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Q1:/n European Review for Medical and Pharmacological Sciences Effect of Vitamin D supplementation in patients with liver cirrhosis having spontaneous bacterial peritonitis: a randomized controlled study A.A. MOHAMED¹, A.A. AL-KARMALAWY², A.A. EL-KHOLY³, D.A. EL-DAMAS+, H.M. ABOSTATE¹, S.M. MOSTAFA5, M. HAMADA, M.A. KHALIK ELKADY', Y. HASSAN, E. AL-HUSSAIN³, M.G. KHALIL', I. BADAWY¹0, D. ELEBEEDY¹⁰, B.A. ALSFOUK¹¹, M.M. SHAHEENL² 'Biochemistry, Molecular Biology and Biochemistry Department, National Hepatology and Tropical Medicine Research Institute, Egypt ²Department of Pharmaceutical Medicinal Chemistry, Faculty of Pharmacy, Horus University-Egypt, New Damietta, Egypt ³Clinical Pharmacy Department, Faculty of Pharmacy, Ain Shams University, Cairo, Egypt 4Microbiology, Faculty of Pharmacy, Egyptian Russian University, Cairo, Egypt 5Department of Hepatology, National Hepatology and Tropical Medicine Research Institute (NHTMRI), Cairo, Egypt 'Internal Medicine Department, Faculty of Medicine, Benha University, Cairo, Egypt 2021; 25: 6908-6919 7Gastroenterology and Hepatology Department, Theodor Bilharz Research Institute, Egypt Clinical Pathology Department, Faculty of Medicine, Faculty of Medicine, Cairo University, Cairo, Egypt 'Toxicology Department, Faculty of Pharmacy, Modern University for Technology and Information (MTI), Cairo, Egypt ¹ºPharmaceutical Biotechnology Department, Faculty of Biotechnology, Misr University for Sciences and Technology, Cairo, Egypt ¹¹Department of Pharmaceutical Sciences, College of Pharmacy, Princess Nourah bint Abdulrahman University, Riyadh, Saudi Arabia ¹²Internal Medicine and Nephrology Department, Cairo University, Cairo, Egypt Amal Ahmed Mohamed and Ahmed A. Al-Karmalawy contributed equally to this work Abstract. OBJECTIVE: Spontaneous Bac- terial Peritonitis (SBP) is one of the most seri- ous liver cirrhosis with ascites complications. Vitamin D (Vit D) deficiency has been associat- ed with a high risk of infection and mortality in cirrhotic patients. Herein, the assessment of Vit D level as a prognostic marker in SBP patients and the impact of Vit D supplementation on their treatment plan was studied as well. PATIENTS AND METHODS: Ascetic patients with SBP and Vit D deficiency were divided ran- domly into treatment and control groups. The control group received standard treatment with- out Vit D and the treatment group received stan- dard treatment plus Vit D. Clinical monitoring of Vit D was done over 6 months. RESULTS: At baseline, all patients in both groups revealed an elevated serum and ascetic TLC, AST, ALT, total and direct bilirubin, in addi- tion to elevation in INR and procalcitonin (PCT) level. Univariate regression analysis confirmed that deficiency of Vit D was an independent pre- 6908 dictor of infection and mortality (p < 0.01; Crude Hazard Ratio: 0.951). Over 6 months, the study revealed significant improvement in serum Vit D level in the treatment group (34.6 ± 9.2 and 18.3 ± 10.0 ng/mL; p < 0.001). Moreover, a statistical- ly significant increase in survival rate (64% vs. 42%; p<0.05) and duration (199.5 days vs. 185.5 days; p<0.05) were recorded as well. Univariate and multivariate regression analysis confirmed that Vit D supplementation was positively cor- related to survival over 6 months (p < 0.001; Ad- justed Hazard Ratio: 0.895). CONCLUSIONS: Vit D deficiency is prevalent in SBP cirrhotic patients and is used as an inde- pendent predictor of infection and death. There- fore, Vit D supplementation revealed improve- ment in their response to treatment. Key Words: Ascites, Spontaneous bacterial peritonitis, Vitamin D deficiency, Survival. Corresponding Author: Ahmed A. Al-Karmalawy, MD; e-mail: akarmalawy@horus.edu.eg Vit D supplementation in patients with liver cirrhosis and SBP Introduction Patients with liver cirrhosis had spontaneous bacterial peritonitis (SBP) infection that showed poor prognosis¹-³. Cirrhosis is the terminal stage of any chronic liver injury which accounts for the fourth major cause of mortality in central Eu- rope¹-6. Egypt has the highest age-standardized