Applying Pharmacotherapy Principles and Practice: How to Use This Study Guide

As health care becomes more complex in the 21st century, the health professional student increasingly is challenged to learn a rapidly expanding amount of information as well as necessary skills to obtain and apply that knowledge in a patient care setting. Students of pharmacotherapy quickly learn that the field is rapidly changing as our knowledge of human disease evolves and new drugs are developed to improve patient outcomes. Students also learn that while drug therapy can have tremendous beneficial effects on patient outcomes, such therapy also has the potential to cause harm. The “art” of pharmacotherapy is in applying knowledge and making therapeutic decisions that are most likely to have maximum positive benefit for a specific patient. As a companion book to Pharmacotherapy Principles and Practice, 6th ed. (PPP), this study guide combined with a simplified electronic medical record (EMR) is designed to assist the student in learning how to obtain and apply didactic knowledge to specific patient situations. Such application requires skills that cannot be learned in lectures or in other passive learning situations but must be learned by practice and repetition. The more students practice applying their knowledge, using their patient assessment skills, and making therapeutic decisions in their preclinical courses, the more prepared they will be to apply these skills to real patients in their clinical rotations.

This study guide is more than a group of patient cases, but it uses patient cases to help students learn to apply pharmacotherapeutic knowledge and skills. Case-based learning is not a new concept in health sciences curricula. As a form of active learning, case-based learning allows the student to practice the skills necessary to provide patient care. The focus of the cases in this study guide is, of course, pharmacotherapeutics. A unique feature of this study guide is the expectation that the student will develop a pharmacotherapy care plan as the “output” for each case while obtaining patient information from an EMR. What follows is a general discussion of the patient care process and then specific information regarding the use of the study guide and development of the pharmacotherapy care plan.

Most pharmacy students are taught about pharmaceutical care early in their pharmacy curriculum. Pharmaceutical care, first described in the late 1980s and early 1990s,¹ can be summarized as “… patient-centered practice in which the practitioner assumes responsibility for a patient’s drug-related needs and is held accountable for this commitment.”² Although the definition of pharmaceutical care does not explicitly state that pharmacists are to perform these tasks, many feel that pharmaceutical care is the central mission of the pharmacy profession.

Although it may seem obvious that health professionals practice in a patient-centered way, all too often, practitioners become distracted by technical or administrative tasks. Pharmacy students, upon graduation, commit to patient-centered practice in the updated Oath of a Pharmacist:³

“I promise to devote myself to a lifetime of service to others through the profession of pharmacy. In fulfilling this vow:

• I will consider the welfare of humanity and relief of suffering my primary concerns.

• I will promote inclusion, embrace diversity, and advocate for justice to advance health equity.

• I will apply my knowledge, experience, and skills to the best of my ability to assure optimal outcomes for all patients.

• I will respect and protect all personal and health information entrusted to me.

• I will accept the responsibility to improve my professional knowledge, expertise, and self-awareness.

• I will hold myself and my colleagues to the highest principles of our profession’s moral, ethical and legal conduct.

• I will embrace and advocate changes that improve patient care. I will utilize my knowledge, skills, experiences, and values to prepare the next generation of pharmacists.

I take these vows voluntarily with the full realization of the responsibility with which I am entrusted by the public.”

A central tenet underlying pharmaceutical care and our desire to improve drug therapy outcomes is the recognition that patients have drug therapy needs. Although sometimes these needs are obvious (“What can I take for my headache?”), in many cases the patient’s drug therapy needs are unrecognized. For the practitioner committed to responsibility for a patient’s drug-related needs, identifying such needs in an accurate and timely way is paramount. During any pharmaceutical care encounter, the patient must be assessed to determine whether the following drug therapy needs are being met:²

1. The medication is appropriate

2. The medication is effective

3. The medication is safe

4. The patient is adherent

The challenge for the beginning pharmacotherapeutic practitioner is in application. How does a student learn to take the scientific and factual information learned in the classroom and in readings and then apply it to patients so that drug therapy outcomes are maximized? This study guide is designed for this purpose, to teach the student the patient care process: how to organize patient information, assess patients in a systematic way, and develop a pharmacotherapy care plan.⁴

