Docstoc

CP SERIES CLINICAL PHARMACY SOAP FORM WORKSHEET CASE TOPIC Hematuria

Document Sample
CP SERIES CLINICAL PHARMACY SOAP FORM WORKSHEET CASE TOPIC Hematuria Powered By Docstoc
					       TOPIC: UTI/Prostatitis
      SUBJECTIVE/OBJECTIVE                           ASSESSMENT                                         PLAN
    PROBLEM:          ETIOLOGY, RISK          EVALUATE NEED FOR THERAPY;           RECOMMEND DRUG   GOALS & MONITORING
   SUBJECTIVE &          FACTORS,      EVALUATE CURRENT THERAPY; THERAPY OPTIONS      TREATMENT;       PARAMETERS         PATIENT
OBJECTIVE EVIDENCE CURRENT MEDS                                                     FURTHER TESTS        (TOXIC &        EDUCATION
                                                                                                       THERAPEUTIC)




                                                                                                                                     1
UTI                          Etio:               Need to treat; need to prevent progression of UTI from urethra =>         Note: In immunocomp,      Goals: Improve QOL,      PE:
Uncompromised UTI –          80-90% e.coli,      bladder => kidney => pyelonephritis; need to prevent high                 pregnant, and diabetic    prevent M/M, prevent     -finish abx as
otherwise healthy pt’s       staphsaprophyticu incidence of mortality in elderly and nosocomial cases.                     patients use 7-10d thx,   reoccurrence, prevent    directed, otherwise
                             s                                                                                             instead of 3d             progression to           infxn could come
Compromised UTI –            (remainder:                                                                                                             pyelonephritis, decrease back or spread to the
                             klebsilla, proteus,
Incr severity, incr risk of tx                                                                                        Non Drug Recc                  discomfort               kidneys
failure                      enterococcus)                                                                            -Hydration                                              -drink plenty of water
                                                 Thx Opt:                                                             -frequent voiding           Monitor:                    -urinate as needed
Cystitis = lower tract UTI   risk factors:       ~common tx~                                                          -post coital voiding        S/sx of UTI                 -post coital voiding
                             female>male,        TMP/SMX: tx’s e.coli, p. mirabilis, klebsiella pneumoniae, staph     -cranberry juice            Urine analysis/culture      -cranberry juice
                             elderly>young,      saprophyticus                                                        -d/c diaphragm use (if                                  -wipe back to front
                             obstruction,        +DOC in simple outpt                                                 applicable)                                             -d/c diaphragm use
S:                           instrumentation, -c/x in sulfa allergy, photosensitivity                                 -abstain from sexual        SE - TMP/SMX                -abstain from sexual
-Pain during                 pregnancy,          CL- renal                                                            intercourse                 sulfa allergy, GI           intercourse
urination/dysuria            DM,                                                                                      -whip from front to back    intolerance , rash, sob,    -report any urinary
-Increased frequency,        Diaphragm use, FQ/Ciprofloxacin: tx’s enterobacter, TMP/SMX resistant e.coli                                         anapylaxis, SJS,            sx/s
urgency                      Lack of             +tx’s bact resistant to TMP/SMX (resistance common on west           Dose – TMP/SMX              anaplastic anemia,          -educated pt on role
-Tenderness/pain             circumcision,       coast)                                                               1 DS tab q12h, 3d (up to    photosensitivity            of prophylaxis (if
(suprapubic)                 Sexual              -CNS stimulation in children <18yo, cyp1A2 inhibitor,                14d in complicated cases)                               app)
-Decreased outflow           intercourse,        photosensitivity, n/v/anorexia, tendonitis, fever/chills, urine crystal                          SE - Ciprofloxacin          PE - TMP/SMX
-Reddish urine               UTI hx              formation                                                                                        GI intolerance , rash, sob, -Use sunblock/hat
                                                                                                                                                  anapylaxis,                 -Drink lots of water
O:                             nosocomial,         Nitrofuration: tx’s enterobacter, many GNR (not pseudomonas, or Dose – Ciprofloxacin           photosensitivity,           -notify MD of rash or
