Heme/Onc TMPs

34 year old female who is a vegan and has menorrhagia (very heavy periods). She is fatigued, dyspneic with minimal exertion and pale.

Ferrous Sulfate tablet once every other day

Can also do Ferric Citrate

Anemia caused by combination of menorrhagia and diet

75 year old male with T2DM x 10 years, HTN x 20 years and Heart Failure x 5 years who is now more fatigued and tachycardic (HR = 92) than usual.

IV iron, can also just do ferrous sulfate

Anemia caused by medications--metformin. As well as comorbidities (anemia of chronic disease)

70 year old female with chronic kidney disease (CKD) with an eGFR of 35 mL/min andHTN who is more fatigued over the last month.

Ferrous Sulfate every M/W/F

Anemia is common in patients with CKD

50 year old female with fatigue of two months duration without bleeding. PMH: Seizure Disorder; Alcohol Abuse; RA

B12 sublingual (cyanocobalamin); already takes folic acid but may need to increase the dosing

Macrocytic anemia can be caused by alcohol abuse.

55 year old male who has started treatment for gout and is currently on a tNSAID for symptom control while he transitions to Allopurinol [Zyloprim] prophylaxis. He has been on the tNSAID for 6 weeks and notes progressive fatigue over the past month.

Ferrous sulfate every other day.

Concern of GI bleed due to long term use of tNSAIDs-> r/o

85 year old male with H&H of 7/22 noted on CBC obtained in the ER for pre-opclearance for repair of a fractured hip. He lives alone and fell yesterday. He was discovered today with the fractured hip. He has a complex PMH including T2DM, CKD,COPD, HTN, a past history of Alcohol and Tobacco abuse (abstinent both since 2018).

Based on labs: 2 units of platelets, then IV iron supplementation (ferumoxytol) and an erythropoiesis-stimulating agent (Epoetin alfa)

Your patient is a 75 year old male with a PMH of CKD who presents with dyspnea on mild exertion, fatigue, and malaise but no hematochezia or hemoptysis.

Ferrous Sulfate tablets

Diagnosed with anemia chronic disease. Caused by his CKD

Your patient is a 65 year old male with chronic pain in his legs when he walks more than 25 yards (i.e. to his mail box). PMH: Tobacco use (40 pack years); HTN; T2DM; COPD

Cilostazol 2x daily and Clopidogrel (or Aspirin) 1x daily to prevent resistance to cilostazol. Council on smoking cessation

Peripheral arterial disease, experiencing peripheral claudication

45 year old male with fatigue and peripheral neuropathy (numbness and tingling in legs bilaterally) for 1 month .PMH: RA

B12 Supplement (cyanocobalamin). Takes folic acid with the MTX for RA.

Pt probably doesn't absorb B12 efficiently. With the peripheral neuropathy for 1 month, we need to be more aggressive with treatment. If >6 months, it will be hard to reverse.

You're writing admission orders for a 60 year old male patient about to undergo right hip replacement surgery. He is otherwise healthy. PMH: Osteoarthritis (OA)

Apixaban to limit the risk of a thromboembolism during post-op. Can switch to Aspirin once up and walking

You see a 30 year old female in the ER with a pulmonary embolus (PE). She is otherwise healthy and without chronic disease.

Apixaban

Your patient is a 65 year old male who is status post-acute myocardial infarction (AMI) and drug-eluting stent placement. You are discharging him from the hospital today. What anti-platelet/anticoagulation drug(s) should he be discharged on?

Ticagrelor and ASA

Your patient is a 65 year old male who is status post-acute myocardial infarction (AMI). You are discharging him from the hospital today and notice that he doesn't have Rx's for his anti-platelet drugs yet. PMH: s/p AMI, ASA Allergy

Ticagrelor or clopidogrel

You are writing orders for your 30 year old female PE patient with an unprovoked distal lower extremity DVT that evolved to a pulmonary embolus. You anticipate that she will be discharged as soon as she is anti-coagulated on out-patient medication. Develop yourplan and write Rx's for her outpatient anticoagulation. (Assume that she has low bleeding risk.)

Warfarin or Rivaroxaban or Apicaban, or Diabigatran

Your patient is a 70 year old female with recent onset atrial fibrillation and long term mitral valve stenosis (without artificial valve) with symptoms of mild fatigue and dyspnea on exertion (climbing two flights of stairs).

PMH: A Fib; T2DM; GI Bleed; Mitral Valve Stenosis; CKD3a; HTN

Concerned about a stroke (left side of the heart) want to anti-coagulate. Start her on warfarin because of the non-valvular involvement

Your patient is a 70 year old female with atrial fibrillation and long term mitral valve stenosis with symptoms of mild fatigue and dyspnea on exertion (climbing two flights of stairs). You have initiated Warfarin therapy and she has been taking 4mg daily. Her INR yesterday was 12.