mortality rate of 72.7 deaths for every 100,000 patients. Approximately one-fifth (18.1%) of most deaths in males of age ranged from 45 to 54 years were caused by liver cirrhosis7-10. Cirrhosis manifests with the presence of vascular fibrosis and distortion resulting in increased hepatic re- sistance, which may cause portal hypertension if there was splanchnic hyperperfusion¹¹-13. Com- plications like variceal bleeding and renal dys- function may be due to portal hypertension¹4-16 Renal dysfunction and splanchnic vasodilation contribute to the development of ascites¹7-19. As- cites are frequently complicated by SBP20,2¹, most commonly due to intestinal bacterial transloca- tion, which can trigger renal failure and is associ- ated with increased mortality. New inflammation biomarkers are needed in clinical practice for the early diagnosis of SBP, such as procalcitonin (PCT)22,23. Meanwhile, the pathophysiology of SBP is not understood, since translocation of bac- teria from the gastrointestinal tract to the ascetic fluid (AF) is thought to be a crucial mechanism behind the development of SBP. Also, SBP is encouraged by impaired defensive mechanisms in cirrhotic patients. It is diagnosed by counting polymorphonuclear (PMN) cell numbers in AF of more than or equal to 250 cells/mm³, where the infectious organism is isolated in about 70% of cases24,25 Procalcitonin (PCT) is a polypeptide precursor for calcitonin synthesized in the thyroid C cells. Microbial toxins and pro-inflammatory media- tors, such as IL-1B, IL-6, and TNF-a, triggered PCT release26-28. In decompensated cirrhosis, se- rum and ascetic fluid PCT were examined and we found they were not effective as a marker in the detection of acute bacterial infection (such as SBP) compared to patients without hepatic impairment ²9-32. PCT, however, appears to be a strong marker for bacterial translocation, a well-established mechanism for decompensat- ed cirrhosis infection that can lead to bacterial infection 33,34 Combining procalcitonin (PCT), the difference in hemoglobin concentration be- tween newly formed and mature red blood cells (dCHC) and mean fluorescence intensity of ma- ture neutrophils (sNFI) in patients with cirrhosis is a valuable predictive composite marker for early detection of ascites infection ³5. The acute stage reactant proteins, such as C-reactive pro- tein (CRP) and procalcitonin (PCT), have been assessed in many clinical situations as indicators for early diagnosis of SBP. CRP and PCT are well known to rise rapidly in response to bacterial infection 36,37. So, they are used as sensitive pre- dictive and monitoring parameters for bacterial infections and controlling the use of antibiotics. In addition, cirrhotic patients usually have Vit D deficiency 38,39 The liver is a crucial organ for Vit D bio- transformation, where it is the only organ that generates the (25-OH) Vit-D3 from Vit D40,41 Low hepatocytes, reduced exposure to sunlight, low adipose tissue, malabsorption of Vit D, and altered hydroxylation of Vit D in the liver are the normal reasons for the decreased levels of Vit D in patients with cirrhosis 42. It was found that low Vit D in the ascetic fluid is related to the higher risk of AF bacterial infection in cirrhotic patients with ascites 43,44 There are few studies available concerning the impact of Vit D supplementation on people with Vit D deficiencies, particularly those with decom- pensated cirrhosis 45,46. The effect of Vit D sup- plementation on mortality rate in those patients is still unclear. The main purpose of the present work is to assess Vit D and procalcitonin levels as prognostic markers in SBP patients, besides, evaluating the effect of Vit D administration on the response of SBP patients for treatment from liver cirrhosis. Patients and Methods Study Design and Setting This study was a prospective randomized con- trolled study that included 328 ascetic patients with spontaneous bacterial peritonitis (SBP) who were admitted to the National Hepatology and Tropical Medicine Research Institute from June 2019 to December 2019. Subject Selection The inclusion criteria were: patients