For more course tutorials visit www.tutorialrank.com Discussion Part One Emily, a relatively healthy 5’5”, 32-year-old young woman weighing 190 pounds, presents to your clinic with hirsutism, anovulation, oligomenorrhea, and at times amenorrhea. Biochemical blood tests reveal elevated luteinizing hormone (LH, without a mid-cycle surge) and androgen elevation.

1. NR 508 Week 1 Discussions
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Discussion Part One
Emily, a relatively healthy 5’5”, 32-year-old young woman weighing
190 pounds, presents to your clinic with hirsutism, anovulation,
oligomenorrhea, and at times amenorrhea. Biochemical blood tests
reveal elevated luteinizing hormone (LH, without a mid-cycle surge) and
androgen elevation.
She mentions that she also has a family history of irregular cycles, and
that her grandmother experienced early menopause. She also states that
she is sexually active, occasionally smokes (1 pack/month), and desires
to be prescribed one medication to mitigate her symptoms, as well as,
prevent her from becoming pregnant.
Please provide a list of differential diagnoses, as well as an indication of
your primary diagnosis.

2. Once this has been completed, please indicate and describe your chosen
pharmacological treatment with inclusion of dose and mechanism of
action of your chosen prescription.
Discussion Part Two
You diagnose Emily with polycystic ovarian syndrome (PCOS) and
decide to prescribe drospirenone-ethinyl-estradiol as a way to control
both the PCOS symptoms, as well as to act as an oral contraceptive.
At what dose should this be prescribed?
What is the mechanism of drospirenone-ethinyl-estradiol, and why
would, because of its mechanism, it be a good choice for her PCOS
symptoms (Include the medication-altered physiology)?
How would you monitor for efficacy and toxicity?
At what dose should this be prescribed?
Discussion Part Three (graded)
Emily subsequently returns to your clinic 5 months later, and decides to
inform you that within the first 3 months after treatment, she struggled
with a severe bout of depression. Instead of returning to your clinic to be
prescribed, yet another pharmaceutical, she consulted her herbalist who
told her about the anti-depressant, over-the-counter, herbal formulation,
St. John’s Wort. She decided to begin taking St. John’s Wort in

3. conjunction with her prescribed oral contraceptive medication, and she
has now reappeared at your clinic because she is pregnant, and is
distraught about how this occurred since she took her oral contraceptive
compliantly since its prescription.
Why then, is she pregnant?
Please include detailed pharmacological mechanisms of how this
occurred, and your subsequent steps in her management.
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NR 508 Week 2 Discussions
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Discussion Part One
Cynthia is a 65-year-old African American female who presents to the
clinic for a check-up. Her last examination was ~5 years ago. She has no
specific, significant, or urgent complaint. She explains that her only

4. issues are thirst, fatigue, and leg numbness and tingling, which is
beginning to occur more often. You decide to do a physical exam, as
well as draw labs and receive the following results:
Social history: no smoking or alcohol consumption.
Physical examination:
GEN: well nourished, slightly obese female
VS: BP 180/103 HR 73 RR 13 T 98.4 Weight 90 kg, Height 5’6”
HEENT: PERRLA
COR: RRR, NMRG
CHEST: CTA
NEURO: monofilament test shows decreased peripheral sensation
EXT: normal
Laboratory (fasting):
Na 139 mEq/L
K 3.8 mEq/L
ALT 34 U/L
Ca 9.1 mg/dL
CL 102 mmol/L

5. HCO3 22 mEq/L
AST 39 U/L
TP 6 g/dL
BUN 33 mg/dL
SCr 2.0 mg/dL
Alb 4.1 g/dL
Cholesterol 254 mg/dL
BG 300 mg/dL
TSH 0.12 mU/mL
UA: SG 1.013 mg/24h, pH 6.5, +++ protein
What are the major problems in this patient, and what diagnoses do these
values indicate?
Additionally, what is your assessment and pharmacological plan for
each of these problems including the medication, dose, and mechanism
of action?
Discussion Part Two (graded)

6. Cynthia has been prescribed a plethora of medications. How will you
properly monitor each medication for efficacy and toxicity? Are you
concerned with any drug-drug interactions? If so, what are they, and
what is the mechanism of the interaction?
Discussion Part Three (graded)
Given Cynthia’s increased creatinine and renal deterioration, metformin
is probably not optimal in this case. Therefore, upon subsequent visits,
you decide to start her on a sulfonylurea. She reappears in your clinic
fairly soon thereafter with complaints of shakiness, sweating, chills,
clamminess, lightheadedness, and a moderately severe headache.
• What is the diagnosis given these symptoms and the medications she is
currently taking from Parts One and Two, and how would you proceed?
• At this point, please also be sure to also provide an accurate summary
of Cynthia’s medication plan.
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NR 508 Week 3 Discussions

