Case Studies: Test Your Skills

FEBRUARY 13, 2011
Craig I. Coleman, PharmD, Justine Dickson, PharmD Candidate, and Dayne A. Lasky, PharmD Candidate

Case One

RP, a 27-year-old woman, walks into the pharmacy and expresses her concern about her new prescription for fluoxetine. She is currently being treated with topiramate 100 mg twice daily for migraine prophylaxis, as well as promethazine for nausea and vomiting, and sumatriptan 100 mg at onset of migraine. Previously she has used butalbital and nonsteroidal anti-inflammatory drugs with no relief of her migraine symptoms. Her psychiatrist recently prescribed fluoxetine and warned to not take her sumatriptan more than twice a week due to a high risk of serotonin syndrome. She is now very concerned about this potential risk and is refusing to take her sumatriptan.

How should the pharmacist counsel RP?

Case Two

JB is a 5-year-old, 19-kg boy who presents to the emergency department (ED) with severe drowsiness, a heart rate (HR) of 45 beats per minute, a blood pressure (BP) of 78/43 mm Hg, and mild sedation. His mother takes metoprolol tartrate (Lopressor) 50 mg at home and thinks her son got into her pill bottle within the last 3 to 6 hours. JB has potentially taken 10 pills, putting him well above the 2.5 mg/ kg pediatric toxicity threshold of metoprolol tartrate. In addition to maintaining a good airway and breathing, restoration and maintenance of JB’s HR and BP are paramount to avoid inadequate perfusion of vital organs. Because JB has presented longer than 1 to 2 hours after ingestion, the tablets may have been absorbed and decontamination measure efficacy would be limited. The pharmacist is asked for a treatment recommendation.

What should the pharmacist recommend?

Dr. Coleman is an associate professor of pharmacy practice and director of the pharmacoeconomics and outcomes studies group at the University of Connecticut School of Pharmacy. Ms. Dickson and Mr. Lasky are PharmD candidates at the University of Connecticut School of Pharmacy.

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