MODULE 5 AND 6

P.S is a 35-year-old, 139-kg, 61-inch-tall man who presents with complaints of indigestion. He
experiences the following: burnings sensation behind his breastbone and belching. His symptoms
began a few months ago and they only occur a few months ago. He is fond of eating large meals
before bedtime. He asks if he could take anything in order to prevent his symptoms. He is using
liquid antacids and states that they work fairly well, but he has to take frequent doses, as the
symptoms return quickly.

A. Which of P.S’ s symptoms are consistent with GERD? (5 points)

B. What are the therapeutic goals for the treatment of P.S.’s GERD? (5 points)
C. Which OTC pharmacologic options (if any) would you recommend to P.S.? (5 points)
*
A. The symptom's of P.S. that is consistent with GERD is that he experience burning sensation
behind his breastbone and bleaching and he is fond of eating large meals before bedtime. B.
Treatment of gastroesophageal reflux disease (GERD) involves a stepwise approach. The goals
are to control symptoms, to heal esophagitis, and to prevent recurrent esophagitis or other
complications. The treatment is based on (1) lifestyle modification and (2) control of gastric acid
secretion through medical therapy with antacids or PPIs or surgical treatment with corrective
antireflux surgery. C. I would recommend Omeprazole to P. S. omeprazole commonly known as
Prilosec, is a PPI that reduces the quantity of food-digesting acid made by the cells within the
lining of your stomach. In fact, Prilosec was one of the first and strongest PPIs created to combat
acid reflux.
L.V a healthy 35-year-oldman who works as street sweeper at NCR. He complains of a 2-week
history of burning stomach with indigestion and bloating. The pain sometimes awakens him at
night, but it has increase the frequency over the last week. A week ago, L.V. tried an OTC H2-
receptor antagonist that “lasted longer” but did not provide adequate symptom relief. L.V.
indicates that he experienced a similar type of pain about 10 years ago when he was treated with
omeprazole for a suspected peptic ulcer. He has smoked one pack of cigarettes daily for the past
20 years, has an occasional glass of red wine with dinner, and usually drinks 4 to 6 cups of
caffeinated coffee throughout the day. L.V. takes acetaminophen for occasional headaches and
amultivitamin but denies the use of any other OTC or prescription medications, including
NSAIDs. L.V. underwent upper endoscopy (EGD), which revealed a single 0.5-cm ulcer in the
duodenal bulb. The ulcer
base was clear without evidence of active bleeding. Antral gastritis was biopsy positive for H.
pylori.

A. What risk factors may have contributed to ulcer recurrence in this patient? (5 points)

B. L.V. is prescribed a 14-day PPI-based three-drug eradication containing amoxicillin and

clarithromycin.
What instructions would you provide R.L. regarding his medications? (5 points)

C. What would have been the preferred initial H. pylori eradication regimen if L.V. had a
documented allergy
to penicillin? (5 points)
*
A. The risk factors that causes of peptic ulcers are infection with the bacterium Helicobacter
pylori (H. pylori) and long-term use of nonsteroidal anti-inflammatory drugs (NSAIDs) such as
ibuprofen (Advil, Motrin IB, others) and naproxen sodium (Aleve) and alcohol consumption. B.
The standard triple therapy as the firstline of treatment to H. pylori infection is based on proton
pump inhibitors (PPI), clarithromycin, and amoxicillin or metronidazole. The therapeutic time
spans from 7 days to 2 weeks. C. pylori-infected patients who are allergic to penicillin may be
treated with a first-line treatment combining a proton-pump inhibitor, clarithromycin and
metronidazole. Rescue options may include a regimen with ranitidine bismuth citrate,
tetracycline and metronidazole.
Z.M., a 27-year-old male college student, has had episodic, watery diarrhea and colicky
abdominal pain relieved by defecation for the past 9 months. Eight weeks before admission, the
diarrhea increased to 3 to 5 semi-formed stools daily. The frequency of the stools gradually
increased to 5 to 10 times a day 1 week ago. At that time, Z.M. noted bright red blood
in the stools. Stool frequency has now increased to 10 to 15 per day, although the volume of each
stool is estimated to be only “one-half cupful.” She feels a great urgency to defecate, even
though the volume is small. She has not traveled outside the United States, has not been
camping, and has not taken any antibiotics within the past 6 months. Z.M. complains of anorexia
and a 10-lb weight loss over the past 2 months. For the past 4 months, she has had intermittent
swelling, warmth, and tenderness of the left knee, which is unassociated with trauma. She denies
any skin rashes or any difficulties with her vision. A review of other body systems and social and
family history are noncontributory. Z.M. appears to be a slightly anxious and tired young woman
of normal body habitus. Her temperature is 100◦F; her pulse rate is 100 beats/minute and regular.
Physical examination is normal, except for evidence of acute arthritis of the left knee and
tenderness of the left lower abdomen to palpation. Stool examination shows a watery effluent
that contains numerous red and white cells with no trophozoites. Stool cultures and an amebiasis
indirect hemagglutination test are negative.
Other laboratory values include hematocrit (Hct), 32% (normal, 33%–43%); hemoglobin (Hgb),
8.5 g/dL (normal, 12.3– 15.3 g/dL); white blood cell (WBC) count, 15,000/mm3 (normal, 4.4–
11.3/mm3) with 82% PMNs (normal, 50%–70%); ESR, 70 mm/hour (normal,<20 mm/hour);
serum albumin, 2.4 g/dL (normal, 3.5–5.0 g/dL); and alanine aminotransferase (ALT), 35
U/mL (normal, 8–20 U/mL). Sigmoidoscopy showed evidence of granular, edematous, and
friable mucosa with continuous ulcerations extending from
the anus throughout the colon.

