Discussion Part One
Leroy is a 70 year-old-man, whose wife passed away 5 years ago, and whose 2 children live out-of–state. His neighbor caretaker (Ms. Webb, a middle-aged retired CNA, whom his children hired to provide home care to him 3x/week) brings him to your clinic. He presents with quite severe confusion, incidentally to very minor changes in his environment, which provokes some violence (a symptom which startles Ms. Webb), increasingly impaired judgment, and increasing repetitiousness and inconsistencies in his usual behavior. Upon initial work-up and physical exam, you notice an increased respiratory rate, a slight fever (100°F), and cost vertebral angle tenderness on his right side.
Discussion Part Two (graded)
The patient is diagnosed with a severe urinary tract infection (pyelonephritis), and you decide to prescribe him sulfamethoxazole/trimethoprim (SMX/TMP) beginning with 2 g initially as a loading dose, followed by 1 g as a maintenance dose BID. Over the next couple of weeks, the symptoms associated with his UTI diminish, and his mental status improves. However, Ms. Webb brings him back to your clinic with symptoms, which scare her yet again, and she explains that she thinks he may have a relapse of his UTI. These symptoms include a high fever (103.6°F) and tachypnea, and upon pulmonary examination at your clinic, you hear crackles, and find classic findings of lung consolidation.
What laboratory tests should you order, and what is your primary diagnosis at this point and subsequent steps in his treatment and management?
Once explained, please indicate and describe your chosen pharmacological treatment with inclusion of dose and mechanism of action of your chosen prescription.
Discussion Part Three
Upon receipt of laboratory results, you notice that his eGFR is ~40mL/min, his serum creatinine is 3.0 mg/dl, and his BUN is 50 mg/dl.
How will the medication regimen(s) have to be adjusted given these new laboratory findings, and how should you be monitoring for efficacy and toxicity of this patient’s pharmacological profile with a summary of where this patient currently stands in his medical treatment?