Pharmacology

Case Study #1 – Worth 5 points
An 8 month old infant comes to your office in February with a 10 day history of URI and expiratory wheezing. Her temp is 101 and chest x-ray is unremarkable. Your diagnosis is bronchiolitis.

1. What is the most likely causative organism?

The most likely causative organism of bronchiolitis is the Respiratory Syncitial Virus (Government of Western Australia, 2014).

2. How would you differentiate bronchiolitis from pneumonia?

Bronchiolitis occurs mainly in the bronchus and pneumonia occurs in the lungs. Therefore, I would assess the symptoms of infection (Government of Western Australia, 2014; Princess Margaret Hospital, 2010).

3. What treatment would you prescribe for this patient?

For this patient with bronchiolitis, I would prescribe an inducement of oxygen to increase the level of oxygen, feeding the child with fluids or milk through a feeding tube (Government of Western Australia, 2014).

4. The patient’s mother is asking for an antibiotic. How would you respond to her request?

Antibiotics would only be administered if the symptoms of the child are dire and require intensive care admission (National Center for Biotechnology Information, 2011). More over antibiotics are rarely used and if they are to be administered, then, close monitoring of the patient needs to be applied.

5. What are the common long-term sequelae of bronchiolitis?

RSV & hMPV 3 days before to 21 days after symptom onset (National Center for Biotechnology Information2011).

Case Study #2 – Worth 5 points

CC is a 52 year old female with a past medical history significant for hypertension and type 1 diabetes mellitus. She is in the office today complaining of fatigue and shortness of breath that has gotten worse over the past week or so. She denies any bleeding including rectal bleeding, menorrhagia, melena, or epitaxis. She denies fever, chills, nausea, or vomiting. She has a history of GERD and has been on Prilosec for the past two years. Laboratory reports indicate:

Hg 9.3, Hct 27%, WBC 6.0, Plt 170,000, MCV 112, MCH 29 and MCHC 34.5,

Retic count 0.3%, Serum iron 65, Serum ferritin 9, TIBC 400

Serum Folate 20, Serum B12 99

 

1. What is your working diagnosis of CC? Explain how you came to this diagnosis.

For anemia in women the values are measured against calculated standard values like: the Hg is below 12 (<12g.dL), Hct is below 37% (<37%), RBC/WBC is below 4 (<4m/ul). The patient has a high MCV instead of the normal 80fL and MCH exceeds the standard 27 pg/RBC.

The working diagnosis shows renal anemia which is common to patients with acute renal failure. The diagnosis is based on the tests that give detailed activity of the bone marrow, level of iron stores, MCH, MCV, RBC/WBC and availability of erythropoiesis, which is the cause of anemia (Tsagalis, 2011). The tests reveal on poor level of iron stores and presence of erythropoiesis.

2.  What are some likely causes of this diagnosis? Renal anemia is caused by erythropoiesis, lack of vitamin B12 and iron deficiency.
3. How would you treat CC?

Prescription would be given for erythropoietin stimulating agent (ESA). This treatment will help stimulate the bone marrow to create more of the red blood cells (Tsagalis, 2011). Additionally, one may be required to use iron supplements and a change of food. This helps the body to have sufficient vitamins and minerals vital for the making of red blood cells.

4. What are your goals of treatment? The goals of these form of treatment is to make more red blood cells and vitamins important for the body.
5. What patient education would you provide?

The management of Anemia is significant for improving the quality of life and health of patients. It helps safeguard fatigue among other signs, improves the health if the heart and lowers hospitalizations.

 

Source: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3139678/

 

Case Study #3 – Worth 5 points

A 68 year old woman has a history of rheumatoid arthritis and has been taking nabumetone (Relafen) 1000 mg po qd for 2 years.  Other pertinent past medical history includes: occasional incontinence, Crohn’s disease with frequent exacerbations, and well-controlled diabetes type 2.  Recently, her arthritis pain has been much worse and she is requesting additional medication for her rheumatoid arthritis.

1. What would be appropriate additional therapy for this patient? The patient would require anti-inflammatory medications like aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen.
2. Please describe why you chose this therapy.

The reason behind this form of medication is that it would help reduce her inflammation.

3. What monitoring would be appropriate because of the therapy?

It would appropriate to monitor the period of the drug use as its extended use of long periods would lead to stomach issues like bleeding and heart complaints (Hoffman, 2012).

4. What patient teaching would you do because of the therapy?

Based on the implications for the therapy, it would be necessary to give her alternative medicine after a stated period of time.

 

Case Study 4: Worth 5 points

 

DF is an 82 year-old male patient who has new onset of uncontrolled atrial fibrillation.

 

1. Identify three potential medications to prevent stroke and discuss the pros and cons of each medication. (2 points)

Antihypertensives help to reduce the level of blood pressure and hence the risk of stroke. However, the drug is ineffective if use alone. Though the use with indapamide can help drop the probability of stroke greatly.

 

Antiplatelet agents help to prevent stroke by stopping bleeding. An example is aspirin. However, some drugs like aspirin may cause bleeding to some patients hence calling for prescription from doctors.

 

Anticoagulants like Warfarin helps prevent stroke through keeping blood clots from getting bigger and prevent new clots (Fava, 2010; GJ. Hughes, et al, 2011). This drug is however meant for the elderly patients only who suffer from atrial fibrillation.

2. You decide to start DF on Coumadin.   What labs will you obtain prior to starting the medication?

Prior to start of taking the Coumadin, blood tests are taken so as to assess the impact of the medication on blood’s ability to clot. This is useful as it informs if one is getting less or more of the needed quantity of medication.

3. What are your treatment goals (include INR)?

The treatment goals lies in preventing and treating abnormal clots and attaining an INR value of between 2.0 and 3.0.

4. How will you initiate the medication?

The drugs are of different colours and milligrams. Prescriptions suggest a single strength of tablet that may be divided into half. The drug is taken daily at any time, preferable same time daily (Fava, 2010). The drug may be ingested on an empty stomach or with food.

The dose is may vary from one day to another annually (GJ. Hughes, et al, 2011). Hence it is required to keep tabs on the doses and blood tests to avoid mix up. Additionally, a review s done with the health practitioner constantly.

5. DF returns to the clinic for monitoring of his INR. His last INR was 3.0 three weeks ago. When questioned, he reports to having been sick last weekend. The doctor at the walk in clinic started him on Levaquin.   His arthritis is also been bothering him and he has been taking 650 mg of Tylenol every 4 to 5 hours for the past 10 days. His INR today is 10. He denies any bleeding. Describe what has likely caused his elevated INR. Discuss how you would treat this patient

 

DF’s elevated INR to 3.0 can be attributed to the concurrent administration of warfarin and Levaquin as well as clinical episodes of bleeding. The patient ought to be monitored for presence of bleeding and have tests done (anticoagulation).

Tylenol may increase INR by taking anticoagulation drugs, this could be managed through a change in the warfarin dosing and monitoring by health practitioners.

Source: http://www.ncbi.nlm.nih.gov/pubmed/21923443

Case Study 5: – Worth 5 points                

An 88 year old female presents to your clinic on 01/16/14. She was found down in her home by her son who had just stopped by.  Per her son, the patient lives alone but has never had anything like this happen before and she is definitely not herself.  The patient is oriented to name only, not time or place. Luckily she has a list of medications in her purse along with start dates next to them:

Singulair 10 mg po QD                       9/14/12
Atenolol 50 mg po QD                       9/14/012- 1/2/14 dose increased to 100 mg po QD
Zoloft 50 mg po QD                           11/30/13
Lasix 20 mg po QD                            12/15/12- 1/2/14 dose increased to 40 mg po QD
Lortab 7.5 mg 1-2 po Q4 hr prn          1/2/12

Her vitals are:  BP 125/80, HR 55, RR 20, T 98.7 degrees
Her labs are:

Glucose 110 mg/dl
BUN 12 mg/dl
Cr 0.8 mg/dl
Na 140 mmol/L
K 3.0 mmol/L
Cl 105 mmol/L

1. What are 3 potential adverse drug reactions this patient may currently be suffering from? Be specific and discuss your choices and how they are related. (3 points)

The patient’ reaction is attributed to:

Lasix

This drug is used to block Na/Cl co-transporter in distal collecting duct. It has the effect of increasing glucose, cholesterol and TG. Additionally, it affects the BP and K. patients that use the drug are bound to feel light headed or experience short breath which is attributed to the body adjusting to the drug.

 

Zoloft

This is an antidepressant with mild side effects that include dizziness and lack of appetite. The withdrawal from its use may result to fatigue, unsteadiness and memory loss. Laboratory experiment show a rise in insulin levels with major changes in glucose.

 

Atenolol

Atenolol is a prescribed drug that lead to major side effects if taken in excess. Side effects may include; breathing problems, fainting, weakness and irregular heart beat as well as high blood pressure

 

These medications are similar in that they affect the breathing pattern of the patient in addition to the blood pressure. The patient in the end feels weak and may faint.

2. Which medication was this patient started on possibly as a result of an adverse effect from another medication?

The drug used by the patient was Zoloft. Patients that use it or combine it with other drugs may lead to dizziness, light head or feeling shaky. This makes the patient to be at risk of falling.

3. How would you alter the patient’s medications to account for the adverse effect in #2?

The best way to alter the medication is to wait a good period of time prior to beginning another medication. This is with prescription from the doctor.

 

 

Case Study #6 – Worth 5 points

SG, age 26, has a history of head injury and tonic clonic seizures.   He is seen in the office today with complaints of “funny” eye movements, feeling uncoordinated, blurred vision and feeling lethargic.

Current medications:

Ritalin 10 mg po BID

Dilantin 300 mg po BID

Paxil 20 mg po daily

Lasix 20 po daily

Lab Values from today   Dilantin level of 11 Albumin 2   WBC 9.9 Plt 177

Na 141   K 4.2   Hg 13.2

 

1. What do you think is causing the patients symptoms?

The symptoms experienced by the patient are attributed to the medication, Paxil. For instance inability to move eyes, feeling lethargic, poor coordination, seizures and fatigue among others.

2. What lab values and calculated corrections support your diagnosis?

Paxil normally with a half-life of 24 hours has the effects of increasing the levels of Dilatine. This increases toxic nature of the blood and one has double visions and cannot balance himself. With an Albumine level of 2, the drug has the side effects of lowering the level of blood albumin vital for protein production.

The white blood cells (9.9) is high as a result of the invasion of the drug and tries to fight it.

In terms of platelet count (Plt) the drug causes a decline of the number of platelets or abnormal nature.

3. What is your treatment plan for this patient?

Paxil used in the treatment of a number of depressive disorders ought to be used cautiously to patients with a past of seizures. With the condition persisting, the patient has to stop using the drug.

4. What patient education is indicated for this patient?

 

The vital education for the patients lies in monitoring him or her for symptoms like moody, dizziness, anxiety and lethargy among others. The discontinuation should not be immediately. If such symptoms persists it would be necessary to go back to the dose but a gradual rate.

 

 

 

 

 

References

Fava, Maurizio (2010). Pharmacotherapy for Depression and Treatment-resistant Depression.       Singapore: World Scientific.

7. Hughes, PN. Patel and N. Saxena (2011). Effect of acetaminophen on international normalized ratio in patients receiving warfarin therapy. Pharmacotherapy, 31(6):591-7.

Government of Western Australia (2014). Child and adolescent Health Service Princess       Margaret hospital for Children. Retrieved from             http://www.pmh.health.wa.gov.au/development/manuals/clinical_practice_guidelines/doc            uments/bronchiolitis_cpg.pdf

Hoffman, F (2012). Rheumatoid Arthritis: New Insights for the Healthcare Professional: 2011       Edition. Atlanta: ScholarlyEditions.

National Center for Biotechnology Information.(2011).Antibiotics for bronchiolitis in babies.      Retrieved from http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0013306/

Princess Margaret Hospital (2010). Clinical Practice Guideline: Bronchiolitis. Retrieved on 8th         April 2014 from:    http://www.pmh.health.wa.gov.au/development/manuals/clinical_practice_guidelines/doc            uments/bronchiolitis_cpg.pdf

Tsagalis, G (2011). Renal anemia: a nephrologist’s view. Hippokratia, 15(Suppl 1): 39–43.