-Pos. bact (urine) culture: catheters (usu:        serratia), TMP/SMX resistant e.coli                                250mg-500mg q12h, 3d (up n/v/anorexia, tendonitis, trouble breathing
(>10^2 org/ml)                 pseudomonas,        +well tolerated                                                    to 10d in complicated       fever/chills, urine crystal -take wf if GI
-gram stain                    providencia,        -short t/12 requires 7d thx, Pulmonary rxn, numbness/tingling in   cases)                      formation                   intolerance
-Pyuria: Pos. WBC count        morganella)         extremities                                                                                                                -may discolor urine
(10WBC/mm^3) by esterase                                                                                                                          SE - Nitrofurantoin         (orange-brown)
test                           risk factors for Fosfomycin: tx: most urinary pathogens, enterococcus faecalis         Dose – Nitrofurantoin       Pulmonary rxn,              -do not take w/
-hematuria (r/i cystitis)      compromised         (not pseudomonas)                                                  Macrodantin: 50mg-100mg numbness/tingling in            antacids
                               UTI: men,           +long t1/2 allows single 3gram dose                                q6h, 7d                     extremities                 -stains soft contacts
                               children, pregnant, -early recurrence; can’t use in men (not studied), children, women Macrobid: 100mg bid, 7d                                 yellow
R/O:                           structural/hormona with sx >6d; pregnant, diabetic or immunocomp require 7d thx        (SR form)                   SE - Fosfomycin             -shake susp well
Acute Pyelonephritis (Fever l abnorm in urinary hydration                                                                                         Rash                        PE - Ciprofloxacin
chills, Flank pain); acute     tract, impaired     urinary acidification                                                                                                      -TMP/SMX PE
cystitis; vulvo-vaginitis      host response,      urinary analgesic                                                  Dose – Fosfomycin                                       (except discolor
(trichomonas, yeast, herpes metabolic/hormon                                                                          Female: 3gm in 4oz of water                             urine and soft
simplex, bact vaginosis);      e abnormalities, ~other tx~(not common)                                                Male: 3gm QD for 3d in                                  contact stain
STD; trauma, allergy, irritant                     Amox: tx’s enterococcus facaleis                                   complicated UTI             PE – Fosfomycin             warnings)
                                                   Cephalosporin (1st-3rd) cefixime, cefpodoxime proxetil,                                        -avoid antacids             -take 2hrs after
                                                   cefprozil: tx’s e. coli, p. mirabilis, k. pneumoniae                                           -if S/Sx do not improve     meals
                                                   -cefixime has poor gram+ activitiy; cephelexin does not eradicate                              w/i 3d contact MD           -sml meals, po care,
                                                   e.coli fr/ vag/fecal areas                                                                                                 chew gum if n/v
                                                   +long t1/2 allows short course thx                                                                                         -notify md if
                                                   Ampicillin or Vanco + AMG:                                                                                                 tendon/joint pain
                                                   Tx’s Enterococcus facaleis                                                                                                 PE - Nitrofurantoin
                                                                                                                                                                              -may darken urine
                                                                                                                                                                              -take wf
                                                                                                                                                                              -susp can be mixed
                                                                                                                                                                              -notify md of sob,
                                                                                                                                                                              cough, tingling, cp
                                                                                                                                                                              -avoid etoh




