NAPLEX REVIEW

Q. A pharmacist receives a prescription for Pulmozyme. Which of the following statements is correct regarding Pulmozyme?

a. Pulmozyme should be stored at room temperature at all times.

b. Pulmozyme is dornase alfa used to cleave DNA; thereby reducing mucous viscosity.

c. Pulmozyme can be mixed with other nebulized medications.

d. Pulmozyme is budesonide solution that should be taken twice per day.

e. Pulmozyme is contraindicated in patients allergic to Chinese hamster ovary cell products and is given via IM injection.

NAPLEX

A 72-year-old man presents for an out patient follow up after being discharged from the hospital two days ago. He was admitted for a transient ischemic attack on the right side of his body which resolved spontaneously. He was worked up and subsequently discharged. Review of his in-patient investigations reveal a carotid doppler which revealed 100% stenosis of the left carotid artery and a 40% stenosis of the right carotid artery. He smoked about 1 pack per day for past several years. His past medical history includes chronic atrial fibrillation for which he has been on Aspirin alone. During the last admission, he was started on Coumadin as well. Today, his INR is therapeutic at 2.5 . His fasting lipid profile shows a calculated LDL cholesterol of 60mg%.  On examination, there are no neurological deficits. His blood pressure is 110/70 mm Hg. In addition to recommending smoking cessation and lifestyle changes along with continuation of coumadin, which of the following is most appropriate at this time?

A) Carotid Endarterectomy of Right Carotid Artery
B) Carotid Stenting of left carotid artery
C)  Carotid Endarterectomy of Left Carotid Artery
D) Carotid Magnetic Resonance Angiography
E) No other intervention indicated

Difference Between Brain Tumor and Brain Cancer

One of the most worrisome illnesses is cancer. Whenever we hear of it, we get hopeless in an instant. We also fear hearing about tumors.
Why? It is because people associate cancer with tumors as well so it also frightens them that the tumor can be malignant or precancerous, whichever is applicable.

In our world now, nothing is stable as illnesses can spring up in an instant. Our environment can also cause us to have this besides our genes. So healthy living is of great help. But what if we are diagnosed with a brain tumor or brain cancer? What does this imply? What are the differences?

A brain tumor can grow in any part of the brain. These are cells that can be both cancerous or non-cancerous. Cancerous cells are termed as malignant while non-cancerous are termed as benign. Brain tumors only become a problem at the later stages since in the early stages the symptoms are not being manifested. When there is already intracranial pressure, then this is the time that the symptoms will manifest such as dizziness, vomiting, and many others.

Antidote / Reversal Agents

• Acetaminophen: acetylcysteine [Mucomyst] 
• Benzodiazepine: flumazenil [Ramazicon] 
• Curare: edrophonium [Tensilon] 
• Cyanide poisoning: methylene blue 
• Digitalis: digoxin immune FAB [Digibind] 
• Ethylene poisoning: fomepizole [Antizol] 
• Heparin and enoxaprin [Lovenox]: protamine sulfate 
• Iron: deferoxamine [Desferal] 
• Lead: succimer [Chemet] 
• Magnesium Sulfate: calcium gluconate 10% [Kalcinate] 
• Narcotics: naloxone [Narcan] 
• Warfarin: phytonadione [vitamin K]

Hypercalcemia

 
Hypercalcemia:
Risk Factors:

• Hyperparathyroidism
• Malignant disease
• Prolonged immobilization
• Vitamin D excess
• Thiazide diuretics
• Lithium

Manifestations:

• Ca++ > 10 mg/dL
• Muscle weakness
• Decreased DTRs
• Hypercalciuria/renal stones
• Dysrhythmias
• Confusion
• Anxiety
• Lethargy/coma

Interventions:

• Increase mobility
• Isotonic IVF
• Furosemide
• Calcitonin
• Glucocorticoids
• Biophosphonates
• NOTE: increased risk of fractures

Hypophosphatemia & Hyperphosphatemia

 
Hypophosphatemia:
Risk Factors:

• Alcoholism
• Chronic diarrhea
• Starvation
• Vitamin D deficiency

Manifestations:

• Phosphorus < 2.5 mg/dL
• Muscle weakness
• Decreased DTRs
• Hypercalciuria/renal stones
• Dysrhythmias
• Confusion
• Anxiety
• Lethargy/coma 

Interventions:

• Correct etiology
• Oral phosphate replacement
• Vitamin D
• Decrease calcium level
  
  Hyperphosphatemia:
  Risk Factors:
  
• Renal failure
• Chemotherapy
• High vitamin D
• High phosphorus intake
• Excessive enema use [Fleet’s]

Manifestations:

• Phosphorus > 4.5 mg/dL
• Tetany, cramps
• Paresthesias
• Dysrhythmias
• Trousseau’s sign
• Chvostek’s sign
• Seizures

Interventions:

• Aluminum hydroxide [with meals]
• Decrease dialysis

Hypomagnesemia

Hypomagnesemia:
Risk Factors:

• GI loss
• Alcoholism
• Diuretics
• Pancreatitis
• Hypocalcemia
• Hypokalemia
• Insulin resistance
• DKA

Manifestations:

• Magnesium < 1.8 mEq/L
• Tetany, cramps
• Increased DTRs
• Paresthesia
• Dysrhythmias
• Trousseau’s sign
• Chvostek’s sign
• Agitation, confusion

Interventions:

• Seizure precautions
• Assess for difficulty swallowing
• Correct underlying cause
• IV magnesium
• Teach food sources
• NOTE: monitor for signs of magnesium toxicity with IV replacement and treat with calcium gluconate

Hypermagnesemia

 
Hypermagnesemia:
Risk Factors:

• Renal failure
• Excessive Mg++ therapy
• Adrenal insufficiency
• Laxative abuse

Manifestations:

• Magnesium > 3.0 mEq/L
• Hypotension
• Drowsiness
• Decreased DTRs
• Bradycardia
• Bradypnea
• Coma
• Cardiac arrest

Interventions:

• Decrease intake
• IV calcium gluconate
• Mechanical ventilation
• Temporary pacemaker

Hyponatremia

 
Hyponatremia:
Risk Factors:

• GI loss
• SIADH
• Adrenal insufficiency
• Diuretics
• Water intoxication
• Decreased intake

Manifestations:

• Na+ < 135 mEq/L
• Weakness
• Lethargy
• Confusion
• Seizures
• Coma

Interventions:

• Daily weight
• Assess CNS changes
• I/O
• Administer IVF [hypertonic (acute); isotonic (restore volume)]
• Seizure precautions
• Teach sodium-rich food
• If etiology is FVE, restrict fluids
• NOTE: risk for hypertonic solutions is cerebral edema

Hypernatremia

Hypernatremia:
Risk Factors:

• Water deficit
• GI loss
• DI
• increased intake

Manifestations:

• Na+ > 145 mEq/L
• Thirst, dry mucous membranes
• Restless, weak
• Orthostatic hypotension
• Muscle irritability, seizures
• Coma

Interventions:

• Daily weight
• Assess CNS changes
• I/O
• Administer IVF: isotonic [restore volume]
• Seizure precautions
• Teach Na+ food sources