جامعة نزوى



Case-1Jock is a 72-year old man with recently diagnosed mild heart failure. He has a background ofischaemic heart disease and occasionally suffers from angina. He has no other significant medicalhistory. Jock lives by himself and is active and independent. He is not overweight, does not drinkalcohol and gave up smoking last year.An echocardiogram eight weeks ago showed Jock had a left ventricular ejection fraction of 30%and no valvular abnormalities. At that time, he was started on lisinopril 2.5 mg once daily andfrusemide 40 mg once daily. His GP has been gradually increasing the lisinopril dose, aiming toget him to a maximal dose (20 mg). Serum biochemistry three weeks ago was normal and his GPincreased his lisinopril from 5 mg to 10 mg once daily. Jock’s other medications are aspirin 100 mgonce daily and sublingual nitrate as needed. Jock had repeat serum biochemistry yesterday whichshowed abnormal results: serum creatinine 0.17 mmol/L (normal range for adult men: 0.06–0.12mmol/L) and potassium 5.7 mmol/L (normal range: 3.8–4.9 mmol/L). All other results were normal.Jock feels well and is asymptomatic.1a. Jock’s GP has called to ask your advice about Jock’s heart failure medications. What changes, ifany, would you make to Jock’s current heart failure medications?? No change ? Cease (please specify drug) ? Change (current medication dose or add a new medication). Please specify: Drug Dosefrequency1b. When would you recommend repeat biochemistry for Jock?2. List two different drug classes that may exacerbate heart failure.3. List four main educational points that you would discuss with Jock regarding the self-managementof heart failure.4. Six months later Jock returns to the pharmacy. As his heart failure has been stable, Jock’s GPrecently started him on bisoprolol 1.25 mg once daily. List three ways that complications withbeta-blockers may be minimized.Case-2John is a 64-year-old male new to the area who presents to the surgery. John reports that he has ahistory of hypertension (20 years) and angina (2 years). He was a heavy smoker, 30 per day for 48years, but ceased 9 months ago. He has no history of gastrointestinal bleeding and nil known allergies.A letter from his previous GP reports that John had a non ST segment elevation myocardial infarction(NSTEMI) 12 months ago for which he underwent a percutaneous transluminal coronary angioplastyand stent to his left coronary artery. John was involved in a cardiac rehabilitation program at the localhospital for six weeks after his discharge. Since then he walks briskly for 40 minutes every day anddescribes no angina.Current medications: aspirin 100 mg daily, clopidogrel (Iscover, Plavix) 75 mg daily, perindopril (Coversyl)4 mg daily, simvastatin (Lipex, Simvar, Zocor) 20 mg daily. Further discussion identifies John’s lack ofunderstanding of the purpose of his medicines and he admits to not always being compliant.On examination his blood pressure is 145/85 mmHg, pulse rate 80 per minute regular and his chest isclear on auscultation. Echocardiogram six months ago showed no evidence of heart failure. Body massindex is 23.5 kg/m2. Blood results taken six weeks ago were mostly normal but you note a totalcholesterol of 5.5 mmol/L, low-density lipoprotein (LDL) cholesterol 3.9 mmol/L, high-density lipoprotein (HDL) cholesterol 0.8 mmol/L and triglycerides 1.8 mmol/L.1. What changes (if any) would you make to John’s medication?Aspirin: Cease Continue increase dose: specify new dose ______ mg frequency ______decrease dose: specify new dose ______ mg frequency ______Clopidogrel: Cease Continue increase dose: specify new dose ______ mg frequency ______decrease dose: specify new dose ______ mg frequency ______If continuing clopidogrel, please indicate reason ______________Perindopril: Cease Continue increase dose: specify new dose ______ mg frequency ______decrease dose: specify new dose ______ mg frequency ______Simvastatin: Cease Continue increase dose: specify new dose ______ mg frequency ______decrease dose: specify new dose ______ mg frequency ______2. List any drug(s) you would add to John’s regimen.Drug Dose Frequencyi. __________________________________________________________________________________ii. __________________________________________________________________________________iii. __________________________________________________________________________________3. Based on the new medication regimen, what do the medication(s) offer in cardiovascular riskreduction for John?___________________________________________________________________________________4. List four points/strategies you would discuss/implement with John about his medicines toimprove compliance.Case-3John is a 52-year-old accountant who presents to you complaining of lack of sleep and poor appetite.He also complains of trouble concentrating, decreased energy and has been feeling anxious forabout 8 weeks now.John says he is anxious at work and in social situations. Meetings with his supervisor are a potenttrigger for inducing anxiety. His episodes of anxiety are associated with rapid heartbeat, dry mouthand sweaty palms. He also avoids social situations such as visiting his in-laws, eating lunch with hisco-workers, and supervising staff. He has found avoidance to be an effective means of decreasinghis anxiety. The avoidance of social functions has been putting a strain on his marriage.John is