Brandon Carter Case Study

HPI: Brandon Carter, a 5-year-old fully immunized hispanic male, complaining of ear pain (rated 7/10) for 2 days. Had upper respiratory infection symptoms, +rhinorrhea, +nasal congestion, +cough for 1 week, which resolved 4 days ago. No temperature with URI but temp was 102 F yesterday and today. Mom is giving Tylenol for fever and pain. Patient more tired than usual, taking additional naps during afternoon and waking up at night in pain. No change in feeding or elimination patterns. Mom noted that she has to talk louder than usual for Brandon to hear her when he is watching TV or reading a book. Patient also had been feeling dizzy occasionally while playing outside with his brother. No sick contacts.

Medical history: Acute otitis media twice in the past 3 years. No overnight hospitalizations or surgeries

Family history: Father (alive) and paternal grandfather (deceased at age 71) both had hypertension.

Medications: None

Allergies: NKDA

Social history: Lives with parents and 3-year-old brother. Attends kindergarten. Father works at a construction agency. Mother works part time as a line cook at a restaurant. No smokers at home.

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Assignment Instructions

Based on the information provided above, complete the patient’s write-up by giving your diagnosis, justifying your diagnosis with a full written assessment, and delineating your treatment plan.

Write a 1,400-word assessment and treatment plan for Brandon.

Determine the following. (Type your answers under each item.)

·       Identify which drugs and/or devices (medical equipment) you would furnish/prescribe pursuant to standardized procedures and in conformance with applicable laws, codes and/or regulations, including knowledge of pharmacy rules and regulations, health and safety code and Federal Register (consider the rules and regulations of your state or the state in which you plan to practice.)

·       Based on the health assessment of the client, identify the appropriate therapeutic regimen, including drugs and/or devices (medical equipment) using the latest guidelines.

·       What is your diagnosis?

·       Evaluate the potential response and compliance of the client to the drugs and/or devices (medical equipment) prescribed and implement appropriate action by identifying necessary patient monitoring (before and after drug regimen) and education strategies. This includes explaining the medications prescribed (name of medication/s, frequency/time of doses, correct dosage/s to take, how to take the medication/s [i.e., with or without food], what to do if a dose of a medication is missed, side effects to expect, and adverse event/s to report to the prescriber, how other medications taken interacts with drug(s) of choice prescribed and alternatives, and involve the client and family in the decision-making process) and clinical endpoints for drugs and/or device (medical equipment) therapies.

·       Use knowledge of pharmacokinetics and pharmacodynamics to identify the indication, rationale, mechanism of action for drugs to observe, and to understand the effects of drugs and/or devices (medical equipment) on a client; and to predict the client’s response.

·       Justify correct dosages, dosage forms, routes, and frequency of administration based on relevant individual client parameters.

·       Evaluate possible uses of vitamins and herbal supplements as they relate to disease prevention and management.

·       What specific conditions relative to pharmacokinetics should be considered, based on the client’s symptomatology, health status, lifestyle, genetics, ethnicity, nutrition, culture, socioeconomic status, etc.?

Include a minimum of 5 peer-reviewed, evidence-based articles referenced and formatted according to APA guidelines. 

Fill out the blank prescription form below to complete the activity.

Review Figure 10-1 Common Components of a Prescription in Ch. 10 of Pharmacology for the Primary Care Provider (4th ed.) to use as a guideline for filling out the prescription.

Submit Brandon’s assessment and treatment plan and his written prescription(s).