Pharmacology interventions
History Data:
Chief concern: “I have been having nasal congestion and Right ear itchy with tenderness for the past two weeks”
HPI: This is 64 years old African American male who has history of HLD, severe rheumatoid arthritis s/p multiple surgeries and s/p right knee replacement in October 2023, Pseudo-GOUT and Anemia secondary to chronic disease. He stated that he has nasal congestion and right ear itchy with tenderness for the past two weeks. he has also had swelling of his both knees and feet for the past two weeks, states that his right knee is more swollen than the left. He stated that he visited surgeon and was diagnosed to be pseudo-gout and prescribed Colchicine 1.2 mg per day and also had arthrocentesis. He denies feeling tired , fever, cough, SOB, night sweats, pain, denies dizziness
Pertinent PMH: This is 64 years old African American male who present to the office on 06/05/2024, with complaint of increased nasal congestion and Right ear itchy with tenderness for the past two weeks. he denies any recent travel or any sick contact at home or at work. Pt has a PMH of pseudo-gout currently taking Colchicine 1.2 mg per day, HLD on Crestor 5 mg tablet , RA, Rt knee replacement, left wrist fusion, right open reduction fixation of the right thumb, s/p colostomy and abdominal surgery post gun shot. Anemia secondary to chronic disease on Cyanocobalamin injections, endorses that he drinks alcohol occasionally, denies tobacco use or recreational drugs. Patient has NKDA, has seasonal allergies. no significant family medical hx, both parents passed from old age. Patient is not married but has one daughter who lives in Atlanta Geogia no health problems were reported His last BM was this morning. Patient is not up to date on his vaccines, refused yearly flu shot, received two Covid vaccines of Pfizer, refused the booster
Currently medications
• vit d2 1.25 mg (50,000 unit), take 1 capsule (50,000 unit) by oral route once weekly
• cyanocobalamin 1,000 mcg/ml, inject 1 milliliter (1,000 mcg) by intramuscular monthly
• folic acid 1 mg tablet, take 1 tablet (1 mg) by oral route once daily
• protonix dr 40 mg tablet, take 1 tablet (40 mg) by oral route once
• Crestor 5 mg tablet, take 1 tablet (5 mg)
• multi-day plus minerals tablet, one once a day
• azelastine 0.1% (137 mcg) spry, spray 2 sprays in each nostril by intranasal route 2 times per day
• singulair 10 mg tablet, take 1 tablet (10 mg) by oral route once daily in the evening
• neomycin-polymyxin-hc ear susp, instill 2 drops into affected ear(s) by otic route 3 times per day left ear and right ear 3 days;
• Claritin 10 mg liquid-gel cap, Flonase allergy rlf 50 mcg spry, inhale 2 sprays (100 mcg)
INSTRUCTIONS
1. Three Differential Diagnosis: ( first one must be the primary diagnosis)
2. Pathophysiology for Diagnosis (each diagnosis) with etiology
3. Pertinence of Research Article (for primary diagnosis)
4. Plan of Care: Testing/Studies:
5. Pharmacological:
6. NONPHARMACOLOGIC METHODS SHOULD BE DISCUSSED ALSO
7. Patient Education:
8. Follow up:
Sample Solution
This information suggests the following:
1. Three Differential Diagnoses:
- Acute otitis media with allergic rhinitis (primary diagnosis): This is most likely due to the combination of ear symptoms (itching, tenderness) and nasal congestion. Allergies can contribute to ear congestion and inflammation, increasing the risk of otitis media.
- Acute rhinosinusitis: This could explain the nasal congestion, but less likely to cause isolated ear symptoms without sinus pressure or facial pain.
- Eustachian tube dysfunction: This could explain ear symptoms, but nasal congestion would be less prominent.
Full Answer Section
Pathophysiology and Etiology:
a) Acute otitis media with allergic rhinitis:
- Pathophysiology: A blocked Eustachian tube (the tube connecting the middle ear to the back of the nose) due to allergies can trap fluid in the middle ear, leading to infection and inflammation.
- Etiology: Allergies cause inflammation and swelling in the nasal passages, affecting the Eustachian tube. Viruses or bacteria can then enter the trapped middle ear fluid, causing infection.
3. Pertinence of Research Article:
A recent study published in the Journal of Allergy and Clinical Immunology showed that allergies significantly increase the risk of developing acute otitis media, particularly in adults with a history of allergies. This research supports the primary diagnosis in this case. (Note: You will need to find a specific research article to reference here).
4. Plan of Care:
- Testing/Studies:
- Otoscopy: Examine the eardrum for signs of infection.
- Nasal endoscopy (optional): May be done to visualize the nasal passages and rule out sinusitis.
- Pharmacological:
- Continue Colchicine: To manage his pseudo-gout.
- Otic antibiotic drops: Treat the ear infection (e.g., Ciprofloxacin or Ofloxacin otic drops).
- Intranasal steroid spray: Reduce nasal inflammation (e.g., Flonase or Budesonide).
- Antihistamine: Alleviate allergy symptoms (e.g., Loratadine or Cetirizine - consider switching from Claritin if he's not already taking it).
5. Non-pharmacological methods:
- Warm compresses: Apply to the affected ear to relieve pain and inflammation.
- Nasal saline irrigation: Clear mucus and allergens from the nasal passages.
- Pain relievers: Over-the-counter pain relievers like Ibuprofen can help with pain and fever.
- Elevation of the head during sleep: Promote drainage from the ears.
6. Patient Education:
- Explain the link between allergies and ear infections.
- Advise on proper use of medications, including ear drops, nasal spray, and inhalers (if using).
- Discuss the importance of completing the full course of antibiotics, even if symptoms improve.
- Emphasize the importance of staying hydrated.
- Educate on allergy avoidance strategies like dust mite control and pollen avoidance.
7. Follow Up:
- Schedule a follow-up appointment in 7-10 days to monitor response to treatment and address any remaining symptoms.
- Encourage the patient to return sooner if symptoms worsen, experience fever, or have difficulty hearing.
8. Additional Notes:
- Consider discussing the benefits of receiving the recommended flu shot and COVID booster with the patient.
- Address any concerns he may have about his medications or allergies.
Disclaimer: This information is for educational purposes only and should not be substituted for professional medical advice. Please consult with a healthcare provider for diagnosis and treatment of any medical condition.