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2. A 79-year-old woman with osteoporosis, hypertension, and coronary vascular disease status post anterior myocardial infarction (MI) 13 years ago is brought to the emergency department (ED) by ambulance after she fell while attempting to get out of bed. On arrival, the woman demonstrates slight right hip pain with no limitation of range of motion. Radiographic studies of the right hip show a nondisplaced subcapital impacted fracture of the femoral neck. Today she is postoperative day 1 following arthroplastic surgery. The woman™s regular physician visits during evening rounds and notes that she does not appear to realize she is in the hospital. Additionally, she shows difficulty focusing on and sustaining attention to the physician™s questions. Nursing notes reflect a clear sensorium this morning with some confused-appearing behavior in the afternoon. The patient believes she is suffering the effects of lack of sleep. Current maintenance medications are alendronate 10 mg daily, chlorthalidone 25 mg daily, lisinopril 20 mg daily, and carvedilol 25 mg twice daily. Medications added since admission are cefazolin 1 gram intravenous (IV) every 8 hours to be discontinued in the morning, morphine sulfate 5 mg IV infusion every 4 hours, enoxaparin 40 mg subcutaneous once daily, oral coumadin 5 mg daily, and ranitidine 50 mg IV every 8 hours. Pulse oximetry shows 92% oxygen (O2) saturation on room air. Her vital signs are within expected limits and the physical examination is essentially unchanged since her last examination 1 year ago, except for her current mental status and obviously, her surgical incision, which shows no signs of infection. While awaiting further diagnostic workup, what would be a reasonable recommended change to the patient™s current pharmacotherapy?


A. Administer Benadryl
B. Administer lorazepam
C. Discontinue enoxaparin
D. Discontinue ranitidine
E. Substitute meperidine for morphine sulfate

CCC

alcohol withdrawl

BBB

alcohol withdrawl

D. Ranitidine.

D....

????

Answer is D
Histamine-2 blockers are known to cause medication-induced delirium. Stress ulcer prophylaxis in the noncritically ill postoperative patient with H2 blockers is not absolutely contraindicated, but recent studies provide little support for this pharmacotherapy.