PHRM4012 Lecture Notes - Lecture 7: Norfloxacin, Paracetamol, Urinary Tract Infection

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azuregnat646

27 Jul 2020

School

Department

Pharmacy

Course

PHRM4012

Professor

Associate Professor Neil Cottrell

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Document Summary

06/09/2019 (friday: customer came into the pharmacy asking for ural sachets for her 40-year-old mother. Her mother is currently taking the antibiotic norfloxacin for her urinary tract interaction (uti) i. e. cystitis. Cystitis is more often in women in 15-40 years old. It is more common among women than in men because the urinary tract of women is shorter than male. If it is the first time a man presents with symptoms of uti or cystitis, it is better to refer him to the doctor because it may be problems of the prostate instead of the urinary tract. Vaginitis can be differentiated from uti using the presence of discharge. Vaginitis will have discharge but uti causes no discharge. Nsaids overuse can lead to uti as well so remember to ask for medication history of patient. She just got the script from the doctor. This is a new drug she had never used before.

Related Questions

Based on âMorgan: A case of Diabetesâ by Lisa Rubin and Clyde Freeman Herreid (National Center for Case Study Teaching in Science)

The Patient:

Morgan Water is a 27-year old Native American that lives on a reservation in Oklahoma. Nearly Â¼ of Morganâs tribe has diabetes but she has no direct family history of diabetes, heart disease, or other serious conditions. She is however obese (BMI = 32) and leads a sedentary lifestyle. Morgan has been suffering from an increasing persistence of symptoms including unusual thirst, dizziness, blurred vision, and numbness in her right foot. The symptoms have been developing over several months but as she is planning her wedding she attributed them to nerves. She is finally persuaded to see her family doctor. Her non-fasting blood glucose level was elevated so the doctor has her return the next morning for a fasting blood sample so they could more accurately measure her blood glucose and insulin. Her blood results are below:

Test	Morganâs values	Normal range	Pre-Diabetic range	Diabetic range
Plasma glucose, mg/dl	260	70 -139	140 - 199	â¥ 200
Fasting glucose, mg/dl	140	â¤ 99	100 - 125	â¥ 126
A1C, %	7.6	~ 5	5.7 â 6.4	â¥ 6.5
Fasting Insulin, mIU/ml	34	2 - 10	10 - 20	â¥ 20

The recommendation of Morganâs doctor was to improve her exercise, good nutrition, and weight loss. He recommends meeting with a nutritionist to assist Morgan in her weight loss goals. When Morgan got home and told her family the diagnosis they however had LOTS of suggestions on how she can lose weight. Below is a description of the advice given to her by three family members.

Best friend Savannah:

âYou know how Iâve been losing weight? Well, Iâve been on the Atkinsâ Diet. I heard about it on TV. Itâs great! You get to eat steak, chicken wings, and all the good stuff. All you have to do is limit carbohydrate intake. You should definitely give it a try. This diet has been around for years and it has worked for lots of people, including me.â

*Note: Atkinâs Diet recommends: 10% carbohydrates, 55% fats, 35% protein

Brother Alan:

âI think the best thing for you to do is exercise and stop eating all of that pizza and candy and food filled with fat. Our people never used to eat that junk. I say eat meals that are nutritionally balanced and high in fiber and low in refined sugars and saturated fats. And run a lot. Stop sitting around the house.â

Grandfather:

âMorgan, it is true that it is best to live in harmony and balance â to eat a nutritionally balanced diet that includes carbohydrates, proteins, and âgoodâ fats to meet your bodyâs needs. That is good. But look to your heritage. Our people were never overweight before we started eating âcivilizedâ food. Look to our native diet. I think you should look to traditional herbal remedies for help. What Alan says is true. Exercise is good. But it is sometimes not enough. Our people have always looked to natural medicine for cures. They will lift your spirits and energize you. Then you will lose weight and you will be healthy again. I hear the herbs from the diet shop are safe and good. But you must take them like the medicine label says. It canât hurt to try them.â

*Note: these herbal supplements Morganâs grandfather is recommending contain the herb

ephedra (ephedrine).

Question 5:

Given Morganâs metabolic state, what is the primary fuel source for her cells currently?

A. Carbohydrates (glucose)

B. Fats

C. Proteins

D. It is a balance of all three

Question 6:

Metabolic ketoacidosis is a common problem with diabetics, which is caused by which of the following?

