WASHBURN UNIVERSITY - Tracy Hill MSN Portfolio



WASHBURN UNIVERSITY

SCHOOL OF NURSING

Tracy Hill

Tracy.Hill@washburn.edu

NU 513 Advanced Pharmacology: Pediatrics

On-line Case Study #1

Complete the case study below. Please do not write this as a formal narrative paper. Number each question so that I can easily find your answer. Reference your resources using APA format. Please do your own work as this is not a group activity. Attach your completed case study and deposit in the appropriate drop box for grading. If you have any questions, please don’t wait to contact me. I am best reached by email at shirley.dinkel@washburn.edu Good luck!

Jesus is a 6 year old Hispanic male with a history of asthma. His grandmother brings him to the office with a chief complaint of low grade fever of 99.8, right ear pain, increased coughing at night, and poor appetite. His current medications are Albuterol 2 puffs QID PRN and Singular 5 mg daily. In the past, he used his inhaler 2-3 time per week prior to swimming lessons. Lately, he has needed it 4 times a day. His grandmother has been using cool baths to control temperature as well as herbal tea. He has no known drug allergies. Physical exam reveals a well developed, well nourished male with a bulging right TM. Landmarks are not visible. His tonsils are +2 without exudate. He has + post auricular nodes on the right which are moveable and soft, yet tender. Breath sounds reveal expiratory wheezing bilaterally in the bases. Vital signs are as follows: BP 92/50, R 22, P 100 T 100.0. The remainder of his exam is unremarkable. PMH = breast fed for the first two months then bottle fed; had colic as an infant; has had multiple ear infections with antibiotic use; asthma diagnosed at age 3.

1. What are your top 5 differential diagnoses? What is your priority diagnosis (Provide rationale)? Remember, differential diagnoses are the potential diagnoses for the same set of symptoms. For example, headache behind the eyes might be tension headache, myopia, or sinusitis.

Differential diagnoses include: Right Acute Otitis Media (OM), Exacerbation of Asthma, upper respiratory infection (URI), pneumonia, Influenza, sinusitis.

Priority diagnosis is Acute OM (AOM). Rationale: c/o right ear pain, low fever (100.0), bulging right TM, with no visible landmarks, and movable, soft, tender post-auricular nodes on the right. Pt also has a hx of multiple ear infections with antibiotic use. Acute OM often results from URI and is usually constant.

I would also treat the exacerbation of asthma as a priority. Pt has increased use of albuterol (up from 2-3 times per week to QID); wheezes noted in bases bilaterally; increased cough, especially at night, poor appetite, and hx of asthma. Is exacerbation of asthma due to poorly controlled treatment of asthma, worsening of condition or as a result of added illness combined with swim lessons (increased exercise and water in ears)?

2. Describe pharmacologic treatment you will recommend and provide rationale.

Discuss with grandmother what antibiotic use has been used in past, what has worked, and if pt has had re-evaluation of OM after antibiotic use to determine if prior antibiotic prescribed worked.

OM is generally treated without the use of antibiotics, and many times will resolve on its own. However, the overwhelming consensus remains that antibiotics are the initial therapy of choice for AOM for 3 valid reasons. First, there is a marked decline in the superlative complications of AOM after the institution of antibiotic therapy. Next, practitioners cannot predict with certainty which patients will develop complications. Finally, studies have demonstrated that the use of antibiotics improves patient outcomes in both the early and late phases of AOM (Donaldson, 2010).

Therefore, for the Acute OM, I would prescribe Amoxicillin HD (90mg/kg/day) in divided doses every 12 hours x 7 days (Gilbert, Moellering, Jr., Eliopoulos, Chambers, & Saag, 2010, p10).

This is only if there have been NO antibiotics in the prior month.

(Taketomo, Hodding, & Kraus, 2008, p. 118)

Based on response to prior antibiotic use and recurrent ear infections:

If antibiotics have been used in last month, consider Augmentin ES 600 (AM-CL) BID x 10 days OR Cefdinir 7mg/kg BID or 14mg/kg QD x 7 days. (Gilbert, Moellering, Jr., Eliopoulos, Chambers, & Saag, 2010, p10)

I would also recommend acetaminophen (15mg/kg) every 4 hours for pain control. Analgesics and antipyretics have a definite role in the symptomatic management of AOM (Donaldson, 2010).

Aspirin-induced asthma can also occur with other nonsteroidal anti-inflammatory drugs and is caused by an increase in eosinophils and cysteinyl leukotrienes after exposure. Primary treatment is avoidance of these medications, therefore I would not include ibuprofen as an analgesic or antipyretic at this time (Morris, 2010).

