Treatment of Rheumatoid Arthritis Discussion Paper

Scenario 1: Jamie is a 38-year-old, male, Homeless Bipolar Patient who presents self for admission with Acute Psychotic Episode.

Problem: The patient’s current state closely resembles an acute psychotic episode; in particular, the patient is experiencing severe paranoia. He has had bipolar disorder and has been taking lithium, and just prescribed imipramine which is dangerous for bipolar patients, as it might trigger mania. Treatment of Rheumatoid Arthritis Discussion Paper

Treatment Plan: Regarding Jamie’s condition, it is crucial in the first instance to withdraw imipramine. Imipramine which belongs to a tricyclic antidepressant class of drugs is known to make the condition of bipolar patients worse as it can cause an onset of mania, Our patient’s condition is likely to worsen if treated with Imipramine (Folsche et al., 2021). It is imperative that the patient continue and remain on lithium and monitor the lithium level since lithium is one of the most effective anti-mood stabilizers that work for bipolar disorder. One needs to monitor serum lithium concentrations to check whether the levels are within the therapeutic range of 0. 6-1. 2 mEq/L (Molenaar et al., 2021). Also, starting antipsychotic treatment with an atypical antipsychotic such as olanzapine would address the clients’ acute psychosis. Typical ones like fluphenazine, haloperidol, chlorpromazine, and others can cause extrapyramidal side effects; atypical ones like olanzapine are useful in treating acute psychosis. They are therefore used in targeting a wide range of symptoms as well as the distressing symptoms that are characteristic of psychotic episodes such as hallucinations, paranoia as well and severe agitation (Lappin et al., 2022). Among the antipsychotics, specifically, olanzapine has a very fast onset of effects and is ideal for acute phase treatments. In bipolar disorder, atypical antipsychotics work, and do more than just target psychosis because they have mood-stabilising properties. It is used in the treatment of both manic and mixed episodes and therefore assists in controlling the change of moods that could be in part or in full contributing to the psychotic episode. Treatment of Rheumatoid Arthritis Discussion Paper

ORDER HERE A PLAGIARISM-FREE PAPER 

Prescription

• Lithium Carbonate: There is no exact stratum-specific dose but the common adult dose recommended is 300 mg per os, twice a day. Special instructions: The patient should have serum level and renal as well as thyroid function checked periodically. Dispensed: 30 days’ supply. Refills: 0.
• Olanzapine: It is used as 10 mg by the oral route at night or bedtime. Special instructions: To follow metabolic side effects including weight gain and high glycemic. Dispensed: 30 days’ supply. Refills: 0.

 Monitoring Therapy: Patients should be monitored for lithium levels every six to twelve hours, renal profile, and thyroid function. Lithium exposure is associated with renal toxicity; hence, long-term use results in nephrogenic diabetes insipidus and chronic kidney disease. Lithium may interfere with thyroid functioning and hence may lead to hypothyroidism or rarely hyperthyroidism may occur. Also, it is necessary to track changes in psychotic disorder and the adverse effects of treatment with olanzapine. Further evaluation of medicine compliance and general psychological well-being should be conducted frequently to ensure Jamie’s treatment is successful; any side effects should also be timely identified. Treatment of Rheumatoid Arthritis Discussion Paper

Scenario 2: AH, a 68-years Female experiencing Rheumatoid Arthritis and other related conditions

Problem: AH’s complaint has also raised his Rheumatoid arthritis pain level yet he is on Meloxicam 15mg per day. Crohn’s disease and occasional incontinence can also be mentioned together with well-controlled diabetes type 2.

Treatment Plan: AH’s care plan can carry on with her present use of meloxicam for RA which has not been effective for her; she may be administered other medications for her condition. Meloxicam will remain an effective anti-inflammatory, although incorporating methotrexate, a DMARD, would help in better long-term control of RA (Huang et al., 2021). Prednisone and other types of corticosteroids tend to be used and prescribed for short-term management of acute flare-ups. Hence, the necessity of close monitoring for possible gastrointestinal side effects due to her Crohn’s disease should the patient be prescribed these drugs. Steroids such as prednisone can also cause inflammation, which is detrimental to Crohn’s disease patients due to the irritation of the GI tract. Prolonged or large doses of aspirin can cause GI bleeding, ulceration, or perforation. There is a potential of exacerbating her type 2 diabetes, which she has been managing well, due to its effect of causing hyperglycemia (Shang et al., 2022). It is likely to worsen insulin sensitivity and increase the amount of glucose that is produced in the liver thus complicating the regulations of blood sugar levels.