All clinicians need a structured rational thought process for making clinical decisions. What sets each profession and professional apart is the application of a unique knowledge base and set of clinical skills to identify and solve problems and to prevent problems from occurring. In the context of drug therapy, Cipolle et al. termed this structured process the “Pharmacotherapy Workup.”²

There are five steps that comprise the patient care process and constitute the Pharmacotherapy Workup (see Fig. 1-1): Collect, Assess, Plan, Implement and Follow-up. As Figure 1-1 indicates, each stage of the process is connected to and continuous with the other stages, and the process is ongoing as the patient’s situation changes.

Collect

The purpose of the collection stage is to gather patient-specific information and then determine if the patient’s drug therapy needs are being met.⁵ To develop the best possible pharmacotherapy plan for the patient, the information gathered must be as accurate and complete as possible. Inaccurate or incomplete information may result in bad therapeutic decisions. There are a variety of sources from which such information is gathered. Although the specific sources may differ based on the patient’s situation, the clinician must strive to obtain information from all available sources. The patient is a crucial source of information, as are family members, caregivers, and other health professionals. In a health-system setting (hospitals, ambulatory care clinics, etc.), the clinician also will have access to subjective and objective information recorded in the patient’s electronic or paper medical record and other institutional databases. For the pharmacotherapy workup, particular attention must be given to obtaining a complete and accurate medication history. Remember that since the patient care process is continuous, the gathering of patient-specific information also must be ongoing. Such information must be documented in an organized and easily retrievable way that maintains patient confidentiality. Since there may be a large volume of patient-specific information generated, particularly in a hospitalized patient, the use of a standardized patient data form facilitates the organization and retrievability of patient-specific information. Despite the clinician’s best effort, in most cases there will be information that is inaccurate and/or incomplete. Never assume that you have all the information you need or that the information you have is correct. The clinician must be mindful of this and seek to “fill in the blanks” by asking appropriate follow-up questions or seeking additional information from other sources.

Assess

After all available information is collected, the next step is to develop a problem list.⁶ The concept of problem list development is well established in the context of the problem-oriented medical record and the use of the SOAP (Subjective, Objective, Assessment, Plan) method of charting progress notes. The development of an accurate and complete problem list based on the patient’s drug therapy needs is crucial in that the development of the pharmacotherapy care plan is derived from the patient’s problem list. If a problem is not listed or is not accurate, then the plan will be incomplete or suboptimal. The problem list must be prioritized to ensure that the most important problems are addressed in a timely fashion. For the student learning pharmacotherapy, developing an accurate and complete list of problems is challenging since many pieces of subjective and objective information (findings) have to be interpreted before something can be labeled as a problem. In many cases, problems are medical diagnoses (hypertension, type 2 diabetes, etc.), and in some cases the problem may be a symptom (headache, nausea, pain, etc.). Keep in mind that the definition of a problem may change as more information is gathered. For example, a patient may present with fatigue and, in the absence of other information, that is how the patient’s problem is defined at that specific time. However, if the patient is referred to a physician and is found to have hypothyroidism, then the patient’s problem list is changed to hypothyroidism, with fatigue as a symptom of the patient’s hypothyroidism. A common trap for the beginning student is listing every finding as a problem. With thought and, ultimately, experience, the student will begin to see that the patient’s signs and symptoms may be “lumped” into broader problems. If the above-mentioned patient also has cold intolerance, cognitive impairment, weight gain, elevated thyroid stimulating hormone (TSH), and slightly elevated low-density lipoprotein (LDL) cholesterol, the patient’s problem is still hypothyroidism, since each of those findings is a common sign/symptom of hypothyroidism. Although the pharmacotherapy problem list may be very similar to the problem list generated by other clinicians or the problem list present in the patient’s medical record, remember that the pharmacist, having a unique body of knowledge, should have a different way of looking at the patient, and the problem list may not be entirely the same. The pharmacotherapy workup must be focused on drug therapy issues, particularly on the presence or risk of drug therapy problems (DTPs). During the entire process, always ask yourself:

• Could the patient’s problem(s) be caused by drug therapy?

