Drug Study Assignment

Why are these medications ordered for Ms. Sears? What is the therapeutic effect of each medication? ?Ancef (Cefazolin)- anti infectives, first-generation cephalosporins Indication: It works by fighting bacteria in the body. Which is the cellulitis (serious bacterial skin infection) in the case of Ms. Maggie. Therapeutic Effect: Bactericidal action against susceptible bacteria. Bind to bacterial cell wall membrane, causing cell death. ?Elavil (Amitriptyline) – tricyclic antidepressants Indication: used to treat symptoms of depression. Therapeutic Effect: anti-depressant action. Potentiates the effect of serotonin and norepinephrine in the CNS.

Has an anticholinergic properties. ?Calcium Carbonate (Calcium Salts)- mineral and electrolyte replacement Indication: PO- Adjunct in the prevention of postmenopausal osteoporosis Therapeutic Effect: Replacement of calcium in deficiency states. ?Vitamin D (Calcifediol) -vitamins Indication: Treatment/ management of metabolic bone disease (osteoporosis) Therapeutic Effect: Promotes reabsorption of calcium and phosphorus. Treatment and PHAR 1000 – BASIC PHARMOCOTHERAPEUTICS 4 prevention of deficiency states, particularly bone manifestations. ?

Actonel (Risedronate)- bone reabsorption inhibitors Indication: Prevention and treatment of postmenopausal and corticosteroid-induced osteoporosis Therapeutic Effect: Reversal of the profression of osteoporosis with decreased fractures and other sequel. ?Vagifem (Estradiol Vaginal Tablet)- hormones Indication: Management of atrophic vaginitis that may occur with menopause. Therapeutic Effect: Restoration of hormonal deficiency states including menopause. ?Imitrex (Sumatriptan)- vascular headache suppressants Indication:

Acute treatment of migraine attacks. Therapeutic Effect: Acts as selective agonist of 5-HT1 at specific vascular serotonin receptor sites, causing vasoconstriction in large intracranial arteries. Relief of acute attacks of migraine. ?Metformin- antidiabetics Indication: Management of Type 2 Diabetes Mellitus Therapeutic Effect: Decreases hepatic glucose production. Decrease intestinal glucose absorption. Increases sensitivity to insulin. Maintenance of blood glucose. ?

Buffered Aspirin (Salicylates)- non-opioid analgesics Indication: Inflammatory disorders including Osteoarthritis. PHAR 1000 – BASIC PHARMOCOTHERAPEUTICS 5 Mild-to-moderate pain Therapeutic Effect: Produce analgesia and reduce inflammation and fever by inhibiting the production of prostaglandins.

Reduction of inflammation. 2. Indicate the safe dosages for the medications ordered. Are the dosages and route for this client safe? ?Ancef (Cefazolin) Safe Dosages: IM, IV: 500mg-2g q6hr-8hr (max 12g/day) Doctor’s Order: 750mg q12hr, 1500mg for 24hrs Is this Safe? : YES ?Elavil (Amitriptyline) Safe Dosages: 50-100mg at bedtime Doctor’s Order: 50 mg q Hs Is this Safe? : YES ?Calcium Carbonate (Calcium Salts) Safe Dosages: 500mg-1. 5g Doctor’s Order: 1000mg (or 1g) once daily Is this Safe? : YES ?Vitamin D (Calcifediol) Safe Dosages: 400-1000 units daily Doctor’s Order: 1000 units once daily Is this Safe? : YES.

?Actonel (Risedronate Safe Dosages: delayed releasetablets 35mg in combination with calcium carbonate Doctor’s Order: 35 mg per week PHAR 1000 – BASIC PHARMOCOTHERAPEUTICS 6 Is this Safe? : YES ?Vagifem (Estradiol Vaginal Tablet) Safe Dosages: 1 tab 10mcg once daily for 2 wks, then twice weekly Doctor’s Order: 10mcg q HS Is this Safe? : YES ?Imitrex (Sumatriptan Safe Dosages: 25mg initially, if response adequate in 2 hr, upto 100mg may be given (initial doses of 25-50mg may be more effective than 25mg). If headache recurs, doses may be repeated q 2 hr (not to exceed 200mg/day) Doctor’s Order: 75mg q4H max 2 doses daily.

