diazepam

Post your answers to the 6 questions corresponding to this week's
content on primary care medication management. Provide your
responses and rationales. Support your rationales with high-level
evidence. (See Post Expectations)

Please answer all questions correctly and provide up to date sources. I
did provide an online textbook to login and use book that is associated
with the course. Place all questions in the document to keep organized.

A 70-year-old woman is in your office complaining of recently having
trouble maintaining her balance after taking diazepam (valium). She
occasionally takes diazepam when she feels anxious and has trouble
sleeping. She has a 15-year history of taking diazepam.

Q1. Explain the cause of this patient's difficulty in maintaining her
balance?

Q2. Diazepam experiences a significant first-pass effect. What is the
first-pass effect, and how can first-pass metabolism be circumvented?

A 75-year-old woman develops symptoms of a cold and buys an over-
the-counter cold medication at the grocery store. The medication
contains diphenhydramine, acetaminophen, and phenylephrine. She
takes the recommended adult dose but soon after taking the
medication she becomes very confused and disoriented.

Q3. What is likely causing the signs of confusion?

A 26-year-old woman who has never been pregnant is seeking
preconception care as she is planning to pursue pregnancy in a couple of
months. Currently, she has no symptoms to report and on review of body
systems, there were no concerns. Her past medical history is significant
for a history of rheumatic fever as a child. She subsequently underwent

valve replacement with a mechanical heart valve. She is followed by a
cardiologist who has already evaluated her cardiac function and she has
received clearance from her cardiologist to pursue pregnancy. Records
from her cardiologist include a recent cardiac echocardiography report
that reveals a normal ejection fraction indicating normal cardiac
function.

She has no alterations in her daily activities related to her heart. She has
no other significant medical or surgical history. She is a non-smoker,
drinks occasionally but has stopped as she is attempting to conceive, and
does not use any non-prescription drugs.

Current Medications: Her current medications include only prenatal
vitamins, which she has begun in anticipation of pregnancy, and warfarin.
She has no known drug allergies.

Vital Signs: On examination, her pulse is 80 beats per minute, blood
pressure is 115/70 mm Hg, respiratory rate is 18 breaths per minute,
and she is afebrile.
Measurements: Weight = 152 pounds, Height = 5′5 ″, BMI= 25.29

Q4. How is warfarin metabolized? Does warfarin cross the placental
barrier?

Q5. Explain the hepatic drug metabolism of children 1 year and older.
How do they compare with the hepatic drug metabolism of infants and
adults?

Q6. Explain protein binding in the neonate.