• Could the patient’s problem(s) be managed by a change in drug therapy?

Assessment for Drug Therapy Problems

The primary focus of the pharmacotherapy workup is the identification and management (treatment and prevention) of DTPs. A DTP is defined as any undesirable event or risk experienced by the patient that involves or is suspected to involve drug therapy and that actually or potentially interferes with a desired patient outcome.⁷ Strand et al.’s original list of DTP categories has been expanded to 14 categories:

• Correlation between drug therapy and medical problems

• Need for additional drug therapy

• Unnecessary drug therapy

• Appropriate drug selection

• Wrong drug

• Drug regimen

• Dose too low

• Dose too high

• Therapeutic duplication

• Drug allergy/adverse drug event

• Interactions

• Failure to receive therapy

• Financial impact

• Patient knowledge of drug therapy

Since there are so many categories and specific types of DTPs, and since patients often receive multiple medications, it is important to use an organized, systematic approach to identify actual and potential DTPs. Once a DTP is identified and categorized, it is then necessary to identify the cause of the problem, thereby leading to potential solutions. When multiple DTPs are identified, they need to be prioritized to determine which problems should be addressed first. The patient’s concerns must be considered in determining the problems that have the highest priority. Remember that the process of DTP identification is connected to the basic tenets of assessing the patient’s drug therapy needs—appropriateness, effectiveness and safety of medications, and the patient’s adherence.

Plan

The pharmacotherapy care plan^8,9 is the roadmap to achieving improved pharmacotherapy outcomes. It is the action plan developed on the basis of the assessment components described above. Care plans have been an integral component of nursing care, and other professionals or certain health care settings may utilize components of a care plan. However, there is no standard or widely accepted method of care plan development in pharmacy. Standard 2.1 of the 2016 accreditation standards for pharmacy education in the United States¹⁰ requires that “…The graduate is able to provide patient-centered care as the medication expert (collect and interpret evidence, prioritize, formulate assessments and recommendations, implement, monitor and adjust plans, and document activities).” Ideally, the patient’s care plan should be constructed with the patient’s involvement and, in a multidisciplinary fashion, developed and altered in a cooperative way by all who are involved with the patient’s care. Further, pharmacotherapy care planning should be a component of the patient’s overall care plan. Care plans developed in isolation or not shared with the patient or other professionals are less likely to have the desired effect on patient outcomes. A pharmacotherapy care plan must be generated as part of the systematic patient care process and should be a dynamic document that reflects changes in the patient’s conditions and drug therapy needs. The care plan is developed in a problem-oriented fashion. Each item in the patient’s problem list must be addressed in the care plan, and the care plan should be prioritized in the same way as the problem list.

The pharmacotherapy care plan has several key components for each problem:

• Current drug regimen

• Drug therapy problems

• Therapy goals, desired endpoints

• Therapeutic recommendations

• Rationale

• Therapeutic alternatives

• Monitoring and follow-up

• Patient education

In patients who have multiple problems, there likely will be some redundancy in the pharmacotherapy care plan in that some problems may be related, and some medications may be used for multiple indications. As the care plan is developed, it is important for the student to see and understand the connections among multiple problems and the pharmacotherapy plan. For example, a patient with hypertension, type 2 diabetes, and chronic kidney disease may be treated with an angiotensin-converting inhibitor (ACE-I) to lower blood pressure (BP), slow progression of renal disease, and reduce risk of cardiovascular events. The student must understand not only that the one drug may be used for several reasons but that the drug could affect the patient’s problems in a variety of ways, such as improving BP control while causing an increase in serum potassium or an acute rise in serum creatinine. The risk and significance of these effects must be considered based on the overall clinical picture. In some patients, unintended effects, at least to a defined point, may be acceptable.

