Case Study 1 – Ulcerative Colitis

A 23- year- old woman with a history of dysmenorrheal associated with abdominal

cramping goes to her primary care physician because of a 1- year history of episodic

diarrhea and blood- streaked stools; symptoms have become more bothersome over

the past 4 weeks.

She reports loose stools with increasing amounts of blood and abdominal cramping

over the past 4 days. She reports no fever or chills. Her appetite has been poor for the

past 3 days. She has no history of recent travel and has been eating at home.

The physician makes a diagnosis of ulcerative coli

1- Define Ulcerative Colitis

Ulcerative Colitis is Inflammatory disease of the rectum and colon.

2- What is The Exact Etiology of Ulcerative Colitis

the exact etiology of ulcerative colitis is unknown, genetic and immunological

factors are likely contributors to the disease.

3- What are the Manifestations of ulcerative colitis:

Chronic, bloody diarrhea

Fever, pain

Weight loss

Possible anemia from blood loss

Possible complications: toxic megacolon , perforation of the intestine,

significant blood loss; an increased incidence of colon cancer

Case Study – 2 Crohn's Disease

Janine, a 22-year-old woman, comes to your office with a 6-week history of 5 loose,

nonbloody stools daily, right lower quadrant abdominal pain (especially after eating),

20-lb weight loss, and bilateral knee and ankle pains. Janine has smoked 1 pack of

cigarettes daily for the past 5 years. Findings from the physical examination show a

definite and moderately tender 5-cm mass in the right lower quadrant of her abdomen.

No joint effusion or skin lesions are noted. Results from the stool studies are negative

for enteric pathogens, and the results from her blood work show mild anemia

(hemoglobin, 11.2 g/dL), with a normal metabolic panel and normal thyroid-

stimulating hormone levels. Radiographic findings demonstrate a 10-cm narrowing in

the terminal ileum (string sign) with a separation of bowel loops around the terminal

ileum. Your diagnosis is Crohn disease.

1- Define Crohn's Disease :

Crohn's disease is Inflammatory disease affect any region of the G.I. tract but

is most commonly seen in the distal ileum and colon.

2- What are the Manifestations of Crohn’s disease

Diarrhea

Intestinal pain similar to indigestion

Fever

Weight loss from intestinal malabsorption

Nausea, anorexia, vomiting

Complications: intestinal obstruction, formation of fistulas

Toxic megacolon

3-What is The Exact Etiology of Crohn’s disease

Although the exact etiology of Crohn’s disease in unknown, there appears to be a

significant autoimmune component.

Case Study -3 Hepatitis

Mr. C.L. is a 55-year-old African American man with hepatitis C virus (genotype 1)

and a high viral load. Cirrhosis was diagnosed by biopsy 3 years ago. He drank

alcohol very heavily for 20 years, but quit 4 years ago. He has a past medical history

of posttraumatic stress disorder and is taking oral medications for diabetes mellitus.

1- Define Hepatitis

The term hepatitis refers to inflammation and possible injury of the liver.

2- What is The Exact Etiology of Hepatitis

Hepatitis may be caused by a number of injurious agents such as viruses, alcohol,

toxins and drugs.

3- What are the Manifestations of viral hepatitis

Range from asymptomatic to severe

Fatigue, malaise, anorexia, nausea

Jaundice

Liver inflammation and abdominal pain

Abnormal liver function and enzyme levels

4- What are the Possible complications of hepatitis

Chronic active or persistent hepatitis can lead to

progressive liver injury

liver failure

death

increased incidence of hepatocellular carcinoma.

Case Study -4 Peptic Ulcer

Mr B is a 57-year-old man who was admitted yesterday after starting to pass

black stools. He has a two-day history of severe stomach pains and has suffered

on and off with indigestion for some months. He is a life-long smoker, with

mild chronic cardiac failure (CCF) for which he has been taking enalapril 5 mg

twice daily for 2 years. He also recently started taking naproxen 500 mg twice

daily for arthritis. Yesterday his haemoglobin was reported as 10.3 g/dL (range

12–18 g/dL

He was mildly tachycardic (87 bpm) and had a slightly

low blood pressure of 115/77 mmHg and was given 1.5 L of saline.

He has just returned from endoscopy this morning and has been newly

diagnosed as having a bleeding duodenal ulcer. He has been written up for his

usual medication for tomorrow if he is eating and drinking again.

1- Define Peptic Ulcer :

The term peptic ulcer refers to erosion of the mucosa lining any portion of the

G.I. tract.

2-What are The causes of peptic ulcer disease

Infection with the bacteria Helicobacter

Stress — Emotional, trauma, surgical.

Injury or death of mucus-producing cells.

Excess acid production in the stomach.

Chronic use of aspirins and NSAIDs.