Is this Safe? : NO. The dose should be lesser. 25-50mg for lesser interval of q2H. ?Metformin Safe Dosages: 500mg twice daily. May increase by 500mg at weekly intervals up to 2000mg/day. If doses >2000mg/day are required, give in 3 divided doses (not to exceed 2500mg/day) Doctor’s Order: 750mg TID with meals Is this Safe? : YES ?Buffered Aspirin (Salicylates) Safe Dosages: 2. 4g/day initially; increased to maintenance dose of 3. 6-5. 4g/day in divided doses (upto 7. 8g/day for acute rheumatic fever) Doctor’s Order: 650mg (or . 65g) q6H PRN Is this Safe? : NO. The dose 650mg (or . 65g) q 6H PRN that was ordered was lesser.

PHAR 1000 – BASIC PHARMOCOTHERAPEUTICS 7 than what is a safe dose according to the drug guide. And dose wouldn’t be enough to help client’s pain. 3. What would you do if the dosage ordered was not safe? Clarify the order with the Physician involved. Refer to the drug guide or any reliable source if necessary. 4. Indicate potential drug interactions with each medication prescribed for Ms. Sears. ?Ancef (Cefazolin) Potential Drug Interaction: Hypersensitivity. oNSAIDs (Aspirin)- Cross-sensitivity may exist oSulfonamides- History of allergic-type reactions. Interaction with Medications Ordered: oASPIRIN: Cross-Sensitivity ?Elavil (Amitriptyline).

Potential Drug Interaction: Amitriptyline is metabolized in the liver by the cytochrome P40 2D6 enzyme, and its action may be affected by drugs that compete for metabolism by this enzyme, including antidepressants. oPhenothiazines, Carbamazepine, class 1C Antiarrhythmics (Propafenone and Flecainaide)- reduce dosage when used with amitriptyline d/t metabolic competition. oCimetidine, Quinidine, Amiodarone, and Ritnovir – ^ effect of amitriptyline. oMAOI Inhibitors- hypotension, tachycardia and potential fatal reactions. oSSRI antidepressants- ^toxicity. Should be avoided. oClonidine- hypertensive crisis. Should be avoided.

oLevodopa- delayed or vabsorption of levodopa or hypertension. oRifamycins- blood levels and effects may be decreased. oMoxifloxacin/Sparfloxacin- ^ risk of adverse cardiovascular reactions. PHAR 1000 – BASIC PHARMOCOTHERAPEUTICS 8 oCNS depressants (alcohol, antihistamines, clonidine, opiods and sedative/hypnotics –additive CNS depression. oBarbiturates- alter blood levels and effects. oAdrenergics and Anticholinergics- side effects may be additive with other agents having anticholinergic properties. oPhenothiazinesand Oral Contraceptives- ^ metabolism and alter effects. oSt. John’s Wort- may v serum concentrations and efficacy.

Interaction with Medications Ordered: oST. JOHN’S WORT (was not ordered but was used by the client for a week) – may v serum concentrations and efficacy. ?Calcium Carbonate (Calcium Salts) Potential Drug Interaction: oAntacids- use with renal insufficiency may lead to milk-alkali syndrome. oHypercalcemia- ^ risk of digoxin toxicity oTetracyclines, Flouroquinolones, Phenytoin, Iron Salts- v absorption when taken orally with Calcium Carbonate. oCalcium Channel Blockers- v effects with excessive amounts. oEtidronate and Risedronate- v absorption. Do not take w/in 2 hrs of Calcium supplements. oAtenolol- v effectiveness.

oDiuretics (thiazide)- may result to hypercalcemia. oSodium Polyestyrene Sulfonate- v ability and v serum potassium. Interaction with Medications Ordered: oNO identified interactions with other meds ordered. ?Vitamin D (Calcifediol) Potential Drug Interaction: oCholestyramine, Colestipol or Mineral Oil- v absorption of vitamin D. oThiazide diuretics- use with Vitamin D for patients with hypoparathyroidism may result in hypercalcemia. oCorticosteroids- v effectiveness of Vitamin D analogues. oDigoxin- ^ risk of arrhythmias.

