CASE ANALYSIS

CASE 1
 DEMOGRAPHIC
o Patient Name: SW
o Address: 109 Red Berry Drive
o Age: 57
o Sex: F
o Weight: 218lb
o Height: 5’5”
o Race: African American
o Allergies: NKDA

 CHIEF COMPLAINT:
o SW is an obese 57-year- old African American female presenting to her primary care
clinic for follow-up of her type 2 diabetes mellitus. She complains of deep burning leg
pain.

 HISTORY OF ILLNESS
o SW was diagnosed with diabetes approximately 8 years ago. For the past year her blood
glucose control has steadily worsened. She has been managed on maximum doses of
Glyburide and Metformin (Glucovance) for the past 6 months. Her self- reported home
glucose readings are consistently above 200mg/dL each morning and 2 hours after
eating her evening meal. She denies any episodes of hypoglycemia. She describes
burning pain below both knees that worsens at night. The pain is somewhere improved,
but is not completely relieved despite compliance with her current therapy.
 PAST MEDICAL HISTORY
o Hypertension x9 years
o Hyperlipidemia x7 years on simvastatin
o Obesity (BMI 36.5)
o Diabetic polyneuropathy in her legs distally
o Depression
o Total hysterectomy 15 years ago

 SOCIAL HISTORY
o She works on a night shift as an aid. She denies any tobacco use or excessive alcohol
intake. For exercise she tries to swim or walk 30 minutes daily, however, she is
consistent with her exercise program. Her diet has improved over the past month. She
has decreased her daily calories and has begun to count her carbohydrate intake. She
has limited finances for medications and office visits.

 FAMILY HISTORY
o Her father died of an acute myocardial infraction at age 53. Her mother, who had type2
diabetes, recently died in a nursing home at age 85. Of her 6 brothers, two have type2
diabetes. Her sister, who is 67 years old, has coronary artery disease and is s/p MI. SW’s
daughter is 30 years old and has had type1 diabetes since she was teenager.

 REVIEW OF SYSTEM
o Remarkable for fatigue, polyuria, nocturia x3, and polydipsia. She denies any visual
changes, slurred speech, or unilateral extremity weakness. She denies chest pain with
 exertion, shortness of breath, or palpitations. She denies any signs or symptoms of
infection and she reports that she checks her feet daily. She does report increased leg
pain with prolonged walking.

 PHYSICAL EXAMINATION
o GEN: Alert and oriented obese female in NAD; flat affect
o VS: 142/88 mmHg (R arm sitting, 1g cuff), 90 bpm, T (98F, RR 12rpm. Wt 218 lb, Ht 65
inches (BMI 36.5)
o HEENT: PERRLA; optic fundi are clear, the thyroid is not enlarged
o CHEST: Clear to auscultation bilaterally
o CV: RRR; there are no murmurs or other adventitial sounds
o EXT: no edema, normal hair distribution, warm to the touch; peripheral pulses 2+ and
symmetric. Feet: without calluses, sores, or ulcers. Hammer toe on the second digit of
the left foot. Monofilament shows loss of protective sensation on the plantar portions of
both feet.

 LABS AND DIAGNOSTIC TESTS:

o Random office glucose 239 mg/dL 2 hours after eating
o Urine dipstick (-) protein, glucose, nitrates, leukocytes
o (Fasting labs obtained 2 weeks prior to this visit.)
o Sodium 139mEq/L
o Potassium 5.1mEq/L
o Chloride 106mEq/L
o CO2 content 28mEq/L
o Serum creatinine 1.2mg/dL (stable)
o Bun 19mg/dL
o Glucose 234mg/dL
o Total cholesterol 167mg/dL
o HDL-C 32mg/dL
o Triglycerides 234mg/dL
o LDL-C 88mg/dL
o LFT’s: wnl; TSH: wnl
o Hgb (A1c): 10.6% (9.4% 6 months prior), urine microalbuminurea 20 microgram/mg of
creatinine

