Case 1

A 62-year-old man, Mr BD, presented to the emergency department following haematemesis

and melaena. He was suffering no pain. His past medical history included non-ST-elevated
myocardial infarction (NSTEMI) for which he had undergone percutaneous coronary
intervention (PCI) and bare metal stent insertion 4 months previously. Mr BD stopped
smoking 2 years ago, drinks alcohol in moderation and is not obese. He is prescribed the
following prescribed medicines:

• aspirin (dispersible) 75 mg daily,

• clopidogrel 75 mg daily,

• ramipril 2.5 mg twice daily,

• atorvastatin 80 mg daily,

• bisoprolol 5 mg daily,

• GTN spray prn.

On investigation, Mr BD’s blood pressure was 98/60 mmHg with a heart rate of 120 beats/min
and respiratory rate of 20 beats/min.

There was no jaundice or stigmata of liver disease. Mr BD’s blood results were as follows:

Value Reference range

Urea 18 mmol/L 3.1–7.9 mmol/L
Creatinine 87 mmol/L 75–155 mmol/L
INR 1.0
Sodium 142 mmol/L 135–145 mmol/L
Potassium 4.3 mmol/L 3.4–5.0 mmol/L
Haemoglobin 8 g/dL 13.5–18 g/dL
MCV 90 fL 78–100 fL
 Endoscopy revealed an actively bleeding gastric ulcer.

Questions

1. What immediate treatment should Mr BD have received before endoscopy?

2. What treatment should he receive at the time of endoscopy?

3. Why should biopsies be taken at the time of endoscopy?

4. What pharmacological treatment should be given to Mr BD to reduce the risk of re-bleeding

following endoscopic haemostatic therapy?

5. What was the likely cause of Mr BD’s bleeding ulcer?

6. When should antiplatelet therapy be restarted, and which agent(s) should be prescribed?

7. Should Mr BD receive gastroprotection following ulcer healing?

8. Identify what aspects of Mr BD’s medicines you would want to discuss with him.

Case 2

A 68-year-old male, Mr MF, presents with melaena. He has a past medical history of atrial
fibrillation and hypertension. On examination, Mr MF is pale and clammy, with a blood pressure
of 95/60 mmHg and a pulse of 110 beats/min with a Blatchford score of 11. His drug history is
recorded as follows:
• warfarin 4 mg daily,
• amlodipine 5 mg daily,
• simvastatin 40 mg daily.
Mr MF’s blood results were as follows:
Value Reference range
Sodium 140 mmol/L 135–145 mmol/L
Potassium 3.9 mmol/L 3.4–5.0 mmol/L
Urea 11.5 mmol/L 3.1–7.9 mmol/L
Creatinine 90 mmol/L 75–155 mmol/L
WBC 7.6 × 109/L 3.5–11 × 109/L
MCV 90 fL 78–100 fL
 INR 2.8
Haemoglobin 10.5 g/dL 13.5–18 g/dL
The impression is that Mr MF has had an upper gastro-intestinal bleed. The plan is for Mr MF to
undergo reversal of anticoagulation, resuscitation with intravenous fluids and then an urgent
endoscopy
Questions
1. If you were confirming Mr MF’s medication history, what particular aspects should be
checked?
2. How should warfarin be reversed?
3. An endoscopy reveals Mr MF has a bleeding duodenal ulcer for which he receives a 72-hour
PPI infusion. A H. pylori test is negative. How should Mr MF’s anticoagulation be managed?

Case 3

A 57-year-old woman, Mrs MG, presents to her primary care doctor with symptoms of epigastric
pain that have interfered with her normal activities over the previous few weeks. Medication history
reveals that Mrs MG takes no prescribed medicines and only 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 nonsmoker and only drinks a small quantity
of alcohol on social occasions. She is not overweight. She has an allergy to penicillin.
Questions
1. How should Mrs MG be treated?
2. Which H. pylori test should be used in primary care?

