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MODULE 9

CASE STUDY 3: DIABETES MELLITUS

Objectives:
1. To explain how blood glucose levels are maintained within narrow limits by insulin and
glucagon.
2. To compare and contrast the etiology and pathogenesis of type 1, type 2 and gestational
diabetes.
3. To describe acute and chronic complications of diabetes.
4. To compare and contrast the pharmacotherapy of the different types of diabetes.

Like the nervous system, the endocrine system is a major controller of homeostasis. Whereas
a nerve exerts instantaneous control over a single muscle fiber or gland, a hormone from the
endocrine system may affect all body cells and take as long as several days to produce an optimum
response. Hormonal balance is kept within a narrow range: Too little or too much of a hormone
may produce profound physiological changes.

Diabetes is one of the leading causes of death in the world. One in every 400 to 600
children and adolescents has type 1 diabetes while 20.9% of all people 60 years or older has
diabetes. Diabetes can lead to serious acute and chronic complications, including heart disease,
cerebrovascular accident (CVA), blindness, kidney failure, and amputations.

Procedure:
1. Review the given case study.
a. Identify and interpret abbreviations used
b. give the meaning of the medical terms used in the case study
c. comment on the abnormal PE findings and laboratory findings
2. Differentiate Type 1 from Type 2 diabetes mellitus
3. Discuss the physiology of insulin. Include the different analogues of human insulin.
4. Answer the questions at the end of the case study.

CASE STUDY:

CC
"I'm here for my regular check up. I don’t have any problems today"

HPI
John McGuire is a 68 yo man who comes to the diabetes outpatient clinic for a follow-up visit. His blood
glucose logbook indicates that he has been monitoring his blood glucose levels twice a day (before breakfast
and dinner) with a range of 140 to 175 mg/dL. He reports adherence to an 1800-calorie meal plan ad 40
minutes of walking on a treadmill every morning.

PMH
Type 2 DM x 5 years
HTN x 13 years
Hyperlipidemia x 1 year

FH
Maternal grandmother had DM, father had emphysema; no family history of CAD
SH
Married, retired factory worker, active in church and a social club. No current tobacco use (stopped 40
years ago), consumes about 7 – 14 alcoholic drinks per week.

Meds
Glynase 6 mg po QD x 1 year
Glucophage 1 gram po BID x 6 months
Zestril 20 mg po QD
EC ASA 81 mg po QD

All
NKDA

ROS
Denies nocturia, polyuria, polydipsia, nausea, constipation, diarrhea, signs or symptoms of hypoglycemia,
paresthesias, and dyspnea. Reports occasional blurry vision and occasional lower leg pain.

PE
Gen
WDWN mildly obese, elderly Caucasian man in NAD

VS
BP 182/82, P 80, RR 16, T 38.6C; Wt 82.2 kg, Ht 66.5”

HEENT
PERRLA; EOMI; R & L fundus exam without retinopathy

Cor
RRR; no m/r/g

Lungs
Clear to A & P

Abd
NT/ND

Genit/Rect
Deferred

MS/Ext
Carotids, femorals, popliteals, right dorsalis pedis pulses 2+ throughout; left dorsalis pedis 1+; feet show
thick calluses on MTPs

Neuro
DTRs 2+ throughout; feet with normal sensation (5.07 monofilament) and vibration

Labs
Na 139 mEq/L Ca 9.8 mg/dL Fasting Lipid Profile
K 5.3 mEq/L Phos 3.3 mg/dL T. chol 238 mg/dL
Cl 102 mEq/L AST 19 IU/L LDL-C 168 mg/dL
CO2 22 mEq/L ALT 13 IU/L HDL-C 42 mg/dL
BUN 23 mg/dL Alk phos 43 IU/L Trig 170 mg/dL
SCr 1.2 mg/dL T.bili 1.0 mg/dL Free thyroxine index 3.4 U
Glu (random) 289 mg/dL HbA1C 8.2%

UA
(-) protein; (-) microalbuminuria

Assessment
The patient reports adherence to diet, exercise, and drug therapy as prescribed. His glycemic control has
improved somewhat (FBG and pre-dinner BG previously 170 to 200 mg/dL) with addition of Glucophage
6 months ago. His cholesterol levels have also improved (T. chol 268 mg/dL 10 months ago) Blood pressure
has remained consistently high for the past 10 months. He has lost 1.6 kg in the last 3 months. His glycemic
control, blood pressure, and lipid profile have not improved adequately in response to a combination of
nutrition therapy utilizing the NCEP Step II diet (2 visits with a dietitian) and drug therapy implemented
for the last 6 months.

