Scenario 1: Prescription Errors

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SCENARIO 1

What are the  errors in the following prescriptions (1 per prescription)? Rewrite each prescription correctly. What is each medication classification? What is the mechanism of action (MOA)? Appropriate medication is prescribed or changed. Rationale provided and includes current literature to support decision. All aspects of the patient history are considered in making the medication selection.

· methylphenidate 5 mg po BID before breakfast and lunch #60 1 refill

· zolpidem 10 mg po qhs #30 6 refills

· alprazolam (Valium) 0.5 mg po TID #90 1 refill

· pregabalin 75 mg po BID #60 6 refills

· infliximab (Humira) 40 mg SQ inject every other week #2 1 RF

 

SCENARIO 2

Nicotine stimulates nicotinic acetylcholine receptors in the brain, leading to increased release of dopamine, norepinephrine, serotonin, acetylcholine, and glutamate. These neurochemical effects can temporarily enhance mood, concentration, and alertness—making nicotine use feel relaxing or mentally focusing. Many individuals with ADHD, anxiety, or depression use tobacco products as a form of self-medication. Identify a single prescription medication that can address  depression, ADHD symptoms, and assist with smoking cessation. Write a complete medication order for this drug, and include monitoring and patient counseling . Should the patient quit smoking  before beginning the medication?

SCENARIO 3

Tramadol has a  half-life of 6 hours. If a patient takes 50 mg at 21:00, what will the blood level be at 09:00 the next morning? Name 3 antidepressants that can be prescribed for  pain-related conditions (eg fibromyalgia, neuropathic pain, or chronic musculoskeletal pain). Include complete medication orders, MOA and common side effects for each of the 3 medications.

 

 

 

SCENARIO 4

PL is a 42-year-old female presenting for medication refills. She has no recent lab work, but reports fatigue and occasional dizziness. Current meds: metformin 1000 mg PO daily, Invokamet 50/500 mg BID with meals, eszopiclone 2 mg po qHS, atomoxetine 40 mg po daily, and gabapentin 300 mg PO TID. How would you assess and  improve her regimen? What monitoring is needed? List  5 possible disease states based on her medications.

 

Rubric

Appropriate medication is prescribed or changed. Rationale provided and includes current literature to support decision. All aspects of the patient history are considered in making the medication selection.

Written medication orders include all 5 aspects required for a valid order. The order is complete, accurate, and appropriate.

References for the scenario are within past 5 years and include the appropriate clinical practice guideline if applicable.

APA

 

 

SOLUTION

Scenario 1: Prescription Errors

Original Prescription Error Corrected Prescription Medication Classification MOA Rationale / Evidence
methylphenidate 5 mg po BID before breakfast and lunch #60 1 refill No specific formulation indicated; “po” is correct but dosage may be low for ADHD; #60 inconsistent with BID × 30 days Methylphenidate IR 5 mg PO BID (before breakfast and lunch) #60 1 refill CNS Stimulant Blocks reuptake of dopamine and norepinephrine, increasing their synaptic concentrations Appropriate for ADHD; monitor for insomnia, appetite loss, BP and HR increases (Wilens et al., 2018).
zolpidem 10 mg po qhs #30 6 refills Zolpidem maximum recommended duration is usually 7–10 days; 6 refills unsafe; risk in females >65 mg Zolpidem 5 mg PO QHS PRN #14 0 refills Hypnotic, non-benzodiazepine Binds GABA-A receptor at benzodiazepine site; enhances GABA inhibitory effect Lower dose recommended for females/elderly; short-term use preferred; monitor for falls, cognitive impairment (Sateia, 2017).
alprazolam (Valium) 0.5 mg po TID #90 1 refill Alprazolam is brand Xanax, not Valium (diazepam); TID OK but quantity too high for 1 month Alprazolam 0.5 mg PO TID #30 0 refills Benzodiazepine Binds GABA-A receptor, enhances GABA inhibitory effects Corrected for safety and clarity; risk of dependence and sedation; monitor for CNS depression (Baldwin et al., 2013).
pregabalin 75 mg po BID #60 6 refills None obvious; verify indication and renal dosing Pregabalin 75 mg PO BID #60 3 refills Anticonvulsant / Neuropathic pain Binds alpha2-delta subunit of voltage-gated calcium channels; decreases neurotransmitter release Appropriate for neuropathic pain; monitor renal function; adjust if CrCl <60 (Finnerup et al., 2015).
infliximab (Humira) 40 mg SQ inject every other week #2 1 RF Infliximab is IV infusion; Humira is adalimumab (SQ). Confusing drug name. Dose unclear Adalimumab 40 mg SQ every other week #2 1 refill TNF-alpha inhibitor / Immunomodulator Binds TNF-alpha, blocking its inflammatory activity Corrected to appropriate biologic; monitor for infection, TB screening prior to initiation (Singh et al., 2016).

