BOOKCHAPTER

CaseStudies
MarkKesterPhD,KellyD.KarpaPhDandKentE.Vrana
Elsevier'sIntegratedReviewPharmacology,227230

patchServlet?publisherName=ELS&orderBeanReset=true&orderSource=ClinicalKey&contentID=B9780323074452000148)

Casestudy1
A54yearoldhomelessmale,whoadmitstosmokingcigarettesallhisadultlife,isadmittedtothe
hospitalwithevidenceoftuberculosis.Thisgentlemanweighs65kgandsayshewasdiagnosedwith
chronicheartfailureandasthmamanyyearsago.Forthepast15years,hehasbeenobtaining
theophyllinesamplesfromaphysicianwhovolunteersatthelocalhomelessshelter,soyoudecideto
continuethedrugwhileheishospitalized.Inthehospital,thepatienthasbeenreceiving100mg
theophyllineevery12hours.However,yourealizethattheophyllineismetabolizedbyP450
microsomalenzymes,andyou'veplacedthepatientonseveralmedicationsthatalterthemetabolism
oftheophylline,includingciprofloxacin,whichisknowntoincreasetheophyllinelevels,and
rifampin,whichisknowntoinducetheP450enzymes,thusreducingtheophyllinelevels.Youdecide
thatitisbesttoobtainlaboratorydatatodeterminewhatthepatient'splasmalevelsoftheophylline
arebecauseofthesepotentialdruginteractions.Thelaboratoryreportindicatesthatthepatient's
plasmaconcentrationoftheophyllineis3.6mg/L(targetrangeis5to15mg/L).
1.Knowingthatthepublishedvalueofvolumeofdistribution(Vd)for
theophyllineis0.48L/kg,calculatethisman'sVdfortheophylline.
2.Knowingthatthepublishedhalflife(t1/2)fortheophyllineinasmokeris4.5
hours,whatistherateatwhichtheophyllineisclearedinthispatient?
3.Whatloadingdoseshouldthispatientbegiventoquicklyincreasehis
theophyllineplasmalevelto10mg/L?

Casestudy2
A68yearoldpatientistransferredtoyourpractice.Sheisconcernedbecauseshehasbeentaking
thesamemedicationfor60yearsforherasthma,butitdoesnotseemtobeworkingverywelllately.
Shesaysthatshehastakenthesamedoseoftheophyllineallherlifeeversinceshewas8yearsold
andshewantedherpreviousdoctortoincreasethedose,buthedidnot.Sheiscertainthatthe

reasonherasthmahasbeenunderpoorcontrolforthepastfewmonthsisbecauseherdoctorrefuses
toprescribemore.(Inactuality,herpreviousdoctorhadsuggesteddiscontinuingthetheophylline
entirelyandswitchinghertoalongactingcorticosteroid/2agonistcombinationbecause
theophyllinerequirescarefulmonitoringandhasnumerousdruginteractionsandseveretoxicities.
However,sherefusedbecauseshehadheardthatsteroidsarebadforyou.)
Theophyllinehasworkedformyentirelife.Whenitstoppedworkingrecently,mydoctorrefusedto
increasethedose.WhywouldadrugI'vetakenmywholelifesuddenlystopworking?
Youreviewhermedicationsandndthatsheisalsotakingcimetidineforgastroesophagealreflux
andrifampinforaseverestaphylococcalboneinfection.Youcheckherserumtheophyllinelevelsand
ndthattheyare4.0mg/L(targetrangeis5to15mg/L).
1.Whataresomeoftheconsiderationsfordosingadrugwithanarrow
therapeuticindex(e.g.,theophylline)throughoutthelifespanofapatient?
2.Arethereanypharmacokineticinteractionsbetweenrifampinandtheophylline
thatcouldaffectthiswoman'stheophyllineplasmalevels?
3.Arethereanypharmacokineticinteractionsbetweencimetidineand
theophyllinethatcouldaffectthiswoman'stheophyllineplasmalevels?

Casestudy3
A16yearoldfemalecomestotheemergencydepartmentwithsevereabdominalcramps.Sheis
sweatyandappearsfeverish.Onworkup,shebecomesnauseatedandvomitspillfragments.She
reportsthatsheingestedahundredpills,butIdon'trememberthetype.Onexamination,her
temperatureis101.2F,herbloodpressureis128/72mmHg,herpulseis120beats/min,andher
respirationsare34breaths/min.
1.Whatisyourinitialmanagementstrategyforthispatientafteraddressingthe
ABCs(airway,breathing,circulation)?
2.Whatoverthecountermedicinecouldberesponsiblefortheinitialsymptoms?
3.Initialarterialbloodgaslevelsaredrawn(pH,7.64pCO2,16mmHgpO2,98
mmHg).Whatarepotentialmechanismsunderlyingthisalkalosis?
4.Repeatlaboratorymeasurementsaretaken2hoursafterthepatientreceives2
Lnormalsaline.TheresultsarenowpH,7.27pCO2,16mmHgandpO2,103
mmHg.Whatarepotentialmechanismsleadingtothesecondaryacidosis?
5.Thepatient'sconditioncontinuestoworsen.Whatisthenextcourseof
treatment?