PHAR 1000 – BASIC PHARMOCOTHERAPEUTICS 9 oPhenytoin, Anticonvulsants, Sucralfate, Barbiturates, Primidone- Vitamin D requirements are increased. oMagnesium Containing Drugs- may lead to hyperglysemia. oCalcium-containing Drugs- ^ risk of hypercalcemia. Interaction with Medications Ordered: oCALCIUM CARBONATE- may lead to ^ risk of hypercalcemia. ?Actonel (Risedronate) Potential Drug Interaction: oNSAIDs, Aspirin- ^ risk of GI irritation. oCalcium Supplements or Antacids- v absorption Interaction with Medications Ordered:

oBUFFERED ASPIRIN- may lead to ^ risk of GI irritation. oCALCIUM- v absorption when adjunct to Actonel. ?Vagifem (Estradiol Vaginal Tablet) Potential Drug Interaction: oWarfarin, Oral hypoglycemic agents or Insulins- may alter requirement.

oBarbiturates or Rifampin- v effectiveness. oSmoking- ^ risk of adverse CV reactions. Interaction with Medications Ordered: oMETFORMIN- may alter requirement. oSMOKING- ^ risk of adverse cardiovascular reactions. ?Imitrex (Sumatriptan) Potential Drug Interaction: oErgotamine or Dihydroergotamine- concurrent use ^ risk of vasopastic reactions. Avoid within 24 hrs of Sumatriptan. oLithium, MAOI Inhibitor or SSRI antidepressants- may cause weakness, hypereflexia and incoordination. Do not use within 2 weeks after discontinuation of MAOI Inhibitors. oSmoking- ^ risk of adverse CV reactions. PHAR 1000 – BASIC PHARMOCOTHERAPEUTICS 10.

Interaction with Medications Ordered: oELAVIL- may cause weakness, hypereflexia and incoordination. oST. JOHN’S WORT OIL – ^ risk of serotinergic side effects including serotonin syndrome. ?Metformin Potential Drug Interaction: oAlcohol or iodinated contrast media- ^ risk of lactic acidosis. oAmiloride, Digoxin, Morphine, Procainamide, Quinidine, Ranitidine, Triamterene, Trimethroprim, Calcium channel blockers and Vancomycin – may complete elimination pathways with metformin. Altered response may occur. oCimetidine and Furosemide- ^ effect of metformin. oNifedipine- ^ absorption and effects. Interaction with Medications Ordered:

oNO identified interactions with other meds ordered. ?Buffered Aspirin (Salicylates) Potential Drug Interaction: oWarfarin, Heparin, Heparin like agents, thrombolytic agents, ticlopedine, clopidogrel, tirofiban or eptifibatide – may ^ the risk of bleeding. oIbuprofen- may negate the cardioprotective antiplatelet effects of low-dose aspirin. oCefoperazone, Cefotetan, Valproic acid or Plicamycin- may ^ risk of bleeding. oPenicillin, Phenytoin, Methotrexate, Valproic acid, oral hypoglycemic agents and Sulfonamides – ^ activities with Asprin. oCorticosteroids- may v serum salicylate levels. PHAR 1000 – BASIC PHARMOCOTHERAPEUTICS 11.

oDiuretics, Antihypertensives, NSAIDs- may blunt therapeutic response. oNSAIDs- ^ risk of GI irritation. oVancomycin- ^ risk of ototoxicity. Interaction with Medications Ordered: oNO identified interactions with other meds ordered. 5. What primary assessments are required prior to administration of these medications? ?Ancef (Cefazolin) oAssess for infection (vital signs, appearance of skin, urine and stool, WBC) at the beginning and during therapy. oBefore initiating therapy, obtain a history to determine previous use of and reactions to penicillns or cephalosporins.

Persons with a negative history of  penicillin sensitivity may still have an allergic response. oObtain specimen for culture and sensitivity before initiating therapy. First dose may be given before receiving results. ?Elavil (Amitriptyline) oMonitor mental status (orientation, mood behaviour) frequently. oObtain weight and BMI initially and periodically. oMonitor BP and pulse before therapy and during therapy.

Notify physician or HCP of decrease in blood pressure (10-20mmHg) or sudden increase in pulse rate. ?Calcium Carbonate (Calcium Salts) oObserve patient closely for symptoms of hypocalcemia (paresthesia, twitching, laryngospasm, colic, cardiac arrhythmias, Chvostek’s and Trousseau’s Sign). Notify Physician and other health care professional when these occur. oProtect symptomatic patients by elevating and padding side rails and keeping bed in low position. ?

Vitamin D (Calcifediol) PHAR 1000 – BASIC PHARMOCOTHERAPEUTICS 12 oAssess for symptoms of vitamin deficiency prior to and periodically during therapy. oAssess patient for bone pain and weakness prior to and during therapy. oObserve patient carefully for evidence of hypocalcemia (paresthesia, twitching, laryngospasm, colic, cardiac arrhythmias, Chvostek’s and Trousseau’s Sign) oChildren: Monitor height and weight, growth arrest may occur in prolonged high-dose therapy. oRickets/ Osteomalacia:

Assess patient for bone pain and weakness prior to and during therapy. ?Actonel (Risedronate) oOsteoporosis: Assess patients via bone density study for low bone mass before and periodically during therapy. oPaget’s disease: Assess for symptoms of Paget’s disease (bone pain, headache, decreased visual and auditory acuity, increased skull size. oAssess serum calcium before and periodically during therapy. oHypocalcemia and Viatmin D deficiency should be treated before initiating Alendronate therapy. ?Vagifem (Estradiol Vaginal Tablet) oAssess BP before and periodically during therapy.

oMonitor intake and output ratios and weekly weight. Report significant discrepancies or steady weight. oMenopause: Assess frequency and severity of vasomotor symptoms. ?Imitrex (Sumatriptan) oAssess pain location, intensity, duration and associated symptoms (photophobia, phonophobia, nausea, vomiting) during migraine attack. ?Metformin oObserve patient for signs and symptoms of hypoglycemic reactions (abdominal pain, sweating, hunger, weakness, dizziness, headache, tremor, tachycardia, anxiety) when combined with oral sulfonylureas. oAssess renal function before initiating and at least annually during therapy.

?Buffered Aspirin (Salicylates) PHAR 1000 – BASIC PHARMOCOTHERAPEUTICS 13 oPatients who have Asthma, allergies and nasal polyps or who are allergic to tartazine are in increased risk for developing hypersensitivity reactions. oPain: Assess pain and limitation of movement. Note type, location and intensity before and at the peak. oFever: Assess fever and note associated signs (diaphoresis, tachycardia, malaise, chills). 6. What are the clinical implications associated with each medication prescribed for Ms. Sears? ?Ancef (Cefazolin) oObserve patient for sign and symptoms of anaphylaxis (rash, pruritus,

laryngeal edema, wheezing). Discontinue drug and notify physician or other health care professional immediately if these problems occur. oKeep epinephrine, an antihistamine, and resuscitation equipment close by in case of an anaphylactic reaction. oMonitor bowel function (diarrhea, abdominal cramping, fever and bloody stools) should be reported to HCP promptly as a sign of pseudomembranous colitis. May begin up to several weeks after cessation of therapy. oAssess patient for skin rash frequently during therapy. Discontinue cephalosporins at first sign of rash; may be life threatening. Stevens-Johnson syndrome or toxic epidermal necrolysis may develop.

?Elavil (Amitriptyline) oPatients taking high doses or with history of cardiovascular disease should have ECG monitored before and periodically throughout therapy. oGeriatric Patients started on amitriptyline may be at an increased risk of falls, start with low dose and monitor closely. PHAR 1000 – BASIC PHARMOCOTHERAPEUTICS 14 oDepression: Monitor mental status and affect. Assess for suicidal tendencies, especially during early therapy. Restrict amount of drug available to patient. oPain: Assess intensity, quality and location of pain periodically during therapy.

May require several weeks for effect to be seen. ?Calcium Carbonate (Calcium Salts) oMonitor blood pressure, pulse, and ECG frequently throughout parenteral therapy. May cause vasodilation with resulting hypotension, bradycardia, arrhythmias and cardiac arrest. (Transient increases in blood pressure may occur during IV administration, especially in geriatric patients or in patients with hypertension. ) oMonitor patient on digitalis glycosides for signs of toxicity. ?

Vitamin D (Calcifediol) oObserve patient carefully for evidence of hypocalcemia (paresthesia, twitching, laryngospasm, colic, cardiac arrhythmias, Chvostek’s and Trousseau’s Sign) oSerum calcium, phosphate and alkaline phosphate concentration should be monitored periodically. ?Actonel (Risedronate) oAssess patients via bone density study for low bone mass before and periodically during therapy. oAssess for symptoms of Paget’s disease (bone pain, headache, decreased visual and auditory acuity, increased skull size. ?