                                                                                                                                                                                                  2
Recurrent UTIs                Etio/risk factors: Need to treat; need to prevent progression of UTI from urethra =>   (See above)           Goals: Improve QOL,       (See above)
                              (See above UTI’s) bladder => kidney => pyelonephritis; need to prevent high                                  prevent M/M, prevent
S:                            untreated or       incidence of mortality in elderly and nosocomial cases.                                   reoccurrence, prevent
-Pain during                  undertreated UTI                                                                                             progression to
urination/dysuria                                ~Prophylactic Abx~                                                                        pyelonephritis
-Increased frequency,                            TMP/SMX: ½ SS tab po QHS or TIW                                (See above)                (See above)               (See above)
urgency                                          TMP: 100mg po QHS                                              (See above)                (See above)               (See above)
-Tenderness/pain                                 Nitrofurantoin: 50-100mg po QHS                                (See above)                (See above)               (See above)
(suprapubic)                                     Intravaginal Estriol:                                          Dose – Estriol             SE – Estriol              PE – Estriol
-Decreased outflow                               + repopulates normal comensals in vagina to maintain low pH and0.5mg cream each night for Spotting, DVT/PE, n/v,    -continue use to
-Reddish urine                                   prevent e.coli binding                                         14d, then biw              depression, ha, change in prevent reoccurrence
                                                 -only use in postmenopausal women                                                         libido                    of UTI
O: UTI’s occur in clusters                                                                                                                                           -wear a pantyliner
-Pos. bact (urine) culture:                     (regular bladder emptying) <=controversial whether really helps                                                      after applying
(>10^2 org/ml)                                  postcoital voiding                                                                                                   medicine
-gram stain                                     d/c diaphragm (if applicable)                                                                                        -insert applicator
-Pyuria: Pos. WBC count                         abstention from sexual intercourse                                                                                   high into vagina
(10WBC/mm^3) by esterase                        cranberry juice                                                                                                      -annual exams
test                                                                                                                                                                 important
-hematuria (r/i cystitis)                       ~Intermittent self administration of Abx~                                                                            -small frequent
-3+ episodes w/i 6mos                           +recurrent UTIs are usually symptomatic, self diagnosis is                                                           meals avoid n/v
                                                accurate, cost effective, less abx toxicitiy
                                                -infections are not being prevented

                                                ~postcoital abx~
                                                + works in pts whose infxns related to intercourse
                                                TMP/SMX: ½ SS tab within 2 hours after intercourse                   (See above)           (See above)              (See above)
                                                Nitrofurantoin: 50mg within 2 hours after intercourse                (See above)           (See above)              (See above)
                                                (or any prophylactic abx regimen listed above)




                                                                                                                                                                                       3
UTIs in men                       Etio:                 Need to treat; need to prevent progression of UTI from urethra => TX 7-10d (10-14d                          Goals: Improve QOL,           (See above)
                                  75% GN, proteus,      bladder => kidney => pyelonephritis; need to prevent high         preferred)                                prevent M/M, prevent
S:                                prvidencia, e.coli;   incidence of mortality in elderly and nosocomial cases.                                                     reoccurrence, prevent
-Pain during                      enterococcus is                                                                         If recurrent (most likely due             progression to
urination/dysuria                 most common GP                                                                          to kidney or prostate infxn)              pyelonephritis or
-Increased frequency,             (bacteriology is                                                                        then tx 4-6wks                            prostatitis
urgency                           less predicatable     TMP/SMX: tx’s e.coli, p. mirabilis, klebsiella pneumoniae, staph
-Tenderness/pain                  in men)               saprophyticus                                                     (See above)                               (See above)                   (See above)
(suprapubic)                                            +DOC in simple outpt
-Decreased outflow                                      same as for women except TX 7-10d (10-14d preferred)
-Reddish urine                 Risk Factors:
                               (See above, with
O: -Pos. bact (urine) culture: exception of             FQ/Ciprofloxacin: tx’s enterobacter, TMP/SMX resistant e.coli
(>10^3 org/ml)                 female specific          same as for women except TX 7-10d (10-14d preferred)                                                        (See above)
-gram stain                    risk factors; ie:                                                                                     (See above)                                                  (See above)
-Pyuria: Pos. WBC count        diaphragm use)
(10WBC/mm^3) by esterase
test
-hematuria (r/i cystitis)