 DIAGNOSIS
o Type 2 diabetes mellitus with microvascular complications of diabetec neuropathy

 MEDICATION RECORD(PRIOR TO ADMISSION)

o Glucovance 5/500 mg, 2 po qAM and qPM
o Prinzide 20/12.5, 2 po qAM
o Ibuprofen 600mg, 1 po q6h prn
o Neurontin 300 mg, 3 qid
o Zocor 20 mg, 1 po qHS
o Desipramine 75 mg, 1 po qHS

 PHARMACISTS NOTES AND OTHER PATIENT INFORMATION

o She often receives monthly samples of Prizide, Glucovance, Nuerontin and Simvastatin
because she is unable to afford her insurance copayments.
QUESTIONS
1. Which of the following are contraindication for the use of metformin in this patient?
I. Elevated serum creatinine and microalbuminuria
II. Increased risk for developing congestive heart failure
III. SW does not have an contraindications

2. Metformin can cause the rare but very serious side effect of lactic acidosis with inadequate renal
function. Which of the following best describes the symptoms of lactic acidosis SW should be
warned of.
I. Rapid onset of nausea, vomiting and diarrhea
II. Rapid onset of chills, fever and malaise
III. Rapid onset of nausea, vomiting, and shortness of breath
IV. Slow onset of malaise, respiratory distress, and abdominal symptoms
3. SW’s Hgb A1c fasting blood glucose (BG), and 2-hour postprandial readings are not at goal.
Which of the following statements best describes the benefits of maglinitide (i.e. Repaglinide) or
an alpha-glucisidase inhibitor (i.e. acarbose) for this patient?
I. Adding a meglitinide will help to significantly lower her fasting BG.
II. Adding a miglitinide should help for further lower her post-prandial BG.
III. Adding an alpha-glucosidase inhibitor will help to significantly lower the fasting BG.
IV. A meglintinide or an alpha-glucosidase inhibitor will have minimal benefits for this patient.

4. Her primary care providers is concerned about her persistent hyperglycemia and inquires about
the addition of a thiazolidinedione. Which of the following best describes the potential side
effects of these agents?
I. Weight gain
II. Peripheral edema
III. Anemia
IV. Weight loss

5. If the addition of insulin were considered for SW, which of the following regimens would be the
most appropriate initial step to control her fasting blood glucose and provide insulin coverage
through the rest of the day?
I. Add lispro insulin before each meal
II. Add regular insulin before meal
III. Add NPH insulin at bedtime
IV. Add insulin glargine (Lantus) at bedtime

6. It is decided to add insulin to SW’s diabetic regimen. Which of the following statements
describes appropriate action if the patient experience symptoms of hypoglycemia?
I. Drink a half glass of juice, one glass of milk, or a regular softdrink
II. Check your BG within 15 minutes of the treatment
III. Give yourself an injection of glucagon
IV. Just rest
7. SW is concerned about her high risk for developing cardiovascular disease. She requests to be
placed on hormone replacement therapy (HRT). Which of the following statements are true
regarding HRT for SW?
I. Estrogen replacement therapy increases the HDL-C
II. Estrogen therapy may increase triglycerides and must be cautiously used in diabetes
patients
III. Estrogen therapy may increase the risk for stroke
IV. Estrogen replacement therapy deccreases the HDL-C
 8. Patient education for proper foot care would include which of the following?
I. Keep your feet clean and dry
II. Wear shoes both indoors and outdoors
III. Inspect both feet daily for sores, calluses, redness, or swelling
IV. Ou can use high hills to increase blood circulation
9. If this patient were taking 30 units of 70/30 insulin, which of the following statements correctly
describes the amount of regular and NPH insulin in this regimen?
I. 21 units of regular and 9 units of NPH insulin
II. 14 units of regular and 16 units of NPH insulin
III. 14 units of NPH and 16 units of insulin
IV. 15 units of regular and 15 units of NPH insulin
10. SW complains of uncontrolled pain related to her diabetic neuropathy. She has been very
compliant with her current therapy of ibuprofen 600 mg qid. Nuerontin 900 mg tid, and
desipramine 75 mg qhs. Which of the following statements describes the most appropriate
action to significantly help decrease SW’s pain?
I. Increase her ibuprofen to 800 mg four times a day
II. Increase her gabapentin to 1200mg four times a day
III. Soak her feet and legs in hot water several times a day
IV. Improve her blood glucose control