Defining therapy goals and endpoints is crucial. You cannot determine whether the patient’s desired outcomes are being achieved if you do not know what those desired outcomes are. Think of goals as broad or general outcomes, whereas endpoints are more specific parameters often used as indicators or surrogate markers to indicate that our goals are being achieved. The goals of therapy must be achievable and realistic for the patient. Drug therapy may aim to (1) cure a disease; (2) reduce or eliminate signs and/or symptoms; (3) slow or halt the progression of a disease; (4) prevent a disease; (5) normalize laboratory values; and/or (6) assist in the diagnostic process. Goals and endpoints must be observable, measurable, and describable using specific parameters.

Going back to our diabetic, hypertensive patient mentioned above, the goals of treating those disorders are to prevent cardiovascular disease (stroke, coronary artery disease, peripheral vascular disease), kidney disease, other microvascular complications of diabetes (retinopathy, neuropathy), etc. We also want the patient to feel better and have improved quality of life (QOL). An important goal of any pharmacotherapy care plan is the avoidance of adverse events. We do not want the patient to have side effects or a worsened QOL due to our recommended drug therapy. What would be endpoints for our patient? In our hypertensive diabetic patient, some endpoints would include BP <130/80 mm Hg, glycated hemoglobin <6.5-7% (0.065-0.07; 48-53 mmol/mol Hb), LDL cholesterol <130 mg/dL (<3.36 mmol/L), and weight loss of 22 lb (10 kg). Goals and endpoints should be associated with a time frame, describing, if possible and realistically, when the goal or endpoint is to be achieved (BP <130/80 mm Hg in 1 month; 22 lb (10 kg) weight loss in 6 months, etc.). The goals and endpoints part of the plan will be directly tied to the monitoring part of the plan, since monitoring is the way we will know if our goals and endpoints have been achieved.

Implement

Therapeutic recommendations are the interventions made to meet the patient’s drug therapy needs. The recommendations must be specific and individualized to the patient’s condition and drug therapy problems. For most problems, there are several ways to intervene to achieve the desired goals and endpoints. The clinician must consider all the possibilities and recommend a therapeutic course that is best for that patient, based on scientific evidence, patient history, cultural and health beliefs, psychosocial issues, health literacy, and cost. Remember that therapeutic recommendations for one problem may have an impact on other problems, so do not lose sight of the big picture.

Although it is important for the clinician to make appropriate therapeutic recommendations, providing a rationale for those recommendations is necessary. The rationale is why you are recommending what you are recommending. From an educational standpoint, providing a well-reasoned rationale shows that the student is thinking and understanding, rather than repeating what is in a book, guideline, or said by others. In the clinical practice setting, it is common for pharmacists to be asked to provide their rationale to other providers as part of a discussion about a patient’s therapy. Pharmacists need to be adept at providing such a rationale in a succinct way. The rationale should be stated in a way that clearly describes why the recommendation was made for this patient, including why it was chosen over other alternatives, and any evidence available to support the recommendation should be provided.

In determining your therapeutic recommendations, several reasonable alternative regimens typically are available. Even after you have recommended your primary plan, the best alternatives must be kept in mind. The patient or prescriber may not agree with your primary recommendation and request an alternative. Your primary plan may not be effective, or an intolerable adverse event may occur, thereby requiring implementation of an alternative plan. As with your therapeutic recommendations, be specific with your alternative recommendations and base your alternative choices on relative effectiveness and safety based on the best evidence available.

