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Pam Lyons
Profession of Pharmacy 3
Fall 2011
Self Care Recommendation
Step 1: Background/Data Gathering (S/O)
□ Who is the patient: Middle-aged, white female
□ CC: Feeling lousy. Thinks that she has the flu.
Symptoms/Presentation
S: fever, chills, swollen glands, achy muscles and joints. Rash.
C: 1010F fever, feels “lousy,” achy all over, bulls-eye shaped rash that is
starting to fade
H: She has never experienced this before
O: Symptoms started a couple of days ago, Sunday before the Steelers’
game
L: whole body chills, swollen glands, aches in muscles and joints, rash on
leg
A: Nothing makes it worse
R: Tried Extra Strength Tylenol – took 2 tablets twice but says that it
didn’t really help and that she wants something else
□ Current Medical Conditions: none
□ Current Medications
 Prescription medications: none
 OTC medications: none
□ Medication Allergies/Reaction: NKA
□ Social History: She has a couple of alcoholic drinks on the weekends. She does
not smoke, use illicit drugs, or use caffeine.
□ Appropriate lab/vitals: None
Step 2: Assessment-Triage
□ Self-care: Yes – for pain and fever
□ MD referral:_Yes_______ Time frame to follow-up:_As soon as possible –
today or tomorrow to discuss possibility of having Lyme disease.
□ ER referral: _No_______
Time frame for follow-up: ___________
Short Justification: It is suspected that the patient has Lyme disease because of the bulls-eye rash
on her leg and the symptoms that she is experiencing. This suspicion excludes her from self care.
However, until the patient can see a doctor, she can be treated with OTC medication to reduce
her fever and make her feel more comfortable.
Type of Problem Identified
Unnecessary Drug Therapy
___No medical indication
___Duplicate therapy
___Nondrug therapy indicated
___Treating avoidable ADR
___Addictive/recreational
Needs Additional Drug Therapy
_X_Untreated condition
__Preventive/prophylactic
__Synergistic/potentiating
Needs Different Drug Product
_X_More effective drug available
__Condition refractory to drug
__Dosage form inappropriate
__Not effective for condition
Dosage Too Low
__Wrong dose
__Frequency inappropriate
__Drug interaction
__Duration inappropriate
Adverse Drug Reaction
__Undesirable effect
__Unsafe drug for patient
__Drug interaction
__Dosage administered or changed
too rapidly
__Allergic reaction
__Contraindications present
Dosage Too High
__Wrong Dose
Description of Problems
Medication and/or Medical Condition Involved
The patient may have untreated Lyme
disease
Potential Resolution of Problem
Treatment with prescription
antibiotic therapy
Patient said that Tylenol did not work to Try Ibuprofen 200-400mg Q6-8 hrs
reduce her fever or ease her pain. PRN
__Frequency inappropriate
__Duration inappropriate
__Drug interaction
__Incorrect administration
Noncompliance
__Directions not understood
__Patient prefers not to take
__Patient forget s to take
__Drug product too expensive
__Cannot swallow/administer
__Drug product not available
Step 3: Identification of Drug Therapy Problems: 2
Step 4: Self-Care Plan
(provide treatment for as many conditions/problems as necessary
□ Treatment(drug, dose, route, duration, expected effect)
PHARMACOLOGIC:
 Motrin® (Ibuprofen) 200-400 mg (1-2 tablets) every 6-8 hours by mouth with food as
needed to reduce fever and help with pain. Do not exceed 1200 mg (6 tablets) in one
day. Patient can continue therapy until she sees her MD.
Patient should expect to see a reduction in fever and pain in 1-2 days. The patient
may also experience upset stomach or mild stomach pain as a result of taking this
medication, especially if she takes it on an empty stomach.
NON-PHARMACOLOGIC:
 Increase fluid intake by ½ cup every hour to prevent dehydration from fever.
Continue to drink increased fluids until fever resolves.
 Increase bed rest and avoid unnecessary physical exertion like camping this weekend.
EDUCATION POINTS:

Lyme disease is not a life threatening illness; however, it is a disease that takes many
months to treat. The sooner the patient seeks medical attention, the sooner she will
feel better.

Patients bitten by ticks have a 1-2% chance of developing Lyme disease even with
proper tick removal.1