CASE 2

A 45-year-old man presents to your office because he was referred by his

optometrist for rapidly changing eyeglass prescription. He is obese. He has had some
nocturia, but no polyuria, polydipsia, or new polyphagia. There is no family history for diabetes. His
parents died in an auto accident when they were 50 years old. He does snore and does have some
periods of falling asleep at work after lunch. He drinks 2 mixed drinks per day and is a current smoker
with a 30 pack year smoking history. He takes Motrin 400 mg thrice daily for knee pain. His BP is 150/88;
Pulse is 96; Respiratory rate is 12 and Temperature is 37 degrees Celsius. Other than obesity (BMI 35),
there are no remarkable findings on physical examination. The knees are not hot, red, or swollen.

11. Which is NOT a recommended way to diagnose diabetes?

I. FBS > 126 on two occasions

II. Random BS > 200
III. 2 h BS > 200 following Oral GTT on 75 Gm oral glucose
IV. HgbA1c > 6.2

12. Which is NOT a targeted outcome for diabetes treatment?

I. Glycemic control
II. Normalizing liver tests
III. Weight control
IV. Favorable lipid profile
V. Blood pressure control

13. Which statement is INCORRECT concerning macronutrients and diabetes?

I. Monitoring CHO intake remains a key strategy in maintaining glucose control.

II. Saturated fat intake should be <7% of total calories.
III. Intake of trans fats should be minimized.
IV. Supplementation with antioxidants such as Vitamin C, E and carotene is advised.
 14. Which statement is CORRECT about screening in diabetics?

I. Screening in Type 1 diabetes should be started as soon as diabetes 

is diagnosed.
II. Screening in Type 1 diabetes may be delayed for 5 years from diagnosis of diabetes.
III. Screening for Type 2 diabetes may be delayed for 1 year from diagnosis of diabetes.
IV. Screening for Type 2 diabetes may be delayed for 5 years from diagnosis of diabetes.
V. Screening for Type 2 diabetes may be delayed for 10 years from diagnosis of diabetes.

15. What is NOT a recommended procedure for screening patients with diabetes?

I. Dilated eye examinations by ophthalmologists annually

II. Test for microalbuminuria annually.
III. Perform a visual inspection of the feet at each routine visit.
IV. Asking about chest pain is sufficient for screening for cardiac disease.

16. Which is NOT thought to be a mechanism involved in diabetic retinopathy?

I. Sorbitol accumulation
II. Protein kinase C-beta
III. Vascular Endothelial Cell Growth Factor (VEGF)
IV. Lipid oxidation

17. Which statement is CORRECT about diabetic retinopathy?

I. Intensive glycemia therapy has no effect on the progression of diabetic

retinopathy.
II. Intensive glycemia therapy does not reduce the risk of moderate vision loss.
III. There is no beneficial effect of fenofibrate on the progression of diabetic retinopathy.
IV. Blood pressure control significantly improves retinopathy.

18. Should his BP be treated?

I. 150/90 is sufficient for this patient early in his disease

II. 140/80 should be the goal for this patient
III. 130/80 should be the goal for this patient
IV. 125/75 should be the goal for this patient

19. When should a diabetic patient be referred to a kidney specialist

(nephrologist)?

