Model case

Jordanian Clinical Skills Competition Program
Case Study Problem Solving
“Model Case”

Demographic and Administrative Information
Date of Birth: 1-1-1936 Date of admission:22/1/2012 Case summary
Past Medical History
A.A presented to the Hospital 2 weeks ago with generalized weakness, and he was Diabetes mellitus for
diagnosed as a case of severe bilateral internal carotid artery stenosis. A right internal the last 5 years
carotid artery stent (CAS) was placed. Two days later, the patient was discharged and Bilateral carotid artery
planned for left CAS later on. Today, A.A presented to the ED with right-sided weakness stenosis S/P right CAS
and cough. He was admitted to CCU for left CAS. Brain CT scan was performed and no Diastolic Heart Failure.
ischemic changes were noticed. A Chest X-ray was done and showed bilateral well defined Chronic Kidney
lung infiltrate seen more in the left peripheral middle zone. As a routine, CBC was Disease
performed and showed leukocytosis. According to all above observations, the patient was
diagnosed as a case of pneumonia.
On the day of admission, his blood glucose level was relatively high and did not fully
respond to insulin sliding scale.
On hospital day (HD) 3, K level was low, and he was started on potassium gluconate and
spironolactone.
On hospital day 5, stent was successfully placed in the intracranial artery.
On hospital day 5, the patient developed nausea, vomiting and watery diarrhea. The
physician suspected C. difficile infection and decided to discontinue antibiotic and to ask

Family History
Social History
Occupation: Retired Status: married Children: 4 sons Life style:
Vitals & Other Tests
Chemistry and CBC
Tests and Procedures
Physical Exam
Allergies/Intolerances
General – Elderly, man who has productive cough. Abd – Soft, non-distended; no masses or obvious tenderness Neuro – general weakness in the left side
PTA Medication
Current Drug Therapy
Pharmacist care plan for current medications
Medical Problem
Treatment Related Issue
Pharmacotherapy Goals
Recommendations
Follow up and monitoring result
or health care
Recommend collecting sputum sample for Gram Monitor for respiratory rate &, in case Vancomycin to a targeted trough of 15-20 Doses: Cefepime 2 gm IV Q 24 h or Ceftazidime 2 gm IV Q 12 h Meropenem 1gm IV Q 12 h Imipenem 250 mg IV Q 6 h Levofloxacin 750 mg IV Q 48 h Ciprofloxacin 400mg IV Q 12 h Vancomycin dosing is flexible, as long as the target trough of 15-20 mcg/mL is achieved. Treat for 7-8 days unless Pseudomonas is cultured (14 days for Pseudomonas). Before and for a minimum of 30 days after CAS, dual-antiplatelet therapy with aspirin (81 to 325 mg daily) plus clopidogrel (75 mg daily) is clopidogrel, ticlopidine (250 mg twice daily) Intraprocedural management includes adequate anticoagulation. Adequate anticoagulation can be LDL <70 mg/dL (because the patient achieved with unfractionated heparin given in sufficient dosage to maintain the activated clotting time between 250 and 300 seconds. Bivalirudin may have advantages over heparin, baseline liver function test, then every including obviating the need for monitoring of periodically; platelets because of concomitant antiplatelet medications. Immediate postprocedural management includes aspirin (81 to 325 mg daily), it is conventional to administer clopidogrel (75 mg daily) for at least 4 weeks, mainly on the basis of experience gained in patients undergoing CAS. Smoking cessation and medications for control of hypertension, hyperlipidemia, and diabetes As the patient is intolerant to statins, he should be started on niacin or bile acid sequestrant according to guideline recommendations, either Continue on potassium gluconate 20 CC *3 which is equivalent to 80 mEq K until reaching Note: Each 15 CC of sopak contain 20 mEq of
Continue on spiranolactone 50mg*1, as the cause of hypokalemia was renal wasting due to continued diuretic use.3 Continue on furosemide 40mg P.O after HD6. 4 Start patient on enalapril 2.5 mg twice daily and Recommend influenza vaccine annually and Give 3.5 units IV initial insulin bolus (initial glucose was about 350 mg/dL which should be divided by 100=3.5 U) followed by insulin infusion at a rate of 3.5 unit/hr (using the same Then adjust insulin infusion rate each hour after initial insulin bolus and infusion according to the Check urine for ketones since N&V may be due Control blood glucose by insulin infusion as concomitant administration of metoclopramide with insulin. Increase the dose of N-acetyl cysteine to 1200 mg twice daily on the day before the procedure Ensure proper hydration by IV fluid as above and skin rash following oral administration of N-acetyl cysteine. including: RBC and Hct decline, dizziness, orthostatic hypotension, black tarry stool, blood in gastric residuals, hematemesis. Continue enoxaparin 40 mg SC daily until pain, leg pain or swelling with redness Monitor for S&S of bleeding (as above) References:
1. American Thoracic Society, Infectious Diseases Society of America. Guidelines for the management of adults with hospital-acquired, ventilator- associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med. 2005;171(4):388. 2. 2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS Guideline on the Management of Patients With Extracranial Carotid and Vertebral Artery Disease Circulation. 2011;124:e54-e130. 3. Mount, DB. Clinical manifestations and treatment of hypokalemia. In: UpToDate, Sterns, RH; Emmett, M (Ed), 2012. 4. Zile, MR; Gaasch, MH. Treatment and prognosis of diastolic heart failure. In: UpToDate, Colucci, WS (Ed), 2012. 5. IV Insulin Infusion Protocol for Critically-Ill Adult Patients in the ICU Setting , algorithms and recommendations of the Texas Diabetes Council's Medical Professionals Advisory Subcommittee, Revised 10/25/07. Available at: http://www.dshs.state.tx.us/diabetes/. Accessed on June, 25, 2012. 6. Longstreth, GF. Approach to the adult with nausea and vomiting. In: UpToDate, Talley, NJ (Ed), 2012. 7. Rudnick,MR; Tumlin,JA. Prevention of contrast-induced nephropathy. In: UpToDate, Palevsky PM (Ed),2012 8. Lanza FL, Chan FK, Quigley EM, Practice Parameters Committee of the American College of Gastroenterology. Guidelines for prevention of NSAID- related ulcer complications. Am J Gastroenterol. 2009; 104(3):728. 9. Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines, Chest, Chest, 2012 141:2 suppl 7S-47S. Questions:

1. Develop an immunization program for prevention of pneumonia in AA.

Influenza vaccine: More than 90 percent of influenza-related deaths occur among people ≥60
years of age. Older adults also experience significantly increased morbidity from the disease.
While everyone should get a flu vaccine each flu season, it’s especially important that certain people get vaccinated either because they are at high risk of having serious flu-related complications or because they live with or care for people at high risk for developing flu-related complications. Risk factors in AA include: Cardiovascular disease & diabetes mellitus); Pneumococcal vaccine: Pneumococcal disease is a significant cause of morbidity and
mortality in older adults. Many studies found the vaccine to be cost-effective in preventing
pneumococcal bacteremia, the incidence of hospitalization for pneumonia and invasive
infection.
The CDC recommends pneumococcal immunization once at age 65 for most adults and need
for routine revaccination for patients who have received the vaccine after age 65 and to
revaccinate once after age 65 if an initial vaccination was given before age 65 and five years
have elapsed since the first dose .
References:
1. CDC (Centers for Disease Control and Prevention). Influenza vaccination: a summary for clinicians. Available at www.cdc.gov. Accessed on June, 25, 2012. 2. CDC (Centers for Disease Control and Prevention). Brief description of pneumococcal disease and vaccine recommendations. Symptoms, treatment, transmission, vaccine recommendations for children and adults, etc. Available at www.cdc.gov. Accessed on June, 25, 2012. 2. Suggest two antibacterial options if VRSA is an issue in this case?
Linezolid: 600 mg twice daily IV (or orally if or when the patient is able to receive oral medications). Telavancin: 10 mg/kg IV daily.(3) Lowy FD. Vancomycin-intermediate and vancomycin-resistant Staphylococcus aureus infections, In: UpToDate, Baron EL (Ed), 2012. 3. What are the latest injectable antidiabetic classes for the treatment of Type 2
diabetes?
Amylin Analog
Pramlintide, a synthetic analog of amylin, is an injectable antihyperglycemic agent that modulates postprandial glucose levels and is approved for preprandial use in persons with type 1 and type 2 diabetes. It is administered in addition to insulin in those who are unable to achieve their target postprandial blood sugar levels. Pramlintide suppresses glucagon release via undetermined mechanisms, delays gastric emptying, and has central nervous system- mediated anorectic effects. It is rapidly absorbed after subcutaneous administration; levels peak within 20 minutes, and the duration of action is not more than 150 minutes. Pramlintide is renally metabolized and excreted, but even at low creatinine clearance there is no significant change in bioavailability. It has not been evaluated in dialysis patients. The most reliable absorption is from the abdomen and thigh; arm administration is less reliable. Pramlintide should be injected immediately before eating; doses range from 15 to 60 mcg subcutaneously for individuals with type 1 diabetes and from 60 to 120 mcg subcutaneously for individuals with type 2 diabetes. Therapy with this agent should be initiated with the lowest dose and titrated upward. Because of the risk of hypoglycemia, concurrent rapid- or short-acting mealtime insulin doses should be decreased by 50% or more. Concurrent insulin secretagogue doses also may need to be decreased in persons with type 2 diabetes. Pramlintide should always be injected by itself with a separate syringe; it cannot be mixed with insulin. The major adverse effects of pramlintide are hypoglycemia and gastrointestinal symptoms, including nausea, vomiting, and anorexia. Glucagon-Like Polypeptide-1 (GLP-1) Receptor Agonists
