Examining the case of Charles Gibson, construct and explain a concept map that describes how you would expect polypharmacy and his age to affect the pharmacokinetics of his medications. Include a discussio 

PATIENT:  CHARLES GIBSON (CHARLIE)

DOB:  OCTOBER 12, 1942

AGE:  74

SEX: MALE

INSURANCE:  BC/BS of SENECA

Presented to the Emergency Room complaining of a fluttering in his chest for the past couple of weeks on and off.  The time of onset of the dizziness and syncope was approximately 30 minutes ago.

Has history of hypertension for which he refuses to take the medication prescribed for him.  Patient states "I feel fine without it."  He has the medication but has not yet opened the prescription bottle.

Has been diagnosed with Diabetes Mellitus Type II for which he takes Metaforim at 1000 mg/day.

Keeps up with his doctor's visits which are scheduled every four months.

Smokes a half of a pack of cigarettes every day.  Cut down from one pack per day over the past couple of years as his doctor told him. 

Enjoys all kinds of food including fried food, fast food and "soft drinks".

He has no acute distress.

NKDA

 

BP:  160/100

HEART RATE:  106 rhythm- Atrial fibrillation

RR: 26 even, slightly labored

Pulse ox- 97% on 2L/min oxygen 

IV- normal saline 75ml/hr

TEMP:  100.5

WEIGHT:  250 pounds

HEIGHT: 6'0" / 113.398 kg

BMI:  33.9

 

(time: one hour ago) Orders:

• CT scan stat
• Neuro-surgical consult stat
• Oxygen 2-3Liter.  Titrate for an oxygen saturation to > 93%
• Tylenol grX  rectal  for fever > 100.5
• Two 18gauge needle IVs
• Normal saline 500ml/hour x 1 hour-  then 100ml/hour x 6 hours.
• Keep BP systolic < 185   > 110
• Keep   diastolic < 105  > 60
• Keep HR > 50  < 110
• 50 mg/ 250 ml  [Titrate]-   Dosing: Initial: 0.3 to 0.5 mcg/kg/min--increase by 0.5 mcg/kg/min increments. 
• May titrate Na nitroprusside to desired BP
• 12- Lead EKG

Labs now:

·         CBC with differential

·         Complete metabolic panel

·         Type and  hold

·         Coagulation profile

·         Comprehensive drug screen with blood alcohol level.

·         CK MB isoenzymes

Call me with results of all labs…

(time: Just now)  Admit to ICU please

 Tissue plasminogen activator now please.  Use a 100mg/100ml bag on Normal Saline.   Use the dosing chart below.

t-PA Dosing Chart (estimated weight)

1.     Do not perform for 24 hours post tPA unless procedure is life-saving: Arterial or central venous punctures/lines, IM injections, nasogastric tubes, Foley catheters

2.     Place the patient on anticoagulation precautions until 24 hours after the infusion

3.     Do not give any antithrombotic drugs (including heparin, warfarin, aspirin, clopidogrel, dipyridamole, ticlopidine, or NSAIDS x 24 hrs)-

Blood pressure monitoring:

During the first 24 hours after tPA, monitor BP:
- Every 15 minutes for 2 hours after starting the infusion, then
- Every 30 minutes for 6 hours, then
- Every 60 minutes until 24 hours after starting treatment

If systolic blood pressure is >180 mmHg or if diastolic blood pressure is >105 mmHg for 2 or more readings 5 to 10 minutes apart, use the following guide:

1.     First tier intervention:  Give IV labetalol 10 mg over 1 to 2 minutes. Labetalol may be repeated up to 3 doses every 10 to 20 minutes (doubling doses if needed depending on effect of preceding dose; eg. 1st dose-10mg, 2nd dose- 20mg, 3rd dose- 40mg, then consider drip)

2.     - For heart rate<60/minute, use hydralazine 5-20mg intravenous over 1-2 minutes every 20-30 minutes.  After second bolus, consider second line intervention.

3.     - Monitor blood pressure and neurologic exam every 15 minutes during treatment and observe for development of hypotension for all 3 tiers of BP interventions.

4.     Second tier intervention:  If 3 doses of labetalol or hydralazine bolus or 30 minutes pass without sufficient BP control, the next step should be a nicardipine drip.

5.     Third tier intervention:  If nicardipine drip fails, then the next step should be a labetalol drip.

**To avoid worsening of cerebral ischemia, target BP of 155-175/85-100.

1.     Swallow Evaluation in 24 hours.

2.     When tPA complete, begin IV infusion of Amiodarone

3.     150-mg IV bolus over 10 minutes (if necessary, bolus may be repeated in 10 to 30 minutes); then 1 mg per minute for 6 hours; then 0.5 mg per minute for 18 hours; then reduce IV dosage or convert to oral dosing when possible.

Call with results of all labs

·         CBC with differential

·         Complete metabolic panel

·         Type and  hold

·         Coagulation profile

·         Serum comprehensive drug screen with blood alcohol level.

·         CK MB isoenzymes

Blood test Results:

White Blood Cell Evaluation 

TEST	FULL NAME - NORMALS	PATIENT RESULT
WBC	White Blood Count	10,000/mm3
Neu,  PMN, polys	Absolute neutrophil count, % neutrophils-   50%-75%	70%
Mono	Absolute monocyte count, % monocytes   0 .6- 9%	4%
Eos	Absolute eosinophil count, % eosinophils    0.3-7%	4%
Baso	Absolute basophil count, % basophils  0.3-2%	1%

RBC Evaluation

TEST	FULL NAME - NORMALS	PATIENT RESULT
RBC	Red Blood Count 3.6-5.0 million/ml	3 million/ml
Hb	Hemoglobin W-  12-16g/dl	12g/dl
Hct	Hematocrit  W- 38-46%	36%
Eos	Absolute eosinophil count, % eosinophils    0.3-7%	4%
Baso	Absolute basophil count, % basophils  0.3-2%	1%

PLATELET Evaluation 

TEST	FULL NAME - NORMALS	PATIENT RESULT
PLT	Platelet Count 150-450,000	200,000

 

TEST	FULL NAME - NORMALS	PATIENT RESULT
Ca+	Calcium 8.5-10.5mg/dl	8 mg/dl1
Albumin	Albumin   3.5-5.0g/dl	4.0 g/dl
Serum total protein	6.4-8.3 g/dl	7.5 g/dl
Na+	135-145  mEq/L	135 mEq/L
K+	3.5-5.0mEq/L	4.2 mEq/L
CL	95-110	100
CO2	22-26 mEq/L	24
BUN	5-15	22
Cr	.5-1.5	1.5
GLUCOSE	70-110	220
PTT	25-40 secs	30
PT	10-15 secs	15
INR	1	1
Fibrin split products	0	Â
D-Dimer  (FSP)	< 230 ng/ml	Â
Fibrinogen	1. G/dl	 < 1 g /dl
Uric acid	3.5-7	7
Lactate level	< 2	2

 

CK MB isoenzymes

CPK-1 (also called CPK-BB)       positive

CPK-2 (also called CPK-MB)      negative

CPK-3 (also called CPK-MM)     negative

Blood alcohol level- 40

 

Serum comprehensive drug screen  

1.    Amphetamines    neg

2.    Methamphetamines   neg

3.    Barbiturates  neg

4.    Benzodiazepines   neg

5.    Marijuana     neg

6.    Cocaine     neg

7.    Opiates     neg

8.    Phencyclidine    neg

9.    Methadone   neg

10.  Propoxyphene   neg

Type and  hold: 

Blood type-     AB +

Antibodies    negative

 

 

Receives 1000 mg daily

 

 

Results of CT scan:

Left side reveals an area of slight hypodensity consistent with an ischemic  area on the left .  Right side reveals no specific areas of hypodensity. 

 

MD Performed stroke severity scale

(NIH stroke scale)

Consult NIH Stroke Scale Chart

 Results revealed:

1a. Level of Consciousness

Scale Definition:

0 = Alert; keenly responsive.

1b. LOC Questions

Scale Definition

0 = Answers both questions correctly

1c. LOC Commands

Scale Definition

0 = Performs both tasks correctly.

 2. Best Gaze

Scale Definition

1 = Partial gaze palsy. Gaze is abnormal in one or both eyes, but forced deviation, or total gaze paresis is not present. Able to move one or both eyes, but may not be able to cross midline.

3.  Best Visual.

Scale Definition

1 = Partial hemianopia. Includes loss in only one quadrant.

4.  Facial Palsy.

Scale Definition

2 = Partial paralysis. Total or near-total paralysis of lower face.

5.  Motor Arm. (a. Left Arm, b. Right Arm)

Scale Definition

5a. 0 = No drift. Limb holds 90 (or 45) degrees for a full 10 seconds.

5b. 3 = No effort against gravity. Limb falls.

6. Motor Leg. ( a. Left Leg, b. Right Leg)

Scale Definition

6a. 0 = No drift. Limb holds 90 (or 45) degrees for a full 10 seconds.

6b. 3 = No effort against gravity. Limb falls

7. Limb Ataxia.

Scale Definition

1 = Present in one limb.

8. Sensory.

Scale Definition

1 = Mild to moderate sensory loss. Patient feels pin prick is less sharp or is dull on the affected side or there is a loss of superficial pain with pin prick, but patient is aware of being touched.

9. Best Language.

Scale Definition

2 = Severe aphasia. All communication is through fragmentary expression; great need for inference, questioning and guessing by the listener. Often limited to one-word answers. Range of information that can be exchanged is limited; listener carries burden of communication. Examiner cannot identify materials provided from patient response.

10. Dysarthria.

Scale Definition

2 = Severe dysarthria. Patient’s speech is so slurred as to be unintelligible in the absence of or out of proportion to any dysphasia or is mute.

11. Extinction and Inattention (formerly neglect).

Scale Definition

1 = Visual, tactile, auditory, special or personal inattention or extinction to bilateral simultaneous stimulation in one of the sensory modalities.

Scoring and Outcomes

• 0= no stroke
• 1-4= minor stroke
• 5-15= moderate stroke
• 15-20= moderate/severe stroke
• 21-42= severe stroke

NIH Scale for Patient - 17

 

 

 

 

 

 n of pathophysiology and health assessment in your discussion.

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