Be sure to take Ibuprofen with food to reduce the stomach upset that can be caused by
taking this medication on an empty stomach.
□ Follow-up plan: Call the doctor today to schedule an appointment. If the doctor is
unable to see the patient for several days, it is recommended that the patient seek
medical help at a MedExpress today or tomorrow.
Step 5: Response/Justification
□
□
□
Provide detailed rationale and justification for your recommendations, in 700 words or
less.
Provide reference source(s) supporting your decisions
See the posted grading criteria for details.
Response:
Lyme Disease is a tick-borne illness caused by spirochetes from the genus Borrelia. This
disease affects more than 27,000 people in the United States every year. It is most common in
the Mid-Atlantic States, the Northeastern United States, and parts of California and Oregon
during the summer months. Those who have been bitten by a tick in these areas have a 1-2%
chance on contracting the disease.1 Lyme disease is characterized by fatigue, fever, muscle pain,
“flu-like” symptoms and a bulls-eye rash, or erythema migrans which develops at the site of the
tick bite.1,2 When left untreated, erythema migrans resolves itself in 3-4 weeks, but the disease
then progresses as the infecting spirochete spreads throughout the body.1 When left untreated,
the disease can lead to very painful arthralgias typically in larger joints, fatigue, myalgias, and
radiculopathy, a non-specific neurological condition which may manifest as an inability to
control certain muscles, weakness, or numbness.1,2,3 These symptoms may take months to years
to develop.3 Although serologic ELISA tests are not required to diagnose Lyme disease, an
enzyme immunoassay is typically employed.1,2,3 It is recommended by the US Centers for
Disease Control and Prevention that this immunologic test be followed by a western blot to
confirm the results of the test because the ELISA tests can be non-specific and produce both
false positives and negatives.1
The patient shows signs and symptoms characteristic of an infection of Lyme borreliosis.
Arthralgia, myalgia, general “flu-like” symptoms, swollen lymph nodes and especially the
“bulls-eye” rash indicate that the patient most likely has Lyme disease and is not a candidate for
self care.2 It is surprising that the bulls-eye rash is starting to fade considering that the patient
was bitten by the tick a few days before coming to the pharmacy. According the literature,
erythema migrans can take 3-4 weeks to resolve.1 However, because erythema migrans is a sign
so characteristic of Lyme disease, it was decided that the patient should be evaluated by a doctor.
The progression of symptoms can be stopped and reversed, but only with the use of prescription
antibiotics.1,2,3 The recommended first line treatment of Lyme disease is doxycycline or
amoxicillin.2 Because there are no recommended OTC agents to treat Lyme disease, it is
recommended that the patient see her physician to be properly diagnosed and treated for the
disease.
The patient was advised to take ibuprofen (Motrin®) because she said that the Extra
Strength Tylenol® (acetaminophen) that she was taking was not effective and because ibuprofen
has been shown to be more effective in the reduction of fever in adults.4 Additionally, ibuprofen
and acetaminophen have been shown to be equally safe to use in adults.4 Therefore, ibuprofen is
not only a more effective treatment for the patient, but it is also safe alternative to
acetaminophen.
References:
1) Graham J, Stockley K, Goldman RD. Tick-borne illnesses a CME update. PMID. 2011.
Feb: 27(2):141-3.
2)British Infection Association. The epidemiology, prevention, investigation and treatment of
Lyme borreliosis in United Kingdom patients: A position statement by the British Infection
Association. J Infect. 2011: 62:329-338.
3)Rossi M. Late manifestations of Lyme borreliosis. Ther Umsch. 2005 Nov;62(11):745-9.
4)Pierce CA, Voss B. Efficacy and safety of ibuprofen and acetaminophen in children and
adults: a meta-analysis and qualitative review. Ann Pharmacother. 2010 Mar;44(3):489-506.
Reflection:
During my interview with the standardized patient, there were several aspects of the
interview that went very well. I feel that I was able to very easily talk with the patient and make
her feel comfortable. I actively listened to her when she was speaking which made it easy for her
to feel at ease while talking to me. She was very open about her condition and willingly
answered any questions that I asked of her. Additionally, I was able to answer the questions that
she had about the product that she brought to me. She had a combination product that had
medications to treat symptoms that she did not have. I was able to describe to her why this
product contained extra ingredients in it that she did not need, and why there may be a different
product more suitable to treat her symptoms. Finally, I feel that I asked the patient about her use
of illegal drugs and alcohol in a way that made her feel at ease. By prefacing the questions with
my concerns about potential drug interactions and the fact that I needed this information to
provide a safe recommendation, I was able to assure the patient that I had her best interest in
mind. This made the patient feel more comfortable and at ease when I asked about her social
history.
Although many aspects of the interview went well, there are aspects that I hope to
improve upon in the future. I noticed that I did not always ask open-ended questions. When the
patient would answer ‘yes’ or ‘no’ to my questions I was forced to ask an additional question to
obtain the information that I needed. This made me more aware of the need to ask open-ended
questions. I also noticed during my interview that I asked leading questions which trapped the
patient into giving me an answer. When I asked her if there were any other symptoms that she
may be experiencing, I gave her suggestions of symptoms treated by the combination product
that she had brought to me. My goal was to determine if she needed the product that she gave to
me, but in doing so, I trapped her into only providing me answers about those specific symptoms
and gave her no room to add additional symptoms. This leads me to the third aspect of the
interview that I would like to improve upon: gathering all the information. Although I thought
that I asked all the questions needed to make a recommendation, I had not gathered all the
information. I should have asked the patient if there were any other symptoms even seemingly
unrelated to her current illness that she was experiencing. This would have led me to the
discovery of her rash which would have led me in a completely different direction for
recommendations. In the future, I will ask more questions and ask more open-ended questions to
gather the information that I need.
Interacting with the standardized patient has opened my eyes to the strengths and
weaknesses of my interviewing skills and has helped me to think more about patient care. My
interaction with the patient has taught me that I can only provide care based on the information
provided to me by the patient. Had not two of my classmates interviewed the patient as well, I
would have sent the patient home with something for the flu instead of recommending that she
see a doctor for Lyme disease. As a health care professional, I can only make a recommendation
based on the information provided to me. I have also learned that it is my duty as the provider to
make sure that I am gathering all the information available so that I can make the best possible
recommendation. I cannot just assume that the patient has a specific condition because that is
what the symptoms look like without looking at the entire picture. This requires me to ask
enough questions and to ask the right questions. Only after I thoroughly interview the patient and
gather all the information that I need will I be ready to provide a sound and safe
recommendation.