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Discussion Part One
Elliot is a 74 year-old male who presents to your clinic with complaints
of frequent nosebleeds (4 in the past week) and several severe bruises
scattered variously throughout his anatomy. The patient is also
complaining of a runny nose, cough, and head/chest congestion. He has
a history of chronic atrial fibrillation and is currently prescribed and
taking warfarin. Approximately 3 weeks previously, he started taking
over-the-counter cimetidine for heartburn he was experiencing. Below
is a list of the patient’s medications, his physical examination, and his
laboratory findings:
Medications
Digoxin 0.25 mg QD Cimetidine OTC BID
Pseudoephedrine SR 120 BID Warfarin 7 mg QD
Allergies: NKDA
Physical Examination
VS: BP: 180/95, HR 75, irregularly irregular, RR 17
Weight: 95 kg

8. HEENT: WNL
ABD: + Bowel Sounds EXT: Bruising on arms and legs
NEURO: Alert & Oriented x 3 GEN: Well developed, well-nourished
male
ECG: atrial fibrillation
Laboratory
Na 143 mEq/L K 4.5 mEq/L
Cl 99 mmol/L CO2 25 mEq/L
BUN 18 mg/dL SCr 0.9 mg/dL
INR 4.8 Hct 42%
Hbg 15 mg/dL Digoxin 3.8 ng/ml
What problems should be identified in this patient?
What are the precise mechanisms of action of each drug?
What do you think is contributing to the patient’s hypertension?
Are there any drug interactions that you can identify as associated with
this current drug regimen, and if so how, mechanistically, are they
occurring?
What is the clinical significance of these interactions?
Discussion Part Two

9. You have decided to have him stop the pseudoephedrine related to his
hypertension, as well as the cimetidine related to its interaction with
warfarin. The patient returns for his monthly follow-up appointment, and
it is noticed that his blood pressure (195/80) has not come under control.
You decide to start him on hydrochlorothiazide.
Is there a better medication than a thiazide, and if so what dose should
you initiate this medication?
How would you proceed, and how you would monitor for efficacy and
toxicity?
Discussion Part Three
He returns a month later complaining of increased fatigue, visual
disturbances, weakness, and nausea; however, his ECG is normal.
Based on this information, what is occurring in this patient? Include
precise mechanism(s) of how it is occurring.
Additionally, please include any drug interactions associated with any
new medications initiated keeping in mind the current regimen.

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NR 508 Week 4 Discussions
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Discussion Part One
Barbara is a married 39-year-old woman with no children, smokes 1
pack/day, and weighs 180 pounds who has scheduled an appointment
with you to discuss feelings of anhedonia that she has been experiencing
for the past few months. She has a history of depression as a teenager,
but has not needed or received therapy for ~20 years. At the appointment,
she relays that she has been experiencing chronic fatigue/loss of energy,
feelings of worthlessness, appetite disturbances, weight gain, inability to
concentrate, psychomotor disturbances, and insomnia.
Please provide a list of differential diagnoses, as well as an indication of
your primary diagnosis.
Once this has been completed, please indicate and describe your chosen
pharmacological treatment with inclusion of dose and mechanism of
action of your chosen prescription.

11. Discussion Part Two (graded)
Monitoring for efficacy and toxicity of the current drug regimen you
prescribed in Part One
Subsequent steps if this patient did not have an adequate response?
Assume you had her on a common, selective serotonin reuptake inhibitor
for several months without great response. Explain why the SSRI should
be slowly discontinued prior to starting bupropion in Part Three.
Discussion Part Three
You decide to begin the patient on bupropion.
At what dose should she be started on bupropion, and how does
bupropion differ from other commonly prescribed antidepressants, such
as fluoxetine, venlafaxine, and nortriptyline?
Why would this be the best option for this patient given her symptoms
and lifestyle? In your answer, be sure to compare and contrast bupropion
with each medication mentioned above (fluoxetine, venlafaxine, and
nortriptyline).

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NR 508 Week 5 Discussions
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Discussion Part One
Leroy is a 70 year-old-man, whose wife passed away 5 years ago, and
whose 2 children live out-of–state. His neighbor caretaker (Ms. Webb, a
middle-aged retired CNA, whom his children hired to provide home care
to him 3x/week) brings him to your clinic. He presents with quite severe
confusion, incidentally to very minor changes in his environment, which
provokes some violence (a symptom which startles Ms. Webb),
increasingly impaired judgment, and increasing repetitiousness and
inconsistencies in his usual behavior. Upon initial work-up and physical
exam, you notice an increased respiratory rate, a slight fever (100°F),
and cost vertebral angle tenderness on his right side.
Discussion Part Two (graded)