Case 4

A 68-year-old woman, Ms WR, presents for review of her medication.Her medical history includes
hypertension and osteoarthritis of the knees. Ms WR receives a regular prescription for the following:
• bendroflumethiazide 2.5 mg daily,
• naproxen 500 mg twice daily.
Ms WR stopped smoking 4 years ago and drinks no more than 10 units of alcohol per week. She is
overweight, with a body mass index (BMI) of 30 kg/m2. Ms WR occasionally purchases an antacid
to treat symptoms of heartburn if she’s eaten a large meal at night. Her blood pressure is 148/92
mmHg with a pulse of 82 beats/min. The results of Ms WR’s routine blood tests are as follows:

Value Reference range

Sodium 138 mmol/L 135–145 mmol/L
Potassium 3.9 mmol/L 3.4–5.0 mmol/L
Creatinine 110 mmol/L 75–155 mmol/L
Blood glucose 6.8 mmol/L <11.1 mmol/L
Total cholesterol 4.5 mmol/L <4.0 mmol/L
Haemoglobin 12.0 g/dL 11.5–16.5 g/dL

Questions
1. What is the mechanism for NSAID-induced peptic ulcer disease?
2. What are the risks associated with NSAID use in this patient?
3. What are the options for treating Ms WR’s pain and minimizing the risk of peptic ulceration?

Case 5.
Mr AD, a 56-year-old man, is admitted to hospital following haematemesis and melaena. He has
a known history of ALD (stopped drinking alcohol 1 year ago) with marked ascites. A
provisional diagnosis of bleeding oesophageal varices is made. A Sengstaken–Blakemore tube is
inserted and the balloon inflated as a temporary measure to arrest bleeding. The patient is
transferred 8 hours later to a specialist regional centre for further management.
Laboratory data on admission are:
Reference range
Na+ 124 133–143 mmol/L
K+ 3.0 3.5–5.0 mmol/L
Creatinine 131 80–124 mmol/L
Urea 14.3 2.7–7.7 mmol/L
Bilirubin 167 3–17 mmol/L
ALT 24 0–35 IU/L
PT 18.9 13 seconds
Albumin 24 35–50 g/dL
Haemoglobin 8.9 13.5–18 g/dL
Drugs on admission:
spironolactone 200 mg one each morning.

Questions
1. What other action would you have recommended before Mr AD was transferred to the
regional centre?
2. What options (drug and/or non-drug) are likely to be available at the regional centre for
managing the patient’s bleeding varices?
3. What further long-term measures would you recommend for Mr AD?

Case 6
Mrs AL, a 68-year-old woman with a long-standing history of ALD, is admitted to hospital with
a 2-week history of vomiting, confusion, increased abdominal distension and worsening
jaundice.
On admission laboratory data are as follows:
Value normal range
Na 116 133–143 mmol/L
K 3.8 3.5–5.0 mmol/L
Urea 8.5 2.7–7.7 mmol/L
Creatinine 119 80–124 mmol/L
Bilirubin 459 3–17 mmol/L
Albumin 23 35–50 g/L
ALT 23 0–35 IU/L
Alkaline phosphatase 524 70–300 IU/L
PT 18.6 13 seconds
Drugs on admission are as follows:
spironolactone 300 mg each morning
temazepam 10 mg at night
 lactulose 10 mL twice daily
Discuss Mrs AL’s initial treatment plan for the management of:
1. ascites
2. nausea and vomiting
3. confusion

Case 7

Miss CM is 45 years old. She presents with a 6-month history of intermittent breathlessness,
wheeze and cough. Miss CM has found that she gets symptoms at least three or four times each
week. She has also noticed that her symptoms are worse first thing in the morning, also
significantly during the winter when she had a minor upper respiratory tract infection. She is
currently taking no regular medication. Apart from seasonal allergic rhinitis, Miss CM has no
other health problems.

1. What is the likely diagnosis?

2. What investigations should be undertaken?

3. What treatment should be started?

4. What non-pharmacological measures should be considered?

Case 8

H.T., a 45-year-old, 91-kg man with a long history of severe-persistent asthma, presents to the
ED with severe dyspnea and wheezing. He is able to say only two or three words without taking
a breath. He has been taking four inhalations of beclomethasone hydrofluoroalkane (HFA; 80
mcg/puff) twice daily (BID) and two inhalations of albuterol MDI 4 times a day (QID) as needed
(PRN) on a chronic basis. H.T. ran out of beclomethasone a week ago; since then, he has been
using his albuterol MDI with increasing frequency up to every 3 hours on the day before
admission. He is a lifelong nonsmoker. His FEV1 was 25% of the predicted value for his age and
height, and his SaO2 was 82%. Vital signs are as follows:
 Heart rate, 130 beats/minute