PMH: T2DM; GI Bleed; Mitral Valve Stenosis; CKD3a; HTN; A Fib

Stop warfarin, one dose of vitamin K 5 mg, then recheck in 24 hours. Repeat until INR is in the 2-3 range.

Your 68 year old Caucasian male patient has persistent a fib without prosthetic valve. You are concerned about his increased stroke risk. He is a golfer and has seen Arnold Palmer on a TV commercial advertising a new med that sounds like it would be good for him. His CHADS2 Score is 3. He wants to know what his options are?

Best option for him is Dabigratran, but he could be a candidate for any of them due to his risk factor.

Your 72 year old female Caucasian patient was hospitalized quickly after a cardioembolic CVA. She is being prepared for discharge from the hospital and needs post-CVA or secondary anticoagulation to reduce the risk of another embolic CVA. Her CHA2DS2-VASc score is 5.

PMH: HTN; COPD; paroxsysmal A Fib

Apixaban, would have to take her off her aspirin bc they have a class C interaction

Your 63 year old Caucasian female patient has newly diagnosed, moderately active Rheumatoid Arthritis and her PMH is complicated by end stage COPD. She would like to know what therapy is best for her.

Prednisone and hydroxychloroquine. Could also potentially do sulfasalazine

You are a hospitalist PA following a 43 year old female who is being treated on day 2 after a Pulmonary Embolus evolved from a DVT that developed while she was traveling cross-country by automobile. She has been treated with Heparin and her most recent aPTT is out of therapeutic range at 150 seconds and she is developing bruises in her skin. What medication could be used to reverse her prolonged aPTT?

Protamine sulfate, antagonist of heparin

Your 27 year old male landscape worker developed an expanding 'bull's eye' rash at his belt line, myalgias, arthralgias, headache, fatigue and a low-grade fever of 100 deg F this morning.

Doxycycline, thinking he had Lyme disease

Your 67 year old male dog walker has malaise, nausea, fever, and headaches for the past three days without other symptoms. He walks dogs at a local park with high grass and frequently has to remove tics from the dogs.

Doxycycline, Lyme disease

Your patient is a 35 year old female outdoor enthusiast who presents with fever, fatigue, headache, arthralgias and myalgias, emotional lability (out of character for her) and nausea of 2 days duration. Assume that she does not have meningitis but a tic vectored disorder which you diagnose as Babeosis.

Azithromycin IV, Atovaquone (bc she honest have a spleen so gotta be aggressive)

Your patient is a 40 year old male college professor who has just returned from leading a 2 week student trip to rural Haiti. He presents with episodes of fever, chills, sweating ,and headache, myalgia, and vomiting. The strains of P. Falciparum malaria currently seen in Haiti are chloroquine sensitive. You double-check this information with the CDC for currency. You also report this illness to the State Dept of Health. What would be thetreatment of choice for this man with uncomplicated malaria?

Artemether-lumefantrine, could possibly do chloroquine as well

38 year old female college professor who has just returned from a malaria endemic region in Africa. The strains of malaria there are chloroquine-resistant. She presents with headache, fatigue, fever, chills, sweats, malaise, but no jaundice. You double-check the strain sensitivity with the CDC and report this illness to the State Health Department. Of the drugs in your Drug table for this module, which would be a drug of choice for treating this non-pregnant lady with uncomplicated malaria?

Artemether-lumefantrine

Your patient is a 35 year old male ranch worker who is visiting relatives in Maine. He lives and works on a ranch in rural Oklahoma. He presents to your rural clinic with a red macular rash on his wrists and ankles with some petechial lesions also. He has had a fever and chills for the past 3 days with severe headache, nausea, vomiting and myalgias. You suspect that he has Rocky Mountain Spotted Fever.

Doxycycline, IV loading dose then can be discharged and start on a lower amount of oral tablets

Your patient is a 60 yo male with a recent mechanical heart valve placement who has developed intermittent atrial fibrillation for 2 days postoperatively. He needs to be anticoagulated. Assume thathe has mild or low bleeding risk.

Warfarin, no DOAC due to mechanical valve

Your patient is a 40 year old female with a left lower leg DVT. Shehas a needle phobia, so she refuses any medications that would need tobe injected. Which direct acting oral anticoagulant could be used for this lady's DVT?

Can use any DOACs. Apizaban or Riveroxaban #1, Warfarin will have to be bridged with a LMWH