3- What are the Manifestations of peptic ulcer disease

Episodes of remission and exacerbation

Pain that for duodenal ulcers is often relieved by eating or antacids

G.I. bleeding and possible hemorrhage (20 to 25% of patients)

Perforation of ulcers with significant mortality

Obstruction of G.I. tract

Case Study -5 Angina

Mr AG, a 57-year-old taxi driver of Indian origin, attends your community

pharmacy with a new prescription for: glyceryl trinitrate (GTN) spray 400

micrograms–

one or two puffs as required.

You dispense this item and speak with him and he tells you that his GP thinks he has

Angina and has asked him to use the spray the next time he gets any minor chest pain

or

tightness. You counsel Mr AG on the correct use of the spray.

1- Define Angina

Angina pectoris is the major symptom of myocardial ischemia. most

commonly presents as pain, pressure or a burning sensation in the area of the

sternum.

2- The Diagnosis of Myocardial Ischemia include:

Electrocardiograph

Holter monitoring — 24 ambulatory electrocardiograph

Stress testing with electrocardiograph

Nuclear imaging

Cardiac catheterization

Case Study – 6 Hypertension

Mr FH, a 48-year-old van driver, was identified by his general practitioner (GP)

As having a resting blood pressure of 162/92 mmHg.

He weighed 95 kg, was 5’7” tall, and had a resting pulse rate of 82 beats per minute

(bpm). He smoked 15 cigarettes per day and drank at least 6 units on 4 nights each

week. His total cholesterol (TC) had been measured as 5.9mmol/L

1- Define Hypertension :

Hypertension is defined as a consistent elevation of arterial pressure above the

normal range expected for a particular age group.

2- What are the Risk Factors for the Development of Essential

Hypertension

Familial history of hypertension

Increasing age

Race and gender: incidence of hypertension is significantly higher in black

men

High dietary salt intake

Hyperinsulinemia

Heavy alcohol consumption

Obesity

Cigarette smoking

Low dietary intake of potassium, calcium and magnesium

3- What are the Complications of essential hypertension

untreated essential hypertension puts patients at a greater risk of :

coronary artery disease, cerebrovascular disease and renal vascular

disease.

Congestive heart failure

renal insufficiency can occur that may eventually progress to renal

failure

damage the retina and eye as a whole.

Case Study -7 Congestive Heart Failure

Mr AB is a 67-year-old man who was admitted to the emergency department

complaining Of increasing shortness of breath.

He has woken on each of the last two nights, struggling for breath.

Diagnosis

A preliminary diagnosis of acute heart failure is made.

1- Define Heart Failure :

Heart failure is a condition in which the heart is no longer pumping blood

effectively.

2- What are the Risk factors for the development of Heart Failure:

High blood pressure

Heart attack

High cholesterol

Damage to heart valves

Diabetes

Obesity

Advancing age

3- What are the Manifestations of left heart failure

1. Decreased stroke volume , increased left-ventricular end-diastolic volume

(LVEDV), increased preload.

2. Congestion of blood in the pulmonary circulation leading to increased pulmonary

pressure and pulmonary edema.

3. Dyspnea, cough, frothy sputum; “rales” or crackling sounds

4. Orthopnea,

5. cyanosis.

6. Generalized fatigue and muscle weakness

4- What are the Manifestations of right heart failure

1. Increased right ventricular workload.

2. Venous congestion and distention

3. Peripheral edema, ascites

4. Swelling of the liver with possible injury and

eventual failure

5. Gastrointestinal symptoms

5-The Diagnosis of heart failure include :

Dyspnea with exertion, orthopnea, nocturnal dyspnea

Rales, cough, hemoptysis

Distention of jugular vein, liver enlargement, ascites

Peripheral and pulmonary edema

ECG (“EKG” or “ECG”), chest x-ray for cardiac hypertrophy ,

Echocardiogram (“echo”)

Cardiac catheterization to assess hemodynamic function

Case Study 8 – Myocardial Infarction

Mr FG is a 69-year-old retired school teacher who was admitted to the emergency

Department complaining of severe chest pain after climbing stairs at his

daughter’s house.

Diagnosis

A preliminary diagnosis of myocardial infarction is made.

1- Define Myocardial infarction

Myocardial infarction or “heart attack” is an irreversible injury to and eventual

death of myocardial tissue that results from ischemia and hypoxia.

2- What are the Manifestations of myocardial infarction

1. Severe chest pain and discomfort

2. Irreversible cellular injury

3. Release of myocardial enzymes such as creatine phosphokinase

(CPK) and lactate dehydrogenase (LDH) into circulation from myocardial

damaged cells.

4. Electrocardiogram changes

5. Inflammatory response from the injured myocardium — Leukocyte infiltration,

increased white blood cell counts, fever.

