1. A patient brought into the emergency room is experiencing severe hypotension. Blood pressure reads 90/50.

i. What class of drugs is indicated for treatment and why?

ii. What precautions should be observed when these drugs are administered?

iii. What would be the first indication that too much drug has been administered?

2. Only certain drugs are capable of crossing the blood brain barrier.

i. How is the blood brain barrier different than barriers found in other areas of the body? Be specific.

ii. What properties of drugs will make it more likely to cross the blood brain barrier? Explain your answers.

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Irving HeathcoteLv2

4 Dec 2018

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Only certain drugs are capable of crossing the blood brain barrier.

i. How is the blood brain barrier different than barriers found in other areas of the body? Be specific.

ii. What properties of drugs will make it more likely to cross the blood brain barrier? Explain your answers.

1) The neurotransmitters acetylcholine and norepinephrine are digested by enzymes that are located at the axon synapse or within the axon terminal of the neurons.

a)What are the names of these different types of enzymes?

b)Where are they located and what is the result of their enzymatic activity?

2) Explain how the Investigational New Drug process works as well as the four different phases of clinical trials. Why are some drugs still taken off the market after approval by the FDA?

3) A single IV injection of 100 mg drug with a half-life of 4 hours is administered to a young adult.

a) Plot drug concentration versus time on a graph making certain to clearly label.

b) How long will it take to eliminate > 95% of the drug?

c) If the volume of distribution is 4L, what is the clearance of the drug?

4) Many drugs are metabolized in the liver through the microsomal metabolizing system.

a) What specific enzymes are involved in this metabolism?

b) What are the main functions of these enzymes?

c) What are some factors that can contribute to individual drug metabolism variation? Explain.

5) Think of an emergency situation requiring immediate and intense physical exertion.

a) List as many body organs as you can and predict the desired level of activity [increased or decreased].

b) Which neurotransmitter would produce these effects and through what receptors?

6) It is interesting that a drug can produce a therapeutic effect and an undesired side effect in one situation, and that the same drug side effect may be considered a therapeutic effect in another situation. Explain this phenomenon using the drug promethazine as an example.

7) A patient brought into the emergency room is experiencing severe hypotension. Blood pressure reads 90/50.

a) What class of drugs is indicated for treatment and why?

b) What precautions should be observed when these drugs are administered?

c) What would be the first indication that too much drug has been administered?

8) Only certain drugs are capable of crossing the blood brain barrier.

a) How is the blood brain barrier different than barriers found in other areas of the body? Be specific.

b) What properties of drugs will make it more likely to cross the blood brain barrier? Explain your answers.

9) A 32-year-old, presents to the Emergency Department by ambulance with vomiting, confusion, salivation, and respiratory distress. The patient states that he was feeling fine until today when I started getting ill. He then vomits. During a physical exam you record the following information: Heart rate 45; Blood pressure 90/60; Respiratory rate 25; Temperature 36.6C; Pupils constricted. During your exam, 4 more ambulances arrive with patients with similar symptoms. You find out they were all riding in the same care on the Red Line when they began feeling ill.

a) What do you feel is happening and why?

b) Would you expect their symptoms to improve over time? Why or why not?

c) What drug would you prescribe to treat these patients and why?

10) Betty has diabetes and asthma. She also has developed high blood pressure, for which doctor just prescribed propranolol. One of your duties as a physicianâs assistant is to make sure patients are not prescribed drugs that are contraindicated because of other health problems.

a) What should you tell the doctor about Bettyâs prescription for propranolol and why?

b) Is there a more appropriate drug for Betty? Explain you answer.

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 102.2Â° F (39Â° 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. â¨ 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? â¨ 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. â¨ 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 Âµg/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. 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