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Week 8 Assignment 1: Miscellaneous Pharmacology Case Studies

Introduction

Heart disease is the leading cause of death for men, women, and most racial and ethnic groups in the United States, according to the Centers for Disease Control (CDC). Patients who need management of these conditions are a common part of the daily practice of most medical providers, therefore familiarity with the medications used to treat disorders of the cardiovascular system is important. The following five case studies highlight these medications in common situations you may see in your practice.

Case Study 1

Guadalupe, 47, comes into the clinic complaining of intermittent nocturnal gastroesophageal reflux. He says he awakens experiencing substernal burning pain as well as pain in the back of his throat. Guadalupe says it feels like“my larynx is closing down” and he is “almost unable to breathe.” As soon as he can breathe effectively, he swallows “a lot” of antacid and washes it down with water. The entire episode is very frightening, and he is often afraid to go back to sleep. Because he already has a problem with mild sleep apnea, he is becoming increasingly tired and unable to function at work due to lack of sleep. He now sleeps only in his recliner. Guadalupe is also concerned about the substernal pain because his father had a myocardial infarction at age 49 and required coronary artery bypass surgery. He is 5 feet 9 inches tall and weighs 220 pounds (BMI is 32.5), with much of his excess weight carried in his abdomen. He is not a smoker, “occasionally” has three or four beers with friends, and “often” has pizza or submarine sandwiches for lunch with a “diet cola.” Guadalupe takes no drugs other than the antacid after a reflux episode. An assessment was performed, and a chest x-ray and electrocardiogram are negative for cardiopulmonary disease, and he is diagnosed by history with gastroesophageal reflux disease (GERD).

Please address the following:

What would be the initial management plan for Guadalupe’s GERD? Please use your textbook, clinical guidelines, and/or primary literature as appropriate.

What educational points would this patient need?

Case Study 2

Elijah, a 26-year-old runner, came into the office today complaining of constant pain in the right ankle. While running his usual route, he accidentally stepped on a branch lying in his path and twisted his ankle inward. He denies hearing a “pop.” He was able to walk, or limp, the remaining quarter mile back to his home, where he immediately elevated and iced the ankle for 30 minutes. He took two acetaminophen 325 mg, showered, and dressed for work, and drove to his place of employment.  Elijah continued to experience significant pain in the ankle, which he said is worse when he walks. His foot became swollen. Since his job in a sporting goods store requires him to be on his feet most of the day, he was unable to continue his normal workday. He made a same-day appointment to be seen. Elijah has no chronic diseases, takes no medication. He sprained the ankle last year but was able to manage that injury at home with acetaminophen. Upon assessment you find an otherwise healthy male who presented limping into the examination room, holding his right shoe in his hand. Elijah grimaces with partial weight-bearing of the affected foot. He has local ecchymosis and 1+ edema over the anterolateral ligaments of the right ankle. Capillary refill, pulses, and sensation of the foot and toes are intact. There is no lateral or anterior instability of the joint or tendons. X-rays of the ankle and foot are negative for fracture or dislocation. Elijah has a grade 1 lateral ankle sprain.

Please address the following:

• Describe your initial treatment for this patient with ankle pain.
• Describe what mediations can be prescribed for pain and why.  Please list all potential treatment options you feel could be appropriate for this patient.

Describe the education that should be provided for a patient taking NSAID or opiate medications.

Case Study 3

Maxwell, 32, arrives in the clinic today to talk about his opioid dependence. He said it began after a motorcycle accident, which happened 4 months ago. At that time, Maxwell was prescribed Percocet (oxycodone and acetaminophen) for pain control since he fractured multiple bones during the accident. However, he is still taking the Percocet four to five times daily. He states he has tried to cut back on the pain medication but has withdrawal symptoms whenever he tries to decrease the amount of medication he is taking daily. Maxwell has heard there is medication-assisted treatment to help him wean off the opioids. Maxwell states he took a dose of Percocet before bed the evening before coming to the clinic. On your exam you find an alert, well-nourished, cooperative patient. Vital signs are stable. Clinical Opioid Withdrawal Scale (COWS) score is 12. Scarring of legs and shoulder noted from old injury.

Please address the following:

• Describe the plan of care for a patient requesting medication-assisted therapy for withdrawal from opioids? Please explain your rationale for this decision.
• Describe how buprenorphine is discontinued. Why does this medication need to be discontinued in this manner?
• Case Study 4

Mike, 46, comes into the clinic with a complaint of “heartburn” for three months. He describes the pain as burning located in the epigastric area. The pain improves after he takes an antacid or drinks milk. Mike has been taking either over-the-counter famotidine or ranitidine off and on for the past two months, and he still has recurring epigastric pain. He has lost six pounds since his last visit. Your physical assessment and examination are unremarkable. Mike’s BP is 118/72 mm Hg. Laboratory values show a normal CBC and a positive serum Helicobacter pylori test.

Please address the following:

What would be the initial management plan for a patient with peptic ulcer disease caused by H. pylori? Include your medication regimen, duration of action, and any other treatments.

Case Study 5

• Elda, a 64-year-old female, presents with a 2-day history of intense pain along her left posterior chest wall. She comes in today complaining of a burning rash in this area. Calamine lotion and Tylenol have been ineffective. Your examination reveals allodynia along the left T5–T7 dermatome, with a blistering rash in the middle aspect of the dermatome. Elda is grieving the recent death of her spouse of 40 years. She is exhausted and unable to sleep or eat due to intense pain. Elda presents as an otherwise healthy older adult woman with a remote history of chickenpox (a classic case of herpes zoster). It is imperative to start antiviral therapy immediately. Judicious amounts of a short-acting opiate may also provide adequate pain relief in the acute phase. Elda is prescribed Valtrex 1 g three times a day, along with Vicodin 5/500, starting with half a tablet every 3 to 4 hours. She is to return to the office in two days.
• When Elda returns two days later, she states the pain continues to be severe, but the blistery rash has not worsened. She takes one Vicodin every 4 hours, can sleep for short periods, and eats little. Examination reveals severe allodynia along the left T5–T7 dermatome. The blisters are drying, and no new blisters have formed.

When Elda returns one week later, the blisters have resolved, but she continues to have significant allodynia. She cannot wear her undergarments. Elda has cut down the Vicodin to half a tablet three times a day because of constipation and sedation.

Please address the following:

Describe a nonopioid plan of care for a patient with postherpetic neuralgia. Explain your rationale and rational drug selection process.

What education does the patient need regarding taking gabapentin or pregabalin?