CASE ONE: NA, a pharmacy student at Take Your Medicine University, is completing an experiential rotation in the emergency department at the local hospital. During the rotation, he is working with a family practice intern to assist with medication recommendations and patient counseling.
During a particularly busy day, a 17-year-old girl is brought to the hospital accompanied by her mother, who found her unconscious in her bedroom. Her mother informs the intern that her daughter has a history of depression, for which she has received counseling for 3 years and has been taking amitriptyline for 1 year. She says that her daughter has struggled for years with her feelings of "not fitting in." Her daughter is insecure about her appearance and keeps only a small circle of friends.
The mother has brought an empty prescription bottle for amitriptyline, explaining that she found the bottle next to her daughter. According to the prescription bottle, it was filled 2 days ago for 100 tablets of amitriptyline 50 mg.
On examination, the intern finds the unresponsive teenager to have an erratic and extremely rapid pulse. Her skin is dry and flushed. Her pupils are constricted and fixed. The electrocardiogram reveals supraventricular tachycardia with a prolonged PR and QT interval, widened QRS complex, and an inverted T wave.
As the intern begins writing orders for treating the teenager's apparent suicidal attempt with amitriptyline, he turns to NA and comments, "This day has been so crazy! I feel like I can't remember anything. Could you tell me how much activated charcoal to give this girl?"
How much activated charcoal should NA recommend for the teenager?
CASE TWO: The following month, NA, the pharmacy student from Take Your Medicine University, is assigned to an internal medicine team at the local hospital. Prior to morning rounds with the team, NA begins his initial workup of a newly admitted patient.
The patient is an elderly woman admitted with multiple medical problems. Upon review of the patient's laboratory results, NA notices that the woman's renal function is impaired. According to his calculations, her estimated creatinine clearance is 40 mL/min.
NA reviews the medication administration record, noting that the patient is scheduled to receive losartan 50 mg every 12 hours, felodipine 10 mg daily, ticlopidine 250 mg twice daily, gabapentin 600 mg 3 times daily, famotidine 40 mg twice daily, cefazolin 1 g intravenously every 6 hours, clindamycin 300 mg every 6 hours, and ciprofloxacin 400 mg intravenously every 12 hours.
As NA finishes reviewing the medication administration record, his preceptor approaches and reminds NA that the team will need recommendations on adjusting the patient's medication doses due to her impaired renal function.
Which medications will need adjusting?
Dr. Schlesselman is an assistant clinical professor at the University of Connecticut School of Pharmacy.