Cases for Teaching CPT

8/8/2019 Cases for Teaching CPT

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Cases for CPT teaching


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Case No 1 70 year old man

PH of Myocardial infarction 7 years ago

Known LV impairment with history of PND Recently discharged from hospital

following aspiration of painful knee jointdiagnosed as gout.

Chronic renal insufficiency with creatinineof 200 said to be due to long standinghypertension


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Presents with severe pain and swelling of

opposite knee joint Drug history

furosemide 20 mg 2x per day

Nifedipine 10 mg 2x per day What other drugs might have been

considered in the past?

Would you recommend any other long termtreatments for his CVS condition?

How will you manage his arthritis / gout?


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Case No 2

A 68 year old man suffers from repeatedepisodes of palpitations which have beendiagnosed as paroxysmal atrial fibrillation.

What steps would have been undertakenbefore that conclusion could have beenreached?

A locum doctor started him on digoxin totry to stop the occurrences. Was that a goodchoice of drug?


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What drug might you have chosen to stop

the attacks? He is admitted feeling unwell and digoxin

toxicity is diagnosed.

What are the features of digitalis toxicity?

Why might digoxin toxicity arise?

How is the diagnosis best made?

He is discharged on no treatment but returns

2 weeks later short of breath with atrialfibrillation with a ventricular rate of150/min.


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What therapeutic possibilities are there

Consider electric shock what precautionsare needed?

Anticoagulation

Consider adenosine, amiodarone, flecainide,digoxin, beta blockers, verapamil.


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Case No 3

A 60 year old man presents with upperabdominal pain for 2 weeks with shortnessof breath at rest and orthopnoea and early

jaundice. Examination reveals grosslyelevated JVP, severe pitting oedema of legs.Crepitations throughout the lungs. Galloprhythm at 120/min. BP 140/90. Smooth

palpable liver with hepato-jugular reflux. He had suffered an anterior myocardial

infarction 3 years previously.


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What immediate measures will you prescribe?

Oxygen, diuretic, possibly iv nitrate, possibly ivmorphine, LMW heparin prophylaxis

What immediate investigations will be required?And what investigations over the next few days?

CXR, FBC and U+E then echocardiogram What is the likely maintenance regime if this is

ischaemic cardiac failure?

Diuretic and ACE inhibition. ?? Beta blocker

What drugs should you avoid in patients withCCF?

Sodium retainers, negative inotropes


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Case No 4

A 45 year old lady presents with increasing

wheeze over the previous 6 months. No

past history of asthma. She is wheezy

throughout both lungs and has a

tachycardia. Her peak flow is 150 l/min.

What immediate investigations are

indicated?

What immediate measures should be taken?


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Think about Oxygen

Steroids

Beta agonists

Ipratropium

Aminophylline Anti-biotics

AVOID sedating drugs


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Case No 5 A 90 year old lady is admitted coughing up blood

and with pleuritic pain in her R side

She had had bilateral ankle swelling CXR clear, D dimer raised, S1Q3T3 on ECG

Current treatment amoxycillin just started,carbamazepine for trigeminal neuralgia, aspirin

prophylactic, diclofenac for shoulder pain. What are the pitfalls when starting anti-

coagulation?


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Factors to consider when using warfarin

Drug interaction pharmacokinetic Drug interaction pharmacodynamic

Concurrent conditions which cause bleeding

Concurrent conditions which affect warfarinkinetics or dynamics

Liver disease, age, renal, gastrointestinal

Compliance

Benefit to risk ratio


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Outline the treatment regime Low molecular weight heparin for 5 days

Load with warfarin

Daily INR

Adjust warfarin according to

recommendation on chart

Deal with over anti-coagulation according

to BNF


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Case no 6 A 45 year old man known to be alcoholic

and addicted to Valium is admitted

following three tonic clonic seizures What might be the possible causes?