Vagifem (Estradiol Vaginal Tablet) oAssess BP before and periodically during therapy. oMonitor intake and output ratios and weekly weight. Report significant discrepancies or steady weight. oMonitor hepatic function periodically during therapy. ?Imitrex (Sumatriptan)

PHAR 1000 – BASIC PHARMOCOTHERAPEUTICS 15 oGive initial subcut under observation to patients with potential coronary artery disease including postmenopausal women, men >40 yo, patients with risk factors for coronary artery disease such as hypertension, hypercholesterolemia, obesity, diabetes, smoking or family history. oMonitor blood pressure before and for 1 hr after initial injection. If angina occurs, monitor ECG for ischemic changes. ?Metformin oPatients who has been well controlled on metformin who develop illness or laboratory abnormalities should be assess for ketoacidosis or lactic acidosis.

oAssess serum electrolytes, ketones, glucose and if indicated, blood pH, lactate, pyruvate and metformin levels. oIf either form of acidosis is present, discontinue metformin immediately and treat acidosis. ?Buffered Aspirin (Salicylates) oAssess for rash periodically during therapy. May cause Steven-Johnson Syndrome. oMonitor hepatic function. oMonitor serum salicylate levels periodically during therapy oMonitor patient for onset of tinnitus, headache, hyperventilation, agitation, mental confusion, lethargy, diarrhea and sweating. 7. Give the appropriate dosage calculations for the medications ordered and indicate the route of each.

MEDICATION ORDERED ROUTE CALCULATION Ancef (Cefazolin) 750 mg IV q12h IV 750 mg x 10 ml = 7. 5 ml 1 000 mg Elavil 50 mg qHs PO 2 x 25mg/tab = 50 mg PHAR 1000 – BASIC PHARMOCOTHERAPEUTICS 16 Calcium carbonate 1000 mg once daily PO 2 x 500mg/tab = 1000mg Vitamin D (Calcifediol) 1000 units once daily PO 2. 5 x 400unit/tab = 1000units Actonel 35mg/week PO 1 x 3. 5mg/tab = 35mg Vagifem 10mcg tab qHs Vaginal 1 x 10mcg/tab =10mcg Imitrex 75mg q4h PRN Max 2 doses daily PO 1. 5 x 50mg/tab = 75mg Metformin 750mg TID with meals PO 1. 5 x 500mg/tab = 750mg Buffered Aspirin 650mg q 6h PO 2 x 325mg/tab = 650mg 8. What teaching should be provided to Ms.

Sears about Actonel and Metformin? Patient/Family Teaching: ?Actonel (Risedronate)- bone reabsorption inhibitors oInstruct the patient on the importance of taking exactly as directed, first thing in the morning, 30 min prior to other medications, beverages or food. Waiting longer than 30 min will improve absorption. oRisedronate should be taken with 6-8oz of plain water (mineral water, orange juice, coffee and other beverages decrease absorption). oIf a dose is missed, skip dose and resume the next morning; do not double doses or take later in the day. Do not discontinue without consulting health care professional (HCP).

oCaution patient to remain upright for 30 min following dose to facilitate passage to stomach and minimize risk of esophageal irritation. oAdvice patient to eat a balanced diet and consult HCP about the need for supplemental calcium and vitamin D. PHAR 1000 – BASIC PHARMOCOTHERAPEUTICS 17 oEncourage patient to participate in regular exercise and to modify behaviours that increases risk of osteoporosis (stop smoking, reduce alcohol consumption) oAdvise female patients to notify HCP if pregnancy is planned or suspected or if she is nursing. ?Metformin oInstruct patient to take metformin at the same time each day, exactly as directed.

If a dose is missed, take as soon as possible unless almost time for the next dose. Do not double doses. oExplain to patient that metformin helps control hyperglycemia but does not cure diabetes. Therapy is usually long term. oEncourage patient to follow prescribed diet, medication and exercise regimen to prevent hyperglycemic or hypoglycemic episodes. oReview signs of hypoglycemia and hyperglycemia with patients. If hypoglycemia occurs, advice patient to take a glass of orange juice or 2-3tsp of sugar, honey or corn syrup dissolved in water, and notify HCP. oInstruct patient in proper testing of blood glucose and urine ketones.