Follow-up: Monitor and Evaluate

Monitoring and follow-up are important components of the pharmacotherapy care plan and the overall patient care process.¹¹ Monitoring is how we determine whether our goals and endpoints (achieving positive goals and avoiding negative endpoints) are being reached. An effective monitoring plan must be realistic for the patient setting and include specific monitoring parameters (clinical and laboratory/diagnostic tests), frequency of monitoring, and when the patient needs to be seen again for follow-up. Students often struggle with developing a monitoring plan since references often provide only general recommendations for what to monitor and how often. In most patients, the intensity and frequency of monitoring are dynamic. In a critically ill hospitalized patient, some pharmacotherapy monitoring parameters may be assessed multiple times daily. As the patient becomes more stable, leaves the intensive care unit (ICU), and is, hopefully, discharged home, monitoring becomes less frequent. A patient initiated on warfarin in the hospital may have an international normalized ratio (INR) measured daily. After discharge with a therapeutic INR, monitoring may be done weekly, and as the patient’s INR and clinical status remain stable, the frequency is slowly reduced until the INR is measured monthly. If the INR or the clinical picture changes, the frequency of INR monitoring likely will be temporarily increased. Regardless of the setting, the frequency of monitoring, particularly for those parameters involving blood collection or other invasive tests, must be realistic and based on how often the information truly is needed, what the patient can or is willing to allow, availability of vascular access, and, in the outpatient setting, the ability of the patient to travel to a laboratory or the availability of home care services. In the home setting, some of the monitoring may be done by the patient, such as assessing presence and severity of signs and symptoms, basic physical assessment parameters (e.g., weight, presence of edema), and certain diagnostic or laboratory tests (e.g., BP, blood glucose). The monitoring plan must be specific—what parameters, frequency of monitoring, who will monitor, and when and with whom the patient will follow-up. The results of monitoring naturally will influence the pharmacotherapy care plan, and in many cases, there should be an upfront determination of what action will be taken based on the results of the monitoring plan (e.g., “the patient’s INR is <2, the warfarin dose will be increased from 4 to 5 mg daily”).

Patient education is a crucial piece of the pharmacotherapy care plan. Patient adherence to drug therapy can be improved with effective and ongoing patient education, and ideally, such education should be provided with verbal communication and written materials. Pharmacy students should utilize skills learned in their communications courses and information available in books^12,13 and begin applying those skills in case-based learning, small group discussions, and internship experience in preparation for their pharmacy practice experience rotations and, ultimately, pharmacy practice. The pharmacotherapy care plan must include a summary of what you will tell and provide the patient regarding their drug therapy.

Remember that our model for the patient care process involves continuous follow-up. As the pharmacotherapy care plan is implemented, the patient’s response to therapy is monitored, and changes in therapy may be necessary. Changes in previous problems or the development of new signs and symptoms will require the assessment process and changes in the pharmacotherapy care plan. Although the patient care process and the application of your didactic knowledge to the patient care setting may seem daunting, by working through the cases in the Study Guide, your skills can only get better and better. Although this book can be used for self-study, ideally, some of the cases in this Study Guide will be used in a small group discussion setting under the guidance of a group facilitator, so you can see how other students think. Group settings also provide the opportunity to discuss and defend your therapeutic recommendations and practice your verbal communication skills. As you work through the patient cases, you will make mistakes and perhaps choose suboptimal therapy that even could cause harm. Beginners always make mistakes, and you should use these mistakes as powerful learning opportunities. Here are some tips for success in patient care:

• CARE about the patient!

• Know your stuff—be prepared

• Realize that every patient is different

• Review and assess all available information

• Be organized and consistent in your approach

• Do not make snap judgments—is your assessment and approach supported by the evidence?

• NEVER make assumptions

• Be skeptical

• Think ahead, and think it through (“… then what?”)

Each patient case in the study guide has been prepared in a standard format, similar to how you will see cases presented in a clinical setting in an EMR. The use of an organized case format will assist you in learning where to find information about the patient and help you get accustomed to the format for when you will be presenting patients yourself in case discussions or rotations. The patient cases in the study guide are meant to be realistic. Patients usually will have multiple, sometimes related, problems, though each case will focus on one primary topic or problem. Patients will have DTPs requiring identification and management. The components of each case in EMR format in study guide include:

1. Patient Identification—name, age, etc.

2. Chief Complaint—why the patient is seeking help, in the patient’s own words.

3. History of Present Illness (HPI)—the patient’s story about why they are seeking help.

4. Past Medical History (PMH)—including all significant illnesses, surgical procedures, injuries.

5. Family History—age and health of immediate family (parents, siblings, children); for deceased relatives, the age and cause of death are included; any hereditary diseases should be noted.