the youngest of 3 siblings. His wife says he has always been a very shy person. He gave upsmoking 2 years ago and says he drinks alcohol to ease his anxiety. He was diagnosed with COPD3 years ago (last exacerbation 3 months ago) which is well controlled with tiotropium 18 microgramsdaily and salbutamol inhaler 200 micrograms every 4-6 hours when required. He has had majordepression 10 years ago which successfully resolved with antidepressants. There is no relevantfamily history.On examination John looks anxious but oriented. He avoids eye contact during consultation. Hedenies any suicidal ideation. His blood pressure is 130/82 mmHg, pulse is 92 beats per min. Theremaining physical examination is normal.1. Based on John’s mental health history what is his likely diagnosis and why?Diagnosis: _____________________________________________________________________________Reason: _______________________________________________________________________________2. a) What management plan would you recommend for John?non-drug therapydrug therapyboth non-drug and drug therapyb) Please provide two reasons for recommending above management plan.(i) __________________________________________________________________________________(ii) _________________________________________________________________________________c) If you recommend non-drug therapy, please specify the type:____________________________________________________________________________________d) If you recommend drug therapy, please specify:Medication Dose Frequency Durationi_______________________ ________________ _______________ ______________________3. List potential adverse effects or drug interactions of the following antidepressants used inthe treatment of anxiety disorders and explain how you would manage theseevents/interactions.AntidepressantAdverse effects/drug interactionsManagementSSRI (escitalopram,paroxetine,sertraline)VenlafaxineMoclobemide4. a) When are benzodiazepines indicated for the management of anxiety disorders?___________________________________________________________________________________b) List two adverse effects/drug interactions when using benzodiazepines for themanagement of anxiety disorders?Case-4Anne is a 75-year-old retired professional who has recently moved to the area. You are seeing her for the first time. Anne is very worried because she is currently experiencing some fatigue and palpitations. Anne was diagnosed with paroxysmal atrial fibrillation (AF) 3 years ago. The investigations at that time included a trans-oesophageal echocardiogram, which showed normal left ventricular function, cardiac valves and left atrium. Since then her AF has been mostly asymptomatic with few episodes of prolonged rapid palpitations which were controlled by a beta blocker at the time. She gave up smoking 5 years ago and does not drink alcohol. Currently, she is not taking any medication. She has no history of previous bleeding episodes. Anne’s father had a non-fatal stroke of presumed ischaemic origin. Her mother had undergone coronary artery bypass surgery. Physical examination shows an irregularly irregular heart rhythm with a rate around 100 beats per minute. Blood pressure is 130/80 mmHg. An electrocardiogram shows AF. Otherwise, her cardiovascular and pulmonary examinations are unremarkable. Anne has brought her pathology results from 1 month earlier. These show normal full blood count, thyroid function tests, serum creatinine and liver function tests.1.a) What is the stroke risk for Anne? Low Moderate High b) What factor(s) led to you decision? 2. In Anne’s case, what are the potential advantages and disadvantages of the following?AdvantagesDisadvantagesAspirinClopidogrelDipyridamolWarfarin3. a) Would you recommend antithrombotic therapy for Anne at this stage? b) If yes, please specify: Medication Starting dose and frequency Time to next review _________________________ _________________________________ Why did you recommend this specific medication(s)? c) If you did recommend any antithrombotic treatment, why not? 4. Regardless of your answers in question 3, if Anne was started on warfarin: a) Are there any existing factor(s) that may increase her risk of major bleeding? If yes, please specify _____________________________________________________________________ b) What information would you give her to achieve optimal anticoagulation? Case-5Lisa is 25 years old and presents a new prescription for budesonide dry powder inhaler,400 micrograms, one inhalation twice a day and salbutamol CFC-free MDI 100 micrograms, oneto two puffs as needed. She has a history of asthma which she previously used salbutamol alone.Lisa?s asthma has been worse lately, she has been using her salbutamol inhaler on approximately5 days of the week to relieve wheeze and chest tightness, she wakes form sleep with wheezeabout once a fortnight. She does not use a peak flow meter to monitor her symptoms.Lisa is otherwise well, has never smoked, takes no other medications and is not allergic to anydrugs.1. How would you grade the severity of Lisa?s asthma?Very mildMildModerateSevereOther (please specify): _____________________________________________2. What adverse effects of inhaled corticosteroids (if any) would you advise Lisa about?____________________________________________________________________________________________________________________________________________________________3. How can Lisa minimise the adverse effects of inhaled corticosteroids?