These tests should be monitored closely during periods of stress or illness and HCP notified if significant changes occur. oExplain to the patient the risk of lactic acidosis and the potential need for discontinuation of metformin therapy if a severe infection, dehydration or severe or continuing diarrhea occurs or if medical tests or surgery is required. Symptoms of lactic acidosis (chills, diarrhea, dizziness, low BP, muscle pain, PHAR 1000 – BASIC PHARMOCOTHERAPEUTICS 18 sleepiness, slow heartbeat or pulse, dyspnea or weakness) should be reported to HCP immediately.

oCaution patient to avoid taking other prescription OTC medications or alcohol during metformin therapy without consulting HCP. oInform patient that metformin may cause an unpleasant or metallic taste that usually resolves spontaneously. oAdvise patient to inform HCP of medication regimen before treatment or surgery. oAdvise patient to carry a form of sugar (sugar air packets, candy) and identification describing disease process and medication regimen at all times.

oAdvise patient to report the occurrence of diarrhea, nausea, vomiting, and stomach pain or fullness to HCP. oEmphasize the importance of routine follow up exams and regular testing of blood glucose, glycosylated hemoglobin, renal function, and hematologic parameters. 9. Ms. Sears tells you she used St, John’s wort oil at home for the inflammation of her leg. What information should Ms. Sears know about St. John’s wort and her medical diagnoses and prescribed medication? ?

St. John’s Wort Common Use/s: Inflammation of the skin, blunt injury, wounds, and burns. Other uses are: for capillary strengthening, decreasing uterine bleeding and reducing tumor size. Action: Anti-inflammatory, anti-fungal, antiviral, and antibacterial properties. Therapeutic Effects: Decreased inflammation of burns or other wounds.

PHAR 1000 – BASIC PHARMOCOTHERAPEUTICS 19 Interactions with medications Ordered: oElavil (Amitriptyline) – Decreases serum concentration and efficacy. oImitrex (Sumatriptan)- ^ risk of serotinergic side effects including serotonin syndrome. ( ^heart rate, shivering, sweating, dilated pupils, as well as overresponsive reflexes) Patient Teaching: oAdvise patient to notify health care professional of medication regimen prior to treatment or surgery. oWarn Patient that St. John’s wort may reduce the therapeutic effectiveness of several drugs (including Elavil and Imitrex that was ordered by the Doctor).

oMay potentiate effect of sedatives and side effects of other antidepressants. Do not take within 2 weeks of MAO Inhibitor therapy. oInstruct patient to consult HCP before taking any prescription or OTC medications concurrently with St. John’s wort. References Deglin, J. H. , & Vallerand, A. H. (2005). Davi’s Drug Guide for Nurses 9th Edition. Philadelphia, PA: F. A. Davis Company. Liley L. L. , Harrington, S. , & Snyder J. S. (2011). PHARMACOLOGY for Canadian Health Care Practice 2nd Canadian Edition. Ontario, Ca: MOSBY Elsvier. PHAR 1000 – BASIC PHARMOCOTHERAPEUTICS 20 Drug Guide. (n. d. ) Retrieved from http://www. drugs. com/.

Current medications: Avandia (rosiglitazone) 2mg BID Glucophage (metformin) 500mg OD Lasix (furosemide) 40 mg daily Potassium supplements (KCl) 20 meq daily Lopressor (metoprolol) 25 mg BID Prinivil (lisinopril) 5 mg daily Allopurinol (zyloprim) 100mg daily Advair 1 inhalation BID He …

Case Study: Emma comes to the medical office with symptoms of urinary frequency and burning. She is diagnosed with a urinary tract infection and is prescribed a sulfonamide and Pyridium. 1)What is the purpose of the sulfonamide, and what patient …

Please remember this is about 1/3 of the pharmacology exam. It may be beneficial for you to practice calculations and/or review a nursing math book to help prep. You may not have used all the calculation methods recently. Questions may …

Chapter 01: Orientation to Pharmacology Key Points: Print Chapter 1 first defines four basic terms of pharmacology: ?A drug is any chemical that can affect living processes. ?Pharmacology is the study of drugs and their interactions with living systems. ?Clinical …

David from Healtheappointments:

Hi there, would you like to get such a paper? How about receiving a customized one? Check it out https://goo.gl/chNgQy