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Society of Air Force Pharmacy
1999-2009

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Each "Pearl" consists of a question testing your knowledge and
understanding of medical conditions and the complications following
pharmaceutical intervention or lack of intervention.
Each problem oriented situation is discussed suggesting recommended courses of
action or solutions to each situation. You will find each session both
interesting and challenging, and an excellent source of continuing education
material for your practitioners and pharmacy staffs.
New Pharmacy
Pearls will no longer be available due to the
retirement of Lt Colonel Zastawny
2005
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5 January
A 45 y/o female patient who's been on a COX2
inhibitor for osteoarthritis for about 6 months
comes in for her annual check-up and
prescriptions refills. She's seen all the
attention in the media recently about the Vioxx®
withdrawal, the 'bad press' on the other COX2s,
and asks you whether she should stay on her COX2
agent or not. She has no other significant
medical history and no drug allergies. Her labs
are WNL and she has no other risk factors for GI
toxicities (previous H/O ulcer or GI bleed or
perforation, concurrent systemic steroids,
concurrent anticoagulation). What do you tell
her? Why or why not? |

2004
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22 December
A 67 y/o male patient presents to your clinic
for his annual check-up and refills on his
prescriptions. As the appointment comes to an
end, he mentioned he's having 'some trouble in
the bedroom.' He'd like a prescription of Viagra
to try out.
He's generally healthy except for very mild
hypercholesterolemia and benign prostatic
hyperplasia. His vital signs are normal and his
labs are within normal limits except for
slightly elevated cholesterol, controlled with
lifestyle changes and diet. His only medication
is terazosin 5mg po QHS for BPH. Do you write
the prescription for Viagra®? Why or why not?
|
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15 December
You're a member on the local Pharmacy and
Therapeutics committee. A
new drug request is presented to the committee
requesting the addition of a new biphosphonate
for osteoporosis and prevention of hip fractures
in post-menopausal women. The drug cost per
tablet is a little bit less than your current
formulary biphosphonate. The side effect profile
is the same or maybe a little bit better for the
requested drug vs. the formulary drug. The
number needed to treat (NNT) for each drug to
prevent one hip fracture is 90. Lifetime risk of
hip fracture in women is 15%. Hormone
replacement therapy is questionable. Other hip
fracture prevention therapies have their risks
as well. This drug is new and getting a lot of
media attention and direct-to-consumer
advertising. Many providers in your area and in
your hospital are using it in moderate to
high-risk women and you've been asked by a
number of women to prescribe this for them.
Do you vote to add the drug to formulary or not?
Why or why not? |
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8 December
A 3/2 y/o female patient presents new
prescription for hydrochlorothiazide (HCTZ - a
thiazide diuretic) to the pharmacy. The
computer system alerts you this patient has
documented allergy to "sulfa antibiotics". She
describes signs and symptoms consistent with a
'fixed drug reaction' which blisters and peels.
She also experiences hives on her body, arms and
legs. Do you fill this prescription? Why or why
not? |
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22 January
As a volunteer additional duty for his EPR, SSgt
Homer has been helping the Immunization Clinic
give flu shots. This morning, while giving
shots at the BX, he accidentally stuck himself
with a needle contaminated with blood from a
patient. You are his supervisor and he comes to
you immediately after the incident. You are a
good supervisor and, following the needle-stick
protocol in place for your facility, you, SSgt
Homer and the patient all go to the ER. The
patient discloses an Infectious Disease
physician has carefully monitored him since he
was diagnosed with HIV 2 years ago. He is not
on antiretroviral therapy, and a month ago his
CD4 count was 400 cells/mm3 and HIV RNA (viral
load) was 1,300 copies/mL. While waiting
to be seen by the ER physician, SSgt Homer asks
you what his chances are of HIV seroconversion
from this one needle stick and if you think he
should begin prophylactic antiretroviral therapy
(a.k.a. post-exposure prophylaxis = PEP).
What do you tell him? |
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2 February
A 38 y/o, 65 kg male patient
being treating with IV gentamicin for a gram
negative, possibly aspiration, pneumonia. His
dosing regimen is 120 mg IVPB every 8 hours. His
renal function is normal (CrCl ~ 85 ml/min) and
has no other underlying medical conditions. His
other meds include clindamycin 900mg IVPB every
8 hours. A peak and trough level was drawn 1-2
days ago around his 3rd dose of gentamicin. The
peak was 8.1 mcg/mL and his trough was 1.1 mcg/mL.
His renal function hasn’t changed and the
patient appears to be getting better. The
medical student wants to redraw the peak and
trough levels. Do you agree or not? Why or why
not? |
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19 February
A 65 y/o female presents to the ED with sudden
onset of severe skin tenderness, sparing her
scalp. Her PMH is significant for epilepsy. Her
labs and vital signs were WNL except for a fever
of 102 F and a slight leukopenia. She was
controlled on phenytoin but developed a rash on
this and was switched to carbamazepine. On PE,
her skin was very tender (i.e. couldn’t tolerate
light touch), blistered, and erythematous. Raw
surfaces exuded serum and she had flaccid bullae
on her torso. The patient shows a positive
Nikolsky sign. What is likely her problem?
What can you do? |
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4 March
A 28 y/o female patient with a history of iron
deficiency anemia presents to the clinic. She
has a fever of 101F, productive cough/rusty
sputum, and describes a single shaking chill.
Her labs show a leukocytosis and a left shift
but otherwise unremarkable. A gram stain of her
sputum shows gram (+) cocci. She’s on oral iron
for her iron deficiency and calcium carbonate
for prevention of osteoporosis but nothing else.
There’s no other significant medical or family
history. After a brief history and
physical, the intern admits the patient with a
diagnosis of community acquired pneumonia (most
likely Strep pneumoniae). The intern starts the
patient on levofloxacin 500mg po every day for
10 days. After 4 days of therapy, she is still
running a fever. The team is perplexed
with her slow progress, esp since she’s on an
antibiotic effective against the identified
pathogen. Is there anything we can do to improve
her medication regimen? |
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11 March
A 68 y/o patient presents to the ER with an
accidental overdose of their prescription
medication. The staff has tried the usual
measures like activated charcoal, gastric lavage,
etc. but with little improvement. The medical
student mentions acute hemodialysis as an
option. The toxicology references you have do
not list anything regarding dialysis as a
potential option. What data would allow you come
to a rational decision regarding the use of
acute hemodialysis in the patient?
|
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31 March
A 58 y/o male presents with complaints of
erectile dysfunction (ED). He’s otherwise
healthy with some benign prostatic hyperplasia (BPH)
for which he uses doxazosin [Cardura®]. He saw a
commercial on TV with Mike Ditka for vardenafil
[Levitra®], a phosphodiesterase inhibitor
similar to Viagra® and Cialis® and was wondering
if this could help his situation. He has no
other health issues and is not on any organic
nitrates, to include as needed SL nitroglycerin.
His labs are WNL and he has no other significant
medical history. You write him a prescription
for Levitra® according to the guidelines at your
facility. About 2 hours later, you get a
message from the pharmacy telling you there’s a
problem with this patient’s prescription. You’re
certain the patient is not on nitrates and
doesn’t have cardiovascular disease and is not
on flying status and his plan doesn’t require a
prior authorization, so what’s the problem?
|
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8 April A 23 y/o female patient
presents to the pharmacy with a prescription
from a dermatologist for spironolactone [Aldactone®]
50mg po every day. You’re not aware on any
significant medical history for this patient.
Her prescription profile only contains
minocycline 100mg po BID. She has no allergies
listed. You explain to her the diuretic effects
of this med, thinking it was for peri-menstrual
swelling and fluid retention. Although strange
coming from a dermatologist. She says ‘this
isn’t what the doctor told her this drug was
for’. If not for it’s diuretic properties, why
would a dermatologist write a prescription for
spironolactone? |
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14 April
A 25 y/o post partum female shows up for a post
partum check-up about 3 months after the birth
of a full term, normal baby. You notice she is
not immune against rubella and has not had her
rubella vaccine. She has no other significant
medical history and has no allergies. She did
receive RhoGam® right after her delivery. Can
you still give her the rubella vaccine or the
mumps-measles-rubella (MMR) vaccine now?
