Page 52 - Demo

CONTINUING PROFESSIONAL DEVELOPMENT
MEDICATION MYSTERIES
A painful case of confusion
BY KARALYN HUXHAGEN MPS
Anna, a 45-year-old woman with a history of migraine headaches, comes into the pharmacy with her husband, Russell. He is complaining that his wife seems confused and disoriented, and has been restless for the past week. Upon taking Anna’s history, you find out that she also has osteoarthritis. Anna is taking paracetamol sustained release (SR) 665 mg (two tablets three times daily) and oxycodone 5 mg (one tablet three times daily). However, due to poor pain control, she was also prescribed tramadol 50 mg to be taken as needed. Anna has also been taking citalopram 40 mg daily for the past year.
Information gathering
You speak with Anna and Russell to investigate the cause of her current symptoms.
Onset of symptoms
How long have you experienced arthritis pain?
The pain from arthritis has been constant since Anna had a bout of influenza about 4 years ago. The pain is intense at times and dies away to a dull pain.
How often do you have migraine attacks?
Do you have particular triggers for the migraines?
Anna has suffered with migraines since she was a teenager. They occur in the first week of her menstrual cycle and last for several days. The headaches have eased as she has become older, and now she experiences one about every 3 months which last for 3–4 days.
Symptoms
Are you experiencing any symptoms at present?
You ask Anna if she is experiencing any other symptoms besides the confusion, disorientation, and restlessness that she has already mentioned, such as:
• continual thirst
• rapid heart rate
• loss of coordination (twitching muscles)
• muscle rigidity
• changes in sleep patterns
• sweats, fevers, chills, shivering, goose bumps
• nausea, vomiting
• constipation or diarrhoea
• hallucinations, visions, phobias
• headache.
These symptoms, as well as confusion, disorientation and agitation, may indicate a clinical presentation of delirium.1–4
Pharmacists routinely use investigative questioning in their pharmacy practice. Medication mystery scenarios are commonly occurring situations where detailed questioning uncovers a complex case requiring a substantial intervention. These articles demonstrate how a pharmacist can adopt a systematic problem-solving approach to improve patient outcomes. For educational purposes, questions and answers are presented collectively, while in practice, questions would be asked and answered sequentially.
Karalyn Huxhagen is a Mackay-based accredited consultant pharmacist and former PSA Pharmacist of the Year (2010). Karalyn also won the PSA QUM in Pain Management Award in 2015.
LEARNING OBJECTIVES
After reading this article, pharmacists should be able to:
• Describe symptoms of serotonin syndrome and alternative
diagnoses
• Outline medicines implicated in serotonin syndrome, and
strategies to reduce and manage its risk
• Discuss the interaction between opioids and selective serotonin
re-uptake inhibitors (SSRIs) leading to the development of serotonin syndrome.
Competencies addressed: 1.3.1, 1.3.2, 2.1.1, 2.1.3, 4.2.1, 4.2.2, 4.2.3, 6.1.1, 6.1.2, 6.1.3, 6.2.1, 6.2.2, 6.2.3, 6.2.5, 7.1.2, 7.1.3, 7.1.4, 7.2.1, 7.2.2, 7.2.3, 7.2.4.
Accreditation number: CAP1701D
50 Australian Pharmacist January 2017 I ©Pharmaceutical Society of Australia Ltd.
This article has been independently researched and peer reviewed.