CSE Workshop Assessment for BPharm year 1 – 2

Mrs. PN is a 55-year-old woman was referred to the pharmacist for pharmacotherapy assessment
and diabetes management. She had multiple medical conditions. She was diagnosed of type 2
diabetes diagnosed in 1995. She also has hypertension, hyperlipidemia, asthma, and longstanding
musculoskeletal pain due to a motorbike accident. Her medical history includes knee replacement
and multiple emergency room admissions for asthma.
Diabetes of Mrs. PN is currently being treated with a premixed preparation of 75% insulin lispro
protamine suspension with 25% insulin lispro preparation (Humalog 75/25), 33 units before breakfast
and 23 units before supper. She says she occasionally ‘takes a little more’ insulin when she notes
high blood glucose readings, but she has not been instructed on the use of an insulin adjustment
algorithm.
Her other routine medications include
Fluticasone metered dose inhaler, two puffs twice a day
Salmeterol MDI, two puffs twice a day
Naproxen 375 mg twice a day
Enteric-coated aspirin, 325 mg daily
Rosiglitazone 4 mg daily
Fluvastatin 20 mg at bedtime
Albuterol MDI, two to four puffs every 4–6 hours for shortness of breath.

She smokes 8 – 10 cigarettes a day but denies use of nicotine, alcohol, or recreational drugs, and
has no known drug allergies.
Her chief complaint now is increasing exacerbations of asthma and the need for prednisone. She
reports that during her last round of prednisone therapy, her blood glucose readings increased to
the range of 300–400 mg/dl despite large decreases in her carbohydrate intake.
She reports that she increases the frequency of her fluticasone MDI, salmeterol MDI, and albuterol
MDI to four to five times/day when she has a flare-up.
However, due to financial constraint she has been unable to purchase the fluticasone or salmeterol
these days and so has only been taking prednisone and albuterol for recent acute asthma
exacerbations.
She reports eating three meals a day with a snack between dinner and bedtime. She takes her
largest meal in the dinner. She has not been able to exercise routinely for several weeks because of
bad weather and her asthma.
Her mean blood glucose level of the past 30 days (avg of 53 tests) was of 241 mg/dl (std. dev. 74).
Her premeal glucose target was set at 70–140 mg/dl. From the blood glucose reading log it was
identified that there were no readings below target, 8% was within target, and 91% was above target.
When last year’s blood glucose record was accessed, her results averaged 112 mg/dl, with a high
of 146 mg/dl and a low of 78 mg/dl.

Her physical exam findings are as following:

Mrs. PN is obese with no acute distress. Physical exam reveals:
 Weight: 302 lb., height 5′1″
 Blood pressure: 130/78 mmHg
 Pulse 88 bpm, respirations 22 per minute
 Lungs: clear to auscultation bilaterally

Her lab results are as below:

 Glycated hemoglobin (HbA1C) measured 6 months ago: 7.0% (target: <7%)
 Creatinine: 0.7 mg/dl (normal range: 0.7–1.4 mg/dl)
 Blood urea nitrogen: 16 mg/dl (normal range: 7–21 mg/dl)
 Sodium: 140 mEq/l (normal range: 135–145 mEq/l)
 Potassium: 3.5 mg/dl (normal range: 3.5–5.3 mg/dl)
 Calcium: 8.2 mg/dl (normal range: 8.3–10.2 mg/dl)
 Lipid panel
o Total cholesterol: 211 mg/dl (normal range <200 mg/dl)
o HDL cholesterol: 52 mg/dl (>55 mg/dl for female)
o LDL cholesterol (calculated): 128 mg/dl (target: <100 mg/dl)
o Triglycerides: 154 mg/dl (target: <150 mg/dl)
 Liver function panel: within normal limits
 Urinary albumin: <30 mg/ml (normal range: <30 mg/ml)

Further assessments revealed the following;

 Poorly controlled, severe, persistent asthma
 Diabetes; control recently worsened by asthma exacerbations and treatment
 Dyslipidemia, elevated LDL cholesterol despite statin therapy
 Obesity, stable
 Chronic pain secondary to previous injury, stable
 Status post–knee replacement
 Financial constraints affecting medication behaviors
 Insufficient patient education regarding purposes and role of specific medications

Assessment questions:
1. List down the issues you identified in this patient.
2. Describes interventions that can be made by pharmacists in order to improve the health and
quality of life of Mrs. PN. (for answer refer ‘FIP’s Diabetes prevention, screening and
management A handbook for pharmacists 2021”)
3. How are you going to help this patient quit smoking? (for answer refer ‘WHO “Toolkit for
delivering the 5A’s and 5R’s brief tobacco interventions in primary care’)