Case Studies (Clinical Pharmacy Assignment) Case Studies Case Study 1. Drug Related Problem Case Study 2. Alcohol Toxicity Case Study 3. Patient Counseling Case Study 4. Peptic Ulcer Case Study 5. Drug and the Newborn Case Study 6. Night time Anxiety Case Study 7. Clostridium Difficile Case Study 8. Epilepsy and Pregnancy Case Study 9. Parkinsonism Case Study 10. Treatment May Be Worse Than Condition

1. Assignment Of Clinical Pharmacy
Submitted by: Quratulain KaimKhani
PHAE/2K9/64
10/29/2013
Faculty Of Pharmacy,
University Of Sindh

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Case Studies
Case Study 1. Drug Related Problem
Case Study 2. Alcohol Toxicity
Case Study 3. Patient Counseling
Case Study 4. Peptic Ulcer
Case Study 5. Drug and the Newborn
Case Study 6. Night time Anxiety
Case Study 7. Clostridium Difficile
Case Study 8. Epilepsy and Pregnancy
Case Study 9. Parkinsonism
Case Study 10. Treatment May Be Worse Than Condition

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Clinical Pharmacy
Terms Used.
Acitretin. Acitretin is used to treat severe psoriasis (abnormal growth of skin cells that
causes red, thickened, or scaly skin). Acitretin is in a class of medications called
retinoids. The way acitretin works is not known.
Athlete's foot. Athlete's foot also known as ringworm of the foot, or tinea pedis, is
a fungal infection of the skin that causes scaling, flaking, and itch of affected areas, and
in severe cases, swelling and amputation of the foot. It is caused by fungi in the
genus Trichophyton.
Campylobacter. Campylobacter (twisted bacteria) is a genus of bacteria that
are Gram-negative, spiral, and microaerophilic. Motile, with either unipolar or
bipolar flagella, the organisms have a characteristic spiral/corkscrew appearance At
least a dozen species of Campylobacter have been implicated in human disease.
Clostridium difficile. A species of Gram-positive spore-forming bacterium that is
best known for causing antibiotic-associated diarrhea. While it can be a minor normal
component ofcolonic flora, the bacterium is thought to cause disease when competing
bacteria in the gut have been wiped out by antibiotic treatment. In severe cases, C.
difficile can cause "pseudomembranous colitis, a severe inflammation of the colon.
Ethosuximide. Ethosuximide is a succinimide anticonvulsant, used mainly
in absence seizures.
Hematemesis. Hematemesis or haematemesis is the vomiting of blood. The source
is generally the upper gastrointestinal tract.
Oxcarbazepine. is an anticonvulsant and mood-stabilizing drug, used primarily in the
treatment of epilepsy. It is also used to treat anxiety and mood disorders, and
benign motor tics. Oxcarbazepine is marketed as Trileptal by Novartis.
Psoriasis. is an immune-mediated disease that affects the skin. It is typically a
lifelong condition. There is currently no cure, but various treatments can help to control
the symptoms. Psoriasis occurs when the immune system mistakes a normal skin cell
for a pathogen, and sends out faulty signals that cause overproduction of new skin
cells. It is not contagious.
Psoralen. It is the parent compound in a family of natural products known
as furocoumarins. It is structurally related to coumarin by the addition of a

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fusedfuran ring, and may be considered as a derivative of umbelliferone. Psoralen
occurs naturally in the seeds of Psoralea corylifolia, as well as in the common
fig, celery, parsley and West Indian satinwood.
PUVA Therapy. PUVA is a psoralen + UVA treatment for eczema, psoriasis, graft-
versus-host disease, vitiligo, mycosis fungoides, large-plaque
parapsoriasis and cutaneous T-cell lymphoma. The psoralen is applied or taken orally to
sensitize the skin, then the skin is exposed to UVA.
Selegiline. Selegiline is used to help control the symptoms of Parkinson's disease
(PD; a disorder of the nervous system that causes difficulties with movement, muscle
control, and balance in people who are taking levodopa and carbidopa combination
(Sinemet). Selegiline may help people with Parkinson's disease by decreasing the dose
of levodopa/carbidopa needed to control symptoms, stopping the effects of
levodopa/carbidopa from wearing off between doses, and increasing the length of time
that levodopa/carbidopa will continue to control symptoms. Selegiline is in a group of
medications called monoamine oxidase type B (MAO-B) inhibitors. It works by
increasing the amount of dopamine (a natural substance that is needed to control
movement) in the brain.
Tonic–Clonic Seizure. Tonic-clonic seizures are the most common and best known
type of generalized seizure. They begin with stiffening of the limbs (the tonic phase),
followed by jerking of the limbs and face(the clonic phase). During the tonic phase,
breathing may decrease or cease altogether, producing cyanosis (turning blue) of the
lips, nail beds, and face. Breathing typically returns during the clonic (jerking phase), but
it may be irregular. This clonic phase usually lasts less than a minute.
Valproic Acid. an acidic chemical compound, has found clinical use as
an anticonvulsant and mood-stabilizing drug, primarily in the treatment
of epilepsy,bipolar disorder, and, less commonly, major depression. It is also used to
treat migraine headaches.
Zolpidem
Zolpidem is a sedative, also called a hypnotic. It affects chemicals in your brain that
may become unbalanced and cause sleep problems. Zolpidem is used to treat
insomnia.

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Clinical Pharmacy
Case Study 1.
A patient visits his physician because he has complain of hypertension, headache, fever
and abdominal cramp. Physician prescribed him atenolol 50mg, ibuprofen 400mg, and
buscopan. After 2days the patient reports about high blood pressure, that his
hypertension not got treated yet. What would you suggest him and what change should
be done in the prescription of the patient?
Answer.
Treatment for this patient is improper. Atenolol is a selective B1-receptor antagonist. It
produces negative ionotropic and negtative chronotropic effects. Hyoscine
butylbromide (Buscopan) is non selective drug. It is peripherally acting antimuscarinic
agent, used as an abdominal specific spasmodic. It causes relaxation of of gastro-
intestinal tract, but in heart it acts on cardiac muscles or muscarinic receptor, and
produce the positive chronotropic and positive ionotropic effects. This effect is against
Atenolo. Buscopan should be replace by Mebverine, which is musculotropic agent and
directly acts on gut wall and causes relaxation.
Case Study 2.
A 24-year old student is brought into the emergency department complaining of
vomiting, light-headedness, chest pain, and difficulty in breathing. You discover that he
fell ill at a party. Initially he and his friends deny any drugs other than beers at party.
Then he told that he is taking metronidazole for about the past 10days to control the
symptoms of athlete’s foot. What might be the cause of his symptoms?
Answer.
Metronidazole shares the ability of disulfirum to block the metabolism of alcohol and
cause an accumulation of acetaldehyde. The student’s symptoms are consistent with
accumulation of this agent.

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Case study 3.
A 28 years old, married woman, who presents a prescription for ciprofloxacin to a
pharmacy to be filled. When giving out the medicine, the pharmacist checks whether
Mrs KH takes any other medicines. She explains she takes iron tablets each morning
but nothing else.
Answer.
The pharmacist recoomends that she takes ciprofloxacin in the morning and at night,
avoiding milk at these times and take the iron at lunchtime. Heavy meal ions such as ion
or calcium can bind with ciprofloxacin to produce an insoluble salt that will not dissolve
and be absorbed from the git. The interaction could cause therapeutic failure of the
antibiotic. This could be avoided by taking ciprofloxacin atleast 2hours before or after
iron or calcium. Taking the iron at lunch time and avoiding milk (which contains calcium)
close to administration times will avoid this interaction. Calcium in the other food
sources in a normal diet is not usually sufficient to impair absorption.
Case study 4.
A 32-year old working woman, who describes her life stressful. She smokes 1 pack of
cigarettes per day. She frequently takes naproxen for headaches. For the past 5 weeks
she has noticed significant epigastric discomfort. This morning she went to the
emergency department complaining of hematemesis. She was admitted, and the
gastroenterologist performed an upper endoscopy that revealed 1-cm ulcer. Is further
evaluation necessary, and what recommendations would you make to this patient?
Answer.
Peptic ulcer disease is most frequently either Helicobacter pylori infection or use of
NSAIDs. The patient does admit to NSAID use (Naproxen), but should also be checked
for concomitant H.pylori infection at time of endoscopy or by a serology test. If patient
was found to have H. pylori, an appropriate eradication regimen should be prescribed.
The patient should be prescribed a proton pump inhibitor for 8 weeks to heal the ulcer.
A repeat endoscopy should be done at that time to document ulcer healing. In addition,
patient should be counseled to stop smoking, which is risk factor for more severe peptic
ulcer disease.

