Assignment Of Clinical Pharmacy

Submitted by: Quratulain KaimKhani

PHAE/2K9/64

10/29/2013

Faculty Of Pharmacy,

University Of Sindh

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Case Studies

Case Study 1. Drug Related Problem

Case Study 2. Alcohol Toxicity

Case Study 3. Patient Counseling

Case Study 4. Peptic Ulcer

Case Study 5. Drug and the Newborn

Case Study 6. Night time Anxiety

Case Study 7. Clostridium Difficile

Case Study 8. Epilepsy and Pregnancy

Case Study 9. Parkinsonism

Case Study 10. Treatment May Be Worse Than Condition

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Clinical Pharmacy

Terms Used.

Acitretin. Acitretin is used to treat severe psoriasis (abnormal growth of skin cells that

causes red, thickened, or scaly skin). Acitretin is in a class of medications called retinoids. The way acitretin works is not known. Athlete's foot. Athlete's foot also known as ringworm of the foot, or tinea pedis, is

a fungal infection of the skin that causes scaling, flaking, and itch of affected areas, and in severe cases, swelling and amputation of the foot. It is caused by fungi in the genus Trichophyton.

Campylobacter. Campylobacter (twisted bacteria) is a genus of bacteria that

are Gram-negative, spiral, and microaerophilic. Motile, with either unipolar or bipolar flagella, the organisms have a characteristic spiral/corkscrew appearance At least a dozen species of Campylobacter have been implicated in human disease.

Clostridium difficile. A species of Gram-positive spore-forming bacterium that is

best known for causing antibiotic-associated diarrhea. While it can be a minor normal component ofcolonic flora, the bacterium is thought to cause disease when competing bacteria in the gut have been wiped out by antibiotic treatment. In severe cases, C. difficile can cause "pseudomembranous colitis, a severe inflammation of the colon.

Ethosuximide. Ethosuximide is a succinimide anticonvulsant, used mainly in absence seizures.

Hematemesis. Hematemesis or haematemesis is the vomiting of blood. The source

is generally the upper gastrointestinal tract.

Oxcarbazepine. is an anticonvulsant and mood-stabilizing drug, used primarily in the treatment of epilepsy. It is also used to treat anxiety and mood disorders, and benign motor tics. Oxcarbazepine is marketed as Trileptal by Novartis.

Psoriasis. is an immune-mediated disease that affects the skin. It is typically a

lifelong condition. There is currently no cure, but various treatments can help to control the symptoms. Psoriasis occurs when the immune system mistakes a normal skin cell

for a pathogen, and sends out faulty signals that cause overproduction of new skin cells. It is not contagious.

Psoralen. It is the parent compound in a family of natural products known

as furocoumarins. It is structurally related to coumarin by the addition of a

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fusedfuran ring, and may be considered as a derivative of umbelliferone. Psoralen occurs naturally in the seeds of Psoralea corylifolia, as well as in the common fig, celery, parsley and West Indian satinwood.

PUVA Therapy. PUVA is a psoralen + UVA treatment for eczema, psoriasis, graft-

versus-host disease, vitiligo, mycosis fungoides, large-plaque parapsoriasis and cutaneous T-cell lymphoma. The psoralen is applied or taken orally to sensitize the skin, then the skin is exposed to UVA.

Selegiline. Selegiline is used to help control the symptoms of Parkinson's disease (PD; a disorder of the nervous system that causes difficulties with movement, muscle control, and balance in people who are taking levodopa and carbidopa combination (Sinemet). Selegiline may help people with Parkinson's disease by decreasing the dose of levodopa/carbidopa needed to control symptoms, stopping the effects of levodopa/carbidopa from wearing off between doses, and increasing the length of time that levodopa/carbidopa will continue to control symptoms. Selegiline is in a group of medications called monoamine oxidase type B (MAO-B) inhibitors. It works by increasing the amount of dopamine (a natural substance that is needed to control movement) in the brain. Tonic–Clonic Seizure. Tonic-clonic seizures are the most common and best known

type of generalized seizure. They begin with stiffening of the limbs (the tonic phase), followed by jerking of the limbs and face(the clonic phase). During the tonic phase, breathing may decrease or cease altogether, producing cyanosis (turning blue) of the lips, nail beds, and face. Breathing typically returns during the clonic (jerking phase), but it may be irregular. This clonic phase usually lasts less than a minute.