Casestudy4
A33yearoldfemaleisbroughttotheemergencydepartmentbyherhusbandoneSaturday
morning.Shereportssuchasevereheadachethatshecannotopenhereyes.Heroraltemperatureis
104.1F.Herhusbandmentions,Mywifehasarashonthebackofherhead.
Accordingtothewoman'shusband,shewaspreviouslyingoodhealth.Onthepreviousday,the
womanroseearlyinthemorningtocompleteherexerciseroutineandremarkedtoherhusband
aboutwhatagreatworkoutshehad.However,asthedayprogressed,shenotedalargepainful
lumponthebackofherhead.Byevening,shenoticedadditionallumpsandwasconcernedbecause
thelumpswerebeginningtospreaddownthebackofherheadandneck.Shealsobeganhaving
diarrheathatevening.Althoughthewomanhadbeenseenbyherfamilydoctorafterhoursthe
previousevening,nodenitivediagnosishadbeenmade,andshewassenthome.Throughoutthe
night,thewomanhadseverediarrheaandvomiting.
Almostassoonasthepatientarrivedintheemergencydepartment,shebegancomplainingofan
irregularheartbeat.Anelectrocardiogramrevealedprematureventricularcontractionsthewoman
deniedapriorhistoryofcardiovascularproblems.Onexaminationofthepatient'shead,therash
onthebackofherheadappearedtobespreadingdownherneckandacrossherface.Atthe
emergencydepartment,anastuteattendingphysiciancorrectlydiagnosedthewomanashaving
erysipelas.Thepatienthasnohistoryofdrugallergies.
1.Whatiserysipelas,andwhichmicroorganismsarethemostlikelyculprits?
2.Whatisthemostlikelycauseofthepatient'scardiacarrhythmias?
3.Ascabisidentiedonthepatient'sscalp,andbothgroupAstreptococciand
staphylococciareisolatedandcultured.Bloodculturesarenegative,whichis
commonwitherysipelas(bloodculturesarepositiveinonly5%ofcases).Discuss
anantimicrobialthatisappropriateforthispatient.
4.After5daysofreceivinganintravenousantibiotic,herfevernallysubsided
andshewasdischargedwithaprescriptionfor10additionaldaysoftherapywith
oraldicloxacillin.Inaddition,atthetimeofdischarge,arstyearresident
informedthepatientthatthelaboratoryhadjustcalledwithresultsofastool
culturethathadbeenconductedduringadmissionbecausethepatient's
abdominalpainanddiarrheahadworsenedwhileshewashospitalized.
Clostridiumdifficiletoxinswereidentiedinthepatient'sstoolculture.Whatis
thesourceofthisgastrointestinalmicroorganism,andhowisthissecondary
infectiontreated?

Casestudy5

A70yearoldmanwithahistoryoflongstandinghypertensionandrecentlydiagnosedtype2
diabetesmellituscomestotheoncologyclinic.Hehasjustfoundoutthegastricpainthathe
attributedtoaflareupofhispepticulcerdiseaseisactuallygiantlargecelllymphoma,an
aggressiveneoplasm.Asthedirectoroftheoncologyclinic,youtellthepatientthathewillbe
receivingsixtoeightcyclesofachemotherapeuticregimenknownasCHOP,followedby
consolidativeradiationtherapytohisstomachandlymphnodes.Thepatientasksforadditional
informationabouttheCHOPregimen,andyouexplainthatthisisacombinationoffourdifferent
drugs:cyclophosphamide,doxorubicin,vincristine,andprednisone.
1.Whenexplainingthelongtermcomplicationsofdoxorubicintothepatient,
whatdoyouwarnhimaboutandwhatcanbedonetopreventorminimizethe
drug'seffects?
2.Whenexplaininglongtermcomplicationsassociatedwithvincristine,ofwhat
doyouwarnthepatient?
3.Whatlongtermcomplicationsareassociatedwithcyclophosphamide,andhow
cantheybeprevented?

