RESPONSE 1:

Choice #2: April

            As stated by Woo and Robinson (2020), human papillomavirus (HPV) causes cervical cancer, the second-biggest cause of female cancer mortality worldwide, with an estimated 288,000 deaths yearly (p.459). Having not received the recommended two doses of HPV vaccine at age 11, April does not need to start over the vaccine series. As stated by CDC (2019), if the vaccination schedule is interrupted, vaccine doses do not need to be repeated (no maximum interval). Hence, because the vaccination series was started before her 15th birthday, the second dose can be given right away since first dose was received several years ago. The two doses are critical for one to become fully protected. 11- to 12-year-olds should receive two doses of HPV vaccine 6 to 12 months apart (CDC, 2020). Two doses are recommended for 9 to 14 years old, while teens who start the series at a later age (15-26 years) need three doses of the HPV vaccine (CDC, 2020). Starting the series older than 15 years, the patient should receive the second dose 1-2 months after the first dose and receive the third dose 6 months after the first dose (0,1-2, 6-month schedule) (CDC), 2019).

            HPV vaccine cultivates a robust immunity and works best when administered promptly, chiefly when given to preteens before the onset of sexual activities. Like any other medication, CDC (2019) records that the HPV vaccine is less likely to cause death, serious injury, or allergic reactions. Gardasil, Gardasil 9 (HPV9), and Cervarix are the three vaccines currently FDA approved in the United States (National Cancer Institute, 2021). Gardasil 9 has been the only HPV vaccine in the U.S. since 2016 to treat HPV and have a 97.9% efficacy against all 9 HPV types (Woo & Robinson, 2020). A study by Cheng et al. (2020) presented that HPV16 and 18 which are the most common HPV types were significantly decreased by 83%, and HPV31, 33, and 45 were decreased by 54% among girls aged 13-19 years. Petrosky et al. (2015) discuss that allergic reactions like anaphylaxis following the HPV vaccine are contraindications to its recipients, with severe or moderate acute complications requiring HPV vaccination to be deferred until the symptoms improve. Additionally, HPV vaccines are produced in Saccaromyces cerevisiae (bakers yeast) and are contraindicated in individuals with hypersensitivity to yeast (CDC, 2020). As with any vaccine or immunization, it is prudent that the patient informs the provider of vision changes, feeling dizzy, or ringing in ones ear. In context, the patient should lay down or be seated during vaccination and maintain the posture for about fifteen minutes after the procedure. Consequently, the administration of HPV vaccine is associated with vaccine reaction risks not limited to nausea, headache or fever, swelling, redness, or soreness on the injection spot after HPV vaccination (CDC, 2019). Other possible side effects include malaise, myalgia, joint or muscle pain, and tiredness.

            The Vaccine Information Statement (VIS) denotes a crucial document informing legal representatives, parents, and vaccine recipients of its implications, including the associated risks and benefits (CDC, 2019). In essence, the VIS highlight the significance of receiving the HPV vaccine, the vaccines overview, reaction risks, what approach to take in case of problems, and the involvement of the federal program, The National Vaccine Injury Compensation Program (CDC, 2019). HPV VIS emphasizes the vitality of consulting ones physician before getting the vaccine and learning resources on the vaccine.

RESPONSE 2:
Choice #3 Janice

Cholesterol: 360

Triglycerides: 450

LDL: 220

HDL: 60

CR: 1.2

GFR: Normal

BP: 150/90

Taking Lisinopril 20 mg (ACE INHIBITOR) / Norvasc 10 mg (CALCIUM CHANNEL BLOCKER)

My first questions are:

Is she taking statins? Is she a diabetic? What kind of diet is she on? Low fats? Low sodium?

According to Woo and Robinson (2020) Janice is a Stage 1 Hypertensive treated with diuretics (Thiazide type) and may consider ACE inhibitors, ARBS, CCB or combination. She is taking an ACE inhibitor and a Calcium Channel Blocker but is not really seeing results. Initial concerns are her race and the use of ACEIs, though our text confirms that when ACEi is used in combo with a diuretic, race is no longer a concern. This can be an important first step in addressing the lack of BP control.

Her kidney function is okay based alone off the labs provided. We could consider a thiazide diuretic as a switch from the CCB in tandem with the ACEi. 

ACE inhibitors do not affect lipid levels or glucose metabolism. Her lipid levels are high and so I want to consider her diet and exercise as a possible reason for her poor BP control.

Widimsky (2009) explains that the combo of an ACE inhibitor and a Calcium Channel Blocker is an optimal combination for treatment of hypertension. He adds that the fixed combo aids in compliance with treatment and is typically used in those at higher risk for DM. The combo improves cardioprotective and nephroprotective effect of hypertension therapy as well, yet we do not see improvement in Janice yet.

A new focus on diet and exercise is now the normal after starting medicine for HTN according to Woo and Robinson (2020). Her cholesterol is high, and this contributes to negative cardiac function. We can mitigate this by referring Janice to a dietician and advising her to begin a low fat/low salt diet to avoid any fluid retention and reduce her cholesterol levels, especially if she is not taking any statins.

Until I have a better understanding of her diet and exercise, whether she is a diabetic, and whether or not she is taking statins I cannot say for sure if the medicine alone is ineffective. Having a better understanding of any other medical conditions she is experiencing and being treated for will give better insight into whether we should be coaching Janice on different types of medications or if we should be considering lifestyle changes.

Considering Janices age, we want to evaluate her ability to perform ADLs and what kind of assistance she has at home. Is she stressed out at home? Are there issues paying bills? Stress can contribute greatly to BP issues. If Janice is struggling with pain, how is she managing it? Our text explains that NSAIDs and CCB do not work well together, which could impair liver function possibly leading to poor lipid levels?

I want to start by addressing her diet and exercise and understanding how she manages that at home. Following diet and exercise, I want to evaluate comorbidities her high cholesterol is of upmost concern. Following that, I want to determine if she is having issues taking her medication or if there are side-effects that she is experiencing that may make her not want to take the medications. After determining any possible complications with medication, we will discuss possible medication changes and medications she is taking OTC, etc.