***voided urine are LESS
likely to be contaminated
than in women.***
                                  ********************* **************************************************************************   *******************************                               ***********************
*******************************   Etio:                 *****                                                                        ***                             *****************************
*                                 Recurrent or          Need to treat; need to prevent progression of pyelonephritis and                                             *                             (See above)
Pyelonephritis                    untreated UTI’s       kidney damage; need to prevent high incidence of mortality in                                                                              PE - Ampicillin
(Upper tract UTI involving        spread into upper elderly and nosocomial cases.                                                    Dosage Ampicillin               SE - Ampicillin               -take on empty
kidneys)                          urinary tract =>                                                                                   500mg po QID, 7D                Stomach upset                 stomach, 2hrs before
                                  kidneys               Ampicillin: if GPC (enterococcus)                                                                                                          or 4 hrs after meals
S:                                                      500mg po QID, 7D                                                                                                                           -use BUM if on Ocs
-flank pain                       Risk Factors:                                                                                                                      SE - Ciprofloxacin
-flank tenderness                 (See above “UTI’s) FQ/Ciprofloxacin: use if GNR                                                    Dosage Ciprofloxacin            GI intolerance , rash, sob, PE - Ciprofloxacin
-fever/chills                     also recurrent and +tx’s bact resistant to TMP/SMX (resistance common on west                      500mg po BID, 7D                anapylaxis,                   -TMP/SMX PE
-loin pain                        untreated UTIs        coast)                                                                                                       photosensitivity,             (except discolor
-n/v                                                    -CNS stimulation in children <18yo, cyp1A2 inhibitor,                                                        n/v/anorexia, tendonitis, urine and soft
-hematuria                                              photosensitivity, n/v/anorexia, tendonitis, fever/chills, urine crystal                                      fever/chills, urine crystal contact stain
O:                                                      formation                                                                                                    formation                     warnings)
-pos bact (urine) culture                                                                                                                                                                          -take 2hrs after
-Gram stain                                                                                                                                                                                        meals
-kidney inflammation                                                                                                                                                                               -sml meals, po care,
-pyuria                                                                                                                                                                                            chew gum if n/v
                                                                                                                                                                                                   -notify md if
                                                                                                                                                                                                   tendon/joint pain




                                                                                                                                                                                                                        4
Acute Prostatitis               Etio:                Need to treat to prevent progression to chronic prostatitis and            4wk thx                         Goals: Prevent            (See above)
(prostatitis type I)            80% e.coli,          prostate damage due to inflammation and infection.                                                         development of chronic
                                (klebsiella,                                                                                                                    prostatitis; improve QOL,
S:                              enterobacter,        (all below abx achieve penetration and high levels in prostatic                                            decrease M/M
-chills                         proteus,             secretions)
-pain upon                      enterococci also
defication/urination            causative)           TMP/SMX: tx’s e.coli, p. mirabilis, klebsiella pneumoniae, staph           Dose – TMP/SMX                  (See above)                   (See above)
                                                     saprophyticus                                                              1 DS tab q12h, 28days
O:                              Risk Factors:        +DOC in simple outpt
-fever                          (See above, with     -c/x in sulfa allergy, photosensitivity
-Pos. bact (urine) culture      exception of         CL- renal
-inflammed prostate             female specific
-tender, warm prostate          risk factors; ie:    Clindamycin                                                                Dose- Clindamycin       SE – Clindamycin                      PE – Clindamycin
                                diaphragm use);      -c. difficile overgrowth                                                   150mg-450mg/dose q6-8h; Pseudomembranous                      -report severe
R/O:                            -40yo+ males                                                                                    max 1.8g/day; 28 days   colitis; diarrhea                     diarrhea
N. Gonorrhoeae in men           -recurrent UTIs      Doxycycline                                                                                                                              -take each dose with
<35yo                                                -only 50% penetration                                                      Dose- Doxycycline               SE – Doxycycline              full glass of water
                                                     CL: renal                                                                  100mg qd; 28 days               Photosensitivity, GI          -finish all medication
***prostatic massage can                                                                                                                                        intolerance                   -do not skip doses
ppt bactermia… avoid                                 Erythromycin                                                               Dose- Erythromycin
prostate test =>                                     -hepatotoxicity                                                            250mg – 500mg 16-12h; 28 SE – Erythromycin                     PE – Doxycycline
contraindicated to exam and                                                                                                     days                     Diarrhea, hepatotoxicity              -avoid sunlight
milk for prostatic fluid of                                                                                                                                                                    -finish all medication
WBC***                                                FQ/Ciprofloxacin                                                           (See above) x28d                (See above)                   -do not skip doses
                                                                                                                                                                                               -take with food
******************************* ********************* ************************************************************************** ******************************* ***************************** -avoid milk
Chronic Prostatitis             Etio:                 Need to treat to prevent continual prostatitis and prostate damage                                                                       products/antacids
(prostatitis type II)           80% e.coli,           due to inflammation and infection.
                                (klebsiella,                                                                                                                                                   SE – Erythromycin
S:                              enterobacter,         (need abx that can penetrate the non-inflammed epith of prostate)                                                                        -avoid milk/antacids
-recurrent UTI’s                proteus,              (All dosages the same as above, except 2-3mos duration of                                                                                -avoid EtoH
                                enterococci also thx)                                                                                                                                          -report diarrhea
O:                              causative)            TMP/SMX
-NO inflammation                                      FQ/Ciprofloxacin
-Pos. bact (urine) culture      Risk Factors:         Doxycycline
-Pos. WBC count                 (See above, with -only 50% coverage
-enlarged, “boggy” prostate exception of
                                female specific       Prostatectomy
                                risk factors; ie:     +suggested in pts with acute recurrent episodes
                                diaphragm use); -
                                50yo+ males, -
                                recurrent UTIs