Casestudy6
Aclinicalstudyisconductedinwhichahealthyvolunteerisadministerednorepinephrine,
epinephrine,andisoproterenol.Bloodpressure,totalperipheralresistance,andheartrateare
monitoredduringdruginfusions.Theresultsofthisstudyaredepictedintheaccompanyingfigure.
1.Explainthewidelydisparateresultsforthesethreeadrenergicagonists.
Specificallyaddressthereceptorsresponsibleforthevarioushemodynamic
changes.

HR,heartrateTPR,totalperipheralresistanceBP,bloodpressureMAP,meanarterialpressure.

Casestudy7
A75yearoldmalecomplainsofstomachpainandmassiverectalbleedingwhenpassingstools.He
isalsogingerlyholdinghisleftshoulder.Onquestioning,hetellsyouthatlastweek,heslippedon
theiceandfellwhileshovelingsnow.Hewasprescribedcelecoxibbyhisfamilydoctorforpersistent
shoulderpainandswelling.Whenthepainfailedtoresolveafterafewdays,thismanscheduleda
secondappointmentwithhisfamilyphysician.Thistime,hisregulardoctorwasoutoftown,sohe
wasseeninsteadbyanotherpartnerinthepractice,whoprescribedibuprofen.Thepainhas
persistedforseveralweeksandduringthistime,hehasbeentakingbothcelecoxibandibuprofen
regularly.Inthemiddleofthenight,themanwasbroughttotheemergencydepartmentwhenhe
lledthetoiletbowlwithbloodystoolstwice.Hewasfeelingfaintandhadnearlypassedoutbefore
hiswifewasabletosummonanambulance.Hismedicalhistoryincludeshypertensionandpeptic
ulcerdisease.Thehypertensioniscontrolledwithmedication,andtherehavebeennoulcersinmore
thanadecade.Thefollowingarethepatient'spertinentlaboratoryvaluesfromhiscompleteblood
count,withnormalvaluesshowninparentheses:
Hemoglobin=11.9g/dL(13.8to17.2g/dL)
Hematocrit=34%(40.7to50.3%)
Meancorpuscularvolume=75.9m3(80.0to97.6m3)
Meancorpuscularhemoglobin=24.0pg/cell(26.7to33/7pg/cell)
Meancorpuscularhemoglobinconcentration=30.0g/dL(32.7to35.5g/dL)
1.Yoususpectthatbecauseofhismassivegastrointestinalbleeding,thepatientis
irondecient.Whatothertestsmightyouordertoconrmyourdiagnosis?
2.Whatdoyousupposecontributedtopatient'slossofiron?
3.Ultimately,surgicalinterventionwasneededtohalttheseveregastrointestinal
bleeding,andthepatientwasdischargedhomewithaprescriptionforiron
supplements.Whatmightyoutellthepatientandnoteinhischartregardingthis
irontherapy?

Casestudy8
A45yearoldmanentersaclinicforthersttime.Hetellsthedoctor,Ifeelne,butthenurseat
worktookmybloodpressure.Itwas150/100mmHgand160/102mmHgontwodifferentdays.She
saysIneedacheckup.

Despiteathoroughexaminationtodetermineanidentiablecauseforhishypertension,nonewas
found,andthepatientwasgivenadiagnosisofstage2essentialhypertension.Thepatientwas
instructedonlifestylechangesincluding(a)smokingcessation,(b)regularexercise,(c)alcohol
limitations(nomorethantwobeersperday),and(d)alowfat,lowcholesterol,lowsaltdiet.
Thepatientwasmotivatedtoinitiatetheselifestylemodications,sothephysicianprescribedonly
hydrochlorothiazideinitiallyandscheduledafollowupexaminationfor2monthslater.Thepatient
returned2weekslaterwithapainful,swollen,redbigtoejoint.Hispotassiumlevelwas3.2mEq/L
(normal,3.5to5.0mEq/L),andhisuricacidlevelwas11.9mg/dL(normal,3to8mg/dL).
1.Accountforthepatient'spainfultoeandhisabnormallaboratoryvalues.
2.Thepatient'spharmacologictherapywaschangedtoatenolol.Althoughthe
patient'sbloodpressurehadloweredto132/94mmHgwithatenolol,hisheart
ratewasonly50beats/min.Thepatientreportedeasyfatigabilityandareduction
inexercisetolerance.Explainhowatenololcausestheseadverseeffects.
3.Becausethepatientreportedotheradverseeffectsassociatedwiththeblocker
(e.g.,reducedlibido,sleepdisturbances),itwasdecidedthatinsteadoflowering
thedose,adrugfromadifferentclasswouldbetried.Atenololwasgradually
taperedoveraperiodof1week.Whywasthedoseofatenololtaperedslowly?
4.Thepatientwasstartedonlisinopril.Howdoeslisinoprilwork,andwhat
adverseeffectsmightthepatientexperience?

