BID
Glyburide 5 mg daily Glyburide 5 mg daily Hypoglycemic and on glyburide. Glipizide a better choice in renal impairment (dose adjustment). Glyburide should be avoided in CrCl, 50ml/min. His est. CrCl = 33.3m/min. (American Geriatric Society Beers Criteria.) DC (discontinue, his BG likely went up due to acute infection)
Simvastatin 40 mg daily Simvastatin 40 mg daily His lipid panel indicates that he does not need statin therapy, and amlodipine when given with simvastatin per FDA warning requires simvastatin dose of not more than 20 mg daily. DC
Nitrofurantoin 100 mg daily Nitrofurantoin 100 mg daily Contraindicated in patients with CrCl < 60ml/min. (nitrofurantoin package insert) DC—patient known to have UT bacterial colonization.
Cranberry supplement Vancomycin oral 250 mg every 8 hours for 10 days Vancomycin oral 250 mg every 8 hours for 10 days Not clear when vancomycin started, need to clarify how many days remain, then re-culture.
Pantoprozole 20 mg daily prn Pantoprozole 20 mg daily This was a prn AST order (routine in hospital) carried forward to discharge which was mistranscribed to be routine. DC
Diclofenac 75 mg twice daily prn Diclofenac 75 mg twice daily NSAIDS are contraindicated in patients on warfarin, and high risk for CV events in elders. (American Geriatrics Society Beers Criteria). DC.
Routine APAP Same Same Same
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