Effect of alcohol on brain

Metabolic abnormality 2ndry to alcohol

Alcohol withdrawal Drug withdrawal

Head injury

Overdose of something


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What specific urgent investigations are

indicated?

CT scan

Glucose and electrolytes, serum Calcium

Toxicology What will you prescribe?

Correct electrolytes, dehydration,

hypoglycaemia Give either lorazepam or phenytoin

parenterally


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Oxygen

Monitor vital signs and possibly EEG

Transfer to ITU for consideration for

ventilation if series of fits continues

Consider need for maintenance treatment Carbamazepine

Valproate

Phenytoin Lamotrigine

Advise not to drive


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Case No 7 A 65 year old man attends for a check upfor insurance purposes. He feels perfectlywell.

He smokes 2 cigars a day and drinks whiskyin the evenings.

Examination reveals BP 165/95, apex beat

1 displaced and heaving in character. He is510 tall and 15 st in weight.

His cholesterol is 5.9 mmol/l. His randomglucose is 10mmol/l.


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He asks about taking aspirin regularly

What will you advise Aspirin?

Weight?

Alcohol?

Smoking?

Blood glucose

BP?

Monitor BP over 3-4 weeks

If sustained treat with drugs


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Case No 8

A 44 year old publican is admitted withgross ascites and leg oedema. He has beendrinking in excess of 6 pints of beer a day

for 20 years. He is jaundiced and has thestigmata of chronic liver disease and earlyasterixis.

His LFTS are completely awry with an INRof 2.1 and a serum albumin of 28 g/l. Hb10.2g/l

Abdo u/s confirms hepatic cirrhosis pattern


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How will you treat his ascites

Slow weight loss Bed rest

Diuretic which one and why

Consider paracentesis

What are the risks in prescribing to this patient Pharmacokinetic disturbance

Pharmacodynamic disturbance

Electrolyte abnormalty

Bleeding Encephalopathy

Hepatic adverse effect


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A 70 year old man with long standing epilepsy develops

chest pain on exertion and his ECG shows ST depressionin V5 and V6.

What key facts do you want to know?

History treated for GORD 10 years ago with omeprazole;

otherwise fit and well; current medication carbamazepine

600 mg. No cigs

Examination fit looking, BP 140/85, systolic murmur at

apex and base of heart, otherwise NAD.

CXR CTR 50%

Cholesterol 6.0

Random blood glucose 5.6; U+E, LFT, TFT - NAD

Echocardiogram NAD

Exercise ECG 1mm horizontal ST depression V4 to V6

Case No 9


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What drugs will you prescribe?

Nitrate

? GTN spray

Beta blocker

? atenolol

Calcium channel blocker

? amlodipine

Lipid lowering agent

? simvastatin

Aspirin

What key points do you know about the pharmacology of

these drugs?


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Patient was treated with diltiazem, isosorbide mononitrateand atorvastatin.

7 days later found to be listless, anorexic and generallyweak and complaining or aching all over and sent tohospital

CPK 50

U+E normal except for plasma Na of 119mmol/l

What is the explanation?

What do you know about the actions, adverse effects andpharmacokinetics of carbamazepine?

What other drugs cause hyponatraemia?

What do you know about enzyme inhibition as amechanism of drug interaction.

What are the adverse effects and interaction risks with thestatins?


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It was decided that the patient did not need thecarbamazepine and he was discharged on his anti-anginal

treatment. However whilst on a 6 month visit to Brazil he had a

heart attack which was followed by late onset asthma.

His drug treatment had been changed to propranolol 80 mgdaily, verapamil 20 mg and Uniphyllin Continus 400mg

twice daily. What are the risks to this patient associated with this drug

regimen?

Within days he had had to call the GP because ofincreasing shortness of breath. He was orthopnoeic,

coughing frothy sputum and his chest had inspiratorywheeze and crackles. His radial pulse rate was 75 / mincompletely irregular and his apex rate was 115 / min with atriple rhythm audible.