Casestudy9
A60yearwhitemaleweighing170poundsisbroughttotheemergencydepartmentbyhiswife
becausehisanklesareswollen.Youviewthepatient'sextremitiesandnotethathehasstage4
pittingedemainhisankles.Thepatienttellsyouthathehasahistoryofpoorlycontrolled
hypertension.Beforeprescribinganymedications,youaskthelaboratorytocheckhisNa+,K+,and
serumcreatinine.Pertinentlaboratoryvaluesare:
K+:3.5(3.3to4.9mmol/L)
Na+:140mmol/L(135to145mmol/L)
Creatinine:2.5mg/dL(0.5to1.7mg/dL)
1.Whatisthispatient'screatinineclearance?
2.Whatisthebestchoiceofmedicationtoreducethispatient'sedemaonan
outpatientbasis?
3.Atyoursuggestion,thepatientfollowsupwiththeinternalmedicine

department.Inadditiontohavinghypertension,healsondsoutthathehastype
2diabetes.Theinternistgivesthepatientanadditionalprescription.
Unfortunately,youseethepatientagainintheemergencydepartment2weeks
afterhisappointmentwithinternalmedicine.Thistime,heisreportingan
irregularheartbeat.Anelectrocardiogramrevealsthatthepatienthasa
prolongedPRintervalandQRSduration,atrioventricularconductiondelays,
andalossofPwaves.Laboratoryworkrevealsthathispotassiumleveliselevated
at5.7mEq/L.Whichclassofmedicationdidtheinternistmostlikelyprescribefor
thepatient'shypertension?

Casestudy10
An8yearoldboywithasthmahasrecentlydevelopedanonproductivecough.Hisasthmahasbeen
wellcontrolledoverthepast3yearssincehestartedallergydesensitizationimmunotherapy(allergy
shots).Heispresentlytakingcromolyn(fourpuffsperday)aswellasalbuterol(twopuffs)when
neededorbeforeexercise.Hedemonstratesgoodinhalertechniqueandusesaspacer.Duringyour
workup,youdiscoverthatthefamilyhasjustadoptedapuppyandtheboy'sasthmasymptoms
havebeenflaringup.Hispeakflowrateshavebeenfalling,andhehasbeenhavingmorenocturnal
symptoms.
1.Whatisyourplantominimizeandmanagethechild'sasthmasymptoms,given
thatthepuppyremainsinthehousehold?
2.Whatadverseeffectsareespeciallyofconcerninayoungchildusinginhaled
corticosteroids?

Casestudy11
A49yearoldmalehasbeengivenadiagnosisofhyperreactiveairwaydiseaseandasthma.Aftera
boutwithinfluenza,hedevelopedarecurrentcoughthatinterfereswithhisjobandactivelifestyle.
Thecoughandassociatedtightchestareunresponsivetooverthecountercoldandflumedications.
Thepatientissomewhatsurprisedwhenyoustartworkinghimupforgastroesophagealreflux
disease(GERD).Hestatesthathisstomachisneandhehasneverhadheartburn.
1.WhatistheconnectionbetweenasthmaandGERD?
2.WhatagentscanbegiventothepatienttotreathisGERDsymptoms?

Casestudy12
A.A41yearoldwomanisadmittedforseverechestpains.Sheappearsasathin,flushed,nervous
woman.Hercomplaintsincludenervousness,palpitations,weightlossdespitestrongappetite,and
unexplainedbruising.Shestatessheisbeingtreatedfordeepveinthrombosiswithwarfarin5

mg/day.Physicalexaminationrevealsabloodpressureof190/95mmHg,pulseof125beats/min,
andtemperatureof102.6F.Yourexamalsorevealsdroopyeyes,decreasedvisualacuity,an
enlargedthyroid,atrialbrillation,pittingedema,andtremor.
1.Whatisyourinitialdiagnosis,andhowwouldyoutreatthepatient?
B.A37yearoldfemalewantstobreastfeedherrstchild.Sherequestsinformationon
contraceptionchoicesbeforeleavingthehospital.Shehasastrongfamilyhistoryofcardiovascular
diseaseandispresentlyatwopackperdaysmoker.Shepreviouslyhadaconventionalintrauterine
devicethatwasremovedbecauseofseverebleeding.Shealsostatesthatspermicidalfoamsand
condomscauseheritchingandburning.
2.Whattypeofcontraceptionwouldyourecommendtothepatient?

Copyright2015Elsevier,Inc.Allrightsreserved.