Leik treatment plan reviews

treatment plan

  1. GERD treatment plan 1. H2 blocker: Ranitidine ( Zantac), famotidine( pepcid)
    2. Ptoton- pump inhibitor(PPI): Omeprazole(Prilosec), pantoprazole(protonix). Do not stop abruptly! It will cause rebound symptoms! Taper dose to wean!
    3. Antacids(mild symptoms). Mylanta, Maalox, Caltrate, Tums,
    4. First line is changing lifestyle. Avoid large/ high fat meals, 3-4 hours before bedtime, lose weight, avoid mint, chocolate, alcohol, smoking.
  2. UTI treatment plan Health female 18-65:
    1. use 3 days treatment:
    Bactria, septra, BIDx3 days
    Or, Augumentin 875/125 mg BIDx5 to 7 days.
    Or, Cipro/ Levaquin QDx3 days
    2. Increase fluid intake to 2500/d.
    3. Restrict high oxalate food such as beans, spinach, beets, potato chip, nuts, tea
    Complicated UTIs(males, DM, pregnant women, children or elderly, HIV, kidney stones…)
    1. Cipro,500mg,BID, Or Levaquin 750mg, QDx7 to 10 days.
    2. recurrent UTI: Bactrim, one tablet, QHS
    3. Sulfa allergy: Keflex, Cipro(>18 y/o), prophylactic antibiotics for 6 months or longer(after rule out pathology)
    4. UA and urine C&S before and after treatment
  3. COPD (Emphysema) treatment plan  1. smoking cessation (nicotine patches or gum)
    2. annual influenza, pneumococcal vaccine every 5 years
    3. SABA(short-acting beta-agonists): Albuterol, Xopenex PRN (first line, for mild COPD) and/or, short-acting anticholinergic: Atrovent combination
    4. if short-acting not controlling symptoms, LABA(long-acting beta-agonists): salmeterol or formoterol. Or LAMA(long-acting muscarinic agent) plus SABA PRN.
    5. for high risk exacerbation, switch to LAMA(first line). if poor control, use combination of LABA(salmeterol, formoterol) and LAMA(long-acting anticholinergic/long-acting muscarinic(tiotropium:Spirivia). Or, LABA with inhaled glucocorticoid, methylxanthines (theophylline).
    6. high risk, refer to pulmonologist.
  4. Community-Acquired Bacterial Pneumonia (CAP) treatment plan 1. Macrolides:
    Azithromycin, QD x5days
    Clarithromycin, BIDx7days
    2. if patient had antibiotic in previous 3 months or macrolide-resistance:
    Doxycycline, 100mg, BIDx5-7days
    Levaquin, 750mgx5days
    Azithromycin or clarithromycin plus amoxicillin or augmentin
    3. with comorbidity or macrolide-resistance:
    Levaquin, 750mg, QD,
    Beta-lactam plus macrolide x7days
    *Augmentin 1000/62.5mg,BIDx7days
    *Cefdinir 300mg,Q12hrsx7days plus Axithromycin or clarithromycin.
  5. Acute Bronchitis Treatmen Symptomatic:
    1. increase fluids and rest, stop smoking
    2. *Dextromethorphan BID to QID
    *Tessalon Perles TID prn
    *Guaifenesin PRN
    *if wheezing, albuterol inhaler(Ventolin), QID
    *if severe wheezing, add short-term oral steroid (Medrol Dose Pack).
    3. Complication: pneumonia from bacterial infection
  6. Pertussis (whooping cough) treatment plan cough up to 21 days(if not treated with antibiotic)
    1. first line is Macrolides
    *Z-pack x5days
    *Erythromycin 500mg QID, x14days .
    2. antitussives, mucolytics, rest, hydraton, frequent small meals
  7. common cold treatment treat symptoms
    1. analgesics: acetaminophen. Or, NSAIDS (ibuprofen) for fever and aches PRN
    2. oral decongestants (Sudafed) PRN
    3. topical nasal decongestants, BID up to THREE DAYS and PRN
    4. Antitussives (Robitussin/dextromethrophan) PRN
    5. Antihistamines (diphenhydramine/Benadryl) for nasal congestion PRN
  8. common cold (viral upper respiratory infection) signs/symptoms self-limiting infection(4-10 days)
    droplet, highly contagious, in winter months
    S/S: fever, sore throat, sneezing, nasal congestion, runny eyes, rhinorrhea of clear mucus, headache.
    *lungs: clear.
    *Nasal tubinates: swollen with clear mucus
    *anterior pharynx: reddened
    *cervical nodes: SMOOTH, MOBILE, AND SMALL OR SHOTTY NODES
  9. Primary Hypertension diagnosis and treatment plan from Kaiser:
    first-line thiazide diuretic (HCTZ)
    add ACEI (Lisonopril)
    add calcium channel blocker (Norvasc)
    add beta blocker (Metoprolol) or spironolactone
    normal: <120/<80mmHg
    prehypertension: <120-139/ 80-90
    stage I: 140-159 / 90-99
    stage II: >160 / >100

