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1. Mrs P, a 32-year-old woman, comes to the dispensary asking to talk to a A. pharmacist. She has recently received a prescription for Colpermin from her General Physician. She says that they gave her terrible indigestion and so she has been taking Alu-Cap capsules, which have not worked terribly well. She has also decreased the number of Colpermin capsules she was taking. She wants to know if you can sell her anything stronger for the indigestion. She feels her problems are just getting worse and worse: first she had constipation, stomach cramps and bloating. Now she has indigestion as well, and her original symptoms are worse than ever. She didn’t used to take any medicines and already she is on two, and she is seeing the hospital doctor in clinic this afternoon and fears she will be taking even more before long. Question: a. Mrs P has irritable bowel syndrome (IBS). What from her history is consistent with this? b. How would this diagnosis have been reached? c. What symptoms would require further investigation? d. What is her prognosis likely to be? e. What lifestyle advice should she have been given? f. Is there anything you should take into consideration when talking to Mrs P? g. What advice can you give her about her current medication? h. What particular difficulty is there with assessing the success of treatment in this type of patient? i. What other treatments are possible in patients with irritable bowel syndrome? Which would you recommend for Mrs P? j. What adverse effects are possible? References:
An 18-year-old man, VB, presents with a history of recurrent episodes of wheeze after walking 200 metres. VB has recently started to go to a gym and his episodes of wheeze have worsened. He goes to see his GP. He can talk in sentences but his respiratory rate is increased. His peak flow is 420 L/min which is 80% of predicted result. A diagnosis of mild asthma is made. He is started on salbutamol metered dose inhaler
(MDI) two puffs when micrograms twice daily.
Question: a. What is asthma? b. What are the risk factors for developing asthma? What risk factors does the patient have? c. What is the pharmacology of beta2-agonists and inhaled corticosteroids? d. What are the side-effects of beta2-agonists? e. What formulations of salbutamol and inhaled corticosteroids are available and f. What are the advantages and disadvantages? g. Describe how to use an Metered Dose Inhaler. h. What are the social implications of this man’s asthma? References:
Mr AB, a 21-year-old, white European, pharmacy student came to the local pharmacy last week with a 7-day prescription for diazepam 10 mg tablets, one to be taken at night. The drug was prescribed to him by his GP because some five weeks ago Mr AB started suffering from insomnia. In fact, although he is typically supposed to wake up at 7.00am to attend his lectures, at 4.00am he is already fully awake. He does not find it difficult to fall asleep, nor does he wake up too frequently during the night. During the day, he feels very tired, anxious and tearful. It is now 3 days since you dispensed his prescription and the patient has returned to you because he claims he is still not able to sleep properly. Question: a. How is insomnia defined? Insomnia is defined as sleeping difficulties or
insomnia is difficulties initiating and/or maintaining sleep, or nonrestorative sleep, associated with impairments of daytime functioning or marked distress for more than 1 month.
b.What are the risk factors for its development? Frequent travel, particularly crossing time lines. Post-traumatic stress syndrome. Brain injuries. Many chronic medical conditions ranging from seemingly minor ones, such as tinnitus (ringing in the ears) to major medication conditions, such as respiratory problems, heart disease, or being on dialysis. c. Does Mr AB have any of the risk factors for developing insomnia?
Yes, his frequent travel with different time zone. d. What group of drugs does diazepam belong to? What are the main pharmacokinetic differences between the components of this class of drugs? Diazepam is in a group of drugs called benzodiazepines.
Diazepam can be administered orally, intravenously (needs to be diluted, as it is painful and damaging to veins), intramuscularly (absorption is slow, erratic and incomplete), or as a suppository.
e. What is the mechanism of action of diazepam in the treatment of insomnia? f. What are the side-effects of diazepam? Suppression of REM sleep,
Impaired motor function, nervousness, irritability, excitement, worsening of seizures, insomnia, muscle cramps, changes in libido (increased or decreased libido) and in some cases, rage, and violence.
g. What formulations are available for diazepam? Available in table, oral
solution, injection (solution), injection (emulsion0, rectal tubes, suppositories, and suspension.
h. What alternative preparation(s) could you recommend for Mr AB? i. What counselling could you give Mr AB to help try and resolve the issue? References: Handbook of drug administration via enteral feeding tubes, google.com, Wikipedia.org,
Ms CD, a 24-year-old white British woman, presents to your pharmacy asking for some information around use of laxatives and diuretics. On further questioning, it appears that she seems to be obsessed with her body weight. Her height is 1.64 m and her weight is 56 kg. Her food intake is quite irregular, being characterised by periodical binges followed by fasting periods. She reports that some recent blood tests have shown a few electrolyte imbalances, including sodium 130 mmol/L, but she doesn’t understand what this means. Question: a. Calculate Ms CD’s body mass index (BMI). Show your solution. BMI BMI= 56 kg/ (1.64)2------ 56kg/2.6896= 20.82 b. What would be causing Ms CD’s electrolyte imbalances? Renal
c. Monitoring and referral criteria; what signs and symptoms should
up, fasting, exercising vigorously, or using diuretics and laxatives. d. What are the treatment choices for the management of bulimia? The treatment of choice for bulimia is cognitive-behavioral therapy. Cognitive-behavioral therapy targets the unhealthy eating behaviors of
you look out for which could indicate a patient may have an eating disorder? People with eating disorders may purge by throwing
bulimia and the unrealistic, negative thoughts that fuel them. e. Ms CD was eventually prescribed fluoxetine 60 mg daily by her
GP. What are the goals of therapy, including monitoring and the role of the pharmacist/clinician? The goals of therapy in monitoring if
the person stop his/her binge-and-purge cycle, and if he/she change his/her unhealthy lifestyle thoughts and pattern and as a pharmacist/clinician we can help or give advice to his/her issues about her condition.
f. What are the social pharmacy issues of this case, including
alternative therapies and lifestyle advice? The social pharmacy issues
in this case that pharmacist can help is that we can observe their psychological condition of the patient in why he/she asking about many thing in the drugs especially the about the laxative and diuretics and after that if the patient has a bulimia can advice her some to seek a professional health provider that can help to her condition and the pharmacist can also give advice to the patient about changing his/her un healthy lifestyle.
References: Helpguide.org Google.com Wikipedia.org
Source: Pharmacy Case Studies edited by: Dhillon, S. &Raymond, R., Pharmaceutical Press 2009.
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