Case-1
Jock is a 72-year old man with recently diagnosed mild heart failure. He has a background of
ischaemic heart disease and occasionally suffers from angina. He has no other significant medical
history. Jock lives by himself and is active and independent. He is not overweight, does not drink
alcohol and gave up smoking last year.
An echocardiogram eight weeks ago showed Jock had a left ventricular ejection fraction of 30%
and no valvular abnormalities. At that time, he was started on lisinopril 2.5 mg once daily and
frusemide 40 mg once daily. His GP has been gradually increasing the lisinopril dose, aiming to
get him to a maximal dose (20 mg). Serum biochemistry three weeks ago was normal and his GP
increased his lisinopril from 5 mg to 10 mg once daily. Jock’s other medications are aspirin 100 mg
once daily and sublingual nitrate as needed. Jock had repeat serum biochemistry yesterday which
showed abnormal results: serum creatinine 0.17 mmol/L (normal range for adult men: 0.06–0.12
mmol/L) and potassium 5.7 mmol/L (normal range: 3.8–4.9 mmol/L). All other results were normal.
Jock feels well and is asymptomatic.
1a. Jock’s GP has called to ask your advice about Jock’s heart failure medications. What changes, if
any, would you make to Jock’s current heart failure medications?
No change
Cease (please specify drug)
Change (current medication dose or add a new medication).
Please specify: Drug Dose frequency
1b. When would you recommend repeat biochemistry for Jock?
2. List two different drug classes that may exacerbate heart failure.
3. List four main educational points that you would discuss with Jock regarding the self-management
of heart failure.
4. Six months later Jock returns to the pharmacy. As his heart failure has been stable, Jock’s GP
recently started him on bisoprolol 1.25 mg once daily. List three ways that complications with
beta-blockers may be minimized.
Case-2
John is a 64-year-old male new to the area who presents to the surgery. John reports that he has a
history of hypertension (20 years) and angina (2 years). He was a heavy smoker, 30 per day for 48
years, but ceased 9 months ago. He has no history of gastrointestinal bleeding and nil known allergies.
A letter from his previous GP reports that John had a non ST segment elevation myocardial infarction
(NSTEMI) 12 months ago for which he underwent a percutaneous transluminal coronary angioplasty
and stent to his left coronary artery. John was involved in a cardiac rehabilitation program at the local
hospital for six weeks after his discharge. Since then he walks briskly for 40 minutes every day and
describes no angina.
Current medications: aspirin 100 mg daily, clopidogrel (Iscover, Plavix) 75 mg daily, perindopril (Coversyl)
4 mg daily, simvastatin (Lipex, Simvar, Zocor) 20 mg daily. Further discussion identifies John’s lack of
understanding of the purpose of his medicines and he admits to not always being compliant.
On examination his blood pressure is 145/85 mmHg, pulse rate 80 per minute regular and his chest is
clear on auscultation. Echocardiogram six months ago showed no evidence of heart failure. Body mass
index is 23.5 kg/m2. Blood results taken six weeks ago were mostly normal but you note a total
cholesterol of 5.5 mmol/L, low-density lipoprotein (LDL) cholesterol 3.9 mmol/L, high-density lipoprotein (HDL) cholesterol 0.8 mmol/L and triglycerides 1.8 mmol/L.
1. What changes (if any) would you make to John’s medication?
Aspirin: Cease Continue
increase dose: specify new dose ______mg frequency ______
decrease dose: specify new dose ______mg frequency ______
Clopidogrel: Cease Continue
increase dose: specify new dose ______mg frequency ______
decrease dose: specify new dose ______mg frequency ______
If continuing clopidogrel, please indicate reason ______
Perindopril: Cease Continue
increase dose: specify new dose ______mg frequency ______
decrease dose: specify new dose ______mg frequency ______
Simvastatin: Cease Continue
increase dose: specify new dose ______mg frequency ______
decrease dose: specify new dose ______mg frequency ______
2. List any drug(s) you would add to John’s regimen.
Drug Dose Frequency
i. ______
ii. ______
iii. ______
3. Based on the new medication regimen, what do the medication(s) offer in cardiovascular risk
reduction for John?
______
4. List four points/strategies you would discuss/implement with John about his medicines to
improve compliance.
Case-3
John is a 52-year-old accountant who presents to you complaining of lack of sleep and poor appetite.
He also complains of trouble concentrating, decreased energy and has been feeling anxious for
about 8 weeks now.
