Lancaster Medical School

Year 3
Therapeutics Scenario Handbook
2021 - 2022

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Contents

Introduction.................................................................................................................................3

Scenario 1.....................................................................................................................................4
Questions..................................................................................................................................5
Other Tasks...............................................................................................................................6

Scenario 2.....................................................................................................................................8
Questions..................................................................................................................................8
Other Tasks...............................................................................................................................9

Scenario 3...................................................................................................................................12
Questions................................................................................................................................12
Other Tasks.............................................................................................................................14

Scenario 4...................................................................................................................................16
Questions................................................................................................................................17
Other Tasks.............................................................................................................................17

Scenario 5...................................................................................................................................18
Questions................................................................................................................................18
Other Tasks.............................................................................................................................19

Scenario 6...................................................................................................................................21
Questions................................................................................................................................21
Other Tasks.............................................................................................................................22

Scenario 7...................................................................................................................................24
Questions................................................................................................................................24

Scenario 8...................................................................................................................................27
Questions................................................................................................................................27
Other Tasks.............................................................................................................................29

References for all scenarios........................................................................................................30

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Introduction
The purpose of these scenarios is to encourage discussion and reading into areas of prescribing and
therapeutics not covered elsewhere in the course. Students will need to work through the questions
and enter their answers.

A sample drug card for the purpose of these scenarios is on Moodle.

A discussion forum will be commenced on Moodle for any queries.

The answers will be posted on moodle. The workbook itself is not assessed however the learning
outcomes are part of the overall year 3 course and likely to be assessed

Ian Chadwick Tom Fisher

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Scenario 1
Gladys Smith is an 86 year old woman, with a background history of left ventricular failure, stage 3
chronic kidney disease (CKD) ( baseline eGFR= 37 ml/min/1.73m2) and ischaemic heart disease. Over
the four days prior to admission, she has become increasingly unwell, with diarrhoea, vomiting and
shortness of breath. On the morning of admission, she is found in her room at her residential home
collapsed on the floor. She is responsive but confused; an ambulance is called and she is taken to
accident and emergency.

On arrival at A&E, her observations are as follows:

 BP 85/50 mmHg
 Respiratory rate: 22/min
 HR 110/min
 Temperature 37.8°C
 SaO2 91% on FiO2 0.4

Medications on admission:

 Aspirin tabs 75mg od

 Ramipril tabs 5mg od
 Furosemide tabs 80mg bd
 Eplerenone tabs 25mg od
 Simvastatin tabs 20mg nocte
 Tramadol caps 50mg qds
 Nitrazepam tabs 10mg on
 Isosorbide Mononitrate MR tabs 60mg om
 Bisoprolol tabs 5mg od
 Paracetamol tabs 1g qds

Gladys complains of increasing shortness of breath and cough, as well as ill-defined pain in her lower
back, worse on inspiration. She feels very thirsty and still feels nauseous. Examination reveals left
basal crackles and abdominal tenderness in the left iliac fossa with no rebound tenderness or
guarding.

Investigations are as follows:

 Hb 10.9 g/dL
 Na 130 mmol/l
 WCC 13.2 x10 9/l
 K 5.9 mmol/l
 Plts 399 x10 9/l
 Ur 45.6 mmol/l
 Cr 620 micromol/L

Chest X-ray: Left lower lobe consolidation with small left basal effusion
Abdominal X-ray: Faecal loading to ascending colon; some borderline dilated small bowel loops.

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She is commenced on appropriate therapy, and is catheterised. Her urine output remains between
10-20mls/hr, and fluids are prescribed. She has no known drug allergies and weighs 57kg.

Questions

1. What is the differential diagnosis for Mrs Smith’s collapse?

2. What are the potential causes of her kidney dysfunction and what investigations would
you perform to find out the cause?

3. What actions would you take in relation to her chest x-ray findings?

4. Please prescribe her medications on the drug chart provided.

5. Please complete her fluid prescription on the fluid chart provided.
6. After her fluids have started she becomes more breathless and pulmonary oedema is seen
on the chest X-ray. What actions would you take now?

