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?

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