Prescription:

• Meloxicam: It is necessary to add no changes in the dose: The patient should take 15 mg PO once daily.
• Methotrexate: 250µgm Diltiazem, 10 mg PO once weekly. Special instructions: Use folic acid one milligram per day to decrease the side effects. Dispensed: 4 weeks supply. Refills: 0.
• Prednisone (for acute flare-up): 10 mg PO once daily for 7 days has been given for meloxicam. Special instructions: Reduce the dosages if the signs reduce. Dispensed: 7 days supply. Refills: 0. Treatment of Rheumatoid Arthritis Discussion Paper

Monitoring Therapy: It is necessary to establish full-schedule follow-ups to monitor the progress of managing AH’s RA therapy and its impact on the patient’s health. Supervision of the symptoms results in the evaluation of the treatment intervention designed for the management of RA and enables modifications promptly to effectively manage her disease. Blood count and liver function tests are essential in the management of AH because methotrexate, which is one of the medications she was on, exerts significant toxic effects on the hematologic and hepatic system (Xu et al., 2022). In this way, frequent examinations enable identifying the possible incidents, including blood-forming organ damage like bone marrow suppression or liver toxicity, at an early stage and prevent further deterioration of the patient’s condition. Besides, AH has coexisting Crohn’s disease, and the possibility of side effects from gastrointestinal troubles must be evaluated because of medication and treatment. This monitoring approach guarantees that AH’s treatment plan is not predisposing her to risks related to her comorbid conditions even as it optimally controls her RA. Treatment of Rheumatoid Arthritis Discussion Paper

 Scenario 3: The client is named Sheila and she is 26 years old; she has a Medical History of hit-on-head & Tonic tonic-clonic seizures.

Problem: Sheila is having some odd sensations that her eyes are moving in funny ways; she has developed poor coordination, experienced blurred vision, and feels always sleepy. Currently, she is using a prescription of Ritalin, Dilantin, Paxil, and Lasix. Her Dilantin level actual value of 11 falls in the subtherapeutic range, while her albumin level detected at 2.

Diagnosis: The manifestations that Sheila is currently presenting entail either phenytoin toxicity or subtherapeutic phenytoin levels touching on the issue of free drug concentration where the level of albumin may contribute to these (Servilha‐Menezes et al., 2022). Phenytoin is highly protein-bound and therefore hypoalbuminemia increases the free fraction of the drug, which leads to toxicity at prevailing total plasma concentrations.

Treatment Plan: For the management of Sheila’s condition, the dose of phenytoin needs to be revised, First of all, there is a low albumin level. Adjusting the dosage of phenytoin is required as she was within the toxic level for phenytoin prime while the total phenytoin level should be within 10-20 mcg/mL (Keats et al., 2022). Patients have to be on blood tests frequently to ensure that phenytoin concentration in their body is checked and the dosage adjusted if necessary. Supplementary observations of the therapeutic impact and symptoms of toxicity are essential to determine whether the drug is working well in seizure management while not causing other damaging effects. Treatment of Rheumatoid Arthritis Discussion Paper

Prescription:

• Phenytoin: The dose level of valproate is 300 mg PO once daily HS, at bedtime. Special instructions: This should be done by observing the serum levels often. Dispensed: 30 days supply. Refills: 1.

Monitoring Therapy: Phenytoin levels need to be taken frequently to determine the correct dosage as well as to prevent toxicity. What is more, thought is required to assess the serum levels and adjust according to the clinical condition (Keats et al., 2022). Further, dedicated follow-ups are needed to assess the effectiveness of the seizure control and adverse effects of the drug. This integration of measures should ensure that the client’s symptoms are controlled while at the same time avoiding drawbacks associated with the use of phenytoin.

 Scenario 4: Xavi- A 44-year-old man with low back pain after an MVA

 Problem: Xavi has acute low back pain now; the pain intensity is at 8/10 after being involved in a motor vehicle accident 10 days ago. He is for a prescription of Lortab.

Treatment Plan: The care plan focuses on the assessment of Xavi’s current pain management plan and the possibility of making the options non-opioid dominated by the combination with physical therapy due to the notable intensity of his lower back pain (Kose et al., 2022). Screening for opioid dependency or misuse is important since it is likely to classify a patient as an opioid depending on their long-term use. However, if continuing with opioids is needed, then it is crucial to prescribe a small amount with a definite reduction regimen. Treatment of Rheumatoid Arthritis Discussion Paper

Prescription:

• Lortab 5/325 mg: If continuing, 325 mg/5 mL PO every 6 hours as needed for pain. Special instructions: Administer should not be more than 8 tablets within 24 hours. Dispensed: 3 days supply. Refills: 0.
• Ibuprofen 600 mg: In addition to Lortab, 600 mg by PO route every 6-8 hours as needed for pain. Special instructions: Should be taken with meals to reduce side effects that affect the stomach. Dispensed: 10 days supply. Refills: 0.

