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?

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?
 

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

 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?

 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?

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?

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?

 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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?