____________________________________________________________________________________________________________________________________________________________4. Outline what counselling you would provide about the use and care of the dry powderinhaler.__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________5. Outline what counselling you would provide about the use and care of the metered doseinhaler.__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________6. What other information (if any) would you provide?_______________________________________________________________________________7. If the patient is not controlled with above medication after a chest infection and is identified to be severe persistent asthma, what changes in treatment is suggested. Write a prescription with drug dosage regimen.Case-6Damien, a 58-year-old brick layer comes for a review of the management of his chronic obstructive pulmonary disease (COPD) as his symptoms have become more troublesome over the past month. He was diagnosed with COPD twelve months ago. Damien was doing well on inhaled salbutamol as needed but for the past 2 months has had a persistent cough and his breathlessness is more apparent. Last spirometry results (5 months ago, after his last COPD exacerbation) were post-bronchodilator FEV1: 60% predicted and FEV1/FVC ratio: 0.65. Damien smokes 25 cigarettes per day (30 years) and has on several occasions attempted to quit smoking without success. His regular medications are salbutamol (Airomir, Asmol, Ventolin) MDI 200 micrograms every 4–6 hours when required. He is also on atenolol (Noten, Tenormin) 50 mg for hypertension and atorvastatin (Lipitor) 10 mg for hypercholesterolaemia (both in the morning). He has no other medical conditions, and has no known allergies. On examination, BP is 135/85 mmHg, pulse 100, respiratory rate 20 and temperature 37°C. He is able to speak in whole sentences and there is no central cyanosis present. Auscultation of the chest reveals widespread expiratory wheezes with slightly reduced air entry on both sides.1. Would you recommend any diagnostic imaging or pathology tests to assist in assessing Damien’s current condition? ??yes (please specify) ??no Investigation: Reason: 2. Would you recommend continuing or adding on any of the following medicines* at this visit? (Mark all that apply i.e. for combination products, mark all ingredients.) regular salbutamol ??yes ??no eformoterol or salmeterol ??yes (alone) ??yes (with salbutamol) ??no ipratropium ??yes (alone) ??yes (with salbutamol) ??no inhaled corticosteroids ??yes(alone) ??yes (with salbutamol) ??no oral corticosteroids ??yes (alone) ??yes (with salbutamol) ??no tiotropium ??yes (alone) ??yes (with salbutamol) ??no atenolol??yes (alone) ??yes (with salbutamol) ??no 3. If you recommend starting another medicine for the management of Damien’s COPD:a) When will you assess the efficacy of the medicine(s)b) How will you assess the efficacy?c) For the medicine(s) you recommended, what are the two most important points you willcounsel Damien on?4. Damien is ready to quit smoking again and would like some help. a) How would you assess the severity of his nicotine dependence?b) Would you recommend drug therapy??yes, please specify:?no, why not?MedicationDoseFrequencyDurationa)c)What are two non-drug therapies you would recommend for Damien to assist him to quit smoking?Case-7Winston is a 64-year-old artist who has come back to see you for worsening back pain. For the past3 years paracetamol and ibuprofen have been effective in controlling his non-specific back pain. Hereports the increasing pain is distracting him from his work and making simple daily tasks such asmoving his easel and walking to the nearby wine bar increasingly difficult.Winston lives alone and drinks 2 or 3 glasses of wine a day. He takes irbesartan (Avapro, Karvea)300mg for hypertension and atorvastatin (Lipitor) 10mg for hypercholesterolaemia (both in themorning). He takes paracetamol 1 g regularly four times a day and ibuprofen when required forbreakthrough pain. Winston has no history of falls or injury. His family history is unremarkable withrespect to cardiovascular diseases, cancer or musculoskeletal disorders. Further questioningrevealed no neurological symptoms or sciatica.On examination there is no sign of asymmetry or inflammation of the lumbar spine. There is somerestriction of movement on lumbar flexion but not on extension. His blood pressure is 126/80 mmHg.His body mass index is 31kg/m2. His renal and liver function test, fasting blood glucose and full bloodcount are in the normal range.1. a) Would you refer Winston for any diagnostic imaging or additional pathologyinvestigations at this stage?yes (please specify): __________________________________________ nob) Would you have requested any diagnostic imaging or pathology investigations whenWinston first presented with a two week history of back pain?yes (please specify): __________________________________________ no2. a) Provide a reason why a pain diary might be helpful for managing Winston’s pain.