6. Coagulative necrosis of the area of the myocardium affected by the infarction.

7. Repair of damaged areas occurs by replacement with scar tissue and not functional

muscle tissue; therefore, some alteration in function is inevitable

2- What are the etiology of Myocardial infarction:

Most heart attacks are the direct Result of occlusion of a coronary

blood vessel by a lipid deposit.

Prolonged vasospasm might also precipitate a myocardial infarction in

certain individuals.

Case Study -9 Asthma

An 18-year-old man, VB, presents with a history of recurrent episodes of wheeze

after walking 200 metres. VB has recently started to go to a gym and his episodes

of wheeze have worsened. He goes to see his GP. He can talk in sentences but his

respiratory rate is increased. His peak flow is 420 L/min which is 80% of predicted

result. A diagnosis of mild asthma is made.

�

1- Define Asthma

Asthma is an Obstructive Respiratory Disorders characterized by reversible

bronchospasm and chronic inflammation of airway passages.

�� 2- What are the etiology of Asthma:

� Although the exact etiology is still uncertain, there appears to be a definite

genetic predisposition to the development of asthma.

2- Potential Asthma Triggers include:

Allergens — Pollen, pet dander, fungi, dust mites

Cold air

Pollutants

Cigarette smoke

Strong emotions

Exercise

Respiratory tract infections

3- What are the manifestations of asthma :

Coughing, wheezing

Difficulty breathing

Rapid, shallow breathing

Increased respiratory rate

Excess mucus production

Significant anxiety

Case Study – 10 COPD

Mr CD, a 75-year-old man, 1.7 m tall, is admitted to hospital very short of

breath. He used to work in the docks as a clerk and has smoked 40 cigarettes

daily for 30 years and stopped 2 years ago. His previous medical history includes

COPD, recurrent infective exacerbations since 1991, no LTOT; type 2 diabetes

mellitus on insulin 14 IU b.d. for 20 years, retinopathy; ischaemic heart disease

– coronary artery bypass graft (twice), hypertension; myocardial infarction

1986; atrial fibrillation; high cholesterol.

� 1- Define Chronic bronchitis

� Chronic bronchitis is a chronic obstructive pulmonary disease that is most

frequently associated with cigarette smoking (approximately 90% of cases).

�

� 2- What Are the Etiology of Chronic bronchitis

cigarette smoking (approximately 90% of cases).

Chronic bronchitis may also be caused by prolonged exposure to inhaled

particulates such as coal dust or other pollutants.

3-What are the Manifestations of chronic bronchitis:

Productive, chronic cough

Production of purulent sputum

Frequent acute respiratory infections

Dyspnea

Hypoxia, cyanosis

Symptoms of cor pulmonale

Fluid accumulation (edema) in later stages

Case Study -11 Pneumonia

CB is a 75 year old married female who presents to the outpatient clinic complaining

of a severe cough, left sided chest pain that has become progressively worse over the

past several days. She appears anxious and her face is flushed. The physician suspects

pneumonia.

1- Define Pneumonia

� Pneumonia is a condition that involves inflammation of lower lung structures

such as the alveoli or interstitial spaces.

� 2- What Are the Etiology of Pneumonia

� It may be caused by

bacteria

viruses

parasites such as pneumocystis carinii.

2- Individuals Most at Risk for Pneumonia include :

Elderly

Those with viral infection

Chronically ill

AIDS or immunosuppressed patients

Smokers

Patients with chronic respiratory disease e.g. bronchial asthma

3- What are the Manifestations of Typical pneumonia

Inflammation and fluid accumulation are seen in the alveoli.

White cell infiltration and exudation can been seen on chest radiographs.

High fever, chest pain, chills, and malaise are present.

Purulent sputum is present.

Some degree of hypoxemia is present.

4- What are the Manifestations of ATypical pneumonia

• Milder symptoms than typical pneumonia.

• Lack of white cell infiltration in alveoli.

• Lack of fluid accumulation in the alveoli.

• Not usually evident on radiographs.

• May make the patient susceptible to bacterial pneumonia.

Case Study - 12 Tuberculosis

A 34 year old Hispanic male was diagnosed with pulmonary tuberculosis based on

clinical findings, positive AFB sputum smears and a Nucleic Acid Amplification test

(NAAT) positive for M. tuberculosis.

1- Define tuberculosis

Infectious disease caused by the organism mycobacterium tuberculosis.

2- What are the Etiology of tuberculosis

caused by the organism mycobacterium tuberculosis.

3- What are the Manifestations of tuberculosis

Productive , prolonged cough

Chest pain, hemoptysis

Chill , fever , night sweats

Anorexia , weight loss

4- The detection ( diagnosis) of tuberculosis include

Mantoux test

Acid-fast staining of sputum

Chest radiograph