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Case study 5.
A mother calls to tell that her week-old baby is having convulsions. She says the baby
showing signs of a serious ear infection soon after birth. A physician prescribed
penicillin G that apparently ear infection appeared to be reduced, but the baby began to
have convulsions about an hour after receiving the last injection of penicillin. What
would you advise the mother to do?
Answer.
Pencillin G is a potent antagonist of the inhibitory neurotransmitter y-GABA. Since
penicillin G normally does not penetrate the blood-brain barrier to any extent, this is not
usually a problem. But the blood-brain barrier is not fully developed at birth, and
substances that normally are excluded from entering the CNS may enter the immature
brain of the newborn. Seizures are a manifestation of several GABA antagonists,
including penicillin G. Since the mother indicates that the seizures have almost ceased,
you instruct her not to administer any more penicillin and to bring her child for checkup
as soon as possible.
Case study 6.
A 22-year old woman who visits her doctor because she is extremely tired she reports
that she is exhausted at bedtime, she typically cannot fall asleep for at least an hour or
two. She moved on to town 2 months ago and has her first full-time job but fears that
her supervisors think she is “dumb” because she has made some mistakes. After
falling to sleep, she sometimes wakes an hour or more before her alarm goes off,
usually thinking about her dumb mistakes. Her problem with sleeping began
approximately 5 months ago, when she was studying for final examinations in her senior
year of college. What treatment would you recommend for her insomnia and fatigue?
Answer.
Zolpidem is the best choice. Patient’s inability to sleep well is probably the result of
anxiety caused by several stresses in her life. She is a recent college graduate, has a
new job, and has moved to a new town. These events constitute three stressors, which
can induce anxiety and sleep loss. The sleep loss and anxiety are usually of relatively
short duration. Zolpidem has a quick onset and a half-life of approximately 2.5 hours. If
taken at bedtime, it should allow her to fall asleep quickly and sleep though most or all
of the night. Its elimination is fast enough that it should not produce residual drowsiness
during the day. A week-long trial of zolpidem should help M.W overcome her sleep
disturbance.

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Case study 7.
A 55-year-old man, presents to the emergency department of the local hospital with a 4-
day history of diarrhea associated with abdominal cramping. He complains that he has
experienced at least 6 bowel movements daily during that time. And the stools have
been watery, but now he is passing blood-tinged stools. He admits to experiencing
fatigue and chills, but no weight loss or change in appetite. Upon further questioning, he
admits that he recently finished a course of antibiotics. Although he is unable to
remember which antibiotic he took, the emergency department pharmacist is able to
contact the pharmacy that filled his antibiotic prescription. According to the retail
pharmacist, the patient received a 10-day supply of cefuroxime. The physician decides
to admit him. Among the tests ordered, the culture is positive for Clostridium difficile.
The culture is negative for Salmonella, Shigella, and Campylobacter. The physician
wants to initiate antimicrobial therapy to treat his C difficile-associated diarrhea. Since
the patient is hospitalized, the physician wants to prescribe intravenous (IV) antibiotics.
He orders IV vancomycin. When the pharmacy receives the order, should the
pharmacist make any recommendations on patient’s antibiotic therapy?
Answer.
Metronidazole remains the treatment of choice for Clostridium difficile. patient does not
have any contraindications to oral medication, so oral metronidazole should be
considered. Although oral vancomycin is effective, the risk of vancomycin-resistant
enterococci makes it a less desirable option. As for intravenous (IV) therapy, IV
vancomycin is considered less effective than IV metronidazole. IV vancomycin does not
achieve sufficient drug concentrations in the intestinal lumen.
Case study 8.
A 28 year-old woman who have been treating for a seizure disorder tells the physician
that she is 2 months pregnant. She has exhibited absence seizures in the generalized
tonic-clonic. She usually has two or three generalized seizures per month. She indicates
that she has had only one episode during the past 2 months and wonders if she should
stop her medication. She is taking oxacarbazepine, valproic acid, and ethosuximide. Are
any of the agents that the patient is taking clearly more teratogenic than others? Is
there any significance to the apparent decreased incidence of seizures during the
pregnancy? How would you treat this patient?
Answer.
Valproic acid has been shown to implicated in causing birth defects. Ethosuximide has
not, but there is little evidence that ethosuximide is effective, since her absence of
seizures terminated months ago.

