Case Studies for Week 1 1. John Tucker, a 49-year-old truck driver, has a history of hypercholesterolemia and hypertension. In addition, he was recently told that he has chronic bronchitis after a visit to his provider for follow-up on a hacking, longstanding cough that is worse in the morning. John takes cholestyramine (Questran) daily for his elevated cholesterol and atenolol (Tenormin) for hypertension. He smokes 2 packs per day and consumes a six-pack of beer every day or two. On occasion, he takes Mylanta for indigestion and "a sour stomach." John is seen today at your Quick Care Clinic because his cough has worsened. It is accompanied by productive yellow sputum and a temperature of 102.2° F (39° C). He states he is allergic to penicillin. It made him sick to his stomach. The physician begins him on azithromycin (Zithromax). When you approach John about smoking cessation, he abruptly tells you that he's not interested. John tells you that he had a friend who was hospitalized with pneumonia, requiring intravenous antibiotics. John is taking atenolol for his hypertension. After completing his antibiotic course of therapy, John returns to the clinic for follow up. While he reports his fever and productive cough are gone, he tells you that he can't sleep because of an intense hacking cough, particularly at night. He is given a 3-day prescription for chlorpheniramine and hydrocodone (Tussionex), a schedule III antitussive. ⨠1. Zithromax is within the drug class called _______________ 2. Based on ethical decision-making, would you insist that John stop smoking because it is a self-harm practice? ⨠3. How do cigarettes and alcohol interfere with drug metabolism? 4. Zithromax has a moderate degree of protein binding. When two drugs have a significant degree of protein binding, there is_____________________ 5. After drug absorption and distribution, the body eliminates drugs by biotransformation and excretion. The chief organ of metabolism is the__________________ 6. Based on the pharmacokinetics of the drug Questran, and given Johns social habits, is this an appropriate drug choice in the management of John's primary hyper-cholesterolemia? Explain your answer. 7. Because of drug-drug and drug-food/nutrient interaction, Questran should be taken: ______â¨â¨8. John takes atenolol for hypertension. In drug-receptor interaction terms, atenolol is a ________ 9. Atenolol may or may not aggravate Johns pulmonary disease. Choose your answer and explain it. 10. Explain the mechanism by which Tussionex will relieve Johns cough? What patient teaching do you want to do with John in relation to this drug? 2. Mrs. Brown is 65. She is widowed, lives alone, and has two supportive children who live 1 hour away. She has a history of arthritis and hypertension managed with hydrochlorothiazide (HCTZ) 25 mg daily. Two weeks ago she was treated for bleeding in the upper gastrointestinal tract attributed to use of nonsteroidal anti-inflammatory drugs (NSAIDs). On the morning of admission, she awoke with a strong feeling of indigestion. She took Pepto-Bismol and Tums, but the feeling persisted. She also felt more tired and "winded." She drove herself to the hospital 12 hours after the onset of pain, and the emergency room (ER) nurse recommended that an electro-cardiograph (ECG) be obtained. ST wave elevations were noted in leads II, III, and AVF, indicating injury to the inferior wall of her heart. â¨â¨Note the long duration of time between the onset of symptoms of myocardial infarction and her arrival in the ER as well as her recent gastrointestinal bleeding. These factors contraindicate the use of fibrinolytic therapy in the setting of her acute coronary syndrome. ⨠1. In the ER, Mrs. Brown's hands and legs feel cool and her pupils are dilated. The adrenergic receptor stimulation that most likely is the cause of these symptoms is: â¨beta1, beta2, alpha1, alpha2 2. The ECG monitor alarm sounds. The nurse notes the sudden onset of ventricular fibrillation. A code is called, and Advanced Cardiac Life Support (ACLS) efforts ensue. Mrs. Brown is defibrillated three times, and cardiopulmonary resuscitation (CPR) initiated. The drug that is indicated at this time is: Epinephrine, Atropine, Morphine 3. Mrs. Brown is stabilized and transported to the critical care unit (CCU) with a diagnosis of an acute inferior wall MI. On admission to the CCU her vital signs are BP 80/50, HR 102, and RR 22. Her skin is cool and clammy. The physician decides to place a pulmonary artery catheter for hemodynamic pressure monitoring and an arterial line for continuous blood pressure monitoring. Her blood pressure continues to be between 80 and 90 mm Hg systolic, and her urine output has decreased to 30 ml/hr. A dopamine infusion is ordered to begin at 3 µg/kg/min. Mrs. Brown weighs 67 kg. The intravenous infusion is supplied 400 mg in 500 ml D5W. What would be an objective finding that would indicate Mrs. Brown is responding to dopamine therapy other then a lower pulmonary capillary wedge pressure? 4. When infusing dopamine, what special precaution is necessary? â¨â¨5. Mrs. Brown's intravenous infusions are tapered off. She is on aspirin 325 mg enteric-coated 1 tablet daily, metoprolol (Lopressor) 25 mg twice daily, and nitroglycerin (NTG) 0.4 mg sublingually prn. What drug class is metoprolol in? 6. What two parameters are essential for the nurse to assess prior to giving the metoprolol to Mrs. Brown? 7. Research supports a decreased mortality rate when beta-blocking drugs are initiated after myocardial infarction. Why? 8. Myocardial infarctions can lead to problems with chronic heart failure called CHF. Beta blockers used to be contraindicated to use in someone who has heart failure. Is there still a risk of increasing symptoms of heart failure with the use of these drugs?