RR, 30/minute

Pulsus paradoxus, 18 mm Hg

BP, 130/90 mm Hg

ABGs on room air were as follows:

pH, 7.40

Pao2, 55 mm Hg

Paco2, 40 mm Hg

Serum electrolyte concentrations were as follows:

Sodium (Na), 140 mEq/L

Potassium (K), 3.9 mEq/L

Chloride (Cl), 105 mEq/L

Because of the severity of the obstruction, H.T. was monitored with an electrocardiogram
that showed sinus tachycardia with occasional premature ventricular contractions.
Albuterol 5.0 mg and ipratropium 0.5 mg were administered by nebulization with
minimal improvement. H.T. then was started on O2 at 4 L/minute by nasal cannula,
followed in 20 minutes by a second dose of albuterol 5.0 mg plus ipratropium 0.5 mg via
nebulizer. Subsequently, H.T.’s heart rate increased to 140 beats/minute, and he
complained of palpitations and shakiness. His PEF was now 25% of personal best.
Laboratory values were as follows:

pH, 7.39

Pao2, 60 mm Hg

Paco2, 42 mm Hg

Na, 138 mEq/L

K, 3.5 mEq/L
 1. What adverse effects experienced by H.T. are consistent with systemic β2-agonist
administration?
2. Why did H.T. fail to respond to the initial therapy? Could tolerance to the β2-agonists
have contributed?
3. Repeat measurements of PEF and ABGs indicate continued significant bronchial
obstruction. What should be the next step in H.T.’s therapy?
4. Are systemic corticosteroids appropriate for H.T.? When can a response be expected?
5. What would be an appropriate dosing regimen of corticosteroids for H.T. in the ED?
Would the dose and route be the same if he were hospitalized?

Case 9

Mr CM is a 56-year-old man with a history of asthma over the preceding 5 years. His height is
177 cm and weight is 80 kg. He had one exacerbation of his asthma 3 years ago that required
hospital admission, and he is currently prescribed Symbicort 200/6 Turbohaler two puffs twice
daily. At his asthma review today, Mr CM reported minimal symptoms from his asthma and
could not remember the last time he used his reliever inhaler. His peak flow was 580 L/min,
which is at his best.

1. Is Mr CM’s asthma controlled?

2. Should Mr CM’s asthma treatment be altered?

3. What potential alterations could be used in Mr CM’s treatment?

Case 10

C.B. is a 3.6-kg newborn boy, born at 39 weeks’ gestational age, who was transferred to the
newborn nursery after delivery. Routine care for neonates during the first hours of life generally
includes administration of erythromycin eye ointment for prevention of neonatal ophthalmia and
1 mg of phytonadione (vitamin K1) given intramuscularly (IM) to prevent vitamin K-deficiency
bleeding of the newborn. C.B.’s parents question the need to give their baby a shot so soon after
birth. How would you explain the rationale for giving phytonadione IM rather than orally?
Case 11

Mr LP, aged 64 years, is attending a medication review clinic. While discussing any concerns Mr
LP has about his medication, he mentions that he suffers from heartburn. On further questioning,
Mr LP explains that his heartburn has been recently getting worse, and that food occasionally
“gets stuck” when he is eating. Mr LP has a past medical history of hypertension, angina and
heart failure. He lives alone and smokes 30–40 cigarettes per day. Mr LP’s medication history is
as follows:

• aspirin 75 mg daily,

• ramipril 5 mg twice a day,

• furosemide 40 mg each morning,

• amlodipine 5 mg each morning,

• isosorbide mononitrate MR 30 mg each morning,

• simvastatin 40 mg at night,

• GTN spray 1–2 sprays when required.

1. What nonmedication advice can you offer Mr LP?

2. What recommendations could you make regarding Mr LP’s drug therapy?

3. Does Mr LP require any further investigation at this stage?

4. How long should the PPI be continued at the treatment dose?

5. Will Mr LP require any further treatment once he has finished the course of treatment
dose PPI?