QUESTIONS

problem identification
1. a. Discuss the pathophysiology of the patient's pathologic condition.
b. What findings indicate poorly controlled diabetes in this patient?

desired outcome
2. a. What are the goals of treatment for the management of type 2 diabetes for this patient?
b. What individual patient characteristics should be considered in determining the goals of treatment?

therapeutic alternatives
3. a. What non-pharmacologic interventions would you recommend for this patient?
b. What pharmacologic interventions could be considered for this patient?

optimal plan
4. a. What pharmacotherapeutic regimen would you recommend for this patient?
b. What alternative therapies might be appropriate if the initial plan fails?

assessment parameters
5. What parameters should be monitored to evaluate the efficacy and possible adverse effects associated
with the optimal regimen you selected?

patient counseling
6. What information should be given to the patient regarding diabetes mellitus and his treatment plan to
increase adherence, minimize adverse effects, and improve outcomes?

follow-up case question


7. What are the measurable objectives and long-term goals for treating hypertension and hyperlipidemia
in this patient?
8. What non-pharmacological and pharmacological interventions would you consider to reach these
goals?
9. Discuss the phenomenon known as syndrome X and the role that insulin resistance is postulated to play
in its sequelae.
10. Explore the advantages and disadvantages of using combination oral agents in the management of type
II diabetes and the rationale for delaying the initiation of insulin therapy.
11. Discuss combination therapy using various oral hypoglycemic agents with insulin.
12. In your assessment of this case, does the absence of retinal changes on physical examination or finding
of no protein on urinalysis exclude the presence of retinopathy and nephropathy, respectively?
13. Conduct a comparative review of the efficacy of several insulin analogues relative to the insulin
products commercially available.
14. Discuss the role of ACE inhibitors in the prevention of the onset and/or the progression of diabetic
retinopathy.

References:
MODULE 10
CASE STUDY 4: PULMONARY TUBERCULOSIS

Objectives:
1. To compare and contrast the types of infections caused by mycobacteria.
2. To explain the pathogenesis of tuberculosis.
3. To describe how the pharmacotherapy of tuberculosis differs from other bacterial infections.
4. To prepare a plan for monitoring the effectiveness of tuberculosis therapy.
5. To know the role of a clinical pharmacist in DOTS.

Mycobacterial infections have been responsible for considerable human suffering and death
throughout history. Mycobacterial disease was once called consumption, because of its ability to
cause the body to waste away if left untreated. Although these infections usually respond to
modern anti-infectives, therapy is prolonged and resistant organisms gave emerged as major clinical
challenges. Despite the effective treatments available for the disease, TB still claims about 1.6 million
lives each year worldwide.

Procedure:
1. Review the given case study. Identify and interpret abbreviations used, medical terms, and
laboratory findings. Comment on the medication history of the patient.
2. Answer the questions at the end of the case study.

Case Study:

SCENARIO
Patient and Setting
RC, a 27-yo female; ED

Chief Complaint
Several weeks of fatigue, weight loss, fevers, chills, night sweats, and a productive cough

HPI
Decrease in energy over the past few weeks, along with weight loss, fevers, chills, night sweats and a
productive cough

PMH
Diagnosed with HIV infection (September 2010) with Pneumocystis carinii pneumonia (PCP) as AIDS-
defining illness; last HIV clinic visit was 2 months ago (12/10/2011); depression (September 2010)

Past Surgical History


None

Family/Social History
FH: Heterosexual female with one sexual partner (also diagnosed with HIV infection); currently lives
with him
SH: Nonsmoker; occasional alcohol; works as accountant

Medication History
Nelfinavir, 1250 mg PO BID
Zidovudine 300 mg/ lamivudine 150 mg (combination), 1 tablet PO BID
TMP-SMX, 1 DS tablet PO 3x/week
Sertraline, 50 mg PO QD
Oral contraceptive (30 μg ethinyl estradiol and 0.3 norgestrel), 1 tablet PO QD
Multivitamin with iron, 1 tablet PO QD

Allergies
NKDA

PE
Gen Thi female with productive cough
VS BP: 110/72, HR: 90, RR: 22, T: 37.5°C, Wt 50 kg (Wt 2 months ago was 55 kg), Ht
160
HEENT PERRLA, lymphadenopathy
Cor RRR
Chest Radiograph: apical fibrocavitary infiltrates
Abd Nontender, no masses
GU WNL
Rect WNL, Guaiac negative
Ext WNL
Neuro A and O x 4, no headache