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22 April
A 67 y/o Caucasian female
presents to your clinic with new onset back
pain. Her past medical history is significant
for rheumatoid arthritis and hypothyroidism. She
is a smoker (50 pack years). Her labs are within
normal limits; she has no allergies, and has no
history of trauma. Her meds include prednisone
5mg po every other day, etanercept 25mg SQ twice
a week, and l-thyroxine 0.1mg po daily. The
medical student does an exam and thinks this
patient’s problem is muscle strain and wants to
send her home with some pain med and muscle
relaxants. Do you agree or not? Why or why not?
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19 May
You’ve been tasked with being the local
hospital’s disaster response rep. Next week
there’s going to be an exercise scenario,
specifically a ‘dirty’ bomb attack with
subsequent cesium exposure. Specifically, your
part in this scenario is recommending which
medications, if any, need to be available? What
medication(s), if any, should you be exploring?
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2 June A 38 y/o male patient presents
to the clinic with a chief complaint of
headache. His vitals are HR 90, BP= 190/115,
resp= 24. The intern does a routine physical
exam and found nothing – no end organ damage.
The patient has no allergies nor any other
significant medical history. The student wants
to treat this elevated blood pressure with
sublingual nifedipine 10mg. Do you concur or
not? Why or why not? |
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9 June A 44 y/o AD male patient comes
to the clinic after playing softball the
previous night. He’s complaining of a sore knee
after running hard during the game. On physical
exam, he has no evidence of broken bones or
joint/ligament injuries. He has no significant
medical history, no allergies, and is on no
other medications. He doesn’t smoke and is only
an occasional user of ethanol. His labs are WNL
from a recent 5-year AF physical. The PA seeing
sick call wants to give him a COX2 because he’s
AD but needs your countersignature because it’s
a non-formulary medication at your hospital. Do
you concur and sign off or not? Why or why not?
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17 June
A 39 y/o patient is scheduled for an MRI to
assess her “back pain”. She has no significant
medical problems other than the back pain listed
above. Her vitals signs are WNL. She’s only a
social drinker and is a smoker but is currently
trying to quit using OTC nicotine patches. Her
family history is non-contributory. The patient
starts her MRI and soon complains of a burning
spot on her chest. The test is stopped. The
machine was just calibrated recently and there’s
no other alarms or indication of a system
malfunction. What’s the problem?
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30 June
A 20 y/o airman is newly assigned to your unit
from basic training. He’s interested in giving
blood during the group’s upcoming blood drive.
He asks you if he’s eligible since he ‘got a
shot of something’ while at basic training. As
you inquire further and review his medical
record, you see his entire squadron at basic
training was inoculated with 1.2 million units
of benzathine penicillin secondary to a
diagnosed case of gram-positive cocci
necrotizing fasciitis. What’s your answer to the
airman and the blood collection folks? Accept
his blood donation or not? Why or why not?
|
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15 July
A 24 y/o patient is brought to your ED with a
non-penetrating spinal cord injury. The injury
occurred only 45 minutes ago. The patient has no
other significant medical history. He is on no
medications, has no allergies, and his last labs
(during a routine physical 3 months ago) were
all within normal limits. The ED physician
wants methylprednisolone [Solu Medrol®]
according to the protocol which calls for a 30
mg/kg intravenous (IV) bolus (over 15 minutes)
followed by a continuous IV infusion of
methylprednisolone 5.4 mg/kg for the next 24
hours. The pharmacy calls back telling the
physician methylprednisolone is on manufacturer
backorder with no estimated release date. Are
there any options for this patient? If so, what?
|
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22 July
A 56 y/o woman presents to the clinic for a
routine appointment. Her labs are WNL and vital
signs are fine. She has no significant medical
history and no allergies. She is on no
medications. As she's leaving, she describes
this funny feeling she gets in her legs, esp.
after she sits down at night to relax before
bed. She describes it as an "unpleasant creeping
feeling" in her legs. As you discuss this more
with her, she relates that moving her legs
temporarily helps and these sensations disturb
her sleep. What's her likely diagnosis? What are
you going to do to treat it? |
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4 August One of your students wants
to publish a cost-benefit analysis of his recent
drug class review and subsequent formulary
decision. He wants to present the clinical
literature review and the cost-benefit of the
decision. Is this the "right" analysis for this
decision? Why or why not? If not, what IS the
correct analysis? |
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12 August
You receive a request for a non-formulary statin.
The patient has elevated LDL with only one other
risk factor. The patient has no allergies and is
on no other medications. The patient has no
other significant medical history. The provider
has not tried the formulary statin nor any other
formulary hyperlipidemic agent and wants to go
directly to this non-formulary agent. He argues
it's clinically appropriate and you should
get it for his patient. In the current fiscal
year, your budget is running very tight and
you've come under significant heat to control
your costs. Do you approve the non-formulary
request or not? |
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18 August
Your student is seeing patients with you. Their
first patient is a 72 y/o patient in for their
every 6 months appointment. The patient
complains of constipation but no other changes
in their general health. Their physical exam and
vitals signs are WNL. Their labs are normal and
they have no allergies. The only medications
they take on a regular basis are amitriptyline
25mg po QHS (for sleep) and chlorpheniramine 4mg
po QHS (for seasonal allergies). The student
writes off the constipation as 'just being old'
and wants you to renew their prescriptions and
sign off his note. Do you sign off or not? Why
or why not? |
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22
September You're a local P&T committee
member. In the current resource-constrained
healthcare environment and in order to provide
quality care at a lower cost, one member
recommends deleting the brand name Coumadin® (warfarin)
in favor of a new A-rated generic warfarin.
Another committee member argues against this
change because it's a narrow therapeutic index (NTI)
drug. He states the facility should continue to
provide the brand name drug despite it's
significantly higher cost solely because of this
"narrow therapeutic index" moniker. The
discussion is over and it's time to vote. Switch
to the A rated generic or stay with the brand
name agent despite it's significantly higher
cost? How do you vote? Why? |
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29
September A 28 y/o male patients has
been diagnosed with narcolepsy after a long
work-up several years ago. His symptoms at that
time included excessive daytime somnolence,
cataplexy, hallucinations at sleep onset, and
muscle paralysis upon awakening. He was treated
with various central nervous system (CNS)
stimulants. They all seemed to work initially
but after time their therapeutic effect lessened
requiring a switch to different drugs. In a
recent journal article a colleague read about a
new drug therapy approved for narcolepsy, sodium
oxybate. Since this drug can be easily abused,
you're a little bit apprehensive. Do you order
the sodium oxybate or not? Why or why not?
|
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14 October
A 35 y/o male patient presents to your clinic.
He was on rofecoxib [Vioxx®], prescribed for
some 'aches and pains' after running and/or
exercising. This is the only NSAID he's tried
for this complaint and has had good results. He
has no other significant medical history and no
allergies. His labs are WNL and he's on no other
medications. He wants to know what formulary
COXII alternatives you have for Vioxx®. What do
you choose to prescribe - another formulary
COXII NSAID? A non-selective NSAID? An OTC
analgesic? Why or why not? |
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10 November
A 71 y/o recently widowed female is diagnosed
correctly with community acquired pneumonia
(CAP). She begs you not to admit her for the
small patch of CAP on her chest X-ray. You
reluctantly agree after she agrees to call you
daily with follow-up and a status report. You
prescribe an appropriate antibiotic and tell her
to drink plenty of water so as not to become
dehydrated. The first day she calls stating her
cough is subsiding and her fever has broken. She
complains about feeling weak and tired but
that's kind of normal given the pneumonia and
the patient's age. The second day the patient's
neighbor calls stating the patient looks funny
and she's talking but not making much sense. You
tell the neighbor to call 911, thinking your
patient is having a stroke. Upon evaluation in
the ED, you find NO evidence of a stroke. What
could be causing these symptoms in this patient?
|

2003
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15 January
A patient presents to your
clinic looking for treatment of his seasonal allergic rhinitis (SAR) secondary
to the blooming mountain cedar. The patient was previously well
controlled on loratadine [Claritin ®]. He's perplexed now because Claritin® is
OTC and his insurance plan doesn't cover OTC medications. What can you do for him?
|
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29 January
You're coming back from a TDY
and are stopped by a person in the airport when he noticed your uniform. He's
planning on going into the Guard and is concerned about taking the smallpox
vaccine. What do you tell him? |
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5
March A 56 y/o patient presents
with an acutely inflamed great toe, suspicious for gout.