Valproic Acid. an acidic chemical compound, has found clinical use as an anticonvulsant and mood-stabilizing drug, primarily in the treatment of epilepsy,bipolar disorder, and, less commonly, major depression. It is also used to treat migraine headaches.

Zolpidem Zolpidem is a sedative, also called a hypnotic. It affects chemicals in your brain that may become unbalanced and cause sleep problems. Zolpidem is used to treat insomnia.

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Clinical Pharmacy

Case Study 1.

A patient visits his physician because he has complain of hypertension, headache, fever

and abdominal cramp. Physician prescribed him atenolol 50mg, ibuprofen 400mg, and

buscopan. After 2days the patient reports about high blood pressure, that his

hypertension not got treated yet. What would you suggest him and what change should

be done in the prescription of the patient?

Answer.

Treatment for this patient is improper. Atenolol is a selective B1-receptor antagonist. It

produces negative ionotropic and negtative chronotropic effects. Hyoscine

butylbromide (Buscopan) is non selective drug. It is peripherally acting antimuscarinic

agent, used as an abdominal specific spasmodic. It causes relaxation of of gastro-

intestinal tract, but in heart it acts on cardiac muscles or muscarinic receptor, and

produce the positive chronotropic and positive ionotropic effects. This effect is against

Atenolo. Buscopan should be replace by Mebverine, which is musculotropic agent and

directly acts on gut wall and causes relaxation.

Case Study 2.

A 24-year old student is brought into the emergency department complaining of

vomiting, light-headedness, chest pain, and difficulty in breathing. You discover that he

fell ill at a party. Initially he and his friends deny any drugs other than beers at party.

Then he told that he is taking metronidazole for about the past 10days to control the

symptoms of athlete’s foot. What might be the cause of his symptoms?

Answer.

Metronidazole shares the ability of disulfirum to block the metabolism of alcohol and

cause an accumulation of acetaldehyde. The student’s symptoms are consistent with

accumulation of this agent.

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Case study 3.

A 28 years old, married woman, who presents a prescription for ciprofloxacin to a

pharmacy to be filled. When giving out the medicine, the pharmacist checks whether

Mrs KH takes any other medicines. She explains she takes iron tablets each morning

but nothing else.

Answer.

The pharmacist recoomends that she takes ciprofloxacin in the morning and at night,

avoiding milk at these times and take the iron at lunchtime. Heavy meal ions such as ion

or calcium can bind with ciprofloxacin to produce an insoluble salt that will not dissolve

and be absorbed from the git. The interaction could cause therapeutic failure of the

antibiotic. This could be avoided by taking ciprofloxacin atleast 2hours before or after

iron or calcium. Taking the iron at lunch time and avoiding milk (which contains calcium)

close to administration times will avoid this interaction. Calcium in the other food

sources in a normal diet is not usually sufficient to impair absorption.

Case study 4.

A 32-year old working woman, who describes her life stressful. She smokes 1 pack of

cigarettes per day. She frequently takes naproxen for headaches. For the past 5 weeks

she has noticed significant epigastric discomfort. This morning she went to the

emergency department complaining of hematemesis. She was admitted, and the

gastroenterologist performed an upper endoscopy that revealed 1-cm ulcer. Is further

evaluation necessary, and what recommendations would you make to this patient?

Answer.

