Cases for CPT teaching

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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 joint diagnosed as
  gout.
• Chronic renal insufficiency with creatinine of
  200 said to be due to long standing hypertension

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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 term
  treatments for his CVS condition?
• How will you manage his arthritis / gout?

4
Think about

• Aspirin
• ACE inhibition
• Calcium channel blockers
• Beta blockers
• Statin
• NSAIDs
• Allopurinol
• Colchicine

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Case No 2

• A 68 year old man suffers from repeated episodes
  of palpitations which have been diagnosed as
  paroxysmal atrial fibrillation.
• What steps would have been undertaken before that
  conclusion could have been reached?
• A locum doctor started him on digoxin to try to
  stop the occurrences. Was that a good choice 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 atrial
  fibrillation with a ventricular rate of 150/min.

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• What therapeutic possibilities are there
• Consider electric shock what precautions are
  needed?
• Anticoagulation
• Consider adenosine, amiodarone, flecainide,
  digoxin, beta blockers, verapamil.

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Case No 3

• A 60 year old man presents with upper abdominal
  pain for 2 weeks with shortness of breath at rest
  and orthopnoea and early jaundice. Examination
  reveals grossly elevated JVP, severe pitting
  oedema of legs. Crepitations throughout the
  lungs. Gallop rhythm 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
  iv morphine, LMW heparin prophylaxis
• What immediate investigations will be required?
  And what investigations over the next few days?
• CXR, FBC and UE 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 with CCF?
• 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 warfarin
  kinetics 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 up for
  insurance purposes. He feels perfectly well.
• He smokes 2 cigars a day and drinks whisky in the
  evenings.
• Examination reveals BP 165/95, apex beat 1
  displaced and heaving in character. He is 510
  tall and 15 st in weight.
• His cholesterol is 5.9 mmol/l. His random
  glucose 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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• What drug will you use
• Thiazide
• Beta blocker
• ACE inhibitor and AII receptor blocker
• Calcium channel blocker
• Alpha blocker
• Statin?

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Case No 8

• A 44 year old publican is admitted with gross
  ascites and leg oedema. He has been drinking in
  excess of 6 pints of beer a day for 20 years. He
  is jaundiced and has the stigmata of chronic
  liver disease and early asterixis.
• His LFTS are completely awry with an INR of 2.1
  and a serum albumin of 28 g/l. Hb 10.2g/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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Case No 9

• A 70 year old man with long standing epilepsy
  develops chest pain on exertion and his ECG shows
  ST depression in 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 UE, LFT, TFT - NAD
• Echocardiogram NAD
• Exercise ECG 1mm horizontal ST depression V4 to V6

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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
  mononitrate and atorvastatin.
• 7 days later found to be listless, anorexic and
  generally weak and complaining or aching all over
  and sent to hospital
• CPK 50
• UE normal except for plasma Na of 119mmol/l
• What is the explanation?
• What do you know about the actions, adverse
  effects and pharmacokinetics of carbamazepine?
• What other drugs cause hyponatraemia?
• What do you know about enzyme inhibition as a
  mechanism of drug interaction.
• What are the adverse effects and interaction
  risks with the statins?

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• It was decided that the patient did not need the
  carbamazepine 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 mg daily, 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 of
  increasing shortness of breath. He was
  orthopnoeic, coughing frothy sputum and his chest
  had inspiratory wheeze and crackles. His radial
  pulse rate was 75 / min completely irregular and
  his apex rate was 115 / min with a triple rhythm
  audible.

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• The GP injected morphine and sent him urgently to
  hospital.
• A CXR showed pulmonary oedema and an ECG showed Q
  waves 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 of these 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 sleep on 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
  whilst waiting 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 been diagnosed 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 this patient?

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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 know
what 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 from
hypertension. His medication was changed about a
month ago. His GP has found his serum sodium to
be 124mmol/l. What ideas come to mind which
might 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
gone wrong 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 in class.
• Perhaps he added a Calcium channel blocker
• Perhaps he added a beta blocker
• Perhaps he thought she had asthma and gave a
  corticosteroid.
• Perhaps a NSAID was prescribed or bought.