CKD-1: GFR: > 90 mL/min/1.3m2

I.
CKD-2: GFR: 60-89 mL/min/1.3m2
II.
CKD-3: GFR: 30-59 mL/min/1.3m2
III.
CKD-4: GFR: 15-29 mL/min/1.3m2
IV.

20. Which diabetic drug is supposed to protect against malignancies?

I. Metformin
II. Glyburide
III. Glipizide
IV. Insulin
Case 3

A 52-year-old man presents for a routine checkup. He has noticed some blurring of vision. He has
trouble sleeping, which is compounded by 3 episodes of nocturia every night. His body mass index (BMI)
is 34 kg/m2 and his sitting blood pressure is 160/100 mm Hg, but his physical examination is otherwise
unremarkable.

21. What is this patient’s BMI category?

I. Underweight
II. Normal weight
III. Overweight
IV. Obese

22. Which of the following is a risk factor for type 2 DM?

I. Blood pressure greater than 130/80 mm Hg

II. High-density lipoprotein (HDL) lower than 45 g/dL
III. Triglyceride level of 150 mg/dL or more
IV. Sibling with type 2 DM

23. Which of the following is considered the best screening test for diabetes?

I. 3-hour glucose tolerance test

II. Fasting plasma glucose (FPG)
III. 2-hour postload plasma glucose
IV. Hemoglobin A1c

24. What percentage of patients with diabetes has at least 1 diabetes-related complication?

I. 20%
II. 30%
III. 40%
 50%

25. Which drug is considered the best first-line therapy in most patients with type 2 DM?

I. Glimepiride
II. Metformin
III. Pioglitazone
IV. Acarbose

26. Which of the following is a side effect associated with metformin use to treat type 2 DM?

I. Lactic acidosis
II. Acute renal failure
III. Hypoglycemia
IV. Normoglycemic diabetic ketoacidosis

27. Which of the following diabetes therapies has the highest risk of hypoglycemia?

I. Biguanides
 II. Sulfonylureas
III. SGLT-2 inhibitors
IV. DPP-4 inhibitors

28. Which statement is correct about pioglitazone use?

I. It increases the risk of myocardial infarction

II. Weight loss is common
III. It increases the risk of fracture
IV. Polyuria is the most common side effect

29. Which statement is correct about use of SGLT-2 inhibitors?

I. Blood pressure usually increases

II. They have shown efficacy in patients with type 1 DM
III. They increase the risk of amputations
IV. For patients with end-stage renal disease or on dialysis, the dose should be cut in half

30. Which statement is correct about dipeptidyl peptidase-4 (DPP-4) inhibitors?

I. Headache is the most common side effect

II. Use has no effect on body weight
III. Decrease CV risk
IV. Increase pancreatic cancer risk

Case continued…
The patient is started on metformin, and the dosage is gradually increased to 2000 mg/day. After 3
months, his hemoglobin A1c is 8.9%.

31. Which of the following medications would have a beneficial effect on his glycemic control, body
weight, and blood pressure when added to metformin?

I. Empagliflozin
II. Pioglitazone
III. Glimepiride
IV. Acarbose
V. Liraglutide

32. Patients with diabetes should be screened regularly for several conditions. Which of the
following is a strongly recommended screening for a patient with diabetes?

I. Foot examination at every health care visit

II. At least an annual eye exam starting when diabetes is diagnosed
III. At least an annual examination of the urine for microalbuminuria
IV. Quarterly checking creatinine clearance

Case 4

Medical Guidelines in using insulin:

A usual starting dosage for patients with type 2 DM: 1U of rapid acting insulin for every 10g of
carbohydrate eaten plus an additional 1U for every 30mg/dL above the target self-monitoring blood
glucose level of 100mg/dL
Scenario: A patient who had a pre-meal self-blood monitoring of 160mg/dL and planning to eat a meal
containing 30g of carbohydrate.