Labs and Diagnostic Tests


Na 137 mEq/L Hgb 10 g/dL Mg 2.5 mEq/L
K 3.6 mEq/L Hct 30 % Ca 8.8 mEq/L
Cl 98 mEq/L Glu 110 g/dL PO4 3.0 mEq/L
CO2 26 mEq/L WBC 3.2 x 103//mm3 Alb 3.6 g/dL
BUN 10 mg/dL Plts 160 x 103//mm3 MCV 115 μm3
SCr 0.8 mg/dL Alk Phos 90 IU/L RBC 3.6 x106/mm3
Tot chol 180 mg/dL AST 22 IU/L T. bili 0.2 mg/dL
HDL 47 mg/dL ALT 23 IU/L LDH 100 IU/L
Uric acid 3.2 mg/dL

Pregnancy test: Negative


G6PD deficiency screening test: Negative (test results 9/2012)
PPD tuberculin skin test: 8 mm
Three serial sputa for AFB stains and cultures were obtained
AFB smear: Positive for mycobacteria
Culture and sensitivity: Pending
Blood, urine, and stool cultures and sensitivity: Pending
Induced sputum: Negative for Penumocystis carinii pneumonia
Arterial oxygen: 90 mm Hg (on room air)

Questions:
1. Discuss the transmission and pathophysiology of pulmonary tuberculosis.
2. Discuss how tuberculosis is diagnosed.
3. Discuss PPD test. How is this done and interpreted?
4. What are the goals of therapy for this patient with active TB?
5. Describe the therapeutic options for TB and how treatment should be initiated and
monitored.
6. Why is multiple drug therapy the norm in the treatment of TB?
7. How should the presence of INH resistance influence the drug therapy?
8. How would the treatment of extrapulmonary TB differ from the treatment of pulmonary
TB?

References:
MODULE 11
CASE STUDY 5: SCHIZOPHRENIA

Objectives:
1. To compare and contrast the positive and negative symptoms of schizophrenia.
2. To explain the theories for the etiology of schizophrenia.
3. To describe the initial and maintenance pharmacotherapy of schizophrenia.
4. To explain the importance of patient drug adherence in the pharmacotherapy of psychoses.
5. To discuss the rationale for selecting a specific antipsychotic drug for the treatment of
schizophrenia.

Severe mental illness can be incapacitating for the patient and intensely frustrating for
caregivers and those dealing with the patient on a regular basis. Schizophrenia, the most common
of the severe psychotic disorders, has been misdiagnosed, misunderstood and mysterious, according
to Vaughan (2004). He went to say that the treatment of schizophrenia has been challenging to
patients and health care providers because of the often severe adverse effects of the antipsychotic
drugs used to treat it.

Psychosis is a general term used in medicine to describe a loss of contact with reality. A
psychosis is a symptom of mental illness and is not considered a disease itself. Psychotic behavior
may range from total inactivity to extreme agitation and combativenesss. Because patients are
unable to distinguish what is real from what is illusion, they are often labeled as insane.

Psychoses may be classified as acute or chronic. Sometimes a specific cause may be attributed
to the psychosis; unfortunately, the vast majority of psychoses have no identifiable cause.

Procedure:
1. Review the given case study.
a. Discuss the theories explaining the causes of schizophrenia.
b. Differentiate the types of schizophrenia from each other.
2. Differentiate positive from negative symptoms.
3. Explain how mental status is done and how this can help in he diagnosis of schizophrenia.
4. Answer the questions at the end of the case study.

Case Study:

CC
"Police brought me in a patrol car."

HPI
This is the first admission for Thelma Baker, a 35-yo woman who was brought to the state hospital by
the police. The patient apparently has been delusional and believes people sneak into her room at night
when she is asleep and put worms inside her body. She also believes that she is being raped by passing
men on the street. She is quite preoccupied about having massive wealth. She claims to have brought
some gold and left it at the grocery store. She believes that her ideas have been given to a communist
who has had plastic surgery to look like her and is using her ID to take possession of all her property.
She states that she is having difficulty getting her property back.
Apparently, the precipitating event causing her hospitalization was that she created a
disturbance at a Mexican fast-food restaurant, claiming that she owned it. Because of the disturbance,
police were called and she subsequently was sent here on an order or protective custody. According to
the patient, she bought a taco and sat down to eat it, and for some reason somebody called the police
and charged her with illegal trespassing. She claims that 6 years ago she was raped by a relative of a
sister and broke her hip in the process. She states that her feet were cut off because she would not do
what her impostors wanted her to do, and her feet were subsequently sent back to here from India and
were reattached.
Her speech is quite rambling, and she speaks of having been part of an experiment in Alabama
where 38 eggs were taken from her body, and children were produced from them and killed by the
government. She also reports that she took part in signing the treaty in 1945 when Germany
surrendered. She claims that she has worms in her that are the type that kill dogs and horses, and says
that they have been put there by the government. She also claims that at one time she had transmitters
in her backbone and that it took three years to have them taken out by the government. She claims to
have had the surgery in the past, and the surgeon didn't know what he was doing and took out her
gallbladder and put it in the intestines where it exploded. The patient also states that on one occasion
a physician was removing the snakes from her abdominal cavity, and the snakes killed the doctor and
a nurse. She also claims that she worked as a surgeon herself before 1963.