To treat the exacerbation of asthma:

Consider whether Jesus has adequate control of his asthma, since he has been increasing the use of his albuterol MDI from 2-3 times a week, to 4 times a day. The use of a short-acting beta-agonist more than 2 d/wk for symptom relief generally indicates inadequate control and the need to step up treatment (Morris, 2010).

Recommend Jesus use a nebulizer instead of the MDI, when possible, until this exacerbation of asthma is resolved, and for future exacerbations. A nebulizer is most effective with more severe exacerbations than an MDI.

A course of oral corticosteroids such as prednisolone (15mg/5ml), 2mg/kg/day in divided doses (Q12 hours) x 5 days would also be appropriate with this exacerbation of asthma (Taketomo, Hodding, & Kraus, 2008, p. 1450).

3. What non-pharmacological treatment will you recommend?

Increase fluid intake/hydration.

Use of a humidifier in the home, or at least one in Jesus’ room.

Try to avoid water in the ears, use ear plugs while doing swimming lessons.

Consider re-scheduling swimming lessons until OM and exacerbation of asthma are resolved.

Consider showing the patients grandmother how to do the Galbreath technique, a simple mandibular manipulation, where the eustachian tube is made to open and close in a "pumping action" that allows the ear to drain accumulated fluid more effectively (Pratt-Harrington, 2000).

4. What patient education will you offer the grandmother and the child?

Discuss purpose of antibiotics, nebulizer, corticosteroids, antipyretics and why they should be taken and for how long.

Discuss adverse drug reactions:

• Amoxicillin and Augmentin (It is important to take the medicine 2 times a day and to take the antibiotic for the entire course of therapy, even if feeling better; do not skip doses, if you miss a dose, take as soon as possible, do not take 2 doses together. Education on hypersensitivity reactions (anaphylaxis, laryngeal edema, with fever, rash and joint swelling, myocarditis) and potentially serious side effects of medication (>10% have GI effects – nausea/vomiting/diarrhea; oral candidiasis (increase yogurt intake). (Edmunds & Mayhew, 2009, p. 640).

• Prednisolone ( nervousness, sleeplessness, irritability are most common- do not administer close to bedtime).

I would recommend that Jesus use his albuterol MDI 15-30 minutes prior to exercise (swimming lessons in this example). Prophylaxis in the form of inhaled medications administered 15-30 minutes prior to exercise is usually required to ensure good control of the underlying asthma.

Continue to re-iterate and teach patient/family asthma self-management based on basic asthma facts, self-monitoring techniques, the role of medications, inhaler use, and environmental control measures.

Make sure Jesus is using a spacer with his MDI; re-educate on its importance and proper use if necessary.

Make sure Jesus is taking his Singulair regularly, not just during exacerbations, but even during symptom-free periods; it should not be discontinued during use of Prednisolone.

Recommend follow-up in 3 days to see if OM is improving (should begin to see improvement within 3 days), sooner if worsening symptoms. Discuss consultation with asthma specialist (pulmonologist or allergist) to ensure good asthma control and proper stepwise asthma management.

Recommend possible consultation with ENT specialist if OM continues.

If grandmother or other family members smoke, recommend no smoking in the home or exposure to second-hand smoke for Jesus.

Well done 20/20

References

Donaldson, J. D. (2010). Middle Ear, Acute Otitis Media, Medical Treatment: Treatment & Medication. Retrieved from

Edmunds, M. W., & Mayhew, M. S. (2009). Pharmacology for the primary care provider (3rd ed.). St.Louis, MO: Mosby.

Gilbert, D. N., Moellering, R. C., Jr., Eliopoulos, G. M., Chambers, H. F., & Saag, M. S. (Eds.). (2010). The sanford guide to antimicrobial therapy 2010 (40th ed.). Sperryville,VA: Antimicrobial Therapy, Inc.

Hamilton, R. J. (Ed.). (2011). Tarascon Pocket Pharmacopoeia: 2011 Classic Shirt-Pocket Edition (25th ed.). Sudbury, MA: Jones & Bartlett Learning, LLC.

Morris, M. J. (2010). Asthma: Differential Diagnoses and Workup. Retrieved from

Pratt-Harrington, D. (2000). Galbreath technique: a manipulative treatment for otitis media revisited. Retrieved from

Taketomo, C. K., Hodding, J. H., & Kraus, D. M. (2008). Pediatric Dosage Handbook (15th ed.). Hudson, OH: Lexi-Comp.

Turkoski, B. B., Lance, B. R., & Tomsik, E. A. (Eds.). (2010). Drug Information Handbook for Advanced Practice Nursing (11th ed.). Hudson, OH: Lexi-Comp.

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