CLINICAL THERAPEUTICS 3B

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CASE 7 QUESTIONS
Source:
Diagnosis, Empiric Management and Prevention of Community Acquired Pneumonia in
Immunocompetent Adults 2016 Update
Harrison’s Principles of Internal Medicine 20th edition
Katzung’s Basic and Clinical Pharmacology 14th edition

1. What is your main clinical diagnosis?

Community acquired pneumonia, moderate risk

2. What are the bases for your diagnosis?

• History: babysitting grandchild with URTI and otitis media

• S/sx: dyspnea, cough, chest discomfort, shortness of breath, fever
• PE: tachypneic, tachycardic, desaturation at 87%, wheezing and decreased breath sounds
on righ lung eld

3. Explain the pathophysiology of your diagnosis.

CAP is usually spread by droplet infection and most cases occurs previously healthy
individual. Several factors can impair the e ectiveness of local defenses and predispose to
CAP. Colonization of the pharynx with pathogens, followed by micro-aspiration, is the
mechanism of entry into the lower respiratory tract. In the interaction between the pathogen
and host pulmonary defense, pneumonia results if there is a defect in host defense or it is
overcome by high inoculum or virulence of the pathogen.

4. What are the potential pathogens involved?

Strep. pneumoniae is the single most common de ned pathogen in nearly all studies of
hospitalized adults with community-acquired pneumonia. Other bacteria commonly
encountered in cultures of expectorated sputum are Haem. in uenzae, Staph. aureus, and
gram- negative bacilli. Less common agents are Moraxella catarrhalis, Strep. pyogenes, and
Neisseria meningitides

5. What other pertinent laboratory tests will you request?

• CBC
• Basic metabolic panel
• Blood gas analysis
• Serum biomarkers i.e CRP and prolactinin
• PCR test

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6. How will you address the patient’s condition pharmacologically?

Initial: IV non-antipseudomonal beta-lactam (BLIC, cephalosphorin) with either an extended

macrolide or respiratory uoroquinolone
• Ampicillin-Sulbactam 1.5 gm q6h IV /Cefuroxime 1.5 g q8h IV /Ceftriaxone 2g OD
• PLUS
• Azithromycin 500mg OD PO / Clarithromycin 500mg BID PO/ Levo oxacin 500mg OD PO/
Moxi oxacin 400mg OD PO

7. How can response to therapy be assessed?

• Temperature, respiratory rate, heart rate, blood pressure, sensorium, oxygen saturation,
and inspired oxygen concentration should be monitored to assess response to therapy.
• Response to therapy is expected within 24 to 72 hours of initiating treatment. Failure to
improve after 72 hours of treatment is an indication to repeat the chest radiograph
• Follow-up cultures of blood and sputum are not indicated for patients who are responding
to treatment.

8. Will your patient need de-escalation of medication?

De-escalation of initial empiric broad-spectrum antibiotic or combination parenteral therapy

to a single narrow spectrum parenteral or oral agent based on available laboratory data is
recommended once the patient is clinically improving, is hemodynamically stable and has a
functioning gastrointestinal tract.

9. Is there a need for repeat chest x ray after completion of medication?

Yes. For patients who are hospitalized, a follow-up radiograph is recommended 4-6 weeks
after discharge.

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CASE 8 QUESTIONS
Reference: Pharmacotherapy: Principles and Practice by Chrisholm-Burns et al (4th
edition, 2016) – Chapter 44 – Thyroid Disorders

1. Describe the methods used in screening for hypothyroidism (see Screening for
Hypothyroidism)(1)

• In most patients with thyroid hormone disorders, measurement of a serum TSH level is
adequate for initial screening and diagnosis of hypothyroidism and hyperthyroidism
• Serum free thyroxine FT4) and triiodothyronine (FT3) levels may be helpful in distinguishing
mild (subclinical) thyroid disease from overt disease.

2. Enumerate the common primary and secondary causes of hypothyroidism (See

Table 44 – 2 - Common Causes of Hypothyroidism)(1)

Primary Hypothyroidism Secondary Hypothyroidism

• Autoimmune Thyroiditis (Hashimoto’s Disease) • Pituitary disease

• Iatrogenic (irradiation, surgery) • Hypothalamic disease
• Drugs (e.g., amiodarone, radiocontrast media,
lithium, interferon-a, tyrosine kinase inhibitors)
• Iodine De ciency and Excess

3. Enumerate the signs and symptoms of hypothyroidism (See Clinical Presentation

and Diagnosis of Hypothyroidism)(1)

Signs Symptoms
• bradycardia
• lethargy, fatigue
• non-pitting edema
• depression
• dry skin
• weight gain, constipation
• slow movements
• cold intolerance
• slow speech
• menstrual irregularities
• hypore exia and delayed relaxation of
• paresthesia
re ex
• hoarseness

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4. What laboratory parameters point to a diagnosis of mild or subclinical and overt

hypothyroidism?(See Clinical Presentation and Diagnosis of Hypothyroidism)(1)

• TSH level of 4.5-10 mIU/L

• Free T4 level will be normal (0.7-1.9 ng/dL)

5. What are the major goals in the treatment of hypothyroidism? (See Treatment of
Hypothyroidism)(1)
• Restoration of euthyroid state
• Reversal of clinical progression of the patient
• Correct metabolic derangements

6. Enumerate the 4 thyroid preparations and describe their content. (See Table 44
– 3 – Thyroid Preparations)(1)

7. Why is synthetic LT4 the treatment of choice for almost all patients with
hypothyroidism? (See Treatment of Hypothyroidism – Thyroid Hormone
Products – Key Concept)(1)
• LT4 mimics the normal physiology of the thyroid gland, which secretes mostly T4 as
a prohormone. Peripheral tissues convert T4 to T3 as needed based on metabolic
demands. If T3 is used to treat hypothyroidism, the peripheral tissues lose their
ability to control local metabolic rates.
• With a 7- to 10-day half-life, LT4 provides a very smooth dose-response curve with
little peak and trough e ect.

8. Fill in the blanks.In patients younger than age 65 years with overt
hypothyroidism,the average LT4 replacement dose is 1.6 __________
mcg/kg/day (use idealbody
weight in obese patients).The full replacement dose in patients older than age 75
1mcg/kg/day .(See Treatment of Hypothyroidism – Thyroid
yearsis lower, about __________
Hormone Products – Therapeutic Use of LT4)(1)

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9. What are the risks of overtreatment and undertreatment with LT4? (See
Treatment of Hypothyroidism – Thyroid Hormone Products – Risks of
Overtreatment and Undertreatment)(1)
• Overtreatment: may cause subclinical hyperthyroidism or even overt
hyperthyroidism with risk of atrial brillation, depression or mental status
changes in adults
• Undertreatment: may cause progression of disease, hypercholesterolemia and
further metabolic derangements
10. How will LT4 therapy be monitored in patients with hypothyroidism? (See Table
44-5 Monitoring LT4 Therapy)(1)

• Serum TSH monitoring every 6-12 months or if there is a change in clinical status
◦or 6-8 weeks after any dose or product change
• Assess for signs and symptoms of over- and undertreatment
• Identify potential interactions between LT4, and foods and/or drugs

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