A. Excessive oxidation of fatty acids, leading to an accumulation of ketone bodies in the blood.

B. Excessive oxidation of glucose, leading to an accumulation of ketone bodies in the blood.

C. Excessive oxidation of proteins, leading to an accumulation of ammonia in the blood.

D. Hyperglycemia.

Question 7:

Which weight loss suggestion is designed to achieve some level of ketosis?

A. Atkins Diet

B. Exercise

C. High fiber diet

D. Herbal treatments

Question 8:

One major side effect of the herbal supplement can be hot flashes and increased perspiration due to increased thermogenesis, what is the likely cause of the heat production?

A. Increasing the activity of phosphfructokinase-1.

B. Increasing the activity of the pyruvate dehydrogenase complex.

C. Increasing the activity of citrate synthase.

D. Increasing the activity of uncoupling proteins.

Question 9:

Would substituting fiber and complex carbohydrates (larger % cellulose) for the simple sugars and starches (high sucrose and amylose/amylopectin) help Morgan lose weight, why?

A. Yes, because complex carbohydrates like cellulose are largely indigestible so they pass through

the digestive tract without being absorbed.

B. Yes, cellulose contains less glucose residues than amylose or amylopectin.

C. Yes, because the fructose in sucrose is much more responsible for weight gain than the glucose.

D. No, because cellulose, amylose, and amylopectin are all composed of glucose so it doesnât

matter.

Question 10:

Which weight loss suggestion will lead to an increased need for gluconeogenesis?

A. Atkins Diet

B. Exercise

C. High fiber diet

D. Herbal treatments

Case Study 1: Case Presentation

John, a healthy twenty-eight year old electrical engineer, was driving home from work one evening when he experienced sudden stabbing pain in his right pectoral and right lateral axillary regions. He began to feel out of breath and both his respiratory rate and heart rate increased dramatically. As luck would have it, John passed a hospital each day on his way home and was able to get himself to the hospitalâs emergency room. The emergency room physician listened to Johnâs breathing with a stethoscope and requested blood gas analysis and a chest x-ray. John answered a few of the doctorâs questions. The doctor noted that John had no history of respiratory problems but was a heavy smoker.

After viewing the chest radiograph, the doctor informed John that he had experienced a spontaneous pneumothorax, or what is commonly called a collapsed lung. The doctor explained that a hole had opened in Johnâs right lung and that this hole had allowed air to leak into the cavity surrounding the lung. Then, as a result of the lungâs own elastic nature, the lung had collapsed. The doctor said he could not be certain of the cause of the pneumothorax, but smoking cigarettes had certainly increased the likelihood of it happening. He told John he was fortunate the pneumothorax was small, which meant that relatively little air had escaped from the lung into the surrounding cavity, and it should heal on its own. He instructed John to quit smoking, avoid high altitudes, flying in nonpressurized aircraft, and scuba diving. He also had John make an appointment for a re-check and another chest x-ray.

Case Background

Spontaneous pneumothorax occurs when a blister on the surface of the lung opens, allowing air from the lung to move into the pleural cavity. This occurs because alveolar pressure is normally greater than the pressure in the pleural cavity. As air escapes from the lung, the lung tissues will recoil, and the lung will begin to collapse. The lung will continue to collapse until the difference between the alveolar pressure and pleural pressure disappears or until the collapsing of the lung causes the opening to seal.

The pneumothorax decreases the efficiency of the respiratory system, which in turn results in decreased blood oxygen concentration, increased respiratory rate, and increased heart rate. If the pneumothorax is small, the air that escapes into the pleural cavity can be reabsorbed into the lung once the opening has sealed shut. If the pneumothorax is large, a needle or chest tube may have to be inserted into the pleural cavity to draw the air out and allow for the reexpansion of the lung.

Questions

Define the following terms and explain how they may have been affected by Johnâs spontaneous pneumothorax.

Visceral pleura

Parietal pleura

Pleural cavity

As a result of a pneumothorax, the lung tissues recoil, and the lung collapses. Explain how recoil and collapse are prevented in a healthy lung?

How does elastic recoil function in breathing?

Why was John instructed to avoid high altitudes and flying in nonpressurized aircraft?