with liv- er cirrhosis, ascites with SBP, and aged over 18 years. The excluded patients from the study were: those with non-peritoneal infections (septicemia, skin infection, chest infection, biliary tract in- fection, urinary tract infection, gastroenteritis, 6909 A.A. Mohamed, A.A. Al-Karmalawy, A.A. El-Kholy, D.A. El-Damas, et al. dental infection, meningitis), administration of non-absorbable antibiotics in the prior 6 weeks, infection with HIV, hepatoma or other forms of malignancy, hepatorenal syndrome on admis- sion, significant cardiac and respiratory disease, pregnancy, patients prepared for transplantation, and signs of gastrointestinal bleeding or bacterial infection in the prior 6 weeks. Clinical Evaluation Detailed patient's clinical history and physi- cal examination were performed. Patients were screened for complete blood count (using Phoe- nix NCC-2310 Hematology Analyzer Device), random blood sugar, liver profile [aspartate ami- notransferase (AST), alanine aminotransferase (ALT), direct bilirubin, total serum bilirubin (TSB), alkaline phosphatase (ALP), serum al- bumin by OLYMPUS biochemistry autoanalyz- er (USA), coagulation profile (prothrombin time (PT), and international normalized ratio (INR)] by kcl delta, renal function tests (urea and serum creatinine), viral markers (HBsAg; hepatitis C vi- rus antibodies (HCV Abs) by ELISA, alpha-feto- protein (AFP) by Eliza according to manufactur- ing instructions. Values were considered normal if > 10 ng/ml. In addition, abdominal ultrasonog- raphy was done for grading of ascites. All stud- ied patients underwent diagnostic paracentesis to obtain AF samples for total leucocyte count (TLC) (polymorph nuclear leucocytes equal or more than 250 cells/mm³ considered as sponta- neous bacterial peritonitis), malignant cells, total protein, albumin, and glucose. Serum Procalcitonin and Vit D Measurements Serum procalcitonin (PCT) was measured us- ing the PCT enzyme-linked immunosorbent as- say kit for the in vitro assessment of serum PCT (Chongqing Biospes Co. Ltd, Chongqing City, China; biopsies). The Vit D level was also mea- sured by ELISA (by direct competitive chemi- luminescence immunoassay using commercially available kit Unicel® DxI 800 immunoassay sys- tems (Beckman Coulter, Inc., CA, USA) within 24 hours of admission. Patient with serum Vit D concentration < 25 ng/mL was considered as Vit D deficient or insufficient. Medication Exposure The total number of patients who participated in this study with Vit D deficiency was 328 pa- tients, randomly divided into control and treat- 6910 ment groups. The control group included patients who received standard treatment without Vit D (n=168). Whereas the treatment group included patients who received standard treatment plus Vit D (n=160). Patients in the treatment group received a dose of 300000 IU of cholecalciferol as a loading dose by intramuscular injection, fol- lowed by a maintenance dose of 800 IU/d orally with oral calcium supplementation in a dose of 1000 mg. Monitoring of Vit D, serum calcium, and phosphorus was measured every month for 6 months or until death, whichever happened first. Administration of Vit D was discontinued if signs of hypercalcemia, renal stone, or Vit D level above 80 nmol/L (> 32 ng/mL) were detected. Ethical Considerations Informed consent was received from all partic- ipants included in the study. The study protocol complied with the Ethical Guidelines set out in the Declaration of Helsinki (sixth revision, 2008) and Good Clinical Practice guidelines. The National Hepatology and Tropical Medicine Research Institute Committee approved the study (Serial: 5-2020). Statistical Analysis The data were analyzed using a statistical package for the social sciences, version 23 (IBM SPSS, Statistics for Windows, Version 23.0, IBM Corp, Armonk, NY, USA). Numerical variables were expressed as mean±SD (standard devia- tion) and median (range). Comparison between treatment and control groups was conducted as follows: for parametric data, a two-sample t-test was used while for the nonparametric data, the Mann-Whitney test was used. For analysis of survival, the