Clinical Pharmacy - I

1 - ‫الصيدلة السريرية‬

Dr. Ahmed Al- Akydy

Assoc. Prof. Pharmacology
&
Therapeutics
Home Assignment-2
 Case -1
 L.F. is a 48-year-old woman who presents to her primary-care provider
complaining of recurrent heartburn occurring daily for the past 6 weeks.
She states that the heartburn occurs frequently after meals and often
wakens her at night. Lately, she has been experiencing difficulty
swallowing solid foods. L.F. currently smokes two packs of cigarettes per
day and likes to have two glasses of wine each night with her dinner.
L.F.’s frequent severe symptoms continue despite OTC famotidine 20 mg
orally twice daily and the presence of warning signs warranted that she
undergo endoscopy, which revealed moderate esophagitis, the presence of
an esophageal stricture, and no evidence of Barrett metaplasia.
 Questions
1. What is the most likely diagnosis for L.F’s condition?
2. What of diagnostic modalities are available for the evaluation of L.F’s
condition?
3. What treatment options exist for L.F’s condition?
 Case -2
 Mrs MW, 59 years old, is divorced and unemployed. She was admitted to an
acute medical ward at the hospital presenting with general malaise, a grossly
distended abdomen, swollen ankles and jaundice. It was noted that she smell of
alcohol and was showing signs of alcohol withdrawal. On examination. Mrs MW
was found to be encephalopathic. The doctor decided to treat her encephalopathy
and ascites. Mrs MW weighs 61 kg (with the ascites) and her laboratory data are
as follows:
Item Patient's results Normal range
Total protein 49 g/L 63-80 g/L
Albumin 20 g/L 32-50 g/L
Total bilirubin 114 micromol/L <17micromol/L
ALP 382 IU/L 100-300 IU/L
GGT 306 IU/L < 50 IU/L
ALT 88 IU/ L 5-42 IU/L
INR >4 2-3

 Diagnosis of alcoholic cirrhosis of the liver was made based on Mrs MW's
clinical features, liver function tests, abdominal ultrasound, CT scan liver biopsy.
 Questions:
1. What is cirrhosis of the liver?
2. List possible causes of cirrhosis.
3. What is the cause of liver cirrhosis in MRs MW?
4. What other clinical signs and symptoms may Mrs MW present with?
5. What causes are likely to have contributed to the development of ascites in Mrs
MW?
6. What is hepatic encephalopathy?
7. What factors may precipitate hepatic encephalopathy?
8. What are the clinical signs and symptoms of hepatic encephalopathy?
9. Describe how Mrs MW's laboratory results relate to her diagnosis.
10. Why is INR is elevated in Mrs MW?
11. What options (drug and/or non-drug) are likely to be available at the hospital
for managing Mrs MG's:
▫ Hepatic encephalopathy
▫ Ascites
12. Mention the circumstances in which the diuretics should be avoided when they
are used to treat ascites
13. What treatment would you recommend to reduce her risk of bleeding?
14. What medications would you advise Mrs MW to avoid in view of her bleeding
risk?
15. What recommendations would you make if the patient was unable to take the
medication orally?
16. What would you monitor in order to determine whether the therapy was
effective in ascitic patient?
17. What drug treatment, would you recommend for MW's alcohol withdrawal?
18. What treatment options are available to help Mrs MW abstain from alcohol in
the future?
 Case -3
 LG, a 34- year – old woman presents in the community pharmacy with epigastric
pain for which she seeks symptoms relief. On enquiry, she does not have any
alarm features such as weight loss, bleeding, dysphagia or persistent vomiting.
The symptoms have been intermittent over the previous couple of weeks. The
pain does not seem to be precipitated by food. She confirms she is not pregnant.
The symptoms are not reflux –like and do not come on with exercise or radiate to
her arms or neck. Her bowel habit is not altered and she is otherwise healthy and
takes no prescribed or purchased medicines
• Questions:
1. What is the suitable initial treatment strategy for LG?
2. LG returns a week later still complaining of discomfort .
 LG is found to be positive for H. pylori. She also reports an allergy to penicillin
and receives a prescription for a 7- day, twice- daily course of omeprazole 20mg,
clarithromycin 250mg and metronidazole 400mg.
3. What information should she receive with her prescription?
 Case -4
 Mrs MG, A 57-year-old woman presents with symptoms of epigastric pain which
has interfered with her normal activities over the previous few weeks.
Medication history reveals that Mrs MG takes no prescribed medicines and
occasional paracetamol as an analgesic for minor ailments. Although she has
occasional heartburn, this is not the predominant symptom. Mrs MG has not
vomited and does not have difficulty or pain on swallowing. She has not lost
weight recently and has normal stools with no evidence of bleeding. The pain is
not precipitated by exercise and does not radiate to the arms and neck. Mrs MG
is a non-smoker and only takes a small quantity of alcohol on social occasions.
She has an allergy to penicillin
• Questions
• How should Mrs MG be treated?
 Case -5
 Mr GF, a 57-year-old, suffered a myocardial infarction 12 months ago and at the time
was also found to have LVSD on echocardiography. He is currently asymptomatic. At
your request, he has agreed to see you for a medication review regarding his drug
therapy. He has a history of T2DM (8 years) and his current prescription includes
enalapril 10 mg twice daily, gliclazide 80 mg twice daily, bisoprolol 5 mg daily,
aspirin 75 mg daily, and a nitroglycerine spray to use when required.
 Question
1. What signs & symptoms experienced by this patient indicate that he has HF?
2. Dose he have right- or left –sided HF or both? Explain your answer.
3. What systems are used to classify HF according to severity of symptoms?
4. Determine which Mr GF heart failure class?
5. Is the current treatment plan for HF optimal?
6. Why Mr GF not received eplerenone in this class ?
7. Why Mr GF not received a furosemide in this class?
8. Was the addition of bisoprolol appropriate for this patient? What is the role of beta
blockers in HF?
9. How does you increase the dose of bisoprolol to maximum tolerable dose?
10.Is the sexual activity in this patient safe? And why?
11.What advice should be given to the patient at discharge with regard to lifestyle
issues?
Thank you
Any
question?