Whitney Dunbar



Dunbar: Case Study One and TwoWhitney L. DunbarWright State UniversityNursing 7202October 22, 2013Dr. Kristine ScordoDunbar: Case Study One and TwoCase Study One1. What are potential etiologies of this patient’s symptoms? (That is, what are the differential diagnoses? Provide rationale for your answer. Use a variety of references. Prioritize your list from most likely diagnosis to least likely diagnosis.There are many potential etiologies for this patient’s presenting symptoms. This patient’s chief complaint is a day and a half severe headache with nausea and vomiting. Other symptoms include photophobia, diarrhea, dehydration and a fever. The following table (Table 1) displays the patient’s outpatient thyroid function test values from her new diagnosis of Grave disease. Table 1Outpatient Thyroid Function Test ValuesLaboratory TestNormal ValuesPatient’s Values - OutpatientThyroid Stimulating Hormone (TSH)0.34 – 4.25 mIU/dL< 0.004 mIU/dLThyroxine (T4)5.4-11.7 IJg/dL45.2 IJg/dLTriiodothyronine (T3)77 – 135 ng/dL453 ng/dLFree Thyroxine Index (FT1)6.7-10.9 IJg/dL56.4 IJg/dL131I uptakeTwo hours4-12%Six hours6-15%58.8% (four hours)24 hours8-30%62.8% Note: Normal values (Gardner & Shoback, 2011; Longo et al., 2012). After reviewing all of the patient’s symptoms, history, and outpatient laboratory results, this patient’s most likely diagnosis is thyroid storm, also known as thyrotoxic crisis. Thyroid storm is an atypical and life-threatening exacerbation of hyperthyroidism. It is condition where there is an unbalanced amount of circulating thyroid hormone produced. The mortality rate can be as high as 30%, including with treatment, due to cardiac failure, arrhythmia, or hyperthermia. It can be initiated by a stressful illness, thyroid surgery, trauma, termination of anti-thyroid medication, thyroid hormone overdose, or radioactive iodine (RAI) administration in a patient with partly treated or untreated hyperthyroidism. Clinical manifestations can consist of delirium, severe tachycardia, seizures, vomiting, diarrhea, coma, agitation, lethargy, dehydration, and a high-grade fever. This patient presents with symptoms and a history that are compatible with the diagnosis of thyroid storm. The history and symptoms include a new diagnosis of one month of Grave hyperthyroidism and the patient received radioactive iodine two days prior to admission with the development of nausea, vomiting, dehydration, and a high-grade fever of 102.3 degrees Fahrenheit within the last 48 hours. Further testing and a physical assessment wound need to be implemented to confirm diagnosis (Longo et al., 2012; Papadakis, McPhee, & Rabow, 2013). Subarachnoid hemorrhage is another diagnosis that the nurse practitioner should consider for this patient. It is also a life-threatening emergency and should have a quick diagnosis in order to initiate the appropriate treatment. Trauma or a rupture of an arterial saccular aneurysm or from an arteriovenous malformation can cause a subarachnoid hemorrhage. Patients with a subarachnoid hemorrhage develop a sudden severe onset headache that they will describe as the worst headache of their life or that they have never previously experienced a headache of such severity. Nausea, vomiting, photophobia, and loss of consciousness can follow the headache. If the patient becomes obtunded they progress to a deepening coma and possibly death. However, the patient is usually confused and irritable if consciousness is returned. Nuchal rigidity and other signs of meningeal irritation will commonly be discovered in a neurologic examination. A fever can develop with a subarachnoid hemorrhage. Findings from this patient that support the diagnosis of subarachnoid hemorrhage include the patient stating her headache was unlike any headache she had previously, nausea, vomiting, fever, and photophobia. However, she said her headache was a gradual onset, denied neck stiffness, and does not display a decrease in level of consciousness. Diarrhea is inconsistent with subarachnoid hemorrhage. Further laboratory testing and a physical assessment could be performed to rule out subarachnoid hemorrhage as a diagnosis for this patient. A head computed tomography without contrast could be executed to rule out a subarachnoid hemorrhage (Papadakis et al., 2013). Meningitis is another potential diagnosis based on this patient’s presenting symptoms and history. It can also be a life-threatening condition and should be diagnosed in a timely manner in order to initiate the proper treatment. A headache is a key feature of inflammation of the brain or its meningeal coverings caused by bacterial, viral, other infections, granulomatous processes, neoplasms, or chemical irritants. The pain is a result