log-rank test was used for binary variables while continuous variables were ana- lyzed using the Cox-proportional hazard method. A p-value below 0.05 was considered statistically significant. Results Demographic Data Out of 328 patients, 160 patients received stan- dard SBP therapy plus Vit D (treatment group) and 168 patients received only SBP standard therapy (control group). The age was expressed as mean±SD in the treatment group (51.4± 12.1), and in the control group (55.0+ 8.5) with a ratio of male to female 85:75 and 81:86, respectively. Vit D supplementation in patients with liver cirrhosis and SBP Regarding the baseline characteristics, no sig- nificant difference (p>0.05) was observed be- tween treatment and control groups, except sig- nificantly higher smoking (p<0.05) in the treat- ment group (Table I). In addition, blood test parameters and ascetic fluid composition were comparable in the control and treatment groups (p>0.05), except for HBsAg positive and AST levels, which were significantly higher in the con- trol group than in the treatment group (p< 0.05) (Table 1). Treatment and control groups showed an elevation in PCT level (1.78± 0.49), (1.84+ 0.78) and deficiency of Vit D (22.5± 11.5), (20.2+ 11.0), respectively. For both groups, there was no significant difference in those values. Effect of Vit D Supplementation After 6 months of treatment and follow-up, most of the blood test parameters and ascetic fluid composition were significantly improved in both groups. However, the level of improvement Parameters Table I. Baseline characteristics, blood tests, and ascetic fluid composition of control and treatment groups. Control group (N = 168) Age in years (Mean ± SD) Gender (Male: Female) BMI (Kg/m²) (Mean ± SD) Smoking [No. (%)] Bleeding [No. (%)] Ascites [No.(%)] Encephalopathy [No.(%)] Fever [No.(%)] Jaundice [No.(%)] HBsAg positive [No.(%)] HCV Ab positive [No.(%)] Hb (g/dL) (Mean ± SD) Serum glucose (mg/dL) (Mean ± SD) Ascetic glucose (mg/dL) (Mean ± SD) Platelet ( 109/L) (Mean ± SD) Serum Creatinine (mg/dL) (Mean ± SD) Total bilirubin (mg/dL) (Mean ± SD) Direct bilirubin (mg/dL) (Mean ± SD) ALT (IU/L) (Mean ± SD) AST(IU/L) (Mean ± SD) Serum albumin (g/dL) (Mean ± SD) Ascetic albumin (g/dL) (Mean ± SD) INR (Mean ± SD) was significantly higher in the treatment group compared to the control group (p< 0.001) (Table II). The PCT, which was investigated as an early diagnostic marker for ascites infection, showed a highly significant reduction in the treatment group than the control group (p< 0.001) (Figure 1). Furthermore, patients in the control group demonstrated an average 9.4% decrease in the mean serum Vit D level (20.2 ng/mL vs 18.3 ng/ mL) at the end of 6 months. On the other hand, patients who received Vit D showed a 53.8% in- crease in mean serum Vit D level (22.5 ng/mL vs. 34.6 ng/mL). Also, a highly significant elevation of Vit D in the treatment group in comparison with the control group (p< 0.001) was observed (Table III) (Figure 2). AFP (ng/mL) [Median (Range)] GGT (IU/L) [Median (Range)] Blood TLC ( 10¾μµL) [Median (Range)] Ascetic TLC (x 103/µL) [Median (Range)] Procalcitonin (ng/mL) (Mean ± SD) Sr.Vitamin D level (ng/mL) (Mean ± SD) Survival Rate Analysis The survival rate was significantly higher in the treatment group (64%) compared to the con- trol group (42%) (p< 0.05). The mean surviv- 55.0+ 8.5 81:86 26.02.2 62 (37.1%) 35 (21%) 167 (100%) 36 (21.6%) 43 (25.7%) 35 (21%) 24 (14.4%) 13 (7.8%) 11.8 ± 2.0 104.2 + 8.5 47.3 ± 9.2 135.5 + 27.02 1.61 ± 0.49 3.87 ± 0.81 0.93 ± 0.40 89.0 ± 23.1 149.0 + 48.3 1.86 ± 0.30 0.73 +0.23 1.32 ± 0.31 7.9 (3.1-9.2) 81.73 (12-187) 11.43 (3.71-23.37) 600 (140-7000) 1.84 ± 0.78 20.2 ± 11.0 Treatment group (N = 160) 51.4 12.1 85:75 25.9 ± 1.9 65 (40.6%) 32 (20%) 160 (100%) 31 (19.4%) 38 (23.8%) 31 (19.4%) 19 (11.9%) 10 (6.3%) 12.0+ 1.5 101.6 15.0 45.0 10.2 138.0 + 71.1 1.56 ± 0.42 3.18±0.73 0.80 ± 0.49 83.1 ± 22.2 138.0 + 46.9 1.90 ± 0.37 0.70 ±0.29 1.29 ± 0.27 8.0 (2.0-8.0) 75.4 (3.4-176.0) 12.10 (4.71-21.73) 587 (120-4300) 1.78 ± 0.49 22.5 11.5 p-value <0.05 > 0.05 > 0.05 < 0.05 > 0.05 > 0.05 > 0.05 > 0.05 > 0.05 <0.05 > 0.05 > 0.05 > 0.05 > 0.05 > 0.05 > 0.05 > 0.05 <0.05 > 0.05 > 0.05 > 0.05 > 0.05 > 0.05 > 0.05 > 0.05 > 0.05 > 0.05 > 0.05 > 0.05 AFP, alpha-fetoprotein; ALT, alanine transaminase; AST, aspartate transaminase; BMI, body mass index; GGT, gamma-glutamyl transferase; Hb, Hemoglobin; HBsAg, Hepatitis B surface antigen; HCV Ab, Hepatitis C virus antibodies; INR, international normalized ratio; SBP, spontaneous bacterial peritonitis; TLC, total leukocytic count. 