Peptic ulcer disease is most frequently either Helicobacter pylori infection or use of

NSAIDs. The patient does admit to NSAID use (Naproxen), but should also be checked

for concomitant H.pylori infection at time of endoscopy or by a serology test. If patient

was found to have H. pylori, an appropriate eradication regimen should be prescribed.

The patient should be prescribed a proton pump inhibitor for 8 weeks to heal the ulcer.

A repeat endoscopy should be done at that time to document ulcer healing. In addition,

patient should be counseled to stop smoking, which is risk factor for more severe peptic

ulcer disease.

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Case study 5.

A mother calls to tell that her week-old baby is having convulsions. She says the baby

showing signs of a serious ear infection soon after birth. A physician prescribed

penicillin G that apparently ear infection appeared to be reduced, but the baby began to

have convulsions about an hour after receiving the last injection of penicillin. What

would you advise the mother to do?

Answer.

Pencillin G is a potent antagonist of the inhibitory neurotransmitter y-GABA. Since

penicillin G normally does not penetrate the blood-brain barrier to any extent, this is not

usually a problem. But the blood-brain barrier is not fully developed at birth, and

substances that normally are excluded from entering the CNS may enter the immature

brain of the newborn. Seizures are a manifestation of several GABA antagonists,

including penicillin G. Since the mother indicates that the seizures have almost ceased,

you instruct her not to administer any more penicillin and to bring her child for checkup

as soon as possible.

Case study 6.

A 22-year old woman who visits her doctor because she is extremely tired she reports

that she is exhausted at bedtime, she typically cannot fall asleep for at least an hour or

two. She moved on to town 2 months ago and has her first full-time job but fears that

her supervisors think she is “dumb” because she has made some mistakes. After

falling to sleep, she sometimes wakes an hour or more before her alarm goes off,

usually thinking about her dumb mistakes. Her problem with sleeping began

approximately 5 months ago, when she was studying for final examinations in her senior

year of college. What treatment would you recommend for her insomnia and fatigue?

Answer.

Zolpidem is the best choice. Patient’s inability to sleep well is probably the result of

anxiety caused by several stresses in her life. She is a recent college graduate, has a

new job, and has moved to a new town. These events constitute three stressors, which

can induce anxiety and sleep loss. The sleep loss and anxiety are usually of relatively

short duration. Zolpidem has a quick onset and a half-life of approximately 2.5 hours. If

taken at bedtime, it should allow her to fall asleep quickly and sleep though most or all

of the night. Its elimination is fast enough that it should not produce residual drowsiness

during the day. A week-long trial of zolpidem should help M.W overcome her sleep

disturbance.

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Case study 7.

A 55-year-old man, presents to the emergency department of the local hospital with a 4-day history of diarrhea associated with abdominal cramping. He complains that he has experienced at least 6 bowel movements daily during that time. And the stools have been watery, but now he is passing blood-tinged stools. He admits to experiencing fatigue and chills, but no weight loss or change in appetite. Upon further questioning, he admits that he recently finished a course of antibiotics. Although he is unable to remember which antibiotic he took, the emergency department pharmacist is able to contact the pharmacy that filled his antibiotic prescription. According to the retail pharmacist, the patient received a 10-day supply of cefuroxime. The physician decides to admit him. Among the tests ordered, the culture is positive for Clostridium difficile. The culture is negative for Salmonella, Shigella, and Campylobacter. The physician wants to initiate antimicrobial therapy to treat his C difficile-associated diarrhea. Since the patient is hospitalized, the physician wants to prescribe intravenous (IV) antibiotics. He orders IV vancomycin. When the pharmacy receives the order, should the pharmacist make any recommendations on patient’s antibiotic therapy?

Answer.

Metronidazole remains the treatment of choice for Clostridium difficile. patient does not

have any contraindications to oral medication, so oral metronidazole should be

considered. Although oral vancomycin is effective, the risk of vancomycin-resistant

enterococci makes it a less desirable option. As for intravenous (IV) therapy, IV

vancomycin is considered less effective than IV metronidazole. IV vancomycin does not

achieve sufficient drug concentrations in the intestinal lumen.