Case Study 2: The Case of the Coughing Housewife

Jessica, a fifty-nine year old mother of four, moved from a ranch in Colorado to Los Angeles, after the death of her husband, to be closer to her oldest son and his family. She has been in Los Angeles for 18 months and has noticed that she is experiencing shortness of breath which has worsened over the last six months. For the last week, she has been coughing and bringing up yellow mucus. She also noticed swelling in her ankles so she decided to visit a physician about her condition.

Jessica's family and medical history include a negative history of asthma or allergies, lack of occupational or home exposure to asbestos, a previous smoking history (one package of cigarettes per day between the ages of 16 and 52), episodes of bronchitis, treated with antibiotics on an outpatient basis, and a positive history of heart disease (father at 52 and brother at 56). Jessica has no history of serious illness, including heart disease, and her weight is within five pounds of her "desired" weight. She usually coughs in the morning to "clear her throat", but there is usually only a small amount of white mucus.

Her nurse practitioner conducts a general physical examination with the following results. Jessica's skin is normal (no rashes or cyanosis) and her nervous system is functioning normally. Her body temperature was 98.4oF while her pulse was regular at 95 beats per minute with an occasional premature beat. Jessica's blood pressure was within normal limits, however her jugular veins were slightly distended. Her respiratory rate was 28 breaths per minute; she breathed with pursed lips and used her accessory respiratory muscles more than would be expected. Jessica presented with a barrel chest and mild dyspnea when climbing onto the examination table. When listening to her breathing, the nurse practitioner noticed that Jessica had prolonged expiration accompanied by expiratory wheezes. Evaluation of her abdomen indicated no masses or tenderness, but she presented with both hepatomegaly and splenomegaly. All of her extremities were normal with the exception of bilaterally pedal edema.

Based on these results, the nurse practitioner suspected a pulmonary disorder and, after consultation with a physician, ordered laboratory tests (blood and sputum), spirometry and chest x-rays. The results of the laboratory tests were as follows: plasma bicarbonate = 38 mEq/L, hematocrit = 49%, white blood cell count = 9000, pH = 7.38; PaCO2 = 56, and PaO2 = 54. Analysis of the sputum sample indicated the presence of epithelial cells, polymorphonucleocytes and gram positive diplococci. Jessica's 1 second forced expiratory volume (FEV1) was 1.5 L/sec and her forced vital capacity (FVC) was 4 L. These values were 40% and 83% of normal, respectively. Results of the chest x-ray indicated scarring and hyperinflation of the lungs.

The results of these tests coupled with the physical examination and history lead to a diagnosis of emphysema. Jessica was prescribed antibiotics for the infection and oxygen by nose as well as a b2-agonist nebulizer as an acute treatment and requested to stay for observation and stabilization. After Jessica's condition was stabilized she was discharged and given a prescription for an inhaler containing a b2-agonist to be used as needed. She was also encouraged to exercise regularly and follow the nutritional guidelines she was given. Jessica was also informed that if the symptoms either worsened or did not lessen within the next week, to return and her treatment would be reevaluated and would possibly include nocturnal oxygen and an inhaler containing corticosteroids.

Answer the following questions about this case

Define the bold terms in the text. (8 points)

What risk factors and symptoms did Jessica present with prior to the physical examination that suggested a pulmonary disorder?

How did the physical examination, chest X-ray and spirometry confirm this hypothesis?

Identify muscles involved in respiration and how these muscles are responsible for the process of ventilation.

How will the b2-agonist in the inhaler help with the respiratory problems Jessica presents with?

Why is it important that a b2-agonist and not simply an b-agonist is used in the inhaler?

If her condition does not progress, why would corticosteroids be used in the inhaler?

Part I â The PA

It had nally arrived! e day Margo had been waiting forâretirement day. And given that the temperature had hovered around 40 degrees the last week of March in Ohio, retirement along with the move to the warm south couldnât come soon enough. Most of Margoâs belongings had been boxed up and sent on to Florida the previous week, but a few remaining items, including her wide screen TV, would be transported in the car.