6911 Table II. Univariate analysis comparing the control and treatment groups regarding blood tests and ascetic fluid composition after 6 months. Platelet ( 10%/L) (Mean ± SD) Serum Creatinine (mg/dL) (Mean ± SD) Total bilirubin (mg/dL) (Mean ± SD) Direct bilirubin (mg/dL) (Mean ± SD) ALT (IU/L) (Mean ± SD) AST(IU/L) (Mean ± SD) Serum albumin (g/dL) (Mean ± SD) Ascetic albumin (g/dL) (Mean ± SD) INR (Mean ± SD) AFP (ng/mL) [Median (Range)] GGT (IU/L) [Median (Range)] Blood TLC (x 10/µL) [Median (Range)] Ascetic TLC ( 10³/µL) [Median (Range)] Procalcitonin (ng/mL) (Mean ± SD) Sr.Vitamin D level (ng/mL) (Mean ± SD) Survival at 6 months: ● • Ratio (alive:dead) (%) Survival (days) [Median (Range)] A.A. Mohamed, A.A. Al-Karmalawy, A.A. El-Kholy, D.A. El-Damas, et al. SERUM PROCALCITONIN (NG/ML) 2.5 Parameters 2 1.5 0.5 al duration was (199.5 days) in the treatment group vs. (185.5 days) in the control group (p< 0.05) (Table II). For detection of the different factors that were associated with the 6 months survival of the patients, univariate and multivar- iate analyses were used. The univariate analysis confirmed that higher TLC, higher creatinine, higher bilirubin level, and higher AST level were nonsignificant predictors of death in ascetic SBP 0 6912 Control Treatment Control group (N = 168) AFP, alpha-fetoprotein; ALT, alanine transaminase; AST, aspartate transaminase; BMI, body mass index; GGT, gamma-glutamyl transferase; Hb, Hemoglobin; HBsAg, Hepatitis B surface antigen; HCV Ab, Hepatitis C virus antibodies; INR, international normalized ratio; SBP, spontaneous bacterial peritonitis; TLC, total leukocytic count. Baseline 141.0±66.8 1.30 ± 0.49 2.05 ± 0.83 0.62 ± 0.38 65.0+ 28.8 104.3 ± 53.4 After 6 months 2.76 ± 0.44 0.68 ± 0.32 1.25 +0.24 7.1 (2-32) 51 (2.9-189) 8.8 (4.5-17.0) 231 (189-291) 1.41 ± 0.86 18.3 ± 10.0 42:58 185.5 (85-535) Figure 1. Change in serum Procalcitonin level in both con- trol and treatment groups over 6 months. Results presented as the mean ± SD. (p <0.001 for each group after 6 months, *p<0.001 vs. the control). Treatment group (N = 160) 283.1 ± 89.1 0.95 ± 0.16 0.76 ± 0.19 0.15 +0.07 57.8 ± 22.4 66.3 ± 26.3 2.84 +0.36 0.54 ± 0.32 0.98 +0.07 6 (2.9-9) 35.5 (25-59) 7.5 (2.5-12.0) 124 (90-3400) 0.65± 0.57 34.6±9.2 64:36 199.5 (85-535) p-value < 0.001 < 0.001 < 0.001 < 0.001 <0.05 < 0.001 > 0.05 <0.05 <0.001 < 0.001 < 0.001 <0.001 < 0.001 < 0.001 < 0.001 Discussion <0.05 <0.05 patients (p>0.05). However, low Vit D level in those patients was the only significant predictive mortality marker (p< 0.01). On the other hand, for assessment of the effect of Vit D supplemen- tation on 6 months survival, both univariate and multivariate analysis revealed a highly significant association (p<0.001) (HR=0.895) (Table IV). Cirrhosis has a noticeable correlation with morbidity and mortality rate in developed coun- tries 47-49. Mortality is 4 times higher in a patient with cirrhosis and infection with a poor progno- sis; 30% of patients die within a month of infec- tion in addition to another 30% within a year 50,51 Spontaneous bacterial peritonitis (SBP) is one of the most frequently diagnosed infections. The ascetic fluid infection happens when there is no visceral perforation or inflammatory focus in the abdominal cavity. For SBP diagnosis, the poly- morphonuclear leukocytic count (PMNLs) from the ascetic fluid obtained through paracentesis must be more than 250 cells/mm52,54. In addition, procalcitonin (PCT) appears to be a sensitive diagnostic indicator that can be used to predict diagnosis, monitor bacterial infections, and guide the clinical use of antibiotics. Vit D may enhanceSee Answer