                                                                                                                                                                                                                    5
Chronic Non-Bacterial         Etio              Tetracycline (See above)x28d                                                       4wk thx                                                        Cure is unusal
Prostatitis (prostatitis type Unclear; possibly                                                                                    (See above)                       (See above)                  (See above)
III)                          chlamydia         Thermal Thx
                              trachomatis,      +relieves pain
S:                            mycoplasma
-pain/inflammation            hominis,
-genitourinary and voiding trichomonas
discomfort                    vaginalis,
                              ureaplasma
O:                            urealyticum or
-Neg. bact (urine) culture    viral
-Pos. WBC count
-highly variable prostate     Risk Factors:
exam results                  30-50yo male




*******************************                       **************************************************************************   *******************************   ***************************** ***********************
***                             ********************* ******                                                                       *                                 **                            **
Chronic Pelvic Pain             *                     Alpha blocking agents                                                        Dose – Prazosin                   SE – Prazosin                 PE – Prazosin
Syndrome                        Etio                  +maybe helpful                                                               initial: 1mg/dose bid-tid         Hypotension                   -Rise from
                                Unclear; possibly -not formally studied as a treatment                                             maint: 3-15mg/day bid-qid         Dizziness                     sitting/lying position
S:                              neuromuscular         ie: prazosin                                                                 max 20mg/day                      Drowsiness                    slowly
-pain                           dysfunction of                                                                                                                                                     -take first dose at
-increased urgency              bladder               muscle relaxants                                                             Dose – carsiopradol                                             bedtime
-dysuria                                              +maybe helpful                                                               350mg TID-QID                     SE – carsiopradol             -report painful,
-decreased force of stream Risk Factors:              -not formally studied as treatment                                                                             Drowsiness                    persistent erection
-voiding problems               30-40yo male          ie: carsiopradol                                                                                               Flushing                      -avoid alcohol
                                                                                                                                                                     fainting
O:
-Neg. bact (urine) culture                                                                                                                                                                        PE – carsiopradol
-Pos. WBC count                                                                                                                                                                                   -dizziness
                                                                                                                                                                                                  -drowsiness
                                                                                                                                                                                                  -avoid CNS
                                                                                                                                                                                                  depressants
                                                                                                                                                                                                  -avoid alcohol