____________________________________________________________________________________b) A pain management plan is formulated for Winston at this stage.Outline two non-drug strategies to be included in his management plan.3. a) Which of the following would you consider recommending for Winston’s painmanagement? (Give one reason why/why not in terms of analgesic effect, precautions,contraindications, etc.)i) buprenorphine yes noReason: ______________________________________________________________________________ii) codeine/codeine combination products yes noReason: ______________________________________________________________________________iii) conventional or COX-2 selective NSAID yes noReason: ______________________________________________________________________________iv) fentanyl yes noReason: ______________________________________________________________________________v) morphine yes noReason: ______________________________________________________________________________vi) oxycodone yesnoReason: ______________________________________________________________________________vii) tramadol yes noReason: ______________________________________________________________________________b) Please specify your preferred opioid for Winston.Medication & formulation Initial dose Frequency Duration Review14. a) When starting an opioid, how long would your trial last?2–4 weeks 4–6 weeks 3 monthsb) Give two instances where an opioid trial would successfully continue to maintenancetherapy.Case-8Stephen is a 68-year-old man who you have recently diagnosed with heart failure. Stephen has ahistory of ischaemic heart disease (5 years) including an ST-segment-elevation myocardial infarction 5years ago for which he had a coronary angioplasty and stent. Since then he has had no angina. Othermedical history: hyperlipidaemia (5 years). His echocardiogram a week ago showed a left ventricularejection fraction of 35%, with no valvular abnormalities. He is not overweight and has no history ofsmoking.Stephen’s current medications are aspirin 100 mg daily, atenolol 50 mg daily and atorvastatin 20 mgdaily. In addition to changing Stephen’s beta blocker, you consider starting an angiotensin II-receptorantagonist, as you recall a recent visit from a pharmaceutical sales representative that provided youwith some information on candesartan and its use in heart failure. The promotional material includedthe statement:‘Candesartan reduces cardiovascular mortality and hospitalisation, and improves symptoms in heart failure patients with a LVEF ≤ 40% as shown in the candesartan in heart failure assessment of reduction in mortality and morbidity (CHARM) program’*You have had little experience with use of angiotensin II-receptor antagonists in heart failure.1. Based on the information from the pharmaceutical sales representative, would you prescribean angiotensin II-receptor antagonist as first-line management for Stephen’s heart failure?No (please indicate why) Yes (please indicate why)2. List the important issues to consider before prescribing angiotensin II-receptor antagonistfor Stephen? (e.g. What was the absolute risk reduction in mortality?)i. _____________________________________________________________________________________ii. _____________________________________________________________________________________iii. ____________________________________________________________________________________3. What specific comparative information would you require about an angiotensin II-receptorantagonist versus angiotensin converting enzyme (ACE) inhibitor before considering prescribingan angiotensin II-receptor antagonist for heart failure? (e.g. What studies have shown if thereduction in mortality is the same for angiotensin II-receptor antagonist and ACE inhibitors?)Efficacy: _____________________________________________________________________________Safety: ______________________________________________________________________________Other considerations: ________________________________________________________________4. List four additional sources of information (if any) you will use to form the basis of yourdecision?i. _____________________________________ iii. ________________________________________ii. _____________________________________ iv. ________________________________________Case-9Mike, a 51-year old businessman. Present for a company sponsored ‘checkup’ . He works long hours and has no specific health complaints and no regular medications. Mike recently cut down to 5-10 cigarettes a day but previously smoked ‘a pack a day’. He doesn’t exercise regularly but is aware of its importance. His father died of acute myocardial infarct aged 75and his mother has never had any ‘heart troubles’. He has two older siblings, one with hypertension and the other with diabetes.On examination his blood pressure is 140/80 mmHg, height 180cm, weight 87 kg (BMI27kg/m2), random BSL 5mmol/L. The remainder of his physical examination is unremarkable.Fasting lipids levels reveal: Test Result(mmol/L) Total cholesterol 6.7 LDL cholesterol 3.6 HDL cholesterol 1.2 Triglycerides 1.8What do you estimate Mike’s level of cardiovascular risk to be? Lower absolute risk/ higher absolute risk( please circle)What additional investigations (if any) would you order?Would you prescribe a drug? Yes or No ( please circle)If you chose to write a prescription please fill in your choice: Drug: Dose and frequency:If you chose not to write a prescription please explain why not:What advice (if any) would you provide?When would you review management? ................
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