Q2:Write a thesis statement and essay in 5-6 pages, double-spaced with 12-point font. Also include a cover page with name, title and recitation section along with a reference page. The goal of a thesis statement is to let your reader know what your paper or essay is about. It helps your reader understand the greater context and scope of your topic, plus it lets your readers know what to expect from the rest of the work. The thesis statement is generally in the first or second paragraph of a paper. The thesis statement shows how all the paragraphs compare, contrast and come together to form an argument or a statement of interest. Be sure to follow the flow of content laid out in the first paragraph and then have a conclusion paragraph that ties it together. Be sure to have evidence to support your statements with references. Additional points to think about before writing: Where are more interpretations needed (ex. Where in the paper would it be helpful to read what the writer thinks about something)? Does the paper open in an appealing, purposeful way? How else might the paper begin, to better capture and direct our attention?/nInstructions thesis topic: Motivational interviewing Skills for Pharmacists: Basic elements Referencing style - MLA Need in 5 pages double spacedSee Answer
Q3:***PHENTERMINE*** please write a 5-page essay The essay should be in APA style, font: Times Roman, Size 12, double-spaced, include a cover page,pictures of the drug, abstract and reference page. include the following in your essay: Brand/Generic/Classification Chemical Formula History Dosage Side Effects Interactions ConclusionSee Answer
Q4: SPECIMEN HANDLING IN THE OPERATING SUITE Presented by Leicel Naval, MN BMDH Perioperative and Endoscopy Services NSW GOVERNMENT Health Western Sydney Local Health District Session Plan •Define specimen, types (perioperative context) ●Specimen identification and labelling Collection and Transport Documentation Standard Precautions/Hazardous Material NSW GOVERNMENT Health Western Sydney Local Health District Common types of Specimen • Histopathology (formalin or normal saline) ● Frozen Section (fresh) Microbiology (Pus swabs, fresh tissue) • Cytology (Study of cells; usually fresh) Glass slide (pap smear) NSW GOVERNMENT Health Western Sydney Local Health District Common types of Specimen Other endoscopic biopsies: Dissacharidase- enzyme presence and functionality (lactase, sucrase, maltase ), lactose-intolerance CLOtest/ RUTtest- presence of helicobacter pylori (gastric ulcer, bloating,nausea, belching and indigestion NSW GOVERNMENT Health Western Sydney Local Health District Specimen Identification and labelling Correct patient and specimen identification shall be confirmed to minimise the risk of an adverse outcome for the patient (ACORN 2020; Standard 2) NSW GOVERNMENT Health Western Sydney Local Health DistrictSee Answer
Q5: SOAP Bob Cat Module 1 New patient HTN Demographics: Patient Name: Bob Cat Age: 50 Gender: Male Subjective: Past Medical History: None Current Medications: None Surgical History: None Allergies: Penicillin, tree nuts ● Social History: Ohio University Advanced Pharmacology Case Study Module 1 Smoking Status: Current smoker, averaging 1 pack per day for the past 20 years Alcohol: Occasionally consumes 1-2 beers with dinner Diet: Strives to eat healthy with no specific diet Exercise: Rarely engages in physical activity Family History: Father passed away at 65 due to heart failure, mother currently 80 and well, no family history of cancer, only child Chief Complaint: "I haven't seen a provider in about 20 years, so I'm here to see you as my new PCP." Review of Systems (ROS): Constitutional: Denies fevers, chills, sweats, and weight changes. Eyes: Denies any visual symptoms, eye pain, crusting, or drainage. Ears, Nose, and Throat: No difficulties with hearing. No symptoms of rhinitis or sore throat. Cardiovascular: Denies chest pains, palpitations, orthopnea, paroxysmal nocturnal dyspnea, or extremity edema. Respiratory: No dyspnea on exertion, no wheezing or cough. GI: No nausea, vomiting, diarrhea, constipation, abdominal pain, hematochezia, or melena. GU: No urinary hesitancy or dribbling. No