John says he is anxious at work and in social situations. Meetings with his supervisor are a potent
trigger for inducing anxiety. His episodes of anxiety are associated with rapid heartbeat, dry mouth
and sweaty palms. He also avoids social situations such as visiting his in-laws, eating lunch with his
co-workers, and supervising staff. He has found avoidance to be an effective means of decreasing
his anxiety. The avoidance of social functions has been putting a strain on his marriage.
John is the youngest of 3 siblings. His wife says he has always been a very shy person. He gave up
smoking 2 years ago and says he drinks alcohol to ease his anxiety. He was diagnosed with COPD
3 years ago (last exacerbation 3 months ago) which is well controlled with tiotropium 18 micrograms
daily and salbutamol inhaler 200 micrograms every 4-6 hours when required. He has had major
depression 10 years ago which successfully resolved with antidepressants. There is no relevant
family history.
On examination John looks anxious but oriented. He avoids eye contact during consultation. He
denies any suicidal ideation. His blood pressure is 130/82 mmHg, pulse is 92 beats per min. The
remaining physical examination is normal.
1. Based on John’s mental health history what is his likely diagnosis and why?
Diagnosis: ______
Reason: ______
2. a) What management plan would you recommend for John?
non-drug therapy
drug therapy
both non-drug and drug therapy
b) Please provide two reasons for recommending above management plan.
(i) ______
(ii) ______
c) If you recommend non-drug therapy, please specify the type:
______
d) If you recommend drug therapy, please specify:
Medication Dose Frequency Durationi
______
3. List potential adverse effects or drug interactions of the following antidepressants used in
the treatment of anxiety disorders and explain how you would manage these
events/interactions.
Antidepressant / Adverse effects/drug interactions / ManagementSSRI (escitalopram,paroxetine,sertraline)
Venlafaxine
Moclobemide
4. a) When are benzodiazepines indicated for the management of anxiety disorders?
______
b) List two adverse effects/drug interactions when using benzodiazepines for the
management of anxiety disorders?
Case-4
Anne is a 75-year-old retired professional who has recently moved to the area. You are seeing her for the first time. Anne is very worried because she is currently experiencing some fatigue and palpitations.
Anne was diagnosed with paroxysmal atrial fibrillation (AF) 3 years ago. The investigations at that time included a trans-oesophageal echocardiogram, which showed normal left ventricular function, cardiac valves and left atrium. Since then her AF has been mostly asymptomatic with few episodes of prolonged rapid palpitations which were controlled by a beta blocker at the time.
She gave up smoking 5 years ago and does not drink alcohol. Currently, she is not taking any medication. She has no history of previous bleeding episodes. Anne’s father had a non-fatal stroke of presumed ischaemic origin. Her mother had undergone coronary artery bypass surgery.
Physical examination shows an irregularly irregular heart rhythm with a rate around 100 beats per minute. Blood pressure is 130/80 mmHg. An electrocardiogram shows AF. Otherwise, her cardiovascular and pulmonary examinations are unremarkable. Anne has brought her pathology results from 1 month earlier. These show normal full blood count, thyroid function tests, serum creatinine and liver function tests.
1.a) What is the stroke risk for Anne?
Low Moderate High
b) What factor(s) led to you decision?
2. In Anne’s case, what are the potential advantages and disadvantages of the following?
Advantages / DisadvantagesAspirin
Clopidogrel
Dipyridamol
Warfarin
3. a) Would you recommend antithrombotic therapy for Anne at this stage?
b) If yes, please specify:
Medication Starting dose and frequency Time to next review
______
Why did you recommend this specific medication(s)?
c) If you did recommend any antithrombotic treatment, why not?
4. Regardless of your answers in question 3, if Anne was started on warfarin:
a) Are there any existing factor(s) that may increase her risk of major bleeding? If yes, please specify ______
b) What information would you give her to achieve optimal anticoagulation?
Case-5
Lisa is 25 years old and presents a new prescription for budesonide dry powder inhaler,
400 micrograms, one inhalation twice a day and salbutamol CFC-free MDI 100 micrograms, one
to two puffs as needed. She has a history of asthma which she previously used salbutamol alone.
Lisa»s asthma has been worse lately, she has been using her salbutamol inhaler on approximately
5 days of the week to relieve wheeze and chest tightness, she wakes form sleep with wheeze
about once a fortnight. She does not use a peak flow meter to monitor her symptoms.
Lisa is otherwise well, has never smoked, takes no other medications and is not allergic to any
drugs.