13. The patient is diagnosed with a severe urinary tract infection
(pyelonephritis), and you decide to prescribe him
sulfamethoxazole/trimethoprim (SMX/TMP) beginning with 2 g initially
as a loading dose, followed by 1 g as a maintenance dose BID. Over the
next couple of weeks, the symptoms associated with his UTI diminish,
and his mental status improves. However, Ms. Webb brings him back to
your clinic with symptoms, which scare her yet again, and she explains
that she thinks he may have a relapse of his UTI. These symptoms
include a high fever (103.6°F) and tachypnea, and upon pulmonary
examination at your clinic, you hear crackles, and find classic findings
of lung consolidation.
What laboratory tests should you order, and what is your primary
diagnosis at this point and subsequent steps in his treatment and
management?
Once explained, please indicate and describe your chosen
pharmacological treatment with inclusion of dose and mechanism of
action of your chosen prescription.
Discussion Part Three
Upon receipt of laboratory results, you notice that his eGFR is
~40mL/min, his serum creatinine is 3.0 mg/dl, and his BUN is 50 mg/dl.
How will the medication regimen(s) have to be adjusted given these new
laboratory findings, and how should you be monitoring for efficacy and

14. toxicity of this patient’s pharmacological profile with a summary of
where this patient currently stands in his medical treatment?
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NR 508 Week 6 Discussions
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Discussion Part One
Jonathon is a 56 year-old retired automobile mechanic who has not been
to the doctor in approximately 6-7 years. He presents to your office
complaining that 3 weeks ago he was awoken with severe pain and
inflammation in his knee, which has been consistent since that initial
night. Upon physical examination of his knee, it appears swollen and
erythematous with periarticular involvement. Upon physical
examination and laboratory results you notice the following:
Physical examination:

15. GEN: well nourished, obese male (310 pounds)
VS: BP 191/112 HR 75 RR 15 T 98.6, HT 5’8”
EXT: Knee joint inflammation
Laboratory (fasting):
Na 139 mEq/L
K 3.8 mEq/L
Ca 9.1 mg/dL
CL 102 mmol/L
HCO3 22 mEq/L
BUN 10 mg/dL
SCr 0.9 mg/dL
Serum Uric Acid 6.5 mg/dL
Alb 4.1 g/dL
Cholesterol 300 mg/dL
UA: pH 6.8, uric acid 250 mg/24h
What problems can be identified in this patient? Please provide a list of
differential diagnoses, as well as indication of your primary diagnosis.

16. What is your pharmacological plan for your primary diagnosis including
the medication, dose, and mechanism of action?
Discussion Part Two (graded)
He returns to your clinic for follow-up blood work, and 4 values catch
your attention:
AST 430 U/L
ALT 535 U/L
Bilirubin 41 mg/dl
BG 60 mg/dl
He admits to a history of moderate-to-high alcohol intake (>12
drinks/week for >10 years). He is slightly febrile (99.7°F) and has
abdominal tenderness. He also admits to taking several, different over-
the-counter pain relievers of different brands daily and continuously to
combat the pain in his knee, in addition to his prescription(s) in Part One.
You decide to run a toxicology lab, and it reveals a blood acetaminophen
concentration of 58 µg/mL.
What is the diagnosis at this point in his case? Please explain the
mechanism for how this occurs/occurred, and the antidote’s mechanism
of action.

17. What is the subsequent management and treatment for this individual
related to the diagnosis in Part One.
Discussion Part Three (graded)
This is your third time seeing this patient, and he reports the NSAID that
he has been prescribed is not addressing his pain. He reports his pain is a
10 out of 10, HR 108, talking extremely fast, he is diaphoretic, unshaved,
his clothes are a bit wrinkled and he is requesting that you prescribe him
Percocet because he doesn’t think Tramadol, that you are considering
prescribing, will work.
What are the possible signs of prescription drug abuse?
What should the NP do when a patient has continued to return?
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NR 508 Week 7 Discussions
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18. Discussion Part One
Adam is an active, healthy 5’10” 34 year-old man weighing 145 pounds.
He presents to your clinic with complaints of wheezing, dyspnea, cough,
and sputum production, especially when running. He informs you that he
is an avid marathon runner competing in one to two 5 or 10K runs per
month. He tells you that he is symptomatic more than 2 times per week,
but less that 1 times per day, and nighttime symptoms hardly ever occur.
He also adds that his symptoms can get worse after and sometimes
during his runs, especially when the outside temperature drops below
50°F.
Please provide a list of differential diagnoses, as well as indication of
your primary diagnosis.
What is your pharmacological plan for your primary diagnosis including
the medication, dose, and mechanism of action?
Discussion Part Two (graded)
Your patient returns to your office 4 weeks following his initial
appointment in Part one with only moderate reduction in symptomology
and an increase in nightly symptoms to 1 time per week. Upon closer
inspection of his medical records you notice that he has also been
prescribed metoprolol (25 mg/day extended release) for uncontrolled
familial hypertension.

19. What is the mechanism of action of metoprolol, and why is this an
important issue in this patient? Be sure to contrast the differences
between your prescribed/discussed medication in Parts One and the
metoprolol just discovered. Also, include your new patient plan with
medication changes and details of dose and mechanism of action.
Discussion Part Three (graded)
How would you monitor for efficacy and toxicity of the current drug
regimen you prescribed in Part One, and what would be your subsequent
steps if this patient did not have an adequate response?
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