The medical student examines and concurs with the
diagnosis of gout. The patient is diabetic with slight
renal insufficiency
(CrCl ~ 40 ml/min). His labs are normal except for an
elevated serum uric acid (9.1 mg/dL). The only meds the
patient is currently on is metformin. The student wants to
treat the patient with oral colchicine. Do you concur or not? Why
or why not? What other options might be considered for the
acute and chronic gout? |
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20 March
You're asked to review a
hospital or clinic operating instruction (OI) addressing a
number of things, including multiple dose vials (MDV). The
OI states all multiple dose vials will be refrigerated
after initial use or thrown out. When you question the POC
for this instruction, they state refrigeration is required
on all MDVs because it deters bacterial growth. Do you concur with the OI
as written? Why or why not? |
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27 March
Since vaccines and
immunizations now fall under your pharmacy budget, a call
comes to you in the pharmacy regarding administration of
vaccines. The tech asks if there's any problem
administering different vaccines together (i.e. at the
same time. What's your
answer/guidance? Why or why not? |
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2 April
A 25 y/o active duty female
presents to the Flight Surgery Clinic after a positive PPD
and is started on a treatment of "latent infection"
(formerly known as prophylaxis) regimen of isoniazid (INH)
300mg once daily and pyridoxine (vitamin B-6) 50mg once
daily for 9 months. She returns to the clinic the next
day voicing significant concerns about potential
teratogenicity since she is actively attempting to become
pregnant. She does not want to comply with the regimen
because she believes the INH poses a significant risk to
her fetus if she does in fact become pregnant. The
Flight Surgeon is looking for some solid answers and comes
to see the pharmacy for some help.
What's your answer/advice? Proceed or not? Why or why not?
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27 April
A 67 y/o patient is found
on the medicine ward one evening, cold and clammy, barely
responsive. The patient's admit diagnosis was 'control of
type I diabetes mellitus'. Other than the diabetes, the
patient has no other pressing health problems. Their
written medication orders include NPH insulin 30.0 u am
and pm, regular insulin 10.0 u in the am and 3.0 u in the
pm, lisinopril 20mg qam, baby aspirin 81mg qam, and
simvastatin 40mg qhs. They have no allergies. After a
quick assessment and check of the most recent labs and a
finger stick, the resident determines the patient is very
hypoglycemic. Some 50%
dextrose and glucagon quickly corrects the hypoglycemia. How could this have
happened? |
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1
May A 45 y/o female patient
presents for her annual check-up and refills on her oral
contraceptives (OCPs). Her labs (drawn pre-appt) are WNL.
Her physical exam and vitals are fine except for a BP of
145/94. Her weight is a little high based on her height.
She does not smoke. She is a social drinker, consuming 1-2
drinks at a happy hour after work on Friday. She has no
other health problems and no other significant past
medical history. What is causing her
hypertension? How would you treat it? |
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4 June
You get a call from the
minor surgery clinic for a vial of buffered lidocaine.
Since it's not commercially available and would need to be
compounded, you contact the provider for details. The
provider states he wants buffered lidocaine is less
painful on injection and works just as well as the
non-buffered lidocaine. Do you proceed or not? Why
or why not? |
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25 June
You receive a phone call
from a 27 y/o male patient at the Sweetwater, TX
rattlesnake roundup who says he's been bitten on the arm
by a rattlesnake. He's searching for advice on first aid.
He mentions things like a tourniquet, sucking the venom
out, and putting ice on the bite. What is your advice? Why?
Taking the scenario to the next step, what, if anything,
would you recommend to the emergency room or his
physician? |
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10 July
A 45 y/o patient with
diabetes mellitus type II and mild congestive heart
failure needs a non-steroidal anti-inflammatory agents (NSAID)
for some arthritis. Acetaminophen and aspirin have not
relived his pain nor helped his range of motion or early
morning joint stiffness. His labs are normal except a
slightly elevated glucose and a serum creatinine of 1.3
mg/dL. The medical student wants
to start indomethacin 25mg po TID as his NSAID.
Do you concur with the student?
Why or why not? |
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17 July
A 23 y/o otherwise healthy
patient is admitted to the ICU with multiple fractures and
injuries due to a motorcycle accident. After several
surgeries, all his fractures are set and healing. After
several days of opioids to control his pain, he develops
significant constipation from the opiates. The team
decides to switch him to injectable ketorolac q6h, which
provides adequate relief of his post-op pain. Three days
later, the patient, recovering nicely, is transferred to
the ward. The intern wants to continue his ketorolac
orally (10mg po TID) for the duration of his hospital
stay, expected to be another 5-7 days. Do you concur or not? Why
or why not? |
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6 August
A 69 y/o male patient
presents to your clinic for a routine appointment. He
mentions he's having some trouble 'in the bedroom' and ask
for you help. He's seen the "blue pill" commercials on the
television. His
medical history is significant for a CABG 14 months ago,
mild CHF, and type II diabetes. His meds include
simvastatin 20mg QD, lisinopril 10mg po QD, glyburide 3mg
po QD, baby ASA po QD, SL nitroglycerin 0.4mg PRN. His
vital signs and routine labs are within normal limits at
this time. He states he's compliant with his medications
and only uses the SL nitroglycerin 2-3 times a month. Do you write the sildenafil
[Viagra®] prescription or not? Why or why not?
|
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13 August
A 68 y/o
female patient presenting with moderate fatigue along with
other non-specific symptoms. Upon closer physical
examination, she shows 'spooning' of the nails and some
mild stomatitis. She is subsequently diagnosed with iron
deficiency anemia, most likely due to poor dietary intake
of iron. Her serum ferritin is 8 g/L. She has been
"scoped" from above and below with no evidence of active
bleeding. Her peripheral smear shows a microcytic,
hypochromic anemia consistent with iron deficiency. The
student wants to replete this patient with oral ferrous
sulfate 325mg po TID but the patient states she's had
significant GI problems with oral iron in the past. What other
options do you have? |
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3 September
A 23 y/o male aircrew
member is deployed to your position in South America on a
humanitarian mission. He presents to the clinic with
complaints of substernal pain. The tech brings him in
hooks him up to an ECG which is normal. He has no
significant medical history. His vital signs are normal.
The only medication he is on is doxycycline 100mg po BID
for malaria prophylaxis. The limited number of labs you
have drawn are all within normal limits. What is your diagnosis? Why
or why not? |
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11 September
A 19 y/o old AD Marine
presents to your clinic after a brief leave to the
Caribbean presenting with a purulent, white penile
discharge and significant dysuria. A quick in-office test
confirms urethral gonorrhea. The medical student working
with you reminds you to treat for Chlamydia, a common
co-infection with gonorrhea. He recommends a single 1 gram
dose of azithromycin to treat both the GC AND Chlamydia.
Do you concur and write the
prescription or not? Why or why not? |
 |
18 September
A 72 y/o patient was
admitted to the unit with pneumonia, moderate CHF,
respiratory failure, and severe hypernatremia (serum
sodium 160 mEq/L). The student caring for this patient,
knowing serum sodium is largely affected by fluid status
and not wanting the patient to get any additional sodium,
orders the patient's peripheral IV changed to sterile
water IV at 100ml/hour. He comes to ask for a
counter signature on his orders. Do you agree
or not? Why or why not? |
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25 September
After a
consult/recommendation with nutritional medicine, your
student wants to start a 68 y/o elderly patient with some
mild senile dementia on "tube feeds" via a nasogastric
tube because her current calorie and protein intake were
not meeting her needs. Because of her age and concurrent
medical conditions, the student wants a small amount of
blue dye placed in the tube feeds in order to more easily
detect aspiration. Do you concur with
the blue dye in the tube feeds? Why or why not?
|
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2
October A 35 y/o male patient is
admitted to the medicine ward by the neurology service to
work up a seizure disorder and stabilize his medications.
His medical history is otherwise unremarkable and his labs
are all WNL. To make the titration easier, he was started
on carbamazepine suspension. The patient's serum levels
were continually on the low sides. The provider kept
increasing the doses over several days. On day seven of
therapy the patient appeared lethargic and hypotensive. What is causing this
apparently sudden change in the patient's status?
|
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8 October
A 38 y/o male patient new
to your clinic with hyperuricemia presents to your clinic.
He has no other significant medical history and his labs
(except uric acid ~ 11 mg/dL) are within normal limits.
He's been treated with uricosuric agents to date but with
only marginal results. Based on your assessment, he's an
'over-producer' of uric acid and you feel he'd be a good
candidate for allopurinol. When you mention this to the
patient, he states he had tried this drug in the past and
had pruritic maculopapular rash, requiring discontinuing
of the drug. He had no anaphylactic-type symptoms during
this episode. He wasn't re-challenged. Do you have any other
therapy(ies) to offer him? If so, what and how?
|
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16
October You're covering a medical
unit and have a patient on your ward team who's terminal.
He's rapidly deteriorating and expected to expire soon.
His heart continues to have irregular rhythms and is the
patient is expected to go into asystole soon. He has made
it known repeatedly he wants to be "DNR"
(do not resuscitate) and wishes to donate his organs.
There's a patient who is a perfect tissue match for your
patient's kidney. The intern raises some ethics issues
regarding this patient, esp. not wanting to hasten his
demise in order to harvest a kidney so another patient may
live. What ethical issue(s)
should you address? |
 |
5
November You have a patient on total parenteral
nutrition (TPN). His every 6-hour 'finger stick' blood
glucoses have been running over 170 and were covered with
sliding scale insulin. The rest of his electrolytes,
albumin, and other labs are within normal limits. The
intern wants to add some insulin to the TPN bag. He
suggests 5-8 units per bag per day. Do you concur or not? Why or why not?
|
 |
26 November
A 65 y/o patient with type II diabetes
presents to your clinic for a routine appointment and
refills on her metformin, lisinopril, and simvastatin. Her
labs, including her HgbA1C, are current and all look good.
You've refilled her medications through the computer.
She's current on her annual foot and eye exam. She has a
current mammogram and PAP on file. Is there anything else you need to do for
her during this visit? |
 |
18 December
A 25 y/o old female presents to the clinic
after a 5 day blood pressure monitor trial. Based on
these readings, she definitely meets the criteria for
hypertension and you decide to start her on low-dose
hydrochlorothiazide (a thiazide diuretic). She's
otherwise in good health
with no other significant medical history. She tells you
she's allergic to sulfa drugs. Upon further questioning,
she states she's taken trimethoprim/sulfamethoxazole [Bactrim®]
for a UTI without any problems. Do you start the thiazide or not? Why or
why not? |

2002
 |
10 January
A 57 y/o female patient comes
to the clinic for her annual physical. She's had all her routine screenings
done (mammogram, pap smear, CHOL, etc). She has no other health problems but
is on hormone replacement therapy (HRT) for prevention of post menopausal
symptoms and ossteeoporosis. Being a rather Internet-savvy patient, she asks
you about the new once a year treatment for prevention of osteoporosis she
found on the Web and asks you to prescribe it for her. What's your answer? Prescribe
it or not? Why or why not? |
 |
6 March
Your staff oncologist contacts
the pharmacy to speak with a board certified oncology pharmacist requesting
the dose of rituximab [Rituxan®] when used in combination with CHOP for
treatment of lymphoma. She presents her patient as follows: 43 year old active duty officer
(male) who underwent a recent excisional biopsy from the right axilla for a
suspicious lymph node. The patient describes an unexplained weight loss and
night sweats over the previous 10 days. Quick pathology results suggest a
tissue diagnosis of Diffuse Large Cell Lymphoma (DLCL). The oncologist has
decided to use CHOP plus rituximab in this patient. The patient specific data
appears below. Locations of lymphadenopathy:
both axilla, neck, submandibular, groin. Pertinent Labs: WBC 12,000, LDH
760, EBV panel (pending), CD20 typing (pending), Lytes (WNL), ESR 65, Albumin
3. Vital signs: Temp 101, HR 96,
BP 115/60. Appearance: healthy 43 yo male
in good physical condition, weight 190 pounds, 5' 10" tall. What dose do you recommend? Is
rituximab even indicated or appropriate in this patient?
|
 |
13 March
The Health and Wellness Center
comes to you and asks that nicotine replacement therapy (NRT) and bupropion SR
be added to the MTF formulary. They're interested in aggressively implementing
the DoD/VA tobacco use cessation (TUC) clinical practice guideline (CPG) in an
effort to get everyone smoke-free and tobacco-free within the next 5 years. Do you approve their request?
What is the current impact of tobacco abuse? What issues do you consider? What
are the most cost-effective drug therapies?
|
 |
27 March
A 52 y/o WF., approx. 1 year
post hemorrhagic stroke, living at home, with pretty good self care (eating,
dressing, etc), generalized seizures controlled with phenytoin. The patient
was on tube feeds initially, but feeding tube was pulled in November 2001.
Prior to stroke, she had a diagnosis of HTN, but no meds. Patient is currently taking
phenytoin 200mg QHS, Prempro® [conjugated estrogens / medroxyprogesterone) po
QD , fexofenadine [Allegra®] 180mg po QD, fluticasone nasal spray [Flonase®]
QD. Over the last week, her phenytoin levels are climbing and she is
ataxic, a definite change over her baseline. She has had a stable serum
phenytoin level around 18 or 19 since November. Subsequent serum phenytoin
levels were - 2/26/02 level = 24.6, 3/1/02 level = 28.3. No change in
nutritional status, renal function, LFTs, or volume status. No other
medications confirmed with family, including over the counter meds and
herbal/alternative medicine products. Albumin is WNL (4.6). She has been on
the same salt and dosage form of phenytoin throughout her course of therapy.
Compliance has been assessed and confirmed by the husband. There is no
evidence of over dosing or 'double dipping'. The attending physician asks
you why this is happening. Is this a lab error? Is a free phenytoin level
indicated? |
 |
3 April
Recently, a medication error
occurred in your facility. An order for MgSO4 2 grams IV (magnesium sulfate 2
grams IV intended) was written and MSO4 2mg IV (morphine sulfate 2 mg IV
actually given) was administered. Luckily, the patient didn't suffer any
long-lasting adverse events other than some drowsiness. There were several
process errors and inattention to detail but the risk management committee has
asked you to devise some recommendations about medical abbreviations. Where do you start and what do
you tell them? |
 |
10 April
A 59 y/o male patient is in for
his semi-annual check up and prescription refill. His medical history is
significant for mild HTN and angina. His meds include atenolol, HCTZ, and PRN
SL nitroglycerin. In conversation with the patient he relays to you some
'problems' with his wife. Upon further exploration, he confides that he has
had some 'trouble performing' recently. He asks you to prescribe that blue
pill they advertise on the TV. Do you agree or not? Why or why
not? |
 |
17 April
A 32 y/o female patient on
continuous oxygen via nasal cannula presents to the pharmacy window with a
prescription for sildenafil [Viagra®]. She seems fatigued and exhibits dyspnea
after walking the short distance across the lobby from the internal medicine
clinic to the pharmacy window.
Do you reject the
prescription immediately, espousing the current Health Affairs policy stating
the drug is used for males > 18 years of age for erectile dysfunction of specified causes?
|
 |
24 April
A 19 y/o female college student
presents to the ER asking to speak to a 'female doctor'. Once the staff
physician get a chance she sits down with the student and tries to elucidate
her story. The student relays that she and her current boyfriend had a
'contraceptive accident' last night and was worried about getting pregnant.
She asks if there's anything you can give her to 'prevent' her from getting
pregnant. The patient is in good health
without any significant medical history. She is on no medications and is not a
smoker. What do you tell her? Do you
prescribe her something? If so, what do you prescribe?
|
 |
2 May
One of your surgeons writes an
order for a continuous IV infusion of ketorolac for a post-op orthopedic
patient. He wants a 30mg IV 'bolus', followed by a continuous infusion of 2-4
mg/hour. The patient is a 32 y/o AD member s/p arthroscopic knee surgery (ACL
repair). He's in good health, on no other chronic medications, and has no
significant medical history. While an inpatient, he's also receiving cefazolin
1gm IVPB q8h x 2 doses and morphine sulfate 2-5 mg IM q3-4h as needed for
pain. The physician states this infusion will provide some 'opiate sparing'
effects. Do you fill the order? Is this an appropriate dose and
route of administration for ketorolac? |
 |
15 May
Your astute pharmacy tech
checks the labs for a patient. The patient's serum potassium (K+) is listed as
5.4 mEq/L (normal 3.5 - 5.0 mEq/L). At the same time, he gets an order for
several IVs - an insulin drip (100 units/100 ml NS, NS with 40 Meq/L K+). The
tech states you should call the provider and convince them the patient doesn't
need the IV potassium since the patient has a supranormal serum K+ level. You
check the computer for other patient labs. The available labs are K+ - 5.4 mEq/L,
Glucose - 350 mg/dL, ketones (+++), pH = 7.15). Do you call the provider or
not? Why or why not? |
 |
5 June
A 29 y/o female patient
presents with green discoloration of several of her fingernails. She made a
manicure and artificial acrylic nails placed about 6 weeks ago. She noticed
the discoloration when one of the artificial nails fell off inadvertently. She
is married with 2 kids. Her medical history is unremarkable and she is on no
current meds. She states no systemic symptoms. Her smoking and alcohol history
is negative. What's your diagnosis(es) and
possible treatment plan(s)? |
 |
13 June
You're a pharmacist at a large
military training base. A couple of cases of varicella (chicken pox) are
diagnosed in the 2,000+ member training wing. The training wing commander
comes to the medical group asking what to do to keep this from becoming an
epidemic within the training wing and losing a lot of training days to the
chicken pox. Despite the cost and the current shortage of vaccine, he wants
you to immunize the entire wing to protect others from the chicken pox and
minimize lost training days. With this request in hand, the medical group
commander comes and asks you for advice. What do you tell him? Do you
vaccinate everyone or not? Why or why not? Any other options? What's your
recommendation(s) to the commander? |
 |
17 July
A 68 y/o female patient is s/p
CABG surgery two weeks ago. She is found unresponsive after having a
generalized seizure. Her medical history is unremarkable. Her hospital course
to date was complicated by ventilator-acquired pneumonia, right hemispheric
stroke, clinically significant GI bleeding, and acute tubular necrosis
requiring hemodialysis. During rounds this morning, the patient looked well
and told the team she 'felt good' for the first time. She has an arterial line
to measure blood pressure, requiring heparin flushes every shift. Other meds
include sliding scale insulin, labetolol 200mg po BID for HTN, omeprazole 20mg
po QD, and zolpidem 10mg po QHS prn sleep. The ICU team arrives almost
immediately and works on controlling the seizure with IV lorazepam and
midazolam after intubating the patient emergently to protect her airway. Her
ABG and serum electrolytes look normal except a slightly low K+. What might have precipitated
the seizure? How would you go about treating the patient?
|
 |
24 July
A 12 y/o asthmatic patient,
who's been compliant with his therapy and under good control based on peak
flow measurement at home and during his last office visit, reports to your
clinic with a complaint of shortness of breath. He had been pretty well
controlled on albuterol MDI alone. You added ipratroprium MDI just a couple of
days ago. The patient's inhaler technique is very good as witnessed by you and
the clinic nurse on his last visit. His inhalers are both almost full when
tested by floating in water. He's has no other medical conditions. He is
afebrile with no obvious signs of infection. He and his mother claim he has no
drug allergies but is allergic to peanuts. He and his mother claim no other
changes in health, environments, exposures, etc. What may be causing this
relatively sudden loss of control? |
 |
31 July
A 57 y/o post-menopausal female
patient presents to your clinic and requires treatment for osteoporosis. A
recently ordered bone density scan shows a T score of >(-) 2.5. She is
Caucasian, of slight build, a non-smoker, exercises very little, and receives
moderate sun exposure tending to her garden. She has no other significant
medical history and is on no other meds. She has no or minimal post-menopausal
symptoms (hot flushes etc). The medical student wants to
treat this patient aggressively using both raloxifene and alendronate. His
rationale is with her T score and other risk factors, dual drug therapy (using
two drugs with different mechanisms of action) will more quickly reverse or
stop the osteoporosis and prevent fractures. Do you concur with the student?
Why or why not? |
 |
18 August
A 37 y/o patient presents to
your clinic with complaints of mouth sores and diarrhea. He's generally in
good health but has felt sluggish recently. His past medical history is
significant for moderate/severe rheumatoid arthritis (RA), which had been well
controlled until recently. He was started on methotrexate by the
rheumatologist during his clinic visit last week. His labs are normal except a
slightly decreased Hct and WBC. His serum creatinine is WNL. What's a likely cause of the
patients' complaints? How would you treat this patient?
|
 |
25 September
A 27 y/o female patient
presents to your clinic with a history of migraine headaches. Her previous
provider started her on sumatriptan oral tablets with instructions to take up
to 100mg per migraine attacks, not to exceed 3-4 attacks per month. Currently,
her chief complaint is almost daily migraine headaches. She has seasonal
allergies treated with OTC antihistamines and has no drug allergies. She does
not smoke cigarettes but drinks large amounts of regular coffee. Her labs were
within normal limits when last checked about 3 months ago. She's asking for
another prescription for her sumatriptan and/or another agent to treat her
migraines. After interviewing the patient and reviewing her pharmacy
profile, you see her use of triptan has increased significantly over the last
30-60 days. She describes her headaches as long lasting (often > 6-8
hours/day), occurring almost daily, varies in location and severity, and
trials of preventive meds (from another provider) were ineffective. Do you write the prescription?
Why or why not? |
 |
9 October
A 65 y/o patient
presents with significant thirst, restlessness, hyperreflexia, and a serum Na
= 158 mEq/L. The patient has no other significant medical history and is on no
other medications. Other labs are WNL and the patient is cardiovascularly
stable. After a thorough history and physical, the patient is diagnosed with
isovolemic hypernatremia. The medical student wants to administer 'free water'
and asks you to order ¼ normal sodium chloride (0.225% sodium chloride) IV @
100 ml/hour. (FYI - Normal Saline = 0.9% Sodium Chloride). Do you write the order or not? Why or why not?
|
 |
17 October
A 76 y/o female patient with a history of type
II diabetes mellitus, hypertension, hyperlipidemia, and mild CHF is brought to
the ER by her husband with complaints of significant lethargy and confusion.
Her vital signs are Temp - 101, HR 94, BP 90/60, Resp - 32. Her labs are : Na
- 132, K - 4.5, CL - 99, HCO3 - 5, BUN 97, Cr - 9.5. Her serum pH was 6.9 from
an arterial blood gas. Her meds on admission were lisinopril, furosemide,
simvastatin, metformin, ibuprofen, and conj estrogens. What is her likely problem? What is the likely
cause? How would you treat this patient? |
 |
31 October
A patient presents to the pharmacy with a
prescription for 'brand name' Zestril® (lisinopril by Astra Zeneca) from a
local physician. You explain to them you only have the generic lisinopril and
would have contact the provider regarding a change to the generic. The patient
is insistent that they 'must have the brand name product because this is their
blood pressure medicine.' What do you tell the patient? How do you educate the patient
and the provider regarding the use of AB-rated generic drugs?
|
 |
7 November
A patient calls asking you if the 'prescription
pills' they got about 8 months ago are still good? The prescription is for an
antihistamine they only use occasionally when symptoms occur during the
spring. They claim it's been stored at room temp since they received it. What do you tell them?
|
 |
21 November
A 40 y/o wm (AD Physician) presents to the clinic after
starting to cough one weekend and initially having a fever up to 103*F. The
fever resolved over the weekend on its own, but coughing continued, severe
enough to keep him awake at night and cause a painful Monday morning staff
meeting to go on even longer than usual. CXR initially obtained secondary to
underlying known disease of Type 1 DM. Patient's meds include only insulin
(via a pump). The patient drinks socially and does not smoke. CXR was
unremarkable. Patient treated with albuterol MDI that helped the chest
tightness present initially, but did not help the cough. Tylenol with codeine®
elixir calmed the cough during the first week enough so the patient could get
some sleep (and during the day kept our asthmatic co-worker from running in
fear whenever he approached). Patient looked much improved by the end of the
first week. The 'post viral' cough was expected to last another week. After
one month, patient is feeling well, but still coughing like a big dog (medical
term). Cough is violent enough to make the intercostal muscles work overtime
and cause discomfort, but no spontaneous pneumothorax evident on physical
exam. Cough is easily started up by making the patient laugh. Even though
'post viral' cough can continue for 2 months. As this is turning into a
chronic cough, the typical chronic cough workup for sinus drainage, GERD, and
RAD has been dismissed in this patient since there was no past history of
these conditions and none of these seemed likely to be the culprit. A culture
was obtained at the one-month period. (Why?) He also got some antibiotics at
this stage of the game. (Why did someone do that?) Also, what else can be used
to give symptomatic relief for the cough?
What's your next step? Do you have a diagnosis?
|
 |
11 December
A 57 y/o patient with significant renal dysfunction (CrCl < 20
ml/min) and CHF (NYHA category II) needs a loop diuretic because of his fluid
retention. He has no other significant medical history but is severely
allergic to sulfa drugs/sulfonamides (developed interstitial nephritis after
furosemide). The physician asks what other diuretic can we use in this
patient? What is your answer? |
 |
19 December
During a recent case presentation, a medical student shows an
ECG from a patient on paroxetine and risperidone (for "anxiety") with a
prolonged QTc of > 600 msec. The student, when questioned, correctly states
this may have been caused by the risperidone. He further elaborates this
prolonged QTc interval resolved upon discontinuation of the drug. When queried
if this had been reported through the hospital's adverse drug reaction (ADR)
process, he said no because it was am already reported side effect/adverse
effect of the drug. How do you answer the student? Do
you answer at all? Is he right or wrong or in need of some mentoring?
|

2001
 |
31 January
The nurse intern catches you on the floor and asks about
infusing a patient's antibiotics. The elderly patient is a "hard stick"
and they only have one line. All intravenous preps are running through
the line. Currently in that line, the patient is receiving a unit of
packed red blood cells (PRBCs) and they won't be finished for another hour or
two. The nurse intern asks if she can infuse the antibiotic into the
same line as the blood. She says the ABX will be going directly into the
blood in the vein anyway, so why not? What's your
advice? Run it with the blood or not?
|
 |
6 February
A local physician writes a prescription for a MTF patient with
toenail onychomycosis for terbinafine [Lamisil®] and ciclopirox nail lacquer [Penlac®].
When you call him asking why the necessity of combined therapy, he states that
his impression is that it works faster and clears the nail more quickly. Do you fill both prescriptions or not? Why or why
not? |
 |
14 February
A different Pearl this week: What was
the total amount of money spent on DTC (direct-to-consumer) advertising by the
drug manufacturers between January and September 2000? What were the top 5 drugs?
|
 |
11 April
A 35 y/o patient with a history of one duodenal ulcer in the
past is seen in clinic with symptoms of another possible ulcer. A diagnostic
test confirms a recurrence of the patient's ulcer. Upon further testing, you
find out he is H. pylori positive. He has no other risk factors for ulcers
except the H pylori and a history of ulcers. The patient has no other medical
problems and is not allergic to any medications. You
decide the patient needs treatment for the H pylori infection to prevent any
further recurrences of his ulcer. What regimen do you use? Why? Do you need to test the patient for H pylori infection after
treatment to ensure eradication of the bacteria? Why or why not?
|
 |
18 April
A 68 y/o female patient comes into your office for her routine
appointment and prescription refills. She has mild hypertension and mild
osteoarthritis, She's on lisinopril 10mg po QD, estrogen replacement therapy,
and a baby aspirin a day. She offers no complaints. Based on her account and
prescription refill record, her compliance is very good. She states another
doctor started her on an "expensive new pill" for her arthritis since her last
visit. On physical exam, her blood pressure is
160/91, up from the last visit 6 months when it was 124/72. She claims to have
been following her low salt diet and walking at the mall 3 days a week. You
can find no other physical or lab cause to explain her increased blood
pressure. What is causing her elevated blood pressure?
|
 |
25 April
A 38 y/o balding male patient comes into your office for his
annual appointment. He's in relatively good health. He's slightly overweight
but does not smoke and tries to walk three times a week for exercise. He has
no other significant medical conditions but does have a history of
cardiovascular disease in his family (father had a heart attack at age 53).
His labs are WNL and his blood pressure is normal.
Besides his positive family history, does he have any other CV risk factors?
|
 |
30 May
An adult patient presents to the window with a prescription for
Augmentin® 500mg po TID for sinusitis. Because of supply problems, you're out
of the 500mg tablets but do have the 250mg tablets. The technician wants to
dispense the 250mg tablets with the directions 2 tablets (500 mg) po TID. Do you concur or not? Why or why not?
|
 |
6 June
You're a representative to the local DoD MTF Pharmacy and
Therapeutics (P&T) committee. A formulary request for atorvastatin [Lipitor®]
comes to the committee. One of the other members argues strongly for the
addition of this agent to the formulary. Do you
support this addition or not? Why or why not?
|
 |
21 June
A provider at your MTF is debating whether to prescribe a
non-sedating antihistamine or a nasal corticosteroid for a patient with mild
intermittent seasonal allergic rhinitis. The patient complains of eye and nose
symptoms in the spring blooming season and when cutting the grass. The
symptoms are relatively mild but bothersome. The provider decides to prescribe
a nasal corticosteroid. Do you agree with this choice
or not? Why or why not? |
 |
27 June
A 35 y/o female patient comes to your clinic with complaints of
throbbing headaches, profuse sweating, constipation, tachycardia, and
palpitations. On physical exams her blood pressure is found to be 210/120.
Thirty minutes later, her blood pressure is 160/90.
After a quick but thorough physical exam and lab work-up, you make the
diagnosis of pheochromocytoma. Your student measure the blood pressure again
and her blood pressure is back to 200/115. The student recommends a beta
blocker to treat the palpitations and lower her blood pressure. Do you agree or not? Why or why not?
|
 |
19 July
One of your medical staff is concerned about
the levothyroxine product on your formulary. You carry Synthroid® and he's
seen lots on reports on CNN regarding the FDA and how they're going to pull it
off the market very soon unless the manufacturer proves safety and efficacy. What do you recommend to the P&T committee -
stand fast or switch? Why are you going to do one or the other?
|
 |
1 August
During a routine Physical Health
Assessment (PHA), a 22 y/o active duty, African American male's test for G6PD
deficiency came back as high/critical. The nurse assigned to that panel
asked the pharmacy which drugs she and the patient's PCM (primary care
manager) should avoid in this patient? |
 |
29 August
A resident in your clinic is
following a 45 y/o obese female patient (BW - 93kg, BMI 39 kg/m2) with several
concurrent medical problems (type II diabetes, HTN, ostearthritis). She's
tried a low calorie diet with limited success for the last couple months. The
resident wants to give this patient the best chance of successful weight loss.