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Other Tasks

A. List 4 common causes of dehydration in a patient with Stage 3 chronic kidney disease
including 3 different drug classes

B. Complete the following table indicating drugs which may cause nephrotoxicity in each of
the following classification:

Pre-Renal Intra-Renal Post Renal Obstruction

1. 1. 1.

2. 2. 2.

3. 3.

4.

C. Complete the following dose adjustments for a patient with chronic renal failure

1. In a patient with an eGFR of 20mls/min/1.73m2 – who is currently taking ramipril 5mg

daily and you are asked to adjust the dose because of the CRF, what dose would you
prescribe
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2. A patient with severe rheumatoid arthritis is admitted in renal failure (eGFR

25/min/1.73m2 ). She is currently prescribed diclofenac 25mg x 3 daily. What action will
you take?
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3. A patient with type II diabetes is admitted with acute deterioration of his renal function
(urea 15.5 Creatinine 220) secondary to a urinary tract infection. Amongst other drugs
he is taking Metformin 1g bd. What action will you take?
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D. Which of the following drugs may cause significant hyponatraemia?

May cause hyponatraemia

Drug
(Please tick)

1 Bumetanide

2 Gabapentin

3 Diclofenac

4 Lanzoprazole

5 Citalopram

6 Amlodipine

7 Atenolol

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Scenario 2
Miss Gemma Jones is a 35 year old lady who presents with a sudden onset pain left calf. On
examination her calf is red, hot, very tender and swollen. She has recently returned from abroad
where she was bitten by an insect. At the time the bite had swollen, however on her return the pain
became much worse. She is obese and her weight is 90kg. She has an allergy to latex

Her blood results show a raised CRP 125 mg/l (<5), her D-dimer is also raised at 1049 ng/ml (0-500).

Miss Jones has a PMH of psoriatic arthritis which is well controlled. Her drug history is as follows;

 Methotrexate tablets 15mg weekly (Monday)

 Folic Acid tablets 5mg weekly (Wednesday)
 Co-codamol tablets 8/500 2 tabs PRN (max 8 per day)
 Celecoxib capsules 200mg BD
 Etanercept injection 50mg weekly (Friday)

Questions

1. Prescribe Miss Jones regular medications on the drug chart provided.

2. In light of the above information create differential diagnoses for Miss Jones.

3. What further investigations are required to confirm the diagnosis of;

DVT
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Cellulitis
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4. Comment on the reliability of D-dimer and CRP as diagnostic parameters

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 5. A diagnosis of a DVT is given, prescribe the appropriate therapy discuss what monitoring
that is required.
Initial therapy
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Follow on
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Alternatives
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6. She is also diagnosed with cellulitis, what antibiotics are appropriate to treat this
infection? Prescribe these.
7. What counselling points should you provide Miss Jones with now?

Other Tasks

A. This patient is prescribed Methotrexate 15mg weekly for Psoriatic arthritis: identify 4
issues you would discuss with the patient to educate them about the risks of taking the
drug and how to minimise the potential risks.

Issue to Discuss How to Minimise Risk

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 B. This patient is going to require warfarin therapy for about 3-6 months, please indicate
which of the following drugs you would have to use with great caution and the reason.

Is there a need for great caution and if

Drug Action to Take
so why

Methotrexate
1
15mg weekly

Folic acid 5mg

2
weekly

Co-codamol
3 8/500 2 tabs
qds prn

Celecoxib
4
200mg bd

Etanercept
5
50mg weekly

C. This patient now requires warfarin therapy: What advice are you going to give to the
patient in the following circumstances and why

Circumstance What advice? Why?

Development of
1 chest infection
requiring
amoxicillin
Flare up in the
2 psoriatic arthritis

Attends chemist
3 with URTI
requesting cough
medicine
Requires tooth
4 extraction

Patient prescribed
co-trimoxazole for
5 PCP pneumocystis
jirovecii
pneumonia
prophylaxis

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 D. List 3 common side effects of NSAID’s e.g. diclofenac and what action you would take in
this patient to minimise the risk

Side Effect Action

E. Fill in the following table to indicate what antibiotics can be used to treat cellulitis- state at
least one counselling point of each

Antibiotic Choice Counselling Point

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Scenario 3
Mr Arthur Findlay is a 39 year old man admitted to AMU with confusion and ascites having collapsed
at home. He is known to the AMU because of frequent attendance due to binge drinking. He is
confused, agitated, picking at the bed clothes. He has a cough and there is green sputum on his
pyjamas. He has a past medical history of COPD and smokes 30 cigarettes per day. He complains of
chest pain on coughing. He has brought a bag full of drugs with him. The bag contains both
paracetamol and co-codamol 30/500.