33. The patient is currently on prandial insulin dose, how many unit of insulin to be administered?
I. 3U
II. 5U
III. 6U
IV. 8U
34. Criteria to be used to diagnosed DM
I. Plasma Glucose >126mg/dL afte an overnight fast.
II. A random plasma glucose > 200mg/dL in patients with classic symptoms of
hyperglycemia
35. Who should undergo OGTT as preferred initial test for screening for DM?
I. A previous FBS screening / impaired fasting glucose (100 to 125mg/dL)
II. A diagnosis of metabolic syndrome
36. Pharmacologic Therapy for type 2 DM
I. May give metformin as initial treatment if not CI and tolerated.
II. Insulin therapy is not recommended if newly diagnosed patient are symptomatic and or
have A1C >10% and a blood glucose level of >300mg Dl

CASE 5

Pt diagnosis: HAP/VAP : risk for MDR pathogens and mortality.

Patient was prescribed with Dual Gram-pseudomonal coverage + MRSA therapy

37. As a Clinical Pharmacist, you agree on RX because upon assessment on the Patient’s condition
you observe the following findings:
I. The patient is Low MDR pathogen risk and Low Mortality risk number
II. The patient has no septic shock
III. The patient is positive on septic shock
IV. The patient in on High MDR pathogen risk/ and or >15% mortality risk.
38. Once the patient is negative to septic shock the following is recommended:
I. Single gram negative agent MRSA therapy
II. Dual Gram-pseudomonal coverage + MRSA therapy
III. Antibiotic Monotherapy
39. Once the patient is positive to septic shock the following is recommended:
I. Single gram negative agent MRSA therapy
IV. Dual Gram-pseudomonal coverage + MRSA therapy
V. Antibiotic Monotherapy
40. Antibiotic monotherapy is recommended for the following condition/s:
I. The patient is Low MDR pathogen risk and Low Mortality risk number
II. The patient has no septic shock
III. The patient is positive on septic shock
IV. The patient in on High MDR pathogen risk/ and or >15% mortality risk.
41. Hospital Acquired Pneumonia (HAP)
I. Nosocomial pneumonia that develops in intensive care unit patients who have been
mechanically ventilated for atleast 48 hours.
II. Infection of the pulmonary parenchyma caused by pathogens that are present in hospital
settings
III. Infection that develops in patients admitted to the hospital for >48 hours and usually the
incubation period is atleast 2 days
IV. Same treatment with CAP
42. Low Risk CAP without comorbid illness treatment/s:
I. Amoxicillin
 II. 2nd generation Cephalosporins
III. Extended macrolides may be considered
IV. Fluoroquinolone
43. For High-Risk CAP without risk of P. aeroginosa treatment/s:
I. BLIC
II. IV respiratory Fluoroquinolone
III. Carbapenem
IV. High Dose of IV levofloxacin
44. For High-Risk CAP with risk of P. aeroginosa treatment/s:
I. BLIC
II. IV respiratory Fluoroquinolone
III. Carbapenem
IV. High Dose of IV levofloxacin
45. For Modorate Risk CAP treatment/s:
I. Extended macrolide
II. Respiratory fluoroquinolone
III. Carbapenem
IV. Cephalosporins
46. Initial antibiotic recommended for the empiric treatment of CAP:
I. MR-CAP – Combination of an IV and non anti-pseudomonal beta lactam
II. HR-CAP – without risk of P. Aeruginosa, combination of an IV antipneumonococcal, anti-
pseudomonal beta lactam with an extended macrolide and aminoglycoside.
47. What should be done for patients who are not improving after 72 hours of empiric antibiotic
therapy?
I. Obtaining additional specimens for microbiologic testing should be considered
II. Follow up chest radiograph is recommended to investigate other conditions.
48. Among atypical pathogens, what cause/s severe pneumonia?
I. L. pneumophila
II. C. pneumoniae
49. Empiric antimicrobial therapy for CAP
I. LR-CAP – amoxicillin
II. HR-CAP – IV non anti-psodomonal beta lactam + respiratory FQ

50. Recommended Initial Empiric antibiotic Therapy for HAP (non-VAP)

I. High Risk of mortality – Linezolid 600mg IV q12
II. If patient has a severe allergy and aztreonam is going to be used instead of any beta
lactam based antibiotic, do not include coverage of MSSA.