Since the two currently available prescription weight loss medications work by
different mechanisms, he plans of starting the patient on both while
continuing a low calorie diet. Do you concur with the
resident? Why or why not. |
 |
5 September
A new patient to your base/post
comes into your office since you are "on call". The patient is 'passing
through' en route to their new PCS station. The mother asks that 'as long as
they were there' if you'd refill their pemoline [Cylert®] for her son's
attention deficit hyperactivity disorder (ADHD) so they wouldn't run out. You
have no records, no medical history, and no labs. Mom says the patient (who's
ADHD has been well-controlled without any apparent adverse events) hasn't been
seen or had labs drawn since their last visit to their PCM almost 6 months
ago. Do you refill the Cylert® or
not? Why or why not? |
 |
27 September
A provider asks you if there's
anything you can recommend to a patient to help maximize the delivery of
inhaled steroids in an asthmatic patient. The provider has already given the
patient a spacer and had him instructed by the patient education nurse on
proper use of a metered dose inhaler (MDI) plus spacer and correct inhalation
technique. |
 |
3 October
You've just finished seeing one
of your patients (a 56 y/o female with well controlled DM Type II) for her
every 6 months check-up. You've covered various issues such as medication
refills, routine labs, scheduled a mammogram, diet, exercise, etc. Is there
anything else you should do for her before she leaves?
|
 |
10 October
A 26 y/o female patient
presents to the pharmacy window with a prescription for an SSRI (serotonin
selective reuptake inhibitor). This is not completely unusual until you notice
that the prescription is from a dermatologist and the directions say take one
tablet daily for hair loss. You try to consult with the patient but she's left
the pharmacy window immediately after dropping off the prescription to use the
ladies room to "wash her hands". Your original thought is that
this is outside the provider's normal scope of practice and the dermatologist
should not be writing for this kind of drug. Being wiser than the average
bear, you decide to check it out before calling the physician. What could this physician
possibly be treating? Is he just doing a favor for the patient, maybe a 'while
I'm here' refill? Is there a legitimate medical reason for the dermatologist
to be using an antidepressant (SSRI)? |
 |
23 October
A patient calls you stating
he's received conflicting information about the availability of oral proton
pump inhibitors (PPIs). He's calling to clarify which drugs are and are not
available through the NMOP. He's had prescriptions for Prevacid® 'approved' at
a local pharmacy through the new DoD/TRICARE pharmacy program and had it
'disapproved' through the National Mail Order Pharmacy (NMOP - Merck-Medco). He
was advised by a representative from Merck-Medco that Prilosec® was available
through the NMOP but according to the PEC website, the drug was removed from
the basic core formulary (BCF), effective 1 Oct 01. He is totally confused at
this point. Is Prevacid® available or not? What about other PPIs?
|
 |
13 November
A 68 y/o patient with moderate
stable CHF (NYHA class III) is currently on a 4 drug cocktail (including
furosemide, digoxin, lisinopril, and low-dose metoprolol). He's been stable
and doing well on this medication combo for over 6 months. He was relatively
asymptomatic during his last visit and his labs were WNL. He's less than happy
with the current medical system and his condition. On his own, he
decides to try some herbal and alternative medications available at a local
health food store. During his next visit his serum
digoxin level was subtherapeutic and he had been noticing increased swelling
of his lower extremities. He claims compliance with his meds and diet. Pills
counts appear to confirm his claims. What do you do? Increase his
current meds? Add another agent? Something else?
|
 |
29 November
A provider in the hospital
calls asking for an oral tablet/capsule of dextromothorphan, preferably in a
sustained release dosage form. You offer what's on your formulary (guaifenesin
DM tabs) but the provider insists on this for a chronic pain patient on
long-term sustained-release morphine (profile shows MS Contin 60mg BID for
several months). Why does the provider want the
dextromothorphan? What antitussive effect would this added to the morphine?
|
 |
12 December
A 43 y/o male patient shows up
at the pharmacy window asking for a recommendation regarding OTC antioxidants
such as vitamin E, vitamin C, selenium, and beta carotene. He's in relatively
good health but has a positive family history of MI in his father at age 55.
He is on a low dose statin for mild hypercholesterolemia. Do you recommend antioxidants
or not? If so, what agent(s) and what dose(s)? If not, why not?
|

2000
 |
2 January
A medical intern wants to order a non-contracted statin (HMG
CoA reductase inhibitor) for his patient because he had an elevated LDL CHOL
(>200 mg/dL) and an elevated TRIG level (>400 mg/dL). The patient had no other
medical problems. His labs, other than his lipids, were within normal limits.
His rationale was that the DoD contracted statins (cerivastatin, simvastatin)
did not have the degree of TRIG lowering that the non-contract statin did. Do you agree with the intern? Do you approve the
non-formulary drug request? |
 |
20 January
An intern sees a 26 y/o male patient who has the
signs and symptoms of mild gastroesophageal reflux disease (GERD). He states
the symptoms do not affect his activities of daily living and do not wake him
up at night. He does not smoke and only drinks alcohol occasionally. He
is not overweight, his labs are WNL, and he has no other concurrent medical
conditions. The intern wants to start
the patient on a proton pump inhibitor (PPI) because "it's the most effective
therapy" for GERD. He says with the new DoD contract price for omeprazole
it's 'not that expensive anymore'. Do you
agree or not? Why or why not? |
 |
26 January
A new parent brings her 4 month old to the clinic for a well
baby check and scheduled immunizations. Mom asks you about the oral polio
vaccine vs. the injectable polio vaccine. She wants to know if one is safer
than the other and which one you recommend? What do
you tell her? Oral or injectable?
|
 |
9 August
A 17 y/o patient with mild but persistent asthma is in the
clinic for a periodic check up and refill of his medications before leaving
for college. The patient states that his asthma is well controlled and that he
only needs his beta agonist inhaler about 2 times a week. He is currently on
no other medications and has no other significant medical problems. The
student working with you wants to refill the patient's prescriptions and send
him on his way. Do you sign off on the student's plan? Why or why not?
|
 |
16 August
A 62 y/o patient with diabetic nephropathy is scheduled to
undergo a CT scan with contrast. The patient's labs are WNL except for a
slightly elevated glucose (135 mg/dL and an elevated serum creatinine (2.4 mg/dL).
The patients meds are Novolin NPH insulin 15 units SQ qam and qpm, diltiazem
XR 240mg po qam, and simvastatin 10mg po qpm. The radiologist is somewhat
concerned about giving contrast to a patient with a serum creatinine of >
2.0mg/dL. Is there anything you can recommend to prevent or minimize the
nephrotoxic effects of the IV contrast agent?
|
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24 August
A 23 y/o female patient comes to the clinic with a chief
complaint of fever and a cough productive of a green sputum. She has no other
significant medical history. Her only meds are oral contraceptive. After
a thorough exam and sputum gram stain, you prescribe a 10 day course of
amoxicillin 500mg po TID. The patient asks if there are any interactions
between her antibiotic and her birth control pills. What do you tell her?
|
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30 August
A 22 y/o female calls the triage desk complaining of dysuria
and frequency and asking for an appointment. She has no systemic symptoms
(fever, chills, flank pain, etc). She has no other significant medical history
and is on no current medications. She is not sexually active. The nurse
wants you to send a prescription to the pharmacy for a short (3 day) course of
antibiotics without seeing the patient or obtaining any lab tests. Do you send the prescription or not? Why or why not?
|
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8 September
A 19 y/o college student comes to your office for some
prescription refills during her spring break. She is on tetracycline 500mg po
BID for acne and no other medications. She has no other significant medical
history. Her physical exam and labs are WNL. As she's leaving she
mentioned experiencing pain on swallowing and wonders if it's diet related.
What do you tell her? What are likely cause(s) in this case?
|
 |
21 September
The local formulary committee is debating the addition of
Maxalt MLT® (orally dissolving tablets for the acute (abortive) treatment of
migraines headaches. The argument used by the presenter is that the orally
dissolving tablets provide quicker relief of migraines. Do you concur and
vote for the addition on this basis or not?
|
 |
27 September
A provider at your MTFs is concerned about his patients after
hearing that this year's flu vaccine will not be available in adequate supply
until early-mid November. He asks that the pharmacy stockpile various oral
antiviral medications (amantadine, rimatadine, zanamivir, and oseltamivir) so
providers can prescribe prophylactic antivirals, esp in patients at high risk. Do you stockpile the meds requested or not? Why or why not?
|
 |
4 October
A 22 y/o female presents to your office in the MHS clinic
asking questions about the new abortion pill recently approved by the FDA.
After a long conversation, you tease out of her the fact that she's pregnant.
She's unmarried and due to start graduate school shortly. She inquires about a
medical abortion and asks you to prescribe the new abortion pill. After a
lengthy discussion, she decides to delay her decision in order to explore
other options before making a final decision. Her questions have made
you realize that more of these kinds of questions will be coming shortly and
that you had better find out more information. If the patient had opted for
the medical abortion, would you have considered prescribing the drug on purely
clinical grounds? |
 |
20 October
A 52 y/o post menopausal woman see you for her routine annual
appointment and is worried about osteoporosis. She refuses to take estrogen
replacement therapy (ERT) and the biphosphonate therapy caused her severe
esophagitis. She had a significant allergic reaction to calcitonin. She is not
overweight and does not smoke cigarettes. Her medical history is unremarkable
except for an elevated LDL. Besides calcium supplementation and weight bearing
exercise, she asks what else you can do for her to prevent or slow her
development of osteoporosis. Is there anything you can offer her?
|
 |
22 November
A 32 y/o AD male recently had orthopedic surgery for an old
football injury incurred while on his college football team. He was given
acetaminophen with codeine #3 post-op for pain control. He is otherwise
healthy. His past medical history is significant for mild depression, mild
hypercholesterolemia, and occasional heartburn. His other medications include
fluoxetine 20mg po QAM, pravastatin 10mg po QHS, and cimetidine 100-200mg po
QHS. His labs are all within normal limits. Upon interviewing the patient he
complains that his pain is not being controlled. He is taking 10-12 tablets a
day (APAP with codeine) and has refilled his prescription 3 times in the past
two weeks. On physical exam, there is no clinical or xray signs that would
lead the surgeon to believe something went wrong with the surgery or that the
patient isn't progressing exactly as he should. The surgeon cannot find any
objective reason for the patient's pain. He wants either another prescription
for acetaminophen and codeine or a prescription for a more potent analgesic.
Do you give him another prescription? For what medication? What do you
think may be going on? |
 |
30 November
Your student is seeing a patient on which you are monitoring INRs. She is a warfarin patient with protein S deficiency. She's 33 years old
and in good health otherwise. Anticoagulation therapy with warfarin, based on
her INRs, is therapeutic (within target range). She complains of heavy
bleeding during her menstrual cycle which is understandable. It's problematic
for her, but not to the extent of being dangerous or life-threatening. The
student is interested in trying to help her and inquires about giving her a
small dose of oral vitamin K (i.e. 2.5 mg) twice during her cycle.
Should it be enough to stop any heavy bleeding but not make it too difficult
to re-anticoagulate her or predispose her to a clot? Would increasing
the amount of green vegetables during her cycle make a difference? Do you prescribe the low-dose vitamin K? Why or why not?
|
 |
20 December
You've just returned from your annual skiing trip to the
Colorado Rockies where you rented a timeshare complete with swimming pool, hot
tub, and a ski-in front door. Everyone had a great time with no broken bones.
About 3 days after you return home, you and a couple of others notice a
raised, pustular rash on your trunk (torso). When examined by the local doc,
he asked the usual questions about changes in food, laundry detergent, new
medications, recent illnesses, etc. Nothing has changed and you haven't been
ill before or since the ski trip. What might be a
possible cause of the rash? How would you treat it?
|

1999
 |
8 September
A medical
student comes to you stating he received a
needle stick when performing a blood draw on an
HIV positive patient. He is exceptionally
concerned with the risk of contracting AIDS from
this incident and wants some prophylaxis? Do you
agree? Disagree? If so, what drug(s) do you
recommend/prescribe? |
 |
15 September
During a month attending on a hospice service, you have several
patients who appear to be in great distress because of a significantly
increased amount of oral secretions. The nurses are having to suction the
patient’s mouth repeatedly and ask you if there’s anything you can do.
What would you try? |
 |
22 September
A 38 y/o active duty male presents to your clinic for an annual
check up. During the examination and review of recent labs, your medical
student notices an elevated LDL cholesterol of 170 mg/dL. His HDL and TRIGs
are within normal limits The patient’s father had an MI at age 52. His medical
history is unremarkable (no HTN, DM, or smoking). The
student wants to start the patient on a statin. He recommends atorvastatin [Lipitor®]
10mg po QD. Do you agree or disagree? Why or why not?
|
 |
29 September
A 24 y/o patient requires extensive dental work. His past
medical history is significant for prosthetic mitral valve replacement 5 years
ago. The patient’s labs are WNL, he has no known allergies, and he has no
other significant medical history. The intern wants to give the patient
amoxicillin 3,000mg po 1 hour before the dental procedure and 1,500 mg po 6
hours after the dental procedure. Do you agree or
disagree with the intern? Why or why not? |
 |
6 October
A 67 y/o patients visits the office today for their annual
check-up and review/renewal of their prescription medications. You've
completed the review and renewed the necessary prescriptions. The patient's
lab work is WNL and physical exam is unremarkable. He has no new complaints. Is there anything else you should do for this patient
before you send them on their merry way? |
 |
13 October
A 57 y/o end stage renal disease (ESRD) patient who is on
chronic hemodialyis presents with persistent hyperphophatemia. He has been on
calcium carbonate and following a phosphate restricted diet. His calcium
phosphate product is ~ 60. The patient wants to avoid aluminum salts because
of what he's read about CNS toxicities with chronic use. What other medical options are available to treat this
patient's hyperphosphatemia? |
 |
20 October
Since the pharmacy benefit (and the cost of the pharmacy
benefit!) has gained such attention in the recent past, this is more of a
pharmacy business Pearl than a clinical Pearl. With the ever-increasing cost of pharmaceuticals and the
increased demand for this benefit, we can not ignore the monetary aspect of
providing pharmaceuticals to our patients and beneficiaries. The pharmacy
benefit has been mentioned in conjunction with the GAO report on the DoD
pharmacy benefit re-design, proposed inclusion into the Medicare benefit, and
the recent Defense authorization bill, just to name a few. How much did the pharmaceutical industry spend on
direct-to-consumer (DTC) advertising in the first 6 months of this year? What
were the Top 5 drugs for television and print advertising? |
 |
27 October
A 62 y/o patient who is on chronic anticoagulation therapy with
warfarin [Coumadin®] comes in for his monthly PT/INR draw and follow-up. He
relays no complaints. His CBC is WNL and his Chem-7 is also WNL. His INR is
6.1. He doesn't have any overt signs of bleeding.
Seeing the elevated INR the medical student wants to order vitamin K 10mg IM
now to lower the INR and decrease the patient's risk of bleeding. Do you agree or disagree with the student? |
 |
17 November
A 36 y/o patient with mild hypertension comes to the clinic
with a chief complaint of upper respiratory symptoms, specifically nasal
stuffiness. His labs are WNL and he has no other significant medical history.
The student wants to prescribe some oral decongestants. Do you agree or
disagree with the student? |
 |
24 November
A 64 year old woman presents complaining of chest "cramps" and
shortness of breath for the last 2 hours. The provider begins to assess the
patient when the patient suddenly collapses onto the floor. She is not
breathing, has no pulse, and ECG indicates V-fib. Successive defibrillation
and multiple trials of epinephrine and lidocaine are unsuccessful. The doctor
wants to give bretylium, but you remind him that it is not available at your
facility at this time. He then requests amiodarone IV. Do
you agree or disagree? |
 |
8 December
A 56 y/o overweight female with type II diabetes mellitus and
osteoarthritis presents to your office for a routine appointment. On metformin,
her diabetes is under good control with a HgbA1C of 7-8 mg/dl. She complains
about aching joints probably due to her osteoarthritis which has been
controlled with acetaminophen and an occasional dose of an OTC NSAID. She asks
you about using glucosamine for her osteoarthritis after hearing about it from
a neighbor. Do you recommend the glucosamine or not in this patient? |
 |
15 December
A 45 y/o male presents to your office for a routine
appointment. He is otherwise healthy but has a positive family history,
elevated CHOL (controlled with diet and niacin), and mild hypertension. He
asks you for some antibiotics to prevent heart disease or a furthering
"clogging of his arteries". He states he read something in a magazine stating
|
 |
22 December
A 23 y/o patient presents to your office for a routine
appointment. During the history, he relays to you a rather embarrassing
problem he has with flatus. He has tried diet changes but nothing seems to
help. He hopes to attend numerous holiday parties but is hesitant because of
his 'problem'. He asks if you have any suggestions? What do you tell the
patient? |

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