DARSHIENY NADARASON ,141501227

MUHD HILMI, 141501228

Problem Identification
1.A) Drug problem
Imitrex 6 mg injection PRN (Not exceeded two days)
This drug for migraine with aura or without aura
The possible effect of drug interactions :
(i)- alcohol : - induce cyto p450 = no effect of sumatriptan
(ii) antidepressant(escitalopram)= dyskinesias with fluoxetine
(iii)smoke (possible interaction)
Meloxicam 15 mg PO daily, initial dose 7.5 mg /daily
This medicine is NSAID especially for Rheumatiod arthritis
high risk of interaction with alcohol , nicotine , caffeine : cause effect the action of drugs

Amitriptyline 75 mg PO bedtime, initial dose 75 mg

Highly risk use and interact with
Escitalopram lead to suicidal thoughts
Smoke (tobacco) reduce lower serum levels
Alcohol can cause death with combination

Ambien CR (Zolpidem) 12.5 mg PO bedtime

- initial dose is 6.25 mg (dose increases when no improves)
-Treatment for insomnia
-Major risk interactions :
i) Escitalopram = increase side effect drowsiness , dizziness
ii) Tobacco= May lower plasma levels , so possibly less hypnotic effect. That is why
there is an increase dose
iii) Alcohol : increase Nervous system effects . same effect like escitalopram

 Hydrochlorthiazide 25 mg PO daily
-initial dose is 25 mg
- Treament for hypertension and edema act as
-May also cause interactions with tobacco and alcohol
-Interactions with meloxicam
Escitalopram 10 mg PO daily
-initial dose is 10 mg
-Treatment of anxiety and depression
- Its highly risk of medicine if interactions with :
*alcohol= lead of judgement thinking (risk of suicidal)
*tobacco= induces CYP1A2 (may cause toxicity)

History of Patient

Patient is 56 years old

Still smokes ( 45 years involved in smoking)
All sibling smokes before 2 of them quit
Having a hysterectomy
Father died because heart attack
29 years old Son having ADHD
A 25 years old Daughter have collapsed lungs 8 years ago
Conflict rise between and patient and son
Having pale , yellow skin , teeth
Patient experienced as passive smokers during breaks
She refused to stop smoking and worried about new regular policy in the
place she works as nurses at night shift
She smoke 2 packs per day

The interventions plans

is by 5 As

- Ask - Identify and document tobacco use status for every patient at every
visit. (You may wish to develop your own vital signs sticker, based on the
sample below).
Advise - In a clear, strong, and personalized manner, urge every tobacco
user to quit.
Assess - Is the tobacco user willing to make a quit attempt at this time?
Assist - For the patient willing to make a quit attempt, use counseling and
pharmacotherapy to help him or her quit. (See Counseling Patients To Quit
and pharmacotherapy information in this packet).

Arrange - Schedule followup contact, in person or by telephone, preferably

within the first week after the quit date.
The one As will be using is Arrange since the patient background is medical line
profession, she know the consequences of smoking effects . By Arranging the
schedule to reduce the withdrawal of nicotine during cessation of smoking. By
arranging the suitable drug and follow up procedure the therapy might works
1.d The aspect of case that the patient has nicotine dependence is :
* She refuse to stop smoking
*She worried the new policy in her place that she works due to ban of smoking in
the compound/area of working (GABA Influence by nicotine which is nicotine
to reduce anxiety and calm the patient but when depletion of nicotine make
her anxiety )
*She drink coffee which caffeine effects is which can cause anxiety but she also
smokes 2 packs per day . Smokers will find themselves in calm mood which
nicotine effect in beta endorphine and reduce the anxiety and calm

The non pharmacological

therapy

The non pharmacological therapy for this patients is by using 5 As interventions. This
method still relevant to accommodate the patient need such by ask the patients
whether the patients still wanna quit smoke . Since the patient worried about new policy
in her workplace , and some more she from medical background , we can do by
counselling to improve her willingness to reduce the nicotine dose slowly. Advise the
patient to quit should be done in a clear, strong, and personalized manner. Expect
ambivalence. Be willing to listen non-judgmentally to /her concerns about quitting
tobacco use. When the patients is willing to quit , we can assist them by enhancing
willingness or motivation and ability or confidence through these methods:
Offer personalized, relevant feedback about the importance of quitting
Explore the individuals perceived pros and cons of smoking and quitting
Discuss the 5 Rs of quitting tobacco use as follows:Relevance- Help the individual identify why quitting tobacco is relevant to him/her.
Risk- Encourage the individual to verbalize possible negative outcomes of tobacco use.
Rewards - Help the individual identify the possible benefits of quitting tobacco use.
Roadblocks - Help the individual to identify possible obstacles to quitting, including those
from/her past quit attempts.

Repetition- It might take more than just one brief intervention before a
tobacco user becomes ready to quit. Use the 5 As at every visit!
Follow-up is most helpful to do it within the first weeks of a quit date and can
be either in person or via telephone. During this call encourage the
individual to remain quit. Discuss any obstacles and how to overcome them.
Congratulate success for those who have been able to quit. For those who
continue to use tobacco, repeated use of the 5 As and 5 Rs is important for
supporting motivational changes over time to move toward Action for
quitting tobacco.

The therapeutic
alternatives
The therapeutic alternatives for this patient
is using first line guide which is nicotine gum
and lowered the dose when the patient feel
slowly improve in mood , stability in nicotine
dependence. The second like is
contradicted to the patient because it might
effect with the current users health which is
insomnia , hypertension and migraine

factor need to be
reconsider

Racial = Mostly African-American tend to be influence in smoking

activity in group of their family and friends. Such abstinence is needed
to succeed in smoking cessation
Ethical= Ban smoking in the workplace is one of the method to reduce
smokers but need to reconsider certain factor like to increase percent
of cessation in smoking , we can put a group for a counselling for
those ex-smoker and those to intend to stop smoking . They can share
the obstacles and how to overcome it
Economy = Most advertisement in media tend to attract patient to start
smoking back. By regularly arrange the schedule , we can share how
the patient try to stop smoking
Psychosocial = by improve the surrounding , avoid interacting with a
smokers group . The son and give the patient moral support to
overcome this issue

therapy
Nicotine Gum
The 2-mg gum is recommended for patients smoking less than 25 cigarettes
per day, whereas the 4-mg gum is recommended for patients smoking 25 or
more cigarettes per day.

Nortriptyline
75 to 100 mg orally daily
Dry mouth( drink more water) , blurred vision, and constipation( add more
fibre)

laboratory assessment
No laboratory assessment

ADVICE

Build a quit plan. Pick a quit date that gives you time to prepare without
losing your motivation to quit. Tell friends and family that you are quitting.
Remove cigarettes and ashtrays from your home, work, and car. Identify
smoking triggers, and decide how you are going to deal with them.

Know your triggers and avoid them early on. Try to stay away from
situations that normally make you feel like smoking, especially during the
first 3 months. This is when you're most likely to start smoking again. Make
a plan. Write down your triggers and how you can manage each situation.

4. Try a new hobby with friends who don't smoke. Do something that
keeps your hands active and reduces stress, such as exercise. This makes
success more likely.

Don't give in to your craving to smoke. Every time you don't smoke when
you have a craving, your chances of quitting successfully go up. Change
your habits, and find other things for your mouth to do such as eating carrot
sticks or sunflower seeds.

Keep your hands busy! Keep your hands busy with something else for
example, an elastic band, a paper clip or a pencil. If youre used to smoking
while talking on the telephone, hold the receiver in the hand you would
normally use to smoke. Get involved in DIY, draw something, take up
photography, play a musical instrument, work on a computer, pet your dog,
play with an anti-stress ball, etc.

Reward yourself! Reward yourself regularly with the money you save by
not buying cigarettes. Suggestion: open a separate bank account for a
vacation, a boat, a motorcycle or a dream youd like to turn into reality