nocturia or urinary frequency. No abnormal urethral discharge. Musculoskeletal: No myalgias or arthralgias. Neurologic: No chronic headaches, no seizures. Patient denies numbness, tingling, or weakness. Psychiatric: Denies problems with mood disturbance. No problems with anxiety. Endocrine: No excessive urination or excessive thirst. Dermatologic: Denies any rashes or skin changes. Objective: Vitals: Height: 5' 10" Weight: 190 lbs ● Ohio University Advanced Pharmacology Case Study Module 1 BMI: 26 Temperature: 97.8°F Blood pressure: 148/94 (recheck 150/88) Heart rate: 70 SPO2: 98% Pain: 0 Physical Exam: General: Well-appearing, well-nourished, in no distress. Oriented x 3, normal mood, and affect. Ambulating without difficulty. Skin: Good turgor, no rash, unusual bruising, or prominent lesions. Normal hair texture and distribution. Nails exhibit normal color with no deformities. HEENT: Normocephalic, atraumatic head. Eyes show intact visual acuity, clear conjunctiva, non-icteric sclera, and normal fundi. Ears have clear ear canals, translucent and mobile tympanic membranes. Nose and mouth exhibit no abnormalities. Neck: Supple, without lesions, bruits, or adenopathy. Non-enlarged and non-tender thyroid. Cardiovascular: No cardiomegaly or thrills; regular rate and rhythm, no murmur or gallop. Assessment: Plan: Respiratory: Clear to auscultation and percussion, no wheezes, rhonchi, or crackles. Abdomen: Normal bowel sounds, no tenderness, organomegaly, masses, or hernia. Back: Normal spine without deformity or tenderness, no CVA tenderness. Extremities: No amputations or deformities, cyanosis, edema, or varicosities. Peripheral pulses intact. Ohio University Advanced Pharmacology Case Study Module 1 Neurological: CN 2-12 normal, normal sensation to pain, touch, and proprioception. Normal deep tendon reflexes, no pathologic reflexes. 1. Z00.00 - Well Adult Exam Psychiatry: Oriented X3, intact recent and remote memory, judgment, insight, normal mood, and affect. ● G/U: Circumcised penis without lesions, normal urethral meatus without discharge, normal-sized testes and epididymides. 2. R03.0- Elevated blood-pressure reading, without diagnosis of hypertension 3. F17.200- Smoker 20-year pack history 1. Z00.00 - Well Adult Exam Labs ordered include CBC, CMP, TSH, A1C, Lipid panel. Counseled on age-related screenings; colonoscopy ordered. Administered PCV15 pneumonia vaccine. 2. R03.0 - Elevated blood-pressure reading, without diagnosis of hypertension Initial elevated blood pressure reading. Follow-up scheduled in one week. ***STUDENT TO PRESCRIBE LIFESTYLE MODIFICATIONS*** 3. F17.200- Smoker 20-year pack history Counseled on smoking cessation; patient not currently ready to quit./nTo/Do Need to Write 2 pages about 3 life style modifications for a person with elevated blood pressure, smoker, no physical activities, overweight APA7 Format Read the SOAP note, the person also is a smoker and has a family history of heart disease, all the information is in the SOAP note.See Answer
Q6:INSTRUCTIONS Need to write 2 paragraph each 150 words writing 2 paragraphs explaining why you are interested in the course (certified Pharmacy Technician)and why we should consider you for this course.See Answer
Q7:Assignment Instructions Your manager explained that all of the emergency center nurses at RGH will be educated in small groups through a short, in-service training session. You have been asked to develop a professional-looking PowerPoint presentation that the trainers will use to guide the in-service sessions. Your PowerPoint will need to: 1. Be professional-looking, have a title slide, and 10-15 content slides. 2. Use the Speaker Notes feature in PowerPoint to reduce the amount of text that appears on the content slides. 3. The Speaker Notes for each slide will contain the text that will guide what the trainer will say while presenting the slides during the in-service. 4. The content slides themselves should be clear and easy to understand; they serve as an outline so the audience can follow along with what is being presented. 5. Be written using proper spelling/grammar and at a level that would be appropriate for the audience. 