Week of April 7th

The drive to Bradenton, Florida, went smoothly. After spending three days on the road, Margo arrived at the condo retirement community. It had all the luxuries one could imagine, including a spa-like pool area, a nail salon providing manis and pedis, a beauty shop, yoga studio, nutritionist, and therapeutic massage service. But before any of those amenities could be enjoyed, final moving efforts had to be undertaken. Although family had o ered to help with the move, Margo wanted to do this solo, and felt there was nothing she couldnât lift or move herselfâso she spent the rest of the afternoon rearranging and positioning the furniture, rugs, stereo, and computer equipment.

Week of April 14th

As she surveyed her new place the following week, Margo felt satisfied that her decision to move to Florida had been the right one and that her new condo suited her perfectly. One final move of the television away from the window and closer to her replace would be her last task. Unfortunately, while positioning the large at screen, she caught her right index finger on the plastic trim, resulting in a painful cut that bled a little more than expected. But after washing the wound with soap and water, things seemed to be under control and the warm sun and balmy 80 degree temperatures made her think it was time for a swim. After the swim, a nice massage would prevent any aches and pains that might result from overdoing the furniture moving, and a manicure to repair the damage the manual labor had done to her nails would be the perfect end to the day.

Week of April 28th

Margo had been enjoying Florida-living for two weeks now. The only down side was the fact that the area where she had cut her ngertip was painful, swollen, appeared red, and felt warm to the touch. If the pain didnât go away soon, Margo was going to have to have her finger looked at by a physician. Then, in the middle of the next night, the throb- bing became unbearable and she knew it was time to head to the doctor. Unfortunately, she hadnât had the time to

find a personal physician in the area and so her only option was to go to the urgent care facility not far from her condo.

May 3rd

At the urgent care center, a physicianâs assistant (PA) asked Margo a variety of personal health questions and carried out his clinical assessment, noting the following details:

Age: 65

BP 134/80

Weight 120 lbs., Height 5 Ì5 Ì

HR 59

Respiration rate 18

O2 sat. 99

Type 2 diabetes (diagnosed 3 years prior)

Following careful cleaning and examination of Margoâs wound, the PA prescribed an antibiotic called Bactrim DS (trimethoprim/sulfamethoxazole-double strength) in a tablet form to be taken by mouth two times a day for 10 days. The patient information sheet that Margo received from the clinic identified her diagnosis as cellulitis, which was curious because the person who had examined her had not mentioned that particular word. Margo dutifully followed prescribing instructions, taking her medication as suggested, but after five days the wound continued to swell, her pain had increased, and moving her finger had become dificult.

Part II â The ARNP

May 8th

The next day, Margo went to another urgent care facility where she hoped she would nd some relief. John, an Advanced Registered Nurse Practitioner (ARNP), took her history and performed his clinical assessment, noting a normal body temperature and normal-size lymph nodes. While examining the injured finger, he observed significant

swelling, mild erythemia, and a small wound with minimal clear exudate. Other than the index finger, the rest of Margoâs hand appeared normal. Upon completing his examination, John cleaned the wound, numbed the area, and injected a medication called Depo-Medrol into Margoâs finger. Afterwards, he talked to Margo about wound infections, including the redness and swelling she had been dealing with. John told Margo to clean her wound three times a day with soap and water and then to dry it thoroughly. He gave her a prescription for the antibiotic Keflex to be taken two times a day for 10 days. He also gave her a visit summary/discharge instruction paper that identified the clinical impression/diagnosis as âcellulitis/foreign body/fungi.â John further instructed Margo to return in 72 hours if her symptoms did not improve.

Once home, Margo closely read the written information she had been given and noted that the document mentioned she had been taking the drug Septra since May 3rd without improvement. Also, her medical services/charge sheet noted âforeign body removalâ as a procedure carried out, yet she had no memory of such a procedure. Although at the end

of her clinical visit Margo had signed the paper acknowledging her treatment, she was now more confused than ever regarding the cause of her wound and the course of her treatment.

Questions

1. What is the function of Depo-Medrol? Speculate on the reasoning/consequences of its use in this particular case. 2. What pathogens are targeted by Ke ex (the newest prescription)?

3. What types (genus/species) of fungal pathogens typically cause wound infections?

4. If a fungal pathogen was implicated, would Ke ex eliminate that particular infectious agent?

5. Why did Margoâs recent documents mention she was taking Septra rather than Bactrim as her earliest (May 3rd) documents listed?

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PHRM4012 Lecture Notes - Lecture 7: Norfloxacin, Paracetamol, Urinary Tract Infection

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