Monitoring Therapy: This is to ensure that Xavi’s pain, function, and side effects status can be evaluated and monitored effectively during follow-up visits. Depending on the situation, it is crucial to monitor the signs of dependency on opioids if Lortab is continued to be taken (Kalkman et al., 2022). Finally, since he has had a long-standing chronic low back pain, thinking about a referral to physical therapy can allow for addressing the basic pathology that seems to be contributing to his pain, as well as help him stay off more medicines. This approach will incorporate effective pain management for Xavi while at the same time avoiding the possible side effects of opioids.

References

Folsche, T., Maier, H. B., Hillemacher, T., & Frieling, H. (2021). Combination Therapies and Switching of Agents in Depression and Bipolar Disorders. In NeuroPsychopharmacotherapy (pp. 1-17). Cham: Springer International Publishing. https://link.springer.com/referenceworkentry/10.1007/978-3-319-56015-1_437-1 Treatment of Rheumatoid Arthritis Discussion Paper

Huang, J., Fu, X., Chen, X., Li, Z., Huang, Y., & Liang, C. (2021). Promising therapeutic targets for the treatment of rheumatoid arthritis. Frontiers in immunology, 12, 686155. https://doi.org/10.3389/fimmu.2021.686155

Kalkman, G. A., van den Brink, W., Pierce, M., Atsma, F., Vissers, K. C., Schers, H. J., … & Schellekens, A. F. (2022). Monitoring opioids in Europe: the need for shared definitions and measuring drivers of opioid use and related harms. European Addiction Research, 28(3), 231-240. https://doi.org/10.1159/000521996

Keats, K., Powell, R., Rocker, J., Waller, J., & Coppiano, L. S. (2022). Evaluation of phenytoin loading doses in overweight patients using actual versus adjusted body weight. Epilepsy & Behavior, 134, 108833. https://doi.org/10.1016/j.yebeh.2022.108833

Kose, S. G., Kose, H. C., Celikel, F., Tulgar, S., De Cassai, A., Akkaya, O. T., & Hernandez, N. (2022). Chronic pain: an update of clinical practices and advances in chronic pain management. The Eurasian journal of medicine, 54(1), S57. https://doi.org/10.5152%2Feurasianjmed.2022.22307

Lappin, J. M., Davies, K., O’Donnell, M., & Walpola, I. C. (2022). Underuse of recommended treatments among people living with treatment-resistant psychosis. Frontiers in Psychiatry, 13, 987468. 

Directions: For each of the scenarios below, answer the questions below using your required learning resources, clinical practice guidelines, and medscape. Explain the problem and explain how you would address the problem. When recommending medications, write out a complete prescription for each medication. What order would you send to a pharmacy? Include drug, dose, route, frequency, special instructions, # dispensed (days supply), refills, etc. Also state if you would continue, discontinue or taper the patient’s current medications. Use at least 3 sources for each scenario and cite sources using APA format. Treatment of Rheumatoid Arthritis Discussion Paper

ORDER HERE NOW

Jamie is a 38-year-old homeless bipolar patient that is diagnosed with an acute psychotic episode. He tells you that he has been on lithium for years and was recently started on amitriptyline (Elavil) 25mg po TID by someone at a free clinic. What treatment plan would you develop for Jamie? Would you discontinue any medications? What medications would you add?

A 68-year-old woman has a history of rheumatoid arthritis and has been taking nabumetone (Relafen) 1000 mg po qd for 2 years. Other pertinent past medical history includes: occasional incontinence, Crohn’s disease with frequent exacerbations, and well-controlled diabetes type 2. Recently, her arthritis pain has been much worse and she is requesting additional medication for her rheumatoid arthritis. What would be appropriate additional therapy for this patient? What monitoring would be appropriate to monitor this medication?

Sheila is a 26-year-old with history of head injury and tonic clonic seizures. She is seen today with complaints of “funny” eye movements, feeling uncoordinated, blurred vision, and feeling lethargic. Her current medications include Ritalin 10 mg po BID, Dilantin 300 mg po BID, Paxil 20 mg po daily, Lasix 20 po daily Lab Values from today Dilantin level of 11 Albumin 2 WBC 9.9 Plt 177 Na 141 K 4.2 Hg 13.2. What do you think is causing the patient’s symptoms? What lab values and calculated corrected medication level support your diagnosis? What is your treatment plan for this patient?

Xavi is a 44-year-old man with complaints of low back pain following a motor vehicle accident. The accident occurred 7 days ago. He rates his pain 8 out of 10. He was prescribed Lortab 5 / 325 in the ER last week. He is requesting a refill of the Lortab today and indicates it just barely makes him comfortable. What treatment plan would you implement for Xavi? What medications would you prescribe and how would you monitor them? What days supply would you prescribe? Treatment of Rheumatoid Arthritis Discussion Paper