1. How would you grade the severity of Lisa»s asthma?
· Very mild
· Mild
· Moderate
· Severe
· Other (please specify): ______
2. What adverse effects of inhaled corticosteroids (if any) would you advise Lisa about?
______
______
3. How can Lisa minimise the adverse effects of inhaled corticosteroids?
______
______
4. Outline what counselling you would provide about the use and care of the dry powder
inhaler.
______
______
______
5. Outline what counselling you would provide about the use and care of the metered dose
inhaler.
______
______
______
6. What other information (if any) would you provide?
______
7. If the patient is not controlled with above medication after a chest infection and is identified to be severe persistent asthma, what changes in treatment is suggested. Write a prescription with drug dosage regimen.
Case-6
Damien, a 58-year-old brick layer comes for a review of the management of his chronic obstructive pulmonary disease (COPD) as his symptoms have become more troublesome over the past month. He was diagnosed with COPD twelve months ago. Damien was doing well on inhaled salbutamol as needed but for the past 2 months has had a persistent cough and his breathlessness is more apparent. Last spirometry results (5 months ago, after his last COPD exacerbation) were post-bronchodilator FEV1: 60% predicted and FEV1/FVC ratio: 0.65.
Damien smokes 25 cigarettes per day (30 years) and has on several occasions attempted to quit smoking without success. His regular medications are salbutamol (Airomir, Asmol, Ventolin) MDI 200 micrograms every 4–6 hours when required. He is also on atenolol (Noten, Tenormin) 50 mg for hypertension and atorvastatin (Lipitor) 10 mg for hypercholesterolaemia (both in the morning). He has no other medical conditions, and has no known allergies.
On examination, BP is 135/85 mmHg, pulse 100, respiratory rate 20 and temperature 37°C. He is able to speak in whole sentences and there is no central cyanosis present. Auscultation of the chest reveals widespread expiratory wheezes with slightly reduced air entry on both sides.
1. Would you recommend any diagnostic imaging or pathology tests to assist in assessing Damien’s current condition?
yes (please specify) no Investigation: Reason:
2. Would you recommend continuing or adding on any of the following medicines* at this visit? (Mark all that apply i.e. for combination products, mark all ingredients.)
regular salbutamol yes no
eformoterol or salmeterol yes (alone) yes (with salbutamol) no
ipratropium yes (alone) yes (with salbutamol) no
inhaled corticosteroids yes(alone) yes (with salbutamol) no
oral corticosteroids yes (alone) yes (with salbutamol) no
tiotropium yes (alone) yes (with salbutamol) no
atenolol yes (alone) yes (with salbutamol) no
3. If you recommend starting another medicine for the management of Damien’s COPD:
a) When will you assess the efficacy of the medicine(s)
b) How will you assess the efficacy?
c) For the medicine(s) you recommended, what are the two most important points you will
counsel Damien on?
4. Damien is ready to quit smoking again and would like some help.
a) How would you assess the severity of his nicotine dependence?
b) Would you recommend drug therapy?
yes, please specify:no, why not? Medication Dose Frequency Duration
a)c)What are two non-drug therapies you would recommend for Damien to assist him to quit smoking?
Case-7
Winston is a 64-year-old artist who has come back to see you for worsening back pain. For the past
3 years paracetamol and ibuprofen have been effective in controlling his non-specific back pain. He
reports the increasing pain is distracting him from his work and making simple daily tasks such as
moving his easel and walking to the nearby wine bar increasingly difficult.
Winston lives alone and drinks 2 or 3 glasses of wine a day. He takes irbesartan (Avapro, Karvea)
300mg for hypertension and atorvastatin (Lipitor) 10mg for hypercholesterolaemia (both in the
morning). He takes paracetamol 1 g regularly four times a day and ibuprofen when required for
breakthrough pain. Winston has no history of falls or injury. His family history is unremarkable with
respect to cardiovascular diseases, cancer or musculoskeletal disorders. Further questioning
revealed no neurological symptoms or sciatica.
On examination there is no sign of asymmetry or inflammation of the lumbar spine. There is some
restriction of movement on lumbar flexion but not on extension. His blood pressure is 126/80 mmHg.
His body mass index is 31kg/m2. His renal and liver function test, fasting blood glucose and full blood
count are in the normal range.
1. a) Would you refer Winston for any diagnostic imaging or additional pathology
investigations at this stage?
yes (please specify): ______no
b) Would you have requested any diagnostic imaging or pathology investigations when
Winston first presented with a two week history of back pain?
yes (please specify): ______no
2. a) Provide a reason why a pain diary might be helpful for managing Winston’s pain.