In type 2 diabetes, the release of glucagon-like polypeptide is diminished postprandially, which leads to inadequate glucagon suppression and excessive hepatic glucose output. Two synthetic analogs of glucagon-like polypeptide, exenatide and liraglutide, are commercially
available to help restore GLP-1 activity. These therapies have multiple actions such as potentiation of glucose-mediated insulin secretion, suppression of postprandial glucagon release through as-yet unknown mechanisms, slowed gastric emptying, and a central loss of appetite. The increased insulin secretion is speculated to be due in part to an increase in beta- cell mass. The increased beta-cell mass may result from decreased beta-cell apoptosis, Exenatide is approved as an injectable, adjunctive therapy in persons with type 2 diabetes treated with metformin or metformin plus sulfonylureas who still have suboptimal glycemic control. and dosage adjustment is required only when the creatinine clearance is less than 30 Exenatide is injected subcutaneously within 60 minutes before a meal; therapy is initiated at 5 mcg twice daily, with a maximum dosage of 10 mcg twice daily. When exenatide is added to preexisting sulfonylurea therapy, the oral hypoglycemic dosage may need to be decreased to prevent hypoglycemia. The major adverse effects are nausea (about 44% of users) and vomiting and diarrhea. The nausea decreases with ongoing exenatide usage. Exenatide mono- and combination therapy results in HbA1c reductions from 0.2% to 1.2%. Weight loss in the range of 2–3 kg is reported in some users, presumably because of the nausea and anorectic effects. A serious and, in some cases, fatal adverse effect of exenatide is necrotizing and hemorrhagic pancreatitis. Antibodies to exenatide are formed with chronic use, the clinical Liraglutide is a long-acting synthetic GLP-1 analog with prolonged half-life that permits once-daily dosing. Liraglutide interacts with the GLP-1 receptor and acts to increase insulin Liraglutide is approved for the treatment of type 2 diabetes as an injectable therapy in patients who achieve inadequate control with diet and exercise, and are receiving concurrent treatment with metformin, sulfonylureas, or Tzds. It is not recommended as a first-line therapy or for use with insulin. Treatment is initiated at 0.6 mg and is titrated in weekly increments of 0.6 mg as needed, and as tolerated, to achieve glycemic goals. Peak levels are obtained in 8–12 hours, and the elimination half-life is about 13 hours. Liraglutide therapy results in a reduction of HbA1c from 0.8% to 1.5%; weight loss ranges from nominal to 3.2 kg. Experience with liraglutide in patients with renal or hepatic impairment is limited and it should be used with caution in these populations. Common side effects of liraglutide are headache, nausea, and diarrhea; antibody formation, urticaria, and other immune reactions also are observed Hypoglycemia can occur with concomitant sulfonylurea use and may require a dose reduction of the oral hypoglycemic agent. Pancreatitis is another serious adverse effect; liraglutide is contraindicated in individuals with a history of pancreatitis and should be permanently discontinued if pancreatitis develops. Because rodents exposed to liraglutide developed thyroid C-cell tumors, there is an FDA mandated "black box" warning that liraglutide is contraindicated in individuals with a personal or family history of medullary cancer or multiple endocrine Although they require injection, the GLP-1 receptor ligands have gained popularity because of the improved glucose control and associated anorexia and weight loss in some users. Safety issues, however, may deter future use.(4) Reference:
Kennedy MSN, Pancreatic Hormones & Antidiabetic Drugs. In: Basic & Clinical Pharmacology, Katzung BG, Masters SB, Trevor AG, eds., 12e, 2011.

Source: http://pharmacyconf2012.ju.edu.jo/Documents/Model%20Case.pdf