Practical Book of Therapeutics

Mansoura University
Faculty of Pharmacy
Department of Pharmacology & Toxicology
By
Prof Dr Tarek Mostafa, Prof Dr Manar A Nader &
Prof Dr Nashwa Aboelsaad
(2021-2022)
B. Pharm. Level Four Therapeutics (PH 429)
(Credit Hours) Practical
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Section-1
CASE
PATIENT PRESENTATION :
Chief Complaint “not available”
History of the present illness (HPI)
M.J. is a 73-year-old man who originally presented to the hospital with symptoms of heart
failure that culminated in aortic and mitral valve replacement surgery. His surgery was
complicated by a 1-hour hypotensive episode, with BP as low as 70/50. Three days post-
operation, purulent drainage was noted from the surgical site, and he was subsequently
diagnosed with mediastinitis. At that time, the patient was also found to have a Serratia
bacteremia (blood cultures × 4 positive for Serratia marcescens, sensitive to gentamicin,
piperacillin, ceftazidime, and ciprofloxacin; resistance was noted to ampicillin). Therapy
was initiated with gentamicin and piperacillin. Thus far, he has completed day 25 of a 6-
week course of antibiotics. A gradual increase in his BUN and serum creatinine
concentration from baseline and signs of volume overload have been noted over the past
7 days
PMH: Type 1 DM, CKD, Gout, Osteoarthritis, HTN, Atrial fibrillation
PSH: Aortic and mitral valve replacement surgery 28 days ago
Family History (FH): Father had Type 1 DM
Meds:
Gentamicin 180 mg IVPB Q 48 h (See Table for previous dosages)
Ceftazidime 1 g IVPB Q 12 h × 25 days
Enalapril 5 mg po once daily
Colace 100 mg po BID
Furosemide 80 mg po Q 12 h × 2 days
Digoxin 0.25 mg po once daily
Allopurinol 100 mg po once daily
Ranitidine 150 mg po Q 12 h
Meperidine 25 mg IM Q 4–6 h PRN pain (started 3 days ago)
Ibuprofen 400 mg po Q 4–6 h PRN pain (started today for joint pain)
Sliding scale insulin
All (allergies): Bactrim (experienced rash about 10 years ago; subsided when drug
discontinued)
Review of systems (ROS): Currently complains of trouble breathing, weakness, general
malaise, and pain in joints in hands. No fever or chills.
Physical Examination:
Gen Confused-appearing man in mild distress.
1
Vital signs (VS): BP 152/90, P 80, RR 26, T 37.7°C; Current Wt 87 kg (admission Wt
73 kg), Ht 5'10''
Skin: Normal skin turgor
Head, eye, ear, nose and throat (HEENT): PERRLA, EOMI, poor dentition
Neck/Lymph Nodes (+) JVD
Chest Basilar crackles, inspiratory wheezes
CV S1, S2 normal, no S3, irregular rhythm
Abd Soft, nontender, (+) BS, (–) HSM
MS/Ext 2+ Ankle/sacral edema
Neuro A & O to person and place, but not to time
Labs Today
Na 138 mEq/L Hgb 9.2 g/dL Ca 8.5 mg/dL
K 3.9 mEq/L Hct 28.5% Mg 2.0 mg/dL
Cl 104 mEq/L Plt 263 × 103/mm3 Phos 4.7 mg/dL
CO2 25 mEq/L WBC 9.9 × 103/mm3
BUN 52 mg/dL (BUN 17 mg/dL on admission)
SCr 3.2 mg/dL (SCr 1.3 mg/dL on admission)
Glu 130 mg/dL
UA
Color, yellow; character, hazy;
glucose (–); ketones (–); SG
1.010; pH 5.0; protein 30 mg/dL;
coarse granular casts 5–10/lpf;
WBC 0–3/hpf; RBC 0–2/hpf; no
bacteria; nitrite (–); osmolality
325 mOsm; urinary sodium 45
mEq/L; creatinine 33 mg/dL,
FENA = 3.2%.
Fluid Intake/Output and Daily Weights

Day I/O Wt(kg)
3 days ago 3,200 mL/1,100 mL N/A
2 days ago 2,500 mL/1,050 mL 76
2
‫‪B. Pharm.‬‬ ‫‪Level Four‬‬ ‫)‪Therapeutics (PH 429‬‬
‫)‪(Credit Hours‬‬ ‫‪Practical‬‬
‫‪Yesterday‬‬ ‫‪2,500 mL/1,250 mL‬‬ ‫‪N/A‬‬
‫‪Today‬‬ ‫‪N/A‬‬ ‫‪80‬‬
‫‪Assessment‬‬
‫‪Acute kidney injury with extracellular fluid expansion‬‬
‫‪3‬‬
Section 2
CASE
A 56-year-old man presents to the emergency department following an episode of
hematuria. He reports continuous bilateral flank pain and progressive worsening of
fatigue, malaise, and nausea for the past several months, but he is uninsured and has
not been able to seek medical care. When questioned, he states that he has been
urinating less than previously. He believes his father suffered from something similar but
is unclear on the details. His temperature is 36.9 C (98.4 F), heart rate is 88/min, and
blood pressure is 168/99 mm Hg. There are bilateral masses palpated on abdominal
exam. Laboratory findings include blood urea nitrogen of 64 mg/dL and creatinine of 3.1
mg/dL.
4
CASE
A 55-year-old man with a past medical history of hypertension and congestive heart
failure presents to the emergency department with a 1-day history of right flank pain,
nausea, and vomiting. The pain was initially mild a few hours ago but progressed
gradually over the course of 30 minutes to severe pain, followed by nausea and vomiting
several times. The pain now radiates to his right testicle. He denies any history of recent
trauma. On examination, his temperature is 36.7° C (98.0° F), pulse is 90/min, blood
pressure is 140/72 mm Hg, and respiratory rate is 14/min. He is lying in bed, doubled
over in pain. Auscultation of his heart reveals a normal S1 and S2 with an S3 gallop and
no murmurs or rubs. He has faint crackles in the bases of both lungs. His abdomen is
soft, nondistended, and somewhat tender in the right flank area, without guarding or
rebound tenderness and with normal bowel sounds present. No abdominal or flank
masses are appreciated. He has pitting edema to the ankles bilaterally. In the hour since
coming to the hospital, he has put out 50 cc of pinkish urine. His medications include
metoprolol, furosemide, captopril, amlodipine, and aspirin.
5
CASE
A 30-year-old man presented to his family physician for evaluation of flank pain that
radiates towards his groin with associated nausea and vomiting. The pain came on
suddenly and is described as intermittent and crampy. Physical examination reveals
some diffuse left-sided abdominal pain to palpation but no other significant abnormalities.
Laboratory evaluation is performed, including a complete blood count, serum chemistry,
and urinalysis. The laboratory evaluation is normal, with the exception of the urinalysis,
which reveals microscopic hematuria and high pH. Based on this patient’s presentation
and laboratory results, a diagnosis of nephrolithiasis is suspected. Note that this is a
single episode, and no prior evaluation has been performed
6
Section 3
Chief Complaint
CASE
“My right arm feels like it’s frozen. I can barely move it.”
HPI
AM is a 67-year-old man who pre-sent to the emergency room at 8:45 AM after noticing
a sudden onset of weakness in his right arm. He woke up at 7:15 AM and went to the
bathroom to brush his teeth. While walking from the bathroom to the kitchen, he noticed
general weakness and had trouble saying “good morning” to his son, Mahmoud, with
whom he lives. His son immediately brought him to the ER. While in the ER, he started
experiencing some dysarthria and began to have a right-sided facial droop. He denied
any dizziness, vomiting, or headache.
PMH
Hypertension, diagnosed 10 years ago
Hyperlipidemia
Two different TIAs in the past, last in 2002
FH
Father passed away at age 87 from a stroke; mother passed away from “old age” at age
82. Brother, age 61, also has HTN. Son, age 34, has DM.
SH Denies ETOH use, admits to occasional cocaine use, quit smoking 20 years ago.
Lives with son
Meds
Ramipril 5 mg po daily
Atorvastatin 10 mg po daily
Atenolol 50 mg po daily
Aspirin EC 81 mg po daily
All PCN (rash), adhesive tape
ROS Denies headache, Vision is blurry.
7
Physical Examination
Gen WD M lying in bed, responsive but sluggish; looks tired.
Speech is slurred.
VS BP 172/92, P 92, RR 21, T 98.6°, O2 Sat 94% on room air;
Wt 90 kg,
Ht 5'8''
Skin Warm, dry
HEENT
PERRLA, EOMI; no nystagmus, exudates, hemorrhages, or papille-dema; right-sided
facial droop
Neck (+) carotid bruits on the left side, (–) lymphadenopathy
Chest Lungs clear to auscultation bilaterally
CV RRR, S1 & S2 normal, no S3 or S4
Abd Soft, non-tender, non-distended, (+) BS
GU Deferred
MS/Ext RUE: 2/5; RLE 4/5; LUE: 5/5; LLE: 5/5
Good pulses, no CCE; DTR: 2+ throughout, normal Babinski reflex
Neuro A & O × 3; (+) dysarthria, right-sided facial droop
Head CT scan: (–) hemorrhage, left-sided middle cerebral artery Infarct
Carotid dopplers: reduced flow, moderate to severe carotid stenosis; 65% stenosis of
right carotid, 50% stenosis of left carotid
Echocardiogram: no evidence of LV thrombus, ejection fraction 55–60%; overall
unremarkable
EKG: Tachycardic sinus rhythm
Assessment
Acute ischemic stroke secondary to carotid atherosclerosis and ischemic disease in a
patient with hypertension, hyperlipidemia, and a prior history of TIAs
8
CLINICAL COURSE
It is now 2 hours later (10:45 AM), and you are seeing the patient with the rest of the
stroke team.
CLINICAL COURSE
The patient is currently 3 days post-stroke and will be discharged home tomorrow
morning. He has regained most strength in his extremities, and his speech has improved
significantly. A mild facial droop is still present when prompted to show his teeth.
7
Section 4
Hypertensive crisis
CASE
Chief Complaint
“I’m having trouble seeing, and my chest feels tight.”
HPI
B.F. is a 63-year-old Hispanic woman who was admitted to the emergency department
with a chief complaint of difficulty seeing and chest tightness. She describes “blurry vision
“that has been happening off and on for the last few days. At first, it would just last for a
second or two and then go away, but it has become progressively more lingering. She
initially attributed this to her eyes “just getting old” but now is more concerned that it
may be something else. The chest tightness started yesterday and was initially very mild,
occurring when she would walk her dog outside and resolving readily with rest. However,
it has since gotten more troublesome and is limiting her daily activities. While the chest
discomfort still improves with rest, it no longer completely resolves. She tried to self-
medicate by taking a double dose of ranitidine last night and another dose this morning,
but she says that didn’t help. She also states that this discomfort is very different from
her gastroesophageal reflux. While seated in the emergency department she describes
the chest discomfort as a 2 on a scale of 1–10 (highest). She has a past medical history
significant for HTN and gastroesophageal reflux. She had been taking lisinopril and
hydrochlorothiazide for several years with good blood pressure control, but about 6
months ago she stopped taking both medicines, because she had to make an urgent trip
to visit her daughter out of state and ended up staying with her for a couple of months.
Since her daughter lives in a rural area with no pharmacy nearby, she never got the
medications refilled when she ran out. After several days, Ms. Flores noticed that she felt
just fine despite not taking the medicines. Consequently, she never resumed them and
has not seen her provider since.
PMH
HTN × 9 years
8
Gastroesophageal reflux × 11 years
FH
Both parents had HTN. Father had a heart attack in his early 60s and died in his late 70s
of a second heart attack; mother died a few years later from a stroke.
SH
Married for 38 years with four children (two boys, two girls all over 25 years of age with
no notable medical problems); she works part time (2–3 days per week) as a cashier at a
large department store. She smoked cigarettes rather heavily when she was younger but
cut back to 1–2 per day when she was raising her children. As her children got older, she
gradually increased her cigarette use and is now smoking about one pack per day and
has been doing so for about the past 10 years. She drinks alcohol infrequently (maybe
once or twice a month) when she is at a social gathering. She denies ever using
recreational drugs. She does not exercise and leads a rather sedentary lifestyle. She
admits to the liberal use of salt during breakfast and dinner.
Meds
• Ranitidine 75 mg PO once daily in the evening (over the counter); she has taken extra
doses over the last 24 hours as mentioned above
• Lisinopril/hydrochlorothiazide 20/12.5 mg PO once daily. stopped approximately 6

months ago
All
NKDA
ROS
Ms. Flores complains of vision trouble as mentioned above, no hearing problems. She
complains of chest discomfort as mentioned above but denies palpitations and dizziness.
She admits to becoming short of breath more easily in the last few weeks and has felt a
loss of energy over this same time period, although she never has been very active. She
denies nausea, vomiting, or abdominal pain. She denies any swelling in her extremities
or weight gain. She denies mental status changes.
9
Gen
The patient is a middle-aged Hispanic woman appearing to be in moderate distress

VS
BP 240/130 mm Hg right arm, 232/128 mm Hg left arm (manual readings performed in

the emergency
department). A repeat measurement in the right arm after several minutes yields a BP of
236/134 mm Hg.
P 74, RR 24, T 36.8°C; Wt. 80 kg, Ht. 5′5″
Skin
Normal tone and temperature, good turgor

HEENT
PERRLA; EOMI; funduscopic exam revealed arterial tortuosity with A/V nicking and
papilledema
Neck/Lymph Nodes
Neck supple, no JVD, no bruits, no thyromegaly, or lymphadenopathy

Chest
CTA
CV
PMI shifted laterally, RRR, no murmurs or rubs appreciated; +S4 heard at apex
Abd
Soft, NT/ND, no guarding, (+) BS, no abdominal bruits appreciated, liver span about 12
cm
Genit/Rect
Normal female genitalia, heme-negative stool

10
MS/Ext
Normal ROM, no CCE, pulses 2+ radial; 1+ to 2+ in the rest of her upper and lower
extremities
Neuro
A & O × 3, CN II–XII intact, motor/sensory normal, DTRs 2+
Labs
UA
Specific gravity 1.010; pH 5.8; negative for blood or protein; negative for recreational
drugs
Chest X-Ray
Enlarged heart, no infiltrates

ECG
Normal sinus rhythm; LVH by voltage criteria. There are no ST-segment changes,
although there does
appear to be some T-wave flattening in the anterior leads. No old ECGs are available for
comparison.
Assessment
A 63-year-old woman with a long-standing history of HTN and gastroesophageal reflux

presents with an
11
extremely elevated blood pressure and signs and symptoms of target organ damage.
She admits to not
taking any antihypertensive drug therapy for 6 months which was initially due to difficulty
in getting her
medications refilled, and then later due to feeling just fine despite not taking the
medications.
Clinical Course
Once Ms. Flores’s blood pressure is lowered to an acceptable level, her inpatient
provider consults with you regarding chronic antihypertensive therapy for Ms. Flores.
12
Section 5
Dyslipidemia
Case
Chief Complaint
“I need refills.”
HPI
F.A. is a 56-year-old woman who presents to pharmacotherapy clinic for intake. She has
recently moved to your area and states she has not seen her primary care provider for the
last 11 months. Her prescriptions have expired, and she is coming to you for “refills.”
PMH
Obesity (BMI 31.5 kg/m2)
Dyslipidemia × 4 years
HTN × 15 years
Postmenopausal—has not had GYN screening since onset of menopause (14 years ago)
FH
Father: age 74 with extensive cardiovascular history, most notably first MI at age 42.
Mother: died at age 61 from MVA, medical history unknown.
Patient has one older sister with HTN and history of “mini-strokes” and one younger sister
with HTN only.
SH
Patient is married with three children, all of whom live out of state.
College graduate works as librarian.
Admits to “social” alcohol and tobacco use, and to previous marijuana use when she
visited her children.
Began sporadic exercise regimen when diagnosed with dyslipidemia.
Meds (Per Patient History; She Did Not Bring Records)

Metoprolol tartrate 50 mg PO BID
Ezetimibe 10 mg PO once daily
Aspirin 81 mg PO once daily
Ibuprofen 200 mg, four tablets PO PRN leg cramps
Naproxen 220 mg, two tablets PO PRN leg cramps
Garlic capsules
All
“Statin” drugs—states she had occasional leg cramps after starting atorvastatin.
13
ROS
Patient states that she just needs refills. She is argumentative about getting labs done and
cannot understand why you would not just refill her medications. She denies any acute
changes in health. She denies unilateral weakness, numbness/tingling, or changes in
vision. She denies CP, and only has SOB when she walks in the park. With further
questioning you find that she rarely exercises, but when she does go for a walk, she
typically overdoes it. She denies changes in bowel or urinary habits and states she does
not need to have GYN follow-ups anymore, because she has gone through “the change.”
She denies any lower extremity edema.
Gen
Obese, somewhat agitated Caucasian woman
VS
BP 162/92, P 89, RR 18, T 37.2°C; Wt 94 kg, Ht 5′8″
Skin
Warm and dry to touch, normal turgor
HEENT
PERRLA; EOMI; funduscopic exam deferred; TMs intact; oral mucosa clear
Neck/Lymph Nodes
Neck supple, no lymphadenopathy, thyroid smooth and firm without nodules
Chest
CTA bilaterally, no wheezes, crackles, or rhonchi
Breasts
Normal, slightly fibrotic, no lumps or discharge
CV
RRR, no MRG, normal S1 and S2; no S3 or S4
Abd
(+) BS, no hepatosplenomegaly
Genit/Rect
Deferred
14
Ext
No pedal edema, pulses 2+ throughout
Neuro
No gross motor-sensory deficits present
Labs (Fasting)
Assessment
Mrs. A. is an obese Caucasian woman who presents to pharmacotherapy clinic for intake.
She has a significant family history of cardiovascular disease. She has uncontrolled HTN,
treated with metoprolol tartrate, and dyslipidemia, treated only with ezetimibe and garlic.
She reports an allergy to atorvastatin but admits that her leg cramps have not improved
since discontinuing the drug and coincide with her rare bouts of exercise. She reports
liberal use of ibuprofen and naproxen to relieve the cramps. She also has previously
undiagnosed anemia.
QUESTIONS
15
Section 6
Deep vein thrombosis

Case
Mary is a 38-y-old female who presents to the emergency department with a

2- day history of edema, sever pain, and warmth in her left leg. She returned
home to Cairo, Egypt 2 days ago from Chicago, USA. She reports that these
symptoms developed after the flight. She had tried massaging her leg, but it
is tender and painful to touch. She tried placing a warm towel on it to alleviate
the pain, but she states that her leg has become increasingly warm since the
symptoms appeared. She states she hates going to the doctor, so she did
not have her symptoms evaluated 2-days ago.
Current medications:
Hydrochlorothiazide 25 mg PO
daily Omeprazole 20mg PO as
needed Combined oral
contraceptive
Ibuprofen 200mg PO as needed for headache or
pain Multivitamins PO daily
Past medical History
HTN x 2 years
GERD x10
years Obesity
Occasional aches and pains
Vital signs
T 37 C, Weight 97 Kg, Height 170 cm.
16
HEENT
PERRLA, EOMI.
Neck and Lymph nodes: no abnormality

Imaging
Evidence of acute non-occluded thrombus in the right popliteal vein
Extremities
1+ pitting edema; tenderness to palpation in LIE; (+) pedal pulses
Assessment
MS is a 38-y-old woman with symptoms and imaging consistent with LIE

DVT
17
Section 7
CASE
Chief Complaint
“My fiancé and I are getting married soon, and we’re not ready for kids just yet.”
HPI
MM is a 24-year-old graduate student who presents to the Clinic for contraceptive
counseling. She and her fiancé are planning to be married in approximately 3 months.
She is here to be evaluated for the use of hormonal contraceptives. The patient states
she began menses at age 14, with irregular cycles of 25–36 days in length. Her last
menses was 2 weeks ago. The patient states she has heard about contraceptive options
that “keep you from having a period,” and she wants to know more about those options,
and if they would be okay for her to try.
PMH
Migraine headaches without aura or focal neurologic symptoms; well controlled for the
past 6 months on prophylactic therapy
FH
Mother, age 52, has HTN and osteoporosis.
Grandmother died from complications of breast cancer, which was diagnosed at age 60.
Father, age 53, has osteoarthritis, hypothyroidism, and hyperlipidemia.
Grandfather died at age 74 of MI.
SH
She admits to occasional social use of tobacco and alcohol
Otherwise, she denies regular smoking or alcohol use during the week, and she denies
illicit drug abuse.
Meds
Propranolol LA 160 mg po once daily for migraine prophylaxis
Naproxen 220 mg, one to two tablets po Q 8 h PRN menstrual cramps
All NKDA
ROS
Menstrual periods are the most irregular during exam times.
Migraine headaches are not accompanied by aura or focal neurologic symptoms and
have been well controlled on prophylactic medication. (Patient states she has not had a
migraine for more than 6 months; however, prior to being placed on propranolol for
migraine prophylaxis, she reported experiencing menstrual-related headaches in addition
to frequent migraines.)
VS BP 116/74, P 66, RR 14, T 37°C; Wt 56 kg, Ht 5'6''
Skin Mild facial acne
HEENT PERRLA; EOMI; TMs intact; oral mucosa clear
Neck/Lymph Nodes Supple without lymphadenopathy or thyromegaly
18
Lungs CTA, no wheezing
CV NSR; no MRG
Breasts Equal in size without nodularity or masses, nontender
Abd Soft, NT, no masses or organomegaly
Genit/Rect Normal vaginal exam w/o tenderness or masses
MS/Ext Normal ROM; normal muscle strength
Neuro A & O × 3
Labs Negative Pap smear and UPT
Assessment
Young, generally healthy female with history of migraine headache disorder that has been
well controlled with prophylactic medication is requesting hormonal contraceptives for
birth control.
CLINICAL COURSE
Madeline returns to the clinic in 2 months complaining of worsening acne and
breakthrough bleeding.
19
Section 8
CASE
Chief Complaint
“I have been having hot flashes for the past few months, and I just can’t take it anymore.”
HPI
Emma Peterson is a 50-year-old woman who reports experiencing two to three hot
flashes per day, occasionally associated with insomnia. She also states she is awakened
from sleep about two to three times per week needing to change her bed clothes and
linens. Her symