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Question 27#

A 38-year-old obese woman with history of chronic venous insufficiency and peripheral edema was admitted to the hospital the previous night for cellulitis involving both lower legs. She has had recurrent such episodes, treated successfully in the past with various antibiotics, including cefazolin, nafcillin, ampicillin/sulbactam, and levofloxacin. Intravenous levofloxacin was again chosen due to the perceived ease in transitioning to a once-daily oral outpatient dose. Normal saline at 50 mL/h is administered. Past history is otherwise significant only for hypertension, which is being treated at home with HCTZ 25 mg, lisinopril 40 mg, and atenolol 100 mg, all once each morning. Admission BP was 144/92 and the orders were written to continue each of these antihypertensives at one tablet po daily. The only other in-hospital medication is daily prophylactic enoxaparin. As you round at 6 PM on the day following admission, the nurse contacts you emergently stating that she has just finished giving evening medicines and the patient’s BP is unexpectedly 90/50. Pulse rate is 92. There is no chest pain, dyspnea, or tachypnea.

What is most likely cause of her hypertension? 

A. An allergic reaction either to the antibiotic or to one of the antihypertensives
B. A vasovagal reaction secondary to pain
C. Hypovolemia due to the cellulitis
D. Acute pulmonary embolism
E. Medication error

Correct Answer is E

Comment:

The concept being advanced here is medication error. A new emphasis is being placed on reducing all medical errors, including those related to misreading of handwriting, which includes avoidance of certain abbreviations and use of an electronic medical record. In this case the pharmacist and/or nurse mistook the medication orders of one tablet po qd (orally once a day) for one tablet po qid (orally four times a day), such that the patient had received three doses of each antihypertensive by 6 PM. Other abbreviations to avoid include q.hs (write “at bedtime” instead), QOD (write “every other day”), U (write “unit”), and MS (write “morphine sulfate”). There is no particular clue to the other listed answers. For example, an allergic reaction would seem unlikely with medications previously well tolerated and in the absence of urticaria or angioedema. There are no symptoms or signs of acute pulmonary embolism, and a prophylactic anticoagulant is in use. Hypovolemia would be unlikely to develop after admission in a patient receiving IV fluids. Vasovagal reaction would be associated with bradycardia.