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Oxacarbazepine has not been clearly shown to be teratogenic, but teratogenicity cannot
be ruled out, since its close chemical and pharmacological relative carbamazipine has
been implicated in causing teratogenicity.
A decrease in seizure frequency is frequently seen during pregnancy. This is not this is
not always the case, and the explainations are not established. Ethosuximde should be
discontinued immediately. It is probably appropriate to discontinue the valproic acid over
the next week or so. At that time, the dose of oxacarbazepine should be decreased by
50% if there is no increased incidence of seizures following termination of valproic acid.
Since the woman has had a relatively long duration of seizure episodes, it is probably
not reasonable to discontinue all medication. She should keep a log of her seizure
incidence and contact immediately to her doctor if the incidence appears to be
increasing.
Case study 9.
A 60-year old architect who designs buildings. His drawings are very detailed and they
must be drawn to a specific scale. During the past month he has developed a slight
tremor in his right hand that causes some embarrassment but does not interfere with
function. He has however, noticed that his writing and drawing have gotten much
smaller, causing problem with his work. His primary care physician has referred him to
a neurologist for evaluation. On examination, the neurologist notes some motor rigidity
in the right arm. He also observes a slight slowing in the patient’s walk and reduction in
the swing of his arms as he walks. What is the diagnosis, and how should the patient be
treated?
Answer.
The patient is in early stage Parkinsonism, most likely idiopathic (Parkinson’s disease).
Clinically, the disease is very mild and the neurologist might consider not treating him at
this point, but because the micrographia interferes with his work, the neurologist
decides to prescribe medication. Several drugs can be used to treat early-onset
parkinsonism. The most commonly used are the dopamine receptor agonists
(pramipexole, ropinirole, pergolide; amantadine is also a possibility, and some people
get an acceptable response to selegiline, the MAO inhibitor). Levadopa-carbidopa could
also be used; however, most clinicians prefer to delay its use until absolutely needed
because of the adverse effects, such as motor fluctuations and dyskinesias, that
accompany long-term use of levadopa.

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Case study 10.
A 35-year old mother of two has moderate psoriasis. She tells that her mother had a
similar condition 3years ago and was successfully treated with the agent acitretin. She
has come to you because her regulgar physician refused to write her a prescription for
acitretin, and she is very uncomfortable with her skin condition. You tell her that there is
a serious risk of teratogenicity if she should become pregnant. She informs you that
she is taking oral contraceptives and that the possibility of pregnancy is very low. Do
you prescribe the drug she has requested anyway?
Answer.
Acitretin should not be prescribed for women of childbearing potential unless no
acceptable alternative is available and the the patient has acknowledged in writing that
she understands the need to use two effective forms of contraception during therapy
and for 3years after she discontinue the drug. She has not been treated yet with puva.
You convince her that this is more appropriate therapy, considering her age and her
childbearing potential. She grudgingly accepts your treatment. She responds well to the
treatment, and after 6 months the psoriasis is greatly improved and treatment is
terminated.
THE END