from the inflammation of intracranial pain-sensitive structures and that involves the blood vessels at the base of the brain. The headache can be described as throbbing, bilateral, and occipital or nuchal in location. Sitting upright, moving the head, pressing the jugular vein, or executing other maneuvers that increase intracranial pressure can aggravate the headache. Other common clinical manifestations of meningitis include photophobia, neck stiffness, fever, lethargy, and confusion. Findings from this patient that support the diagnosis of meningitis include fever, headache, and photophobia. She denied any neck stiffness or altered mental status. Further laboratory testing and a physical assessment could be performed to rule out meningitis as a diagnosis for this patient. The physical assessment should include Kernig and Brudzinski’s sign. Diagnostic studies include obtaining a serum white blood cell count and examining cerebral spinal fluid that is collected from a lumbar puncture. The diagnostic studies would only be executed if the previous two potential etiologies were ruled out (Greenberg, Aminoff, & Simon, 2012). Another possible diagnosis that should be considered is a migraine. This is not a life-threatening emergency etiology compared to the previous three potential etiologies. It is described by recurrent, generally unilateral, and frequently pulsatile or throbbing headaches. Other clinical manifestations include photophobia, phonophobia, nausea, vomiting, and intensification with movement of the head. The onset of the migraine is usually gradual. Classic migraines are associated with an aura, typically visual, followed by the headache and other previously listed clinical manifestations. Common migraines are without auras. Both migraines may be lead by imprecise warning variations in mood and appetite. Also, a history of similar headaches and a family history of migraines are common in patients with migraines. Young woman can have migraines during premenstrual period due to a decrease in estradiol. Clinical manifestations that support the diagnosis of migraine include the patient presenting with a severe headache with a gradual onset, describing her headache as “a hammering in the back of her head” for the past one and a half days, worsening photophobia, nausea, and vomiting. Also, this could be a recurrence of her migraine since she has a history of difficult to control migraines. However, the nurse practitioner could rule out migraine as a diagnosis since her headache is unlike any headache she has had before, no precipitating symptoms, and she has a history of a high-grade fever that is not associated with migraines. Further testing and a physical assessment would need to be implemented to confirm diagnosis (Ropper & Samuels, 2009). Another possible diagnosis that should be considered is pheochromocytoma. Presenting signs and symptoms of pheochromocytoma are caused by an excess secretion of catecholamines and include hypertension, tachycardia, headache, perspiration, palpitations, and anxiety. Patients with pheochromocytoma have a normal serum TSH and T4 level (Papadakis et al., 2013). Pheochromocytoma can be ruled out as a diagnosis for this patient due to her elevated serum T4 and decreased serum TSH level.2. Which of the following is not considered a diagnostic criterion for thyroid storm? Bold the correct answer. Provide rationale for your answer and why you eliminated the others.A. Nausea and vomiting B. TachycardiaC. TremorD. FeverE. Pulmonary edemaTremor can occur in patients experiencing thyroid storm, however, tremor is not considered a diagnostic criterion for thyroid storm because it is not consistently found in patients experiencing thyroid storm. Also, tremor is not one of the neurologic criteria in the diagnostic tool for thyroid storm. Nausea and vomiting, tachycardia, fever, and pulmonary edema can be excluded as the answer because they are frequently observed systemic symptoms of thyroid storm and are included in the diagnostic tool for thyroid storm. The systemic symptoms are outcomes from detectable alterations in basal metabolic rate, cardiovascular hemodynamics, psychiatric, and neurophysiological functions due to a surplus in serum thyroid hormones and suppression of TSH. The systemic symptoms are attributed to the rise in β-adrenergic receptors and catecholamines (Bahn et al., 2011; Klubo-Gwiezdzinska & Wartofsky, 2012; McCance & Huether, 2010). The diagnosis of thyroid storm can be recognized mostly by clinical presentation since laboratory results may not be altered much from patients with uncomplicated hyperthyroidism. Laboratory results with hyperthyroidism will display elevations in serum free T3 and T4 while TSH is greatly reduced or