6. Remember the purpose of the training is to help nurses learn to educate their clients about the use of a medication. With that in mind, it may be helpful to provide examples of how to explain the information to a client in an easy-to- understand way without complicated, technical terms. 7. Include APA formatted in-text citations for at least 3 scholarly references and present the sources in APA format on a References slide. 8. Contain content addressing the items below for rivaroxaban 9. Pharmacotherapeutics 10.State the drug name and its therapeutic category. 11. Pharmacodynamics- how does this drug work to achieve its intended response? 12. Pharmacokinetics - how is this drug absorbed, distributed, metabolized, and excreted? 13. Discuss dosage, scheduling, route, and length of therapy. 14. Describe what clients can expect regarding their therapeutic response and when it should develop. 15. Introduce non-drug measures that clients can do to enhance their therapeutic response (eg, specific diet to follow, exercise requirements, substances to avoid, special precautions to take, etc.). 16. Side Effects, Adverse Effects, and Interactions 17. Explain the symptoms of common side effects, and what clients can do to minimize any discomfort. 18. Explain the symptoms of any major adverse effects, and what clients should do if they experience them. 19. List the major adverse drug-drug interactions and drug-food interactions that clients need to be made aware of. 20. Follow-up Care 21. Provide information regarding when clients should call their doctor for advice (eg,, questions, non-urgent symptoms, unpleasant side effects, etc.). 22. Emphasize any symptoms for which clients should seek immediate care (e.g. when to go to the emergency center or call 911).See Answer
Q8:Describe how homeostatic mechanisms maintain normal function.See Answer
Q9: How many mL are supplied in the insulin dosage ordered? Humulin R Regular U-100 insulin 34 units with Humulin N NPH U-100 insulin 61 units subcut stat_ mL totalSee Answer
Q10: Calculate the amount you will prepare for one dose. Order: calcium gluconate 0.5 g IV Supply: calcium gluconateSee Answer
Q11: Calculate the total amount you will prepare for one dose. Order: Neupogen 0.225 mg subcut daily x 2 weeks Supply:See Answer
Q12: In the previous problem (queston 17), what syringe size (in mL) would you use to administer the medication? Select:See Answer
Q13:19. Calculate the total amount you will prepare for one dose. Order: Humulin R Regular U-100 insulin 70 units subcut statSee Answer
Q14: Calculate the total amount you will prepare for one dose. Order: Neupogen 0.225 mg subcut daily x 2 weeks Supply:See Answer
Q15: Calculate the total amount you will prepare for one dose. Order: Valium 3 mg IV stat Supply: Valium 10 mg/2 mLSee Answer
Q16: Calculate the total amount you will prepare for one dose. Order: Valium 3 mg IV stat Supply: Valium 10 mg/2 mLSee Answer
Q17: Calculate the amount you will prepare for one dose. Order: Prostigmin 0.25 mg IM Supply: Prostigmin 1:2,000See Answer
Q18: Calculate the amount you will prepare for one dose. Order: Epinephrine 0.3 mg IM Supply: Epinephrine solutionSee Answer
Q19:A novel compound to treat sickle cell crisis is being developed that would act at 2 mg dose. It is currently formulated as a tablet of a total weight of 200 mg due to the need for excipients, and the total number of particles is determined at 200 000 per gram. Calculate all parameters as in question 8 and compare and contrast these two formulations. Suggest any alterations to these powders to alleviate the found problems. Calculate the standard deviation, the coefficient of variation and the acceptable number of particles in the scale of scrutiny to ensure that we detect 1.5% as acceptable deviation.See Answer
Q20:1) Describe the five basic mechanisms of antibiotic action against bacterial cells. Give examples of drugs that are used in each category. 2) In many instances, resistance builds to antibiotics over time. Describe at least seven ways this resistance develops. See Answer

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