                                                                                                                                                                                                                         6
Catheter Associated UTI’s Etio:           treat only if symptoms are present; colonization is common          Not applicable   Not applicable   Not applicable
                          Catheter
S:                                        Systemic Abx (see above, abx used to treat UTIs) – only
-pain                     Risk Factors:   transiently decrease bacteriuria and may select for resistant
-increased urgency        catheter        organisms
-dysuria
                                          ~Catheter irrigation~
O:                                        polymixin-neosporin irrigation
-pos. bact culture                        -no effect on bacteriuria, most organisms that colonize are
                                          resistant

                                          chlorhexidine and acetic acid irrigation
                                          + helps to prevent bacteriuria
                                          - not studied

                                          2% provodone-iodine solution
                                          +decreases bacteriuria from 28% => 4% in straight catheterization
                                          -it’s effect on indwelling catheters is unknown

                                          H2O2 disinfection of collection bag
                                          +/- conflicting results

                                          ~catheter placement/use~
                                          ***remove catheter as soon as feasible***
                                          +best way to prevent infection, 35%pts with bacteriuria
                                          spontaneously clear after removal, can be combined with single
                                          dose abx thx (ie: TMX/SMP DS one dose)

                                          suprapubic catheterization/intermittent catheterization
                                          + decreases incidence of bacteriuria, especially in those who
                                          require long term catheterization, can be combined with
                                          prophylactic abx




                                                                                                                                                                 7
Asymptomatic Bacteriuria etio                      Thx NOT indicated in                                                      Not applicable                  Not applicable               Not applicable
                         persistent e.coli         -School aged children
S:                                                 -non-pregnant women
-none                    Risk Factors              -diabetics
                         Women > men               -elderly
O:                                                 -catheter pts undergoing exchange
-Pos culture
                                                   No compelling reason to treat, not associated with increased
                                                   mortality, increased incidence of pyelonephritis, or incontinence;
                                                   Single course thx will clear bacteriuria in 60% pt at 6mos
                                                   compared to 35% who receive no thx


                                                   Thx indicated in (see above “UTI” for regimens)
                                                   -neonates
                                                   -preschool children
                                                   -pregnant women
                                                   -non elderly men (30-60yo)
                                                   -pts with abnormal urinary tracts
                                                   -pts undergoing invasive urologic procedures

                          ********************* **************************************************************************
*******************************                                                                                              ******************************* ***************************** ***********************
*                         *                     ******                                                                       *                               **                            *
Fungal UTI                etio                  usually don’t need to treat since candiduria and candidemia are
Uncommon outpt infxn;     candida vaginititis, uncommon; treat when urinary tract manipulation or surgery can
effects susceptible inpt  candida albicans; lead to candiduria and candidemia; also treat if pt is of extremely
S:                        candida galbrata compromised health or has bladder cancer
-Pain during              (rare)
urination/dysuria                               Fluconazole                                                                  Dose – Fluconazole              SE - Fluconazole             PE – Fosfomycin
-Increased frequency,     Risk Factors          +tx’s candida                                                                200mg po qd, 7d                 Hepatotoxicity; monitor      -take with food
urgency                   -women > men          -DDI, hepatotoxicity                                                                                         LFTs; GI                     -complete entire
-Tenderness/pain          -intercourse with                                                                                                                                               course of thx
-Decreased outflow        infected partner      (5FC                                                                                                                                      -use BUM if on OCs
-Reddish urine            -inpatient            50-75mg/kg/day in 4 divided doses
                          -prolonged            caspofungin (IV) or voriconazole
O:                        catheterization       tx’s c. galbrata) <= 5FC, Caspofungin (IV), and voriconazole were
-Pyuria: Pos. WBC count   -diabetes             not emphasized in class or in the syllabus… these will come up
(10WBC/mm^3) by esterase -steroid thx           later in the fungal lectures
test                      -abx thx
-hematuria (r/i cystitis)                       remove catheter
                                                alkalinize the urine
                                                ampho B catheter irrigation 50mg/l at 42ml/hr for one day
                                                -UCSF data suggests this is rarely effective if catheter remains in
                                                place




                                                                                                                                                                                                                 8

				
DOCUMENT INFO
Shared By:
Categories:
Stats:
views:34
posted:5/17/2011
language:English
pages:8