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The GP injected morphine and sent him urgently tohospital.

A CXR showed pulmonary oedema and an ECG showed Qwaves in leads 3 and AVF and atrial fibrillation.

What treatment would you implement?

Frusemide (furosemide)

Oxygen

(Diamorphine) Nitrate

ACE inhibitor

Anti-coagulant

?? DC cardioversion ?? Amiodarone ?? Digoxin Beta blocker

What key points do you know about the pharmacology ofthese drugs?


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At discharge from hospital the patient is reasonably mobile

but SOB on walking up 2 flights of stairs but able to sleepon 2 pillows. His drugs are furosemide 40 mg daily,

perindopril 4 mg, digoxin 0.25 mg and carvedilol 6.25 mg

twice daily and warfarin.

He reports to his GP complaining of dizziness whilstwaiting for a bus and when getting up in the morning. He

is prescribed Stemetil (prochlorperazine)

Do you think this was necessarily a wise prescription?

What are the dangers of using this drug for symptomatic

dizziness?

What adverse effects often occur with phenothiazine drugs

in the elderly?


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Two months later he develops painful swelling in the foot

following a brief episode of gastroenteritis.

He is treated with indomethacin for suspected gout

Why might gout have developed?

Was the right drug chosen?

What are the potential adverse effects of indomethacin in

this patient?

How might you have managed the probable gout?


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One year later the patient develops low mood because of

increasing limitation of activity. He has developed

symptoms of bladder neck obstruction which has beendiagnosed by a urologist as benign prostatic hypertrophy.

In view of his low mood he has been prescribed

amitriptyline 50 mg every evening.

What are the potential risks of this prescription in thispatient?


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An 82 year old lady is admitted because she keeps falling over.

She says it has got much worse since the doctor changed her

tablets. She takes 5 different lots of tablets but does not knowwhat any of them are for. What types of drug might you

specifically try to exclude from the drug history?

Nitrates

ACE inhibitors, Calcium channel blockers, other

vasodilators

Beta blockers

Diuretics

Sleeping tablets

Anti-depressants / anxiolytics

Drugs with negative inotropy


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A 55 year old man is admitted with a 2 month history of

nausea culminating in vomiting blood on one occasion. He has

been in atrial fibrillation following a myocardial infarction 5

years previously. He has also suffered from chronic back pain

for many years. What drugs might you need to ask about

which could be relevant?

Digoxin Aspirin

Warfarin

Statin

NSAIDs


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A 48 year old man who is a known epileptic has become increasingly

drowsy and ataxic over the last week. He is also known to suffer fromhypertension. His medication was changed about a month ago. His GP has

found his serum sodium to be 124mmol/l. What ideas come to mind whichmight explain his symptom as drug related?

Drug induced hyponatraemia can occur with carbamazepine and some

other anti-epileptics and other CNS active drugs such as SRIs. Hyponatraemia also occurs with diuretics which are used to treat

hypertension.

The drowsiness might be due to excessive anti-epileptic (phenytoin or

carbamazepine). The clearance of these agents is affected by

concurrent administration of many agents including the anti-hypertensive diltiazem

Phenytoin is notorious for causing a cerebellar syndrome. Why is it

so susceptible to drug interaction?


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A 75 year old lady with known ischaemic heart disease and left

ventricular impairment has become increasingly short of breath and has

developed ankle swelling after a locum doctor changed her tablets. What

will you try to elucidate in the drug history? What might have gonewrong with the prescribing?

What was her drug treatment? Why did she see the locum?

The ideal maintenance would be an ACE inhibitor and a

(loop) diuretic. Perhaps these were stopped or reduced inclass.

Perhaps he added a Calcium channel blocker

Perhaps he added a beta blocker

Perhaps he thought she had asthma and gave acorticosteroid.

Perhaps a NSAID was prescribed or bought.

Cases for Teaching CPT

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