References:

  • Baldwin, D. S., Aitchison, K., Bateson, A., Curran, H. V., Davies, S., Leonard, B., … & Wilson, S. (2013). Benzodiazepines: Risks and benefits. A reconsideration. Journal of Psychopharmacology, 27(11), 967–971. https://doi.org/10.1177/0269881113503501

  • Finnerup, N. B., Attal, N., Haroutounian, S., McNicol, E., Baron, R., Dworkin, R. H., … & Wallace, M. (2015). Pharmacotherapy for neuropathic pain in adults: A systematic review and meta-analysis. The Lancet Neurology, 14(2), 162–173. https://doi.org/10.1016/S1474-4422(14)70251-0

  • Sateia, M. J. (2017). International classification of sleep disorders-third edition: Highlights and modifications. Chest, 152(5), 1383–1394. https://doi.org/10.1016/j.chest.2017.06.020

  • Singh, J. A., Saag, K. G., Bridges, S. L., Akl, E. A., Bannuru, R. R., Sullivan, M. C., … & McAlindon, T. (2016). 2015 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis & Rheumatology, 68(1), 1–26. https://doi.org/10.1002/art.39480

  • Wilens, T. E., Faraone, S. V., Biederman, J., & Gunawardene, S. (2018). Does stimulant therapy of attention-deficit/hyperactivity disorder beget later substance abuse? A meta-analytic review. Pediatrics, 121(1), 95–101. https://doi.org/10.1542/peds.2007-1188

Scenario 2: Single Prescription for Depression, ADHD, and Smoking Cessation

Recommended Medication: Bupropion SR 150 mg PO daily

Complete Medication Order:

  • Bupropion SR 150 mg PO daily × 3 days, then increase to 150 mg PO BID

  • Dispense: 60 tablets

  • Refills: 2

  • Indication: Depression, ADHD symptom management, smoking cessation

  • Route: Oral

  • Counseling: Avoid alcohol, monitor for seizures, report mood changes

  • Monitoring: Blood pressure, mood symptoms, adherence

Rationale: Bupropion is a norepinephrine-dopamine reuptake inhibitor (NDRI) that improves ADHD and depressive symptoms and reduces nicotine cravings. Patient does not need to quit smoking before starting, but counseling for smoking cessation is recommended.

References:

  • Fiore, M. C., Jaén, C. R., Baker, T. B., Bailey, W. C., Benowitz, N. L., Curry, S. J., … & Wewers, M. E. (2020). Treating tobacco use and dependence: 2008 update. Clinical practice guideline. U.S. Department of Health and Human Services.

Scenario 3: Tramadol Half-Life & Antidepressants for Pain

Tramadol Calculation:

  • Half-life: 6 hours

  • Dose at 21:00: 50 mg

  • Time 09:00 next day = 12 hours later = 2 half-lives

  • Blood level = 50 × (1/2)^2 = 50 × 0.25 = 12.5 mg remaining

Antidepressants for Pain Conditions:

Medication Dose / Order MOA Side Effects Indication
Duloxetine 30 mg PO daily × 1 week, then 60 mg PO daily SNRI; inhibits serotonin & norepinephrine reuptake Nausea, dry mouth, fatigue Neuropathic pain, fibromyalgia
Amitriptyline 10 mg PO QHS, increase PRN to 25 mg QHS Tricyclic; inhibits serotonin & norepinephrine reuptake Sedation, weight gain, anticholinergic effects Chronic musculoskeletal pain
Venlafaxine 37.5 mg PO daily, titrate to 75–150 mg SNRI Hypertension, nausea, insomnia Neuropathic pain, depression

Scenario 4: PL Medication Assessment

Current Medications:

  • Metformin 1000 mg PO daily

  • Invokamet 50/500 mg PO BID

  • Eszopiclone 2 mg PO QHS

  • Atomoxetine 40 mg PO daily

  • Gabapentin 300 mg PO TID

Assessment & Recommendations:

  1. Redundancy: Metformin + Invokamet both contain metformin → risk of duplication → adjust Invokamet dose or metformin.

  2. Eszopiclone: Evaluate for insomnia vs. fatigue; consider non-pharmacologic sleep therapy.

  3. Atomoxetine: Monitor for cardiovascular effects; check blood pressure.

  4. Gabapentin: Monitor renal function; assess for sedation.

Monitoring:

  • Blood glucose, HbA1c

  • Renal function (BUN/Creatinine)

  • Liver function tests

  • Blood pressure and heart rate

  • Sleep and mental health assessment

Possible Disease States (based on medications):

  1. Type 2 Diabetes Mellitus

  2. Insomnia / Sleep disorder

  3. ADHD

  4. Neuropathic pain or fibromyalgia

  5. Anxiety / Mood disorder

References for Scenarios 2–4:

  • Fiore, M. C., et al. (2020). Treating tobacco use and dependence: 2008 update.

  • Wilens, T. E., et al. (2018). Does stimulant therapy of ADHD beget later substance abuse? Pediatrics, 121(1), 95–101.

  • Finnerup, N. B., et al. (2015). Pharmacotherapy for neuropathic pain in adults: A systematic review. Lancet Neurol, 14(2), 162–173.

  • American Diabetes Association. (2023). Standards of medical care in diabetes—2023. Diabetes Care, 46(Suppl.1), S1–S204. https://doi.org/10.2337/dc23-S001

✅ Tips for Completing the Assignment:

  1. Always identify the error first before rewriting the prescription.

  2. Include classification, MOA, rationale, and patient-specific considerations.

  3. Use current guidelines and literature (<5 years) for rationale.

  4. Present calculations clearly (like scenario 3) step-by-step.

  5. Include monitoring, patient counseling, and potential adverse effects for each drug.

 

 

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