Case study 8.

A 28 year-old woman who have been treating for a seizure disorder tells the physician

that she is 2 months pregnant. She has exhibited absence seizures in the generalized

tonic-clonic. She usually has two or three generalized seizures per month. She indicates

that she has had only one episode during the past 2 months and wonders if she should

stop her medication. She is taking oxacarbazepine, valproic acid, and ethosuximide. Are

any of the agents that the patient is taking clearly more teratogenic than others? Is

there any significance to the apparent decreased incidence of seizures during the

pregnancy? How would you treat this patient?

Answer.

Valproic acid has been shown to implicated in causing birth defects. Ethosuximide has

not, but there is little evidence that ethosuximide is effective, since her absence of

seizures terminated months ago.

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Oxacarbazepine has not been clearly shown to be teratogenic, but teratogenicity cannot

be ruled out, since its close chemical and pharmacological relative carbamazipine has

been implicated in causing teratogenicity.

A decrease in seizure frequency is frequently seen during pregnancy. This is not this is

not always the case, and the explainations are not established. Ethosuximde should be

discontinued immediately. It is probably appropriate to discontinue the valproic acid over

the next week or so. At that time, the dose of oxacarbazepine should be decreased by

50% if there is no increased incidence of seizures following termination of valproic acid.

Since the woman has had a relatively long duration of seizure episodes, it is probably

not reasonable to discontinue all medication. She should keep a log of her seizure

incidence and contact immediately to her doctor if the incidence appears to be

increasing.

Case study 9.

A 60-year old architect who designs buildings. His drawings are very detailed and they

must be drawn to a specific scale. During the past month he has developed a slight

tremor in his right hand that causes some embarrassment but does not interfere with

function. He has however, noticed that his writing and drawing have gotten much

smaller, causing problem with his work. His primary care physician has referred him to

a neurologist for evaluation. On examination, the neurologist notes some motor rigidity

in the right arm. He also observes a slight slowing in the patient’s walk and reduction in

the swing of his arms as he walks. What is the diagnosis, and how should the patient be

treated?

Answer.

The patient is in early stage Parkinsonism, most likely idiopathic (Parkinson’s disease).

Clinically, the disease is very mild and the neurologist might consider not treating him at

this point, but because the micrographia interferes with his work, the neurologist

decides to prescribe medication. Several drugs can be used to treat early-onset

parkinsonism. The most commonly used are the dopamine receptor agonists

(pramipexole, ropinirole, pergolide; amantadine is also a possibility, and some people

get an acceptable response to selegiline, the MAO inhibitor). Levadopa-carbidopa could

also be used; however, most clinicians prefer to delay its use until absolutely needed

because of the adverse effects, such as motor fluctuations and dyskinesias, that

accompany long-term use of levadopa.

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Case study 10.

A 35-year old mother of two has moderate psoriasis. She tells that her mother had a

similar condition 3years ago and was successfully treated with the agent acitretin. She

has come to you because her regulgar physician refused to write her a prescription for

acitretin, and she is very uncomfortable with her skin condition. You tell her that there is

a serious risk of teratogenicity if she should become pregnant. She informs you that

she is taking oral contraceptives and that the possibility of pregnancy is very low. Do

you prescribe the drug she has requested anyway?

Answer.

Acitretin should not be prescribed for women of childbearing potential unless no

acceptable alternative is available and the the patient has acknowledged in writing that

she understands the need to use two effective forms of contraception during therapy

and for 3years after she discontinue the drug. She has not been treated yet with puva.

You convince her that this is more appropriate therapy, considering her age and her

childbearing potential. She grudgingly accepts your treatment. She responds well to the

treatment, and after 6 months the psoriasis is greatly improved and treatment is

terminated.

THE END