On questioning you ascertain that Mr Findlay has been taking maximum dose of paracetamol and co-
codamol 30/500 (which he got from his mother) for a ‘good few days’.
On examination he is shaky and sweaty, his pulse is regular and bounding at 120 bpm. His BP is
145/85 mm Hg and GCS is 15. Oxygen sats are 80% on air, Respiratory rate 25/min, axillary temp
38.1˚C. He has scattered spider naevi on his chest and signs of gynaecomastia. His heart sounds are
normal. He is tender on the right lower ribs where percussion is painful and dull. There are coarse
crepitations and bronchial breathing on auscultation in the right base with a scattered expiratory
wheeze; his lips have a blue tinge. He states he has been using his blue inhaler a lot more recently
and has been bringing up a lot of green coloured sputum. He is tender in the right upper
hypochondrium, his spleen is palpable. His weight is 60kg.

Drug History
 Salbutamol CFC inhaler 100 micrg/dose/2 puffs prn
 Carbocisteine tabs 750mg TDS
 Uniphyllin continus tablets 200mg BD
 Paracetamol 2 tabs qds prn
 Seretide 500 accuhaler 1 puff BD
 Tiotropium 18micrograms Handihaler 1 puff OD

Allergies: Amoxicillin
Chest X-ray: Right Lower Lobe Pneumonia

Notable Blood Results

 WCC 13.5 109/l
 Prothrombin time: 14.1 second
 Albumin 29 g/l
 ALT 155 U/l
 Gamma GT 202 U/L
 Bilirubin 48 micromol/l
 HB 10.8 g/dL
 MCV 115.9 fl
 Urea 1.2 mmol/l
 Creatinine 95 micromoles/l

Questions

1. Complete Mr Findlay’s drug chart, and prescribe anything you feel necessary at this time.

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2. Comment on how you are going to treat Mr Findlay’s accidental Paracetamol overdose.
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3. What antibiotics would you consider to be appropriate to treat Mr Findlay?

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4. What measures should you take to try and deal with this gentleman’s alcohol
detoxification? Who could you refer him to?
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5. Is this gentleman suitable for oxygen management? Prescribe what you think is
appropriate.
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Other Tasks

A. As he is allergic to penicillin (confirmed from his records); name 3 antibiotics from

different classes you would consider using: underline the one you would be most likely to
choose. Indicate any significant side effects concerns over using these drugs.

Antibiotic (including dose

Significant side effect / Concern in prescribing
& frequency)

B. Despite some sedation relating to managing his delirium tremens he complains of severe
chest pain. List 3 options for treatment and a potential serious risk from each approach.

Pain Control Risk of this approach

C. List 5 common drugs that are associated with Hepatotoxicity using the classification
detailed below:

Intra-Hepatic Liver Cell Damage - Hepatitis Liver Cell Fibrosis

Obstruction/Cholestasis
1. 1. 1.

2. 2. 2.

3. 3.

4.

5.

6.

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 D. When prescribing the following drugs in a patient with significant liver disease, why should
you be cautious and what effect would the liver disease have on prescribing the drug?

Why should you be cautious What is the effect on prescribing drug

Drug
prescribing it? of the liver disease?

Aspirin
1

Codeine
2 Phosphate

Diazepam
3

Furosemide
4

Heparin
5

NSAID’s
6

Phenytoin
7

Rifampicin
8

Simvastatin
9

Warfarin
10

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Scenario 4
Mr Paul Jones is a 65 year old Type II diabetic, with known ischaemic heart disease, peripheral
vascular disease, COPD and hypertension. Over the past three weeks, he has developed increasing
pain (although he usually has chronic burning pain in his feet) over his left heel with gradually
increasing symptoms of general malaise and fever. At his routine podiatry appointment (the first he
has remembered to attend in three years), it is noticed that he has developed a deep, 2 by 3 cm
ulcer over his left calcaneum on the dorsal aspect of his left foot. The podiatrist notes slough and
necrotic areas with surrounding cellulitis to above his malleoli. His posterior tibial and dorsalis pedis
pulses are not palpable in his left foot. The podiatrist consults with Mr Jones’ GP, and the decision is
made to send him to the acute medical unit for further evaluation. This includes blood tests and an
X-ray of the left ankle.

Medications

 Aspirin dispersible tabs 75mg od

 Ramipril tablets 10mg od
 Furosemide tablets 40mg od
 Naftidrofuryl caps 100mg TDS
 Isosorbide mononitrate tabs MR 90mg od
 Nicorandil tabs 30mg bd
 Ivabradine 7.5mg bd
 Simvastatin tabs 40mg on
 Metformin 500mg bd
 Novomix 30 flexpen INSULIN s/c 52 units am 48 units pm

Allergies: Penicillin which caused a rash

Blood Tests Reveal

 Normal U+Es, Hb 8.7 g/dL, mcv 75.0 fl WCC 13.2 x10 9/l platelets 470 x10 9/l.
 Hb A1C is 10.8% Ferritin 20 (12-200 ug/L)

X-ray of the left ankle reveals disruption of the periosteum with the some destruction of the
calcaneum underlying the ulcer base.

Swabs taken from the site of the ulcer reveal pseudomonas as well as a heavy mixed growth.
An MRI of the foot confirms the plain X-ray findings the next day.

The orthopaedic team are contacted and review Mr Jones. In order to debride the ulcer and obtain a
sample for microbiology, he is listed for surgery the following day on the trauma list. The
orthopaedic team request that a blood transfusion is given prior to surgery and to ensure that Mr
Jones is nil by mouth from midnight, with appropriate preparations made given Mr Jones’ diabetes.

Following surgery, Mr Jones makes a reasonable recovery, albeit complicated by severe pain and
vomiting. Repeat FBC following surgery reveals an Hb 9.1g/dL. Appropriate antibiotics are
commenced following the results of the samples taken during surgery, but Mr Jones is now very
keen to get home after what he believes to be ‘curative’ surgery.

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Questions
1. What is the differential diagnosis for Mr Jones’ anaemia and what tests would you
undertake to investigate it?

2. Please write up Mr Jones’ drug and fluid chart for the pre-operative and post-operative
period.
3. What are the principal micro-organisms that cause osteomyelitis? What antibiotics are
used for the treatment of osteomyelitis and why?
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4. Please prescribe Mr Jones’ antibiotics. How long are antibiotics going to be given for and
what methods of administration can be used to reduce Mr Jones’ hospital stay?
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5. What action would you take in relation to Mr Jones’ HbA1c? What monitoring does Mr
Jones require in the community with regards to his diabetes and its complications?
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Other Tasks

A. Write up the regime he will require for the insulin to be given over the course of his
surgery. ( Use a separate IV fluids chart)
B. You are asked to cross match blood for his surgery: Complete the entry below indicating
how you will write up a 2 unit blood transfusion (IV fluids chart)
C. He is in considerable pain following surgery. Write up appropriate pain relief for his
immediate post-operative management
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Scenario 5
Mandy Adams is a 25 year old who has a history of bipolar affective disorder, she is 38 weeks
pregnant. Prior to becoming pregnant she had been taking Lithium 300mg daily which she stopped
before she became pregnant, as she didn’t want to harm her baby. Her psychiatrist convinced her to
recommence this in the 3rd trimester as she was beginning to develop features of hypomania, the
Lithium improved these symptoms. She is now admitted acutely psychotic to the AMU. She is febrile
although able to give a reasonable history, although her speech is rapid and copious. Her pulse rate
75bpm regular BP 145/95 mmHg. Her husband is with her and says that until 2 days before she was
her normal self.

She does not smoke, has not been drinking alcohol and does not take any recreational drugs and
has NKDA.

Medication:

 Lithium (Priadel) 200mg tablets 1.5 OD (at night),

 Ferrous Sulphate 200mg tablets TDS
 Folic acid 400 micrograms tablets OD.

Her admission investigations show:

 HB 11.9 g/dl
 MCV 94 WCC 14.5 x109/l with a neutrophil leucocytosis
 Platelets 367 x109/l
 Ur 12.2 mmol/l
 Cr 120micrmol/L
 CRP 39 mg/l
 Sodium 130 mmol/L
 Potassium 3.4 mmol/L

Questions

1. Create a differential diagnoses for Ms Adams symptoms

2. A lithium level subsequently comes back as low 0.3mmol/L (Normal range 0.6 – 1.2
mmol/L). What are you going to do?
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3. Write up Mrs Adams drug chart for this admission.

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 4. Lithium follows 1st order pharmacokinetics, taking this into consideration what dose
might be appropriate for this patient?
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5. What significance does this BP measurement have in this patient? What further
investigations need to be carried out now?
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6. Mrs Adams wants to breast feed, what advice should you give to her regarding this?

Other Tasks

A. List 4 different sources to help you dose drugs in pregnancy- what advice does it give you
about Lithium?

Source Advice

B. List 4 ways which pregnancy can affect the pharmacokinetics of drugs in pregnancy

Changes to PK How it affects drug therapy

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 C. From the list below investigate which are considered safe which are cautioned and which
are definitely contraindicated in pregnancy. Indicate if safe in one trimester and not
others.

Drug Safe / Unsafe Why? All trimesters?

1 Paracetamol

2 Ibuprofen

3 Ramipril

Sodium
4
Valporate

5 Trimethoprim

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Scenario 6
Mr Jerry Jones is a 70 year old gentleman with Parkinson’s disease. He developed left arm weakness
at home which was noticed by his wife, she rang the ambulance and he was admitted to the stroke
admissions unit. On admission his BP is 145/95 mmHg, He has a left hemiparesis. The CT shows an
ischaemic right cerebral infarct. He has a PMH of hypertension and had an Acute coronary
syndrome in 2009.

On day 2 he develops dyspnoea and a productive cough, CXR reveals a right sided pneumonia likely
to be secondary to aspiration. He has been made nil by mouth pending swallowing assessment.
Shortly thereafter develops two grand mal seizures unresponsive to treatment with rectal diazepam.
Mr Jones weighs 70 kg and has NKDA.

Drug history from GP repeat form:

 Aspirin tabs 75mg MANE

 Atenolol tabs 50mg OD
 Isosorbide Mononitrate tabs MR 60mg OD
 GTN spray 1-2 spray PRN for chest pain
 Ferrous Sulphate tabs 200mg TDS
 Co-careldopa tabs 25/100mg QDS
 Ropinirole tabs 2mg TDS
 Domperidone tabs 10 mg TDS
 Simvastatin tabs 40mg ON
 Paracetamol tabs 1g QDS

Questions

You are clerking the patient

Day 1
1. Which drugs are to continue if the patient is unable to swallow and how can they be
given?

Day 2
2. On day 2 after the seizure he deteriorates with further generalised seizures and the
consultant asks you to load Mr Jones with IV phenytoin, please work out the dose and
prescribe it on the prescription chart, with administration information for the nursing
staff.
3. What antibiotic choice would you consider in this patient to treat his aspiration
pneumonia?
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 4. Consider this patient’s fluid and nutritional requirements
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5. Describe whether you would continue Mr Jones phenytoin

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Other Tasks

A. List 5 drugs (from different groups) regularly used to treat Parkinson’s. State how these
work and what different routes can they be given by?

Drug / Dose /
Action Formulations Available
Frequency

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 B. List 4 different bacteria that commonly cause aspiration pneumonia, suggest antibiotic
that would cover each bacteria

Bacteria Antibiotic

C. List 4 different crystalloid fluids and describe their content:

Fluid Mineral Content in 1l

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Scenario 7
Caroline is a 25 year old medical student who will shortly be going on her elective. She has prepared
her risk assessment for travel and attends the Travel Health Clinic for pre-elective advice and
immunisations. She is going to Malawi where she will work in a children’s hospital for 5 weeks, and
spend 2 weeks with a community outreach programme.

Questions

1. List 5 risks Caroline should include in her risk assessment at the Travel Health Clinic.

2. What steps should she take to reduce the risk of her travel?

On her return from Malawi, she presents to her GP complaining of fever.

3. List 5 important features of the travel history:

4. What is your differential diagnosis?

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5. How would you investigate this fever?
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Her GP is concerned and sends her to the AMU of her local hospital. She complains of fever
accompanied by sweats and chills. She feels fatigued and is breathless on minimal exertion.

Examination is normal except for a palpable spleen tip.

She is admitted and diagnosed with malaria.

6. Name the 4 species of malaria known to cause disease in humans, indicate the most
common

7. How might Caroline be treated at this stage?

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8. Caroline becomes confused and lethargic. Bruises appear spontaneously over her arms
and legs. List 5 complications of severe or complicated malaria:

9. What is the treatment of severe or complicated malaria?

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 10. Name 3 causes of diarrhoea in a returning traveller and their treatment

Causes Treatment

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Scenario 8
Agnes Higgins is an 85 year old lady who has been admitted to the Acute Medical Unit. She gives a
history of loose and watery stools (opening her bowels four to six times per day) over the past
several days accompanied by general systemic upset, colicky abdominal pain and occasional fever.
She has not noticed any blood, mucus or melaena. Prior to developing diarrhoea, she had been
prescribed a course of antibiotics for a urinary tract infection (ciprofloxacin 500mg bd) after her
urine had been tested during a routine health review at her GP practice. Ordinarily, Mrs Higgins
describes her bowels as stubborn, and is ordinarily on regular laxatives; she had noticed that she was
increasingly constipated prior to the diarrhoea starting with occasional bouts of nausea. Past medical
history includes gastritis (diagnosed by OGD 3 months ago for symptoms of dyspepsia. Her aspirin
was stopped), previous myocardial infarction (10 years ago), osteoporosis and recurrent UTIs.

Systemic examination revealed BP 100/55mmHg, HR 90/min, T 36.7 C, SaO2 96% on room air and RR
of 18/min. Cardiovascular and respiratory examination were essentially normal. Examination of her
abdomen revealed mild distension with central and left iliac fossa tenderness but no guarding and
rebound and normal bowel sounds. Blood tests (including U+Es, FBC and glucose) were all normal
apart from a mildly raised WCC (11.7) and a raised urea (9.4).

Medications:

 Clopidogrel tablets 75mg od

 Alendronic acid 70mg weekly on Saturday
 Calcichew D3 forte 1 bd
 Pravastatin tablets 20mg nocte
 Amlodipine tablets10mg od
 Co-codamol 30/500mg tablets, 2 tabs qds
 Buprenorphine 5microgram/hr patch weekly on Saturday
 Lansoprazole capsules 30mg od
 Senna tablets 15mg on
 Lactulose solution 20mls bd

Questions

1. What is the differential diagnosis for Mrs Higgins’ diarrhoea and what tests would you do
to investigate it?

2. Please prescribe her medications on the drug chart provided.

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3. Her stool sample subsequently comes back as C. difficile Toxin positive. What changes to
her management would you institute? What are the likely causative factors?
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4. She subsequently becomes more unwell, with abdominal distension and vomiting.
Abdominal X-ray reveals a dilated large bowel with mucosal oedema, and WCC has risen
to 28. She is made NBM. What changes would you make to her management?
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5. After recovering from her episode of CDT diarrhoea, she becomes constipated again. How
would you manage this?
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Other Tasks

A. Name 5 drugs likely to cause constipation (from different groups)

Drug By what mechanism

B. Name 5 drugs used to treat constipation, their mode of action and indications / contra-
indication.

Drug Mechanism / Contraindications

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References for all scenarios
See therapeutics resources on Moodle.

IV fluids: http://www.nice.org.uk/guidance/CG174 Look up resources. Useful algorithm on fluids

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