undetectable. Criterion for thyroid storm has been produced and outlined to aid in the diagnosis and assessment of thyroid storm. There are seven criteria and consist of thermoregulatory dysfunction, central nervous system (CNS) outcomes, gastrointestinal (GI)/hepatic dysfunction, cardiovascular dysfunction, congestive heart failure (CHF), atrial fibrillation, and precipitant history. There are point values given for particular findings within each category and then the values from each category are added together for a cumulative score. The cumulative score aids the nurse practitioner in evaluating the likelihood of thyroid storm diagnosis. When the cumulative score is 45 or greater there is a high probability for thyroid storm. A cumulative score of 25 to 44 proposes impending storm and a cumulative score less than 25 implies an unlikely diagnosis of thyroid storm. This scoring system is a sensitive diagnostic tool but it is not specific for diagnosing thyroid storm (Bahn et al., 2011; Klubo-Gwiezdzinska & Wartofsky, 2012). The following table (Table 2) displays the point scale for the diagnosis of thyroid storm. Table 2Point Scale for the Diagnosis of Thyroid Storm CriteriaPointsCriteriaPointsThermoregulatory DysfunctionTemperature (°F)Gastrointestinal-Hepatic DysfunctionManifestation99°F-99.9°F5Absent0100°F -100.9°F10Moderate (diarrhea, abdominal pain, nausea/vomiting)10101°F -101.9°F15Severe (jaundice)20102°F -102.9°F20103°F -103.9°F25>104°F30CardiovascularTachycardia (beats per minute)Central Nervous System DisturbanceManifestation100-1095110-11910120-12915Absent0130-13920Mild (agitation)10> 14025Moderate (delirium, psychosis, extreme lethargy)20Severe (seizure, coma)30Atrial FibrillationPrecipitant HistoryStatusAbsent0Present10Absent0Present10Congestive Heart FailureScores TotaledAbsent0> 45Highly likely thyroid stormMild (edema)525-44Impending stormModerate (bibasilar rales)10<25Storm unlikelySevere (pulmonary edema)15Note: Criteria and points values (Bahn et al., 2011). The patient presents with a precipitant history, mild agitation, nausea and vomiting, a heart rate of 105 beats per minute, and a temperature of 102.3°F. Her cumulative score is calculated at 55 and supports a highly likelihood for thyroid storm diagnosis. 3. Based on this patient’s symptoms and diagnostic studies, which of the following management strategies is not appropriate? Provide rationale for your answer and why you eliminated the others.A. Ablation with 131I (RAI)B. ThyroidectomyC. β–blocker and a thionamide (propylthiouracil or methimazole)D. Lugol solutionE. Corticosteroids Ablation with 131I radioactive iodine (RAI) is an inappropriate management strategy for this patient due to the severity of the patient’s presenting symptoms and elevated thyroid function tests. Management of thyroid storm generally uses a multimodal approach and consists of beta-blocker treatment, anti-thyroid drug treatment, inorganic iodine treatment, corticosteroid treatment, respiratory support, acetaminophen and cooling blankets, volume resuscitation, and continuous cardiac monitoring in an intensive care unit (Bahn et al., 2011).Since the 131I RAI therapy precipitated the thyroid storm for this patient, it would not be an appropriate management strategy for this patient. Ablation with 131I RAI focuses on lessening the amount of thyroid tissue and reducing hormone synthesis for patients with Grave disease. However, ablation with 131I RAI treatment has risks. It can initially exacerbate the patient’s symptoms of hyperthyroidism due to thyroid gland tissue damage and the release of thyroid hormone (Bahn et al., 2011). Therefore, ablation with 131I RAI can cause a patient to develop thyroid storm. A patient should be pre-medicated an hour prior to infusion with propylthiouracil 600 mg, and then maintained on 300 mg orally every six hours when they are going to receive ablation with 131I RAI. This medication blocks the conversion of T4 to T3, thus enhancing the action of the 131I RAI. Also, a patient should receive a beta-blocker prior to ablation with 131I RAI to try to decrease the overexcited thyroid function (Longo, 2012). Patients who are pregnant or have active ophthalmopathy should not be given 131I RAI due to teratogenic effects and intensifying the ophthalmopathy (Bahn et al., 2011).A thyroidectomy is an appropriate management strategy for certain conditions. A thyroidectomy is considered when there is a very large or multimodal goiter with low RAI uptake, for a malignant thyroid nodule, in cases of Graves opthalmopathy, women who are or wish to become pregnant within a year after treatment, in children, cases of amiodarone induced hyperthyroidism, and when the patient has failed anti-thyroid medications. Laryngeal