Past Psychiatric History


The patient denies any prior hospitalization for mental problems, denies any street drugs or significant
substance use. There is some history of her having frequent visits to the local hospital. She denies any
drug or alcohol use and denies using any tobacco products.

PMH
The patient's past records indicate that she did have gallbladder surgery (cholecystectomy) 2 months
ago. There is no record of her having being raped or having a broken hip. No further medical history is
known.

Family Psychiatric History


The patient claims that her alleged family is not really her family and that she is not sure who her
family is.

Meds
None noted

All
Penicillin - rash

Legal/Social Status
Divorced, heterosexual; lives in an apartment alone; employment history unknown.

Mental Status Exam


The patient is a Caucasian female, modestly dressed with some disarray. Her hair is brown and
unwashed. She is alert, oriented and in no acute distress. Her speech is clear, constant, pressured, with
many grandiose delusions and illogical thoughts. She is quite rambling, going from one subject to the
other without interruption. Her affect is mood congruent, her mood is euphoric, and there is a marked
degree of grandiosity. Her thought processes are quite illogical with marked delusional thinking. There
is no evidence of auditory hallucinations, and she denies visual hallucinations. She denies any suicidal
or homicidal ideation, but she is quite verbal and pressured in her thought content, verbalizing a great
deal about the things that have been taken away from her illegally by people impersonating her. She
has marked delusional symptoms with paranoid ideation prominent. Her memory (immediate, recent,
and remote) is fair. Her cognition and concentration are adequate. Her intellectual functioning is within
the average range. Insight and judgment are markedly impaired.

ROS
Reports occasional GI upset; complains that worms are inside her stomach. Otherwise negative.

PE
VS BP 132/ 79, P 80, RR 17, T 37.1 °C, Wt 80 kg, Ht 6'3"
HEENT PERRLA; EOMI; fundi benign; throat and ears clear; TMs intact
Skin Scratches on both hands
Neck Supple, no nodes; normal thyroid
CV RRR, normal S1 and S2
Lungs CTA & P
Abd (+) BS, non-tender
Ext Full ROM, pulses 2+ bilaterally
Neuro A & O x 3; reflexes symmeteric; toes downgoing; normal gait; normal strength;
sensation intact; CN II - XII intact

Labs and Diagnostic Tests


Na 140 mEq/L Hgb 14.6 g/dL T. bili 0.9 mg/dL WBC 11.0 x 103//mm3
K 3.9 mEq/L Hct 45.7 % Ca 9.6 mg/dL Neutros 66%
Cl 104 mEq/L Glu 91 mg/dL PO4 5.1 mg/dL Lymphs 24%
CO2 22 mEq/L TSH 4.5 μIU/mL Alb 3.6 g/dL Monos 8%
BUN 19 mg/dL Plts 232 x 103//mm3 RBC 4.7 x 106/mm3 Eos 1%
SCr 1.1 mg/dL Alk Phos 89 IU/L MCV 90.2 μm 3 Basos 1%
Tot chol 190 mg/dL AST 34 IU/L MCH 31 pg
RPR negative ALT 22 IU/L MCHC 34.5 g/dL
GGT 38 IU/L

Urine pregnancy: negative


UA: Color, yellow; appearance, slightly cloudy; glucose (-); bili (-); ketones, trace; SG
1.025; blood (+); pH 6.0; protein (-); nitrites (-); leukocyte esterase (-)

Questions:
1. a. What information (signs, symptoms, laboratory values) indicates the presence or severity of
an acute exacerbation of schizophrenia, paranoid type?
b. What target symptoms are present in this patient?
2. What are the goals of pharmacotherapy in this case?
3. a. What non-drug therapies might be useful for this patient?
b. What pharmacotherapeutic alternatives are available for the treatment of this patient?
4. a. What drug, dosage form,, dose, schedule, and duration of therapy are best for this patient?
b. What alternatives would be appropriate if the initial therapy fails or cannot be used?
5. a. What clinical and laboratory parameters are necessary to evaluate the therapy for
achievement of the desired therapeutic outcome and prevent adverse effects?
6. What information should be provided to the patient to enhance compliance, ensure successful
therapy and minimize adverse effects?
7. Perform a literature search on the use of vitamin E for the treatment and prevention of tardive
dyskinesia. What is the proposed mechanism of action? Would you recommend this therapy? If
so, what dose would you suggest?
8. Discuss the ethical and pharmacoeconomic issues surrounding the use of risperidone rather than
haloperidol in this patient.

References: