Kasus 1

Debbie James is a 32-year-old woman who returns to her PCP (Pneumocystis carinii
pneumonia) with complaints of worsening palpitations and continuing shortness of
breath with exertion. She saw the PCP 2 weeks ago for the shortness of breath and
was diagnosed with bronchitis. Despite treatment with an antibiotic and an inhaler, the
symptoms have not resolved. The palpitations started a few months ago and would
come and go until the past week when they began occurring more frequently, almost
daily. She reports a 10-kg weight loss over the past 2 months, despite a good appetite.
She feels hot all of the time and sweats a lot. She also reports that she has been losing
her hair recently and that that she is more irritable than usual.
Family History :
Father has HTN; mother has Graves’ disease and a history of
ovarian cysts prior to having a hysterectomy
Social History :
Lives with her husband and two daughters, ages 7 and 5 years; does not smoke and
drinks alcohol
Medication history : multivitamin everyday
Allergy : Sulfa (rash)
Lab values :
Na 138 mEq/L Phos 3.9 mg/dL Glu 101 mg/dL AST 12 IU/L
K 3.9 mEq/L Hgb 13.8 g/dL SCr 0.7 mg/dL ALT 20 IU/L
Cl 102 mEq/L WBC 6.2 × 103/mm3 BUN 9 mg/dL T. bili 0.1
mg/dL
Ca 9.7 mg/dL RBC 3.24 × 106/mm3
Mg 1.7 mEq/L Plt 341 × 103/mm3 .
Total T3 368 ng/dL Free thyroxine index 28.7 Total T4 18 mcg/dL TSH <0.018
mIU/L
T3 resin uptake 35%

1. What signs, symptoms, and laboratory values indicate the presence or severity
of hyperthyroidism
2. What are the goals of pharmacotherapy in this case?
3. What nondrug therapies and instruction might be useful for this patient?
4. What feasible pharmacotherapeutic alternatives are available for the treatment
of hyperthyroidism in this patient?
5. What clinical and laboratory parameters are necessary to evaluate the response
to therapy and to detect or prevent adverse effects?

Kasus 2
Beverly Jones is a 75-year-old Caucasian woman with a history of HTN,
hyperlipidemia, COPD, hypothyroidism, and osteoporosis. She presents to the family
medicine clinic for a follow-up visit for her HTN and osteoporosis. She has been
experiencing episodes of constipation and flatulence since she began taking Os-Cal
500 after her last clinic visit.
PMH
HTN first diagnosed at age 50.
S/P MI 12 years ago.
Hyperlipidemia × 13 years; patient modified diet and took cholestyramine
for several years.
Hypothyroidism × 27 years, treated with levothyroxine.
Osteoporosis diagnosed by DXA scan 2 years ago.
COPD diagnosed several years ago. History of repeated exacerbations requiring
prednisone; last exacerbation 6 months ago. Currently stable on multiple inhalers.
Breast cancer with mastectomy of left breast and radiation therapy at age 40.
Menopause at age 39.
Right carotid endarterectomy 2 years ago.
GERD.
Family History
Paternal history (+) for CAD; father died at age 60 of “heart trouble.” Maternal
history (+) for stroke and vascular disorders; mother became menopausal at
approximately age 40.
Review Of System
Mild headaches and new onset back pain, treated with acetaminophen; vaginal
dryness; has noticed that her height has decreased by 2'' since she was 35 years old;
denies shortness of breath or chest pain
Meds
Ramipril 10 mg po BID × 2 years
Tiotropium 18 mcg inhaled once daily × 9 months
Advair 250/50 1 puff BID × 9 months
Albuterol MDI 2 puffs Q 6 h PRN
Synthroid 100 mcg po once daily × 20 years
Atenolol 50 mg po once daily × 10 years
Aspirin 81 mg po once daily × 12 years
Omeprazole 20 mg po once daily × 1 year
Lipitor 10 mg po once daily × 3 months
Os-Cal 500 po TID × 3 months

Lab values :
Na 141 mEq/L TSH 3.492 mIU/L
K 4.2 mEq/L AST 32 IU/L
Cl 104 mEq/L ALT 27 IU/L
BUN 17 mg/dL SCr 1.0 mg/dL
Glu 98 mg/dL

Current fasting lipid profile: Three months ago:

T. chol 177 mg/dL. T.chol 250 mg/dL
Trig 215 mg/dL Trig 265 mg/dL
LDL 102 mg/dL LDL 167 mg/dL
HDL 32 mg/dL HDL 30 mg/dL
AST 20 IU/L
ALT 17 IU/L

Problems :
1. What information (signs, symptoms, laboratory values) indicates the presence
or severity of the patient’s osteoporosis?
2. What are the goals of pharmacotherapy in this case?
3. What nondrug therapies and instruction might be useful for this patient?
4. What feasible pharmacotherapeutic alternatives are available for the treatment
of hyperthyroidism in this patient?
5. What clinical and laboratory parameters are necessary to evaluate the response
to therapy and to detect or prevent adverse effects?