edema, laryngeal nerve damage, and hypoparathyroidism are complications of a thyroidectomy. The need for surgical intervention can be discussed when this patient’s thyroid status improves (Doherty, 2010).An appropriate management strategy for thyroid storm can include a beta–blocker, such as propranolol, and a thionamide, such as propylthiouracil or methimazole. This management strategy can be implemented for thyrotoxic patients with a resting heart rate above 90 beats per minute or patients with pre-existing cardiovascular disease. Propranolol is the preferred beta-blocker for use in patients with thyroid storm due to the side effect of decreasing T4 to T3 conversion. The suggested dose of propranolol is 60 to 80 mg every four hours. Beta-blockers decrease the patient’s heart rate, decrease myocardial contractility, decrease blood pressure, and decrease oxygen demand. Propranolol is an unlabeled use for thyroid storm. Propylthiouracil is an effective medication and a labeled use for thyroid storm since it inhibits new hormone synthesis and blocks conversion of T4 to T3. The suggested dose is 500 to 1,000 mg loading dose and then 250 mg every four hours. Methimazole is an effective medication for thyroid storm because it blocks the production of thyroid hormones by inhibiting the oxidation of iodine in the thyroid gland. It is an unlabeled use for thyroid storm. The suggested dose for methimazole is 60 to 80 mg each day (Bahn et al., 2011; Lexi-Comp, Inc., 2013). This patient has a heart rate of 105 beats per minute. Therefore, this treatment would be an appropriate management strategy for this patient. An Adult Gerontological Acute Care Nurse Practitioner (AGACNP) in Ohio with a Certificate to Prescribe (CTP) may prescribe beta-blockers and anti-thyroid medications. However, a physician needs to initiate or be consulted before an AGACNP can prescribe a medication for an unlabeled use (Ohio Board of Nursing, 2013). Lugol solution, saturate solution of potassium iodine, is an unlabeled use but is an appropriate management strategy for thyroid storm. Lugol solution momentarily inhibits thyroid hormone synthesis and thyroid hormone secretion. It can reduce the size and vascularity of the thyroid gland. Also, Lugol solution can decrease the serum concentration levels of T3 and T4 for many weeks but the effect will not be sustained. Lugol solution decreases the risk of RAI exposure causing thyroid cancer by inhibiting uptake of radioiodine by the thyroid (Lexi-Comp, Inc., 2013). The suggested dose for Lugol solution is five drops (0.25 mL or 250 mg) orally every six hours. Lugol solution should not be started until one hour after antithyroid treatments have been administered (Bahn et al., 2011). Physician initiation or consultation needs to be implemented before an AGACNP with a CTP in Ohio can prescribe Lugol solution for thyroid storm since Lugol solution would be prescribed for an unlabeled use (Ohio Board of Nursing, 2013).Corticosteroids are prescribed as an unlabeled use but are an appropriate management strategy for thyroid storm because they inhibit the conversion of T4 to T3. Also, it helps prevent the occurrence of adrenal insufficiency. Hydrocortisone is the suggested corticosteroid to be prescribed for thyroid storm with dexamethasone as the alternative drug of choice. Hydrocortisone should be administered with a load dose of 300 mg intravenous and then 100 mg every eight hours (Bahn et al., 2011; Lexi-Comp, Inc., 2013). Physician initiation or consultation needs to be implemented before an AGACNP with a CTP in Ohio can prescribe a corticosteroid for thyroid storm since the corticosteroid would be prescribed for an unlabeled use (Ohio Board of Nursing, 2013).Case Study Two1. What is the most appropriate next step in this patient’s diagnostic evaluation? Provide rationale for your answer.A. Contrast-enhanced CT scan of the brainB. Magnetic resonance imaging (MRI) of the brainC. Lumbar puncture with cerebrospinal fluid analysisD. ElectroencephalogramE. No further diagnostic testingThe next most appropriate step in this patient’s diagnostic evaluation is a lumbar puncture (LP) with cerebrospinal fluid (CSF) analysis. The healthcare provider should suspect a central nervous system (CNS) infection, for a diagnostic consideration since this patient presents with a low-grade fever of 100.9 °F, nuchal rigidity, altered mental status, and had a diffuse headache one night prior to presentation. These are common signs and symptoms for a CNS infection. Specifically, bacterial meningitis, an acute purulent infection of the subarachnoid space, is highly considered as a diagnosis for this patient. It is a life-threatening infection where specific tests need to be executed quickly in order to establish a diagnosis and provide appropriate therapy. A LP with CSF analysis is a diagnostic test for bacterial meningitis. The initial management of a patient suspected with bacterial meningitis includes obtaining blood cultures and this patient had two sets of blood cultures drawn. This patient presents confused, lethargic, and unable to answer questions or follow commands, therefore, a non-contrast computed tomography (CT) of the brain should be executed prior to the LP. In addition to altered mental status, it is recommended that any patient who has papilledema and/or neurological focal deficits, are immunocompromised, has a history of recent head trauma, or known malignancy should have a non-contrast CT or magnetic resonance imaging (MRI) of the brain implemented prior to a LP due to the potential to herniate from increased intracranial pressure and to rule out hemorrhagic stroke, brain mass lesion, or other intracranial structural abnormalities. Empirical antibiotic treatment and adjunctive dexamethasone should be started once blood cultures are obtained when neuroimaging is going to be performed before the LP. Antibiotic treatment that is administered before the LP will not greatly change the CSF white blood cell count or glucose concentration, inhibit visualization of organisms by Gram’s stain, or inhibit recognition of bacterial nucleic acid by polymerase chain reaction assay. It is unnecessary to execute further imaging studies since this patient’s non-contrast CT is negative. Therefore, the next step is performing a LP with CSF analysis since it can confirm the presence of a CNS infection. Also, an electroencephalogram is implemented to record brain activity and will not aid in diagnosing bacterial meningitis or a CNS infection (Longo et al., 2012; Tunkel et al., 2004).2. Which of the following is this patient’s most likely diagnosis? Provide rationale for your answer.A. Viral meningitisB. Fungal meningitisC. Bacterial meningitisD. Mycobacterial meningitisE. Noninfectious meningeal irritationThe most likely diagnosis for this patient is bacterial meningitis. Bacterial meningitis is a CNS disease caused by bacteria in the subarachnoid space and characterized by inflammation of the meninges around the brain or spinal cord. The diagnosis of bacterial meningitis can be confirmed with the LP with CSF analysis and a culture of the CSF or blood. The CSF analysis of a patient with bacterial meningitis would have an opening spinal fluid pressure above 180 mm H2O and this patient has an opening spinal fluid pressure of 270 mm H2O. Pleocytosis in the CSF is another finding in patients with bacterial meningitis. The white blood cell count can range from 250 to 100,000 cells/mm3 but it typically between 1,000 to 10,000 cells/mm3 with 85% to 95% neutrophils. The amount of mononuclear cells increase when the infection resumes for days. This patient’s CSF white blood cell count is 1,050 mm3 with 93% neutrophils and 7% monocytes. Also, in more than 90% of the bacterial meningitis cases, the amount of protein in the CSF is above 45 mg/dL. This patient’s CSF protein level is 81 mg/dL. The CSF glucose concentration is typically less than 40 mg/dL in patients with bacterial meningitis and this patient’s CSF glucose level l is 121 mg/dL. A Gram stain of the CSF can provide a definite diagnosis in most cases of bacterial meningitis by identifying the causative organism. Also, only 70% to 90% of CSF cultures are positive in bacterial meningitis cases (Ropper & Samuels, 2009). 3. Based on the Gram stain, which of the following antibiotic regimens is most appropriate in this patient? Provide rationale for your answer.A. Penicillin GB. CeftriaxoneC. Ceftriaxone and vancomycinD. Ampicillin and cefotaximeE. CefepimeThe most appropriate antibiotic regimen for this patient based on the Gram stain is ceftriaxone and vancomycin. A Gram stain analysis provides exact identification of the causative organism in 60% to 90% of individuals with community-acquired bacterial meningitis and has a specificity equal to or greater than 97%. Empiric antibiotic treatment should be administered after blood cultures are drawn and before the results of the Gram stain. The most common bacterial pathogens to generate community acquired bacterial meningitis for adults more than 50 years old are Streptococcus pneumoniae, Neisseria meningitides, Listeria monocytogenes, and aerobic gram-negative bacilli. This patient’s Gram stain result suggests Streptococcus pneumoniae as the causative pathogen due to several Gram-positive cocci in pairs. The recommended treatment for bacterial meningitis caused by Streptococcus pneumoniae is vancomycin and a third-generation cephalosporin. Ceftriaxone and cefotaxime are the recommended third-generation cephalosporin medications that can be given for bacterial meningitis. This is the recommended antimicrobial regimen because of the increase incidence of high-level penicillin-resistant pneumococci (Ropper & Samuels, 2009; Tunkel et al., 2004). An Adult Gerontological Acute Care Nurse Practitioner (AGACNP) with a Certificate to Prescribe (CTP) in Ohio can prescribe cephalosporins and oral vancomycin. Intravenous vancomycin can be prescribed by an AGACNP with a CTP in Ohio in an institutional setting per institutional standards or physician initiated/consult (Ohio Board of Nursing, 2013). 4. Complete the following table. Provide references at the end of the table. Table 1Cerebrospinal Fluid Analysis in MeningitisMeasurementNormalBacterial MeningitisAseptic Meningitis (Viral)Granulomatous Meningitis (Mycobacterial, Fungal)Spirochetal MeningitisOpening pressure (mmH20)70 – 180 mmH2OMarkedly elevatedSlightly elevatedModerately elevatedSlightly elevatedWBCs0 – 5 lymphocytes200 – 20,000 polymorpho-nuclear neutrophils25 – 2000, mostly lymphocytes100 – 1,000 mostly lymphocytes100 – 1,000 mostly lymphocytesGlucose (mg/dL)45 – 85 mg/dL< 45 mg/dLNormal or low< 45 mg/dLNormalProtein (mg/dL)15 – 45 mg/dL> 50 mg/dL> 50 mg/dL> 50 mg/dL> 50 mg/dLNote: Values (Papadakis et al., 2013). 5. Should this patient receive adjuvant therapy with dexamethasone? Explain your answer.Yes, this patient should receive dexamethasone for adjuvant therapy. Dexamethasone is a synthetic glucocorticoid and is used as an anti-inflammatory or immunosuppressant agent (Lexi-Comp, Inc., 2013). Recent clinical trials have revealed when 10 mg intravenous of dexamethasone is administered prior to the first dose of antibiotics and given every six hours for four days it decreases the mortality rate and improves the overall result of the patient (Ropper & Samuels, 2009). Dexamethasone should be given 15 to 20 minutes prior to the first administered antibiotic treatment in order to allow adequate time for the macrophages and microglia to block the production of tumor necrosis factor-alpha (TNF-α). The inflammatory cytokines TNF-α and interleukin-1 beta (IL-1 β) are produced in the subarachnoid space due to the destruction of the bacterial cell wall from bactericidal antibiotics. Dexamethasone has exhibited its effectiveness in decreasing the incidence of sensorineural hearing loss, seizures, and coma. However, dexamethasone can cause learning deficits by increasing hippocampal cell injury (Longo et al., 2012). Also, adjunctive dexamethasone should not be given when an antibiotic treatment has already been administered to a patient because it is improbable that dexamethasone will improve the patient result (Tunkel et al., 2004). ReferencesBahn, R., Burch, H., Cooper, D., Garber, J., Greenlee, M., Klein, I., … Stan, M. (2011). Hyperthyroidism and other causes of thyrotoxicosis: management guidelines of the American Thyroid Association and American Association of Clinical Endocrinologists. Endocrine practice: official journal of the American College of Endocrinology and the American Association of Clinical Endocrinologists, 17, 456-520. Retrieved September 20, 2013, from , G. (2010). Current diagnosis and treatment: Surgery (13th ed.). New York, NY: McGraw-Hill Companies.Gardner, G., & Shoback, D. (2011). Greenspan’s basic and clinical endocrinology (9th ed.). New York, NY: McGraw-Hill Companies.Greenberg, D., Aminoff, M., & Simon, R. (2012). Clinical Neurology (8th ed.). New York, NY: McGraw-Hill Companies.Klubo-Gwiezdzinska, J., & Wartofsky, L. (2012). Thyroid emergencies. Medical Clinics of North America, 96, 385-403. doi:10.1016/j.mcna.2012.01.015Lexi-Comp, Inc. (2013). Lexi-DrugsTM. Lexi-Comp, Inc. Accessed October 5, 2013. Longo, D., Fauci, A., Kasper, D., Hauser, S., Jameson, L., & Loscalzo, J. (2012). Principles of internal medicine (18th ed.). New York, NY: McGraw Hill Education. McCance, K., & Huether, S. (2010). Pathophysiology: The biologic basis for disease in adults and children (6th ed.). Maryland Heights, MO: Mosby Elsevier.Ohio Board of Nursing (2013). The formulary developed by the committee on prescriptive governance. Retrieved October 5, 2013, from , M., McPhee, S., & Rabow, M. (2013). Current medical diagnosis and treatment (52nd ed.). New York, NY: McGraw Hill Medical. Ropper, A., & Samuels, M. (2009). Adams and victor’s principles of neurology (9th ed.). New York, NY: McGraw-Hill Companies.Tunkel, A., Hartman, B., Kaplan, S., Kaufman, B., Roos, K., Scheld, W., & Whitley, R. (2004). Practice guidelines for the management of bacterial meningitis. Clinical Infectious Diseases, 39(9), 1267-84. doi:10.1086/425368 ................
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