6. Social History—may include where the patient is from or lives, ethnicity/race, marital status, number of children, educational background, occupation, diet.

7. Social Determinants of Health.

8. Health Literacy.

9. Insurance status.

10. Tobacco/Alcohol/Substance Use.

11. Allergy/Intolerances/Adverse Drug Events (ADEs)—a common area where information from the patient is missing or incomplete.

12. Medication History—should include current (or medications prior to admission if hospitalized) and previous medications; the list should include what the patient actually is taking, not just what is prescribed, and must include OTC drugs and dietary supplements (including herbal and complementary/alternative products).

13. Immunization History.

14. Review of Systems (ROS)—systematic, head-to-toe questions asked to elicit symptoms and potential problems not noted by the patient in the HPI. Positive findings and pertinent negatives (significant absence of a symptom) are included.

15. Physical Examination (PE)—nature and completeness of the examination will depend on the patient’s history and overall clinical picture. Rarely will a complete PE be done; rather, the examination will be targeted to the situation. Positive and pertinent negative findings will be included in the PE. If you are not familiar with the meaning or significance of some of the examination findings, make sure you look those up. Components of the PE may include:

    • General

    • Vital Signs (include pain as fifth vital sign)

    • Skin

    • HEENT

    • Neck and Lymph Nodes

    • Chest

    • Breasts (in women)

    • Cardiovascular

    • Abdomen

    • Neurology

    • Extremities

    • Genitourinary

    • Rectal

16. Laboratory and Other Diagnostic Tests—only data that are common and/or directly relevant to the case will be included. A list of normal laboratory values is included as Appendix B of this study guide. All laboratory results will be presented in conventional units typically used in the United States and in Systéme Internationale (SI) units for students using the book in other countries. If you are not familiar with the meaning or significance of some of the laboratory findings, make sure you look those up.

17. Assessment—the clinician’s impression and/or diagnosis.

18. Student Workup—for each case, you will be asked if there is missing information and to evaluate and develop a Patient Database, Drug Therapy Problem Worksheet, and Pharmacotherapy Care Plan. When you are working with actual patients, you will find that the patient’s history and information from other sources including EMR can be incomplete and/or inaccurate. Patient cases in the study guide will have missing information, and it is important that, as you evaluate each case, you recognize what needed information is missing so that you can make an accurate assessment of the patient. One way to remember to assess for missing information is to always create as one of your patient’s problems “Inadequate Database,” and then list the missing information elements under that problem in your Care Plan. A more detailed description of the Patient Database, Drug Therapy Problem Worksheet, and Pharmacotherapy Care Plan forms will follow.

19. Targeted Questions—each case will include a series of questions targeted toward helping you better understand the key elements of the case and the patient’s primary problems. A unique feature of this study guide is questions will be followed by a hint that will often guide you to the pages in Pharmacotherapy Principles and Practice, 6th ed. (PPP) or other important reference material where you can find the information to answer the question.

20. Follow-up—some cases will provide a brief clinical follow-up that may include some outcomes of your initial Care Plan. The Follow-up section may include additional Targeted Questions, with hints to further assist your studies.

21. Global Perspective—another unique feature of this study guide is the inclusion of a Global Perspective section that highlights an issue related to the case that is important to countries outside North America or involves different ethnic groups or races. Global Perspectives may highlight differences in disease incidence or manifestations, pharmacokinetics or pharmacodynamics, treatment standards, culturally based beliefs and/or treatments, and drug response.

22. Case Summary—a short summary of the key points addressed by the case.

23. References—will be included in the patient case only if a key reference has been published that is not included in PPP. For most cases, the references included in the relevant PPP chapters are excellent sources for you to obtain additional information.