    * first line: thiazide diuretic plus an ACEI or thiazide diuretic alone as initial therapy for stage 1 HTN
    * for two drugs: combination therapy of a thiazide diuretic plus an ACEI for stage 2 HTN and/or prior stroke /TIA with HTN stage 1 or 2.
    * for three drugs: if blood pressure is not controlled with a combination thiazide diuretic/ACEI, add calcium channel blocker.
    * for four drugs: if blood pressure is not controlled with thiazide diuretic/ACEI and CCB, add a beta blocker or spironolactone

  10. HTN medications (Beta-Blockers)(Beta-Antagonists) Propranolol;
    Carevedilol(cored);
    Atenolol;
    Metoprolol;
    Timolol or timolol ophthalmic drops(Glaucoma).
    Contrindication: 1.asthma (cause bronchoconstrictoin)
    2. COPD (cause bronchoconstriction)
    3. chronic bronchitis (causes bronchoconstriction)
    4. emphysema (cause bronchoconstricgtion)
    5. Bradycardia and atrioventricular(AV) block (second to third-degree block)
  11. HTN medication(ACE inhibitors and Antiotensin Receptor Blockers) 1. ACEI: Ramipril (Altace)
    Lisinopril (Zestril, Prinivil)
    Benazepril (Lotensin)
    Captopril (Capoten)
    Enalpril (Vasotec)
    Combination: Lisinopril and HCTZ (Zestoretic), enalpril and HCTZ (Vaseretic),
    Captopril and HCTZ (Capozide),
    Benazepril and amlodipoin (Lotrel)
    ——————————————————–
    ARBs: Losartan(Cozaar)
    !!!Valsartan (Diovan) NO MORE USE!!! since it cause cancer!!!!
    Candesartan (Atacand)
    Irbesartan (Avapro)
    combination: Losartan and HCTZ(Hyzaar)
    Valsartan and HCTZ (Diovan HCT)
    Valsartan and amlodipine (Exforge)
  12. SOAP note CC
    HPI (OLDCART)
    Current medication
    Allergies
    PMHx
    Soc Hx
    Fam Hx
    ROS(Constitutional, HEENT, Skin, Cardiovascular, Respiratory, Gastrointestinal, Genitourinary neurological, musculoskeletal, hematological, lymphatics, psychiatric, endocrinologic, Allergies)
    ROS(includes in ROS)
    Differential diagnostic
    Rx
    Education
    Referral
    Follow up
  13. allergic rhinitis treatment 1. First line is Topical nasal spray: Flonase, Nasacort, combination of azelastine and Flonase.
    2. Decongestant: Sudafed
    3. Oral antihistamine PRN: Zyrtec, Claritin. Benadryl is first generation cause sedation.
    4. Eliminate environmental allergens.
  14. Acute pharyngitis by
    Streptococcal Pharyngitis/Tonsillopharyngitis(“Strep” Throat)
    1. signs and symptoms:
    * pharynx dark pink or bright red.
    * adults usually afebrile or mild fever (high fever >102F=38.8C)
    * tonsillar exudate that is yellow to green color.
    * anterior cervical lymph nodes mildly enlarged.
    * may have petechiae in the hard palate
    2. treatment plan:
    * rapid”strep” test or throat C&S
    * first line: oral penicillin V 500mg, BID to TID x10days
    * alternative: Amoxicillin 500mg, BID x10 days
    * if penicillin or beta-lactam allergy: Azithromycin x 5 days.
    * add Tylenol or Advil.
    * throat lozenges, drink more fluids, repeat C&S after antibiotic treatment.
  15. Indigestion treatment Maalox
    Zenpep, 3000-10000 unit, QID
  16. Interpretation of pulmonary function test 1. post bronchodilator FEV1/FVC: if <70, there is obstruction.
    2. Severity?
    Post bronchodilator FEV1:
    Gold 1-Mild: FEV1>=80%
    Gold 2-moderate: 50-79%
    Gold 3-severe: 30-49%
    Gold 4-very severe: <30%
    3. Reversibility?
    post bronchodialtor FEV1 or FVC has 12% improvement
  17. Diagnosis of COPD S/S: dyspnea, chronic cough or sputum production
    Post bronchodilator, FEV1/FVC ratio less than 0.7 confirm the presence of persistent air flow limitation
  18. CHF for stable HF treatment guideline: start Lasix 20mg or high dose (up to 320mg) orally for diuresis initially. if acute decompensated CHF refer to ED (IV furosemide, oxygen, vasodilators, others).start on ACEI or ARB
    2. then add a beta-blocker / aldosterone-receptor antagonist(spironolactone)
    3. add Other medications as needed
    4. Limit sodium intake
    5. use Beta-blocker if with reduced EF (carevedilol, bisoprolol, extended-release metoprolol succinate)
    6. Refer to cardiologist
  19. HTN medication (Beta-Blocker) 1. Ends with “olol”
    Metoprolol, Atenolol
    2. Other uses: acute MI, post MI, Migraine headache, Angina, glaucoma, resting tachycardia, hyperthyroidism