1. Would it be safe to administer loperamide to Z.M.? (5 points)

2. What agents can be used to induce disease remission in Z.M.? (5 points)
3. What if Z.M.’s UC was limited to the distal colon or rectum? Would topical corticosteroids be
indicated?
When should other topical agents be used (e.g., 5-ASA)? (10 points)
*
1. Yes, but Loperamide may increase your risk for stomach or bowel problems. Check with your
doctor right away if you have bloating, blood in the stools, constipation, fever, loss of appetite,
nausea or vomiting, or stomach pain. If you've bought loperamide from a pharmacy or shop, do
not take it for more than 48 hours without talking to a doctor. Only take the recommended
amount. Too much loperamide can cause serious heart problems (including a fast or irregular
heartbeat). 2. Cyclosporine is effective for inducing remission in severely active and refractory
ulcerative colitis, with an efficacy equivalent to that of infliximab. Tacrolimus is effective for
inducing remission in active disease, but no long-term safety and efficacy data exist. 3.
Prednisone is a steroid with anti-inflammatory effects. It is used to treat inflammation in
ulcerative colitis. However, steroids do not prevent symptoms from returning and have many
side effects. Prednisone can be taken with or without food. The tablets may be crushed, and there
is a liquid solution available. You should take extra calcium and vitamin D because prednisone
affects bone strength.

MODULE 7&8

Ms. M.P is a 31-year old woman who has no significant medical history, except for primary
dysmenorrhea and motion sickness when travelling by air. She previously took dimenhydrinate
for airplain trips. She is to be married soon, so she decided to travel abroad together with her
fiancé. She is concerned that she may also develop sea sickness and that dimehydrinate may not
control her symptoms.

1. Will M.P be at higher risk for motion sickness? (5 points)

2. What non-pharmacologic measures may be useful for reducing motion sickness? (5 points)
3. What medications are available to prevent and treat motion sickness for M.P? (5 points)
*
MODULE 7

1.Will M.P be at higher risk for motion sickness?

ANSWER: Avoiding situations that cause motion sickness is the best way to prevent it, but that
is not always possible when you are traveling. As it define, motion sickness happens when the
movement you see is different from what your inner ear senses. This can cause dizziness, nausea,
and vomiting. You can get motion sick in a car, or on a train, airplane, boat, or amusement park
ride. Motion sickness can make traveling unpleasant, but there are strategies to prevent and treat
it. So in the situation of M.P she take a medicine dimehydrinate, so there is a chance that she
may control her symptons.

2.What non-pharmacologic measures may be useful for reducing motion sickness?

ANSWER: Non-oharmacologic interventions are classified as behavioural interventions and
include relaxation, biofeedback, self-hypnosis, cognitive distraction, guided imagery and
systemic desensitization.

3.What medications are available to prevent and treat motion sickness for M.P? ANSWER:
Antihistamines are the most frequently used and widely available medications for motion
sickness; nonsedating ones appear to be less effective. Antihistamines commonly used for
motion sickness include cyclizine, dimenhydrinate, meclizine, and promethazine (oral and
suppository).
P.T., a 70-year-old man with long-standing hypothyroidism, has been receiving L-thyroxine 0.2
mg/day. Currently, he is in the hospital with a stroke and paralysis that prohibits him from
swallowing oral medications. His last thyroid function tests were normal.

1. What is a reasonable method of administering thyroid hormone to P.T.? (5 points)

*
In my own opinion, the reasonable method of administering thyroid hormone for P.T is that
thyroid hormone is liberated into the bloodstream by the process of proteolysis within thyroid
cells. A reasonable method to administer thyroid hormones to P.T. is a blood test. Since P.T is
prohibited from swallowing oral medications.

V.V. is a 35-year-old woman with Hashimoto’s thyroiditis who is 6 weeks pregnant. Laboratory
test results showed TT4, 5 mcg/dL (normal, 5–12) and FT4, 0.7 ng/dL (normal, 0.7–1.9). She
takes her medications in the morning, which include L-
thyroxine 0.1 mg/day and a prenatal vitamin enriched with iron and calcium. V.V. delivered a
healthy baby, B.V., at term without difficulty. B.V.’s postpartum screening serum T4 level was 5
mcg/dL (normal, 5–12), and TSH was 35 μunits/mL (normal, 0.5–4.7). At home, B.V. became
lethargic, had a weak cry, sucked poorly, and failed to thrive.

1. What dosing adjustments are required because of P.K.’s pregnancy? (5 points)

2. How is mental development affected? (5 points)
*
1. Levothyroxine (L-thyroxine, T4) It should be started on 50 mcg daily of levothyroxine and
increased in to 100 mcg daily after month.

2. Postpartum thyroiditis is a relatively rare condition that affects some women after pregnancy.
An estimated 5% of women may experience this in the year after giving birth. It can result in
hyperthyroidism and thyroid disease can affect your mood — primarily causing either anxiety or
depression. Weight loss, anxiety, feeling warm, feeling anxious, rapid heart rate, excessive hair
loss is one of the symptoms of thyroiditis.