The desired student workup of each case in this study guide is the development of a Pharmacotherapy Care Plan. The principles of the pharmacotherapy workup, patient assessment, and development of a care plan were reviewed earlier in this chapter. Your workup of the study guide cases will apply these principles. To facilitate your accomplishing these tasks in a thoughtful, organized, and systematic way, you are provided three forms—Patient Database, Drug Therapy Problem Worksheet (DTPW), and Pharmacotherapy Care Plan. The forms used in this study guide are adapted with permission from those originally developed by the American Society of Health-System Pharmacists (ASHP) in the early 1990s as part of its Clinical Skills program,^5,6,8,11 and similar forms are currently used by participants in the ASHP Clinical Skills Competition (https://www.ashp.org/about-ashp/awards/student-awards/ashp-clinical-skills-competition).

Different clinicians and institutions use many different types of patient-monitoring forms. Think of the forms used in this study guide as a tool to help you learn to provide the best patient care. The forms are designed to help you organize information and your thinking. Although you will find the use of such forms helpful, do not obsess about the forms or using them the “right” way. Again, the forms are a tool to help you achieve what you should obsess about—making the patient’s drug therapy the best it can be.

To help you understand how to best utilize these forms as you workup the study guide cases, we have prepared a practice case presented in the same format as other cases in the study guide and a completed student workup. Before you embark on your first study guide patient case, look over the practice case and the completed forms. We added some tips in certain places in the practice case forms to help you better understand their application. Learning to effectively assess patients and develop a care plan involves skills that require practice and repetition. As you begin learning pharmacotherapeutics, applying your didactic knowledge to patient situations may seem difficult, and it is likely you will make mistakes. That’s okay! The point of this study guide is to help you learn and to develop your skills. Through your coursework, reading, and use of this guide, you will see your knowledge and skills increase and you will become a great practitioner who will improve patient drug therapy outcomes.

Learning Objectives

• Recognize the signs, symptoms, and risk factors for hypovolemia, hypokalemia, and metabolic alkalosis

• Develop an appropriate treatment and monitoring plan for hypovolemia, hypokalemia, and metabolic alkalosis

• Recognize the impact of pregnancy on medication choice and disease management

Chief Complaint

“I feel so tired and dizzy, and I can’t stop throwing up.”

EMR Link for Practice Case

Insert link to chapter 1 patient case at http://mcgrawhilltherapeuticsehr.com/v2/index.html?Chapter=1#

Brief Assessment

Twenty-three-year-old pregnant woman with ECF volume depletion, vomiting and diarrhea, significant hypokalemia with ECG changes, hyponatremia, and metabolic alkalosis. Urine toxicology screen indicates active illicit drug use.

Student Workup

1. What signs and symptoms of ECF volume depletion, hypokalemia, and metabolic alkalosis does the patient have?

   Hint: See Body Fluid Compartments, Electrolytes, and Basic Pathophysiology in PPP

2. What are the causes of this patient’s alkalosis?

   Hint: See Table 28-5 in PPP

3. What are the risks of administering potassium intravenously?

   Hint: See Electrolytes in PPP

4. What are the signs and symptoms of opioid withdrawal, and what drug interactions may occur with methadone?

   Hint: See Treatment in PPP

5. What medications have proven to have teratogenic effects in humans?

   Hint: See Pathophysiology in PPP

Three months later, the patient calls you after being discharged from an inpatient substance abuse program. She says she feels great, is staying clean, and her baby is doing well. Her obstetrician recently told her that she has low thyroid and wants her to take levothyroxine. She is afraid that it will hurt her baby and she wants your advice. You look up her laboratory tests in the computer and note that her TSH is 10.1 µIU/mL (10.1 mIU/L). What is your advice to her?

Hint: See Hypothyroidism and Table 48-7 in PPP

• Young pregnant woman with history of depression, eating disorder, and substance abuse who presents with ECF volume depletion, hypokalemia, and metabolic alkalosis due to vomiting and diuretic use. Volume and potassium replacement must be initiated, and the underlying causes addressed to prevent recurrence.

• She is actively abusing drugs, placing her and the fetus at risk for multiple complications. Substance abuse treatment referral is warranted.

• The patient needs a referral to an obstetrician for assessment and prenatal care.