    3. Contraindications: Asthma, COPD, emphysema, chronic bronchitis, II or III degree heart block
  20. HTN medication (calcium channel blocker) 1. Side effects: ankle edema, heart block or bradycardia, reflex tachycardia, headache
    2. Contraindications: heart block, bradycardia, CHF
    3. Dihydropyridine( Nifedipine, Amlodipine), Nondihydropyridine (Verapamil, Diltiazem).
  21. HTN medication ( Aldosterone receptor Antagonists Diuretics) 1. Indications: HTN, CHF,
    2. Avoid combining with potassium-sparing diruetics, ACEIs, or potassium supplement
    3. side effects: hyperkalemia,GI, postmenopausal bleeding, erectile dysfunction
    4. contraindications: hyperkalemia, renal infufficiency, DM II,
    5. Spironolactone(Aldactone), daily
  22. HTN medication (Thiazide Diuretics&Loop Diuretics)  1. Thiazide Diuretics: hydrochlorothiazide.
    side effects: hyperglycemia, hyperuricemia, hypertriglyceridemia and hypercholesteremia, hypokalemia, hyponatremia, hypomagnesemia
    contraindications: sensitivity to sulfa and thiazides
    2. Loop Diuretics: Futosemide, Bumetanide(Bumex)
    side effects: hypokalemia, hyponatremia, hypomagnesemia
  23. Type II Diabetes Mellitus treatment plan:
    Metformin
    Metformin + Glucotrol/Amaryl
    Glucotrol/Amaryl + Metformin
    Metformin and Glucotrol/Amaryl + Lantus
    Metformin and Glucotrol/Amaryl + Actos
    NEVER COMBINE insulin and Prandin or Starlix
    1. lifestyle changes: weight loss for 3-6 months if mild A1C elevation
    2. Metformin is first-line treatment. start on 500mg daily(maximum is 2000mg/dL).
    3. if metformin is at maximum dosage but A1C is still high, add sulfonylurea (Glucotrol XL 20mg/d).
    3′. if sulfonylurea at the maximum dose(e.g., Glucotrol XL 40mg/d) and A1C still high, add metformin.
    3″. if metformin is at maximum dosage, other choices to add are incretin mimetics (Byetta), and/or TZDs (Actos), others.
    4. if patient is on both metformin and sulfonylurea(Glucotrol XL), consider starting a basal insulin (Lantus SC daily).
    4′ if patient is on both metformin and Glucotrol XL but refused insulin, add thioglitazones(Actos), Byetta, others.
    5. NEVER combine insulins with meglitinides(Glinides) such as Repaglinide(Prandin), nateglinide(Starlix).
  24. diabetes medication contraindications:  1. Biguanides: Metformin(Glucophage). do not use if renal disease, hepatic disease, alcoholics, hypoxia.
    2. Sulfonylureas FIRST generation: chlorpropamide(Diabinese) will cause hypoglycemia. with long half-life(12 hrs).
    SECOND generation: glipizide (Glucotrol), glyburide(DiaBeta), glimepiride(Amaryl): will cause hypoglycemia. avoid if impaired hepatic or renal function.
    3. Thiazolidinediones (TZDs): Pioglitazone (Actos). avoid CHF, bladder cancer. cause water retention and edema.
    4. Meglitinide(Glinides): Repaglinide (Prandin), nateglinide(Starlix). hypoglycemia. hold dose if skip a meal. side effects are bloatingm abdominal cramps, diarrhea.
    5. Bile-acid sequestrants: Cholestyramine(Questran). take with meals. side effects are kidney and liver(check creatinine, GFR, LFTs).
  25. Contact dermatitis = irritant dermatitis=allergic dermatitis (redness, itching, bullae/papules/vesicles surrounding with erythema)(scalling, cursing, oozing)
    (thin-skinned: eyelids, genitalia, antecubital space)
    1. Antihistamine cream
    2. Corticosteroids
    3. for 2nd infection: antibiotic cream
    1. corticosteroids from low potency to high potency:
    a.hydrocortisone(Hytone), desonide (Desonen), alcometasone(Aclovate)
    b. betamethasone (Luxiq), fluocinolone acetonide (synalar)
    c. Triamcinolone Acetonide (Kenalog or TMC)
    d. Betamethasone diporpionate (Diprolene) =flocinonide (vanos)
    2. antihistamine cream:
    a. diphenhydramine (Benadryl)
    b. doxepin (Prudoxin)
    3. clindamycin phosphate 1% gel (clindamycin-Benzayl for Acne).
  26. Pharyngitis/Tonsillitis by viral infection:
    concurrent conjunctivitis, nasal congestion, hoarseness, cough, diarrhea or viral rash, sore throat, pharyngeal edema,
    treatment:
    antipyretics/analgesics for fever and throat pain
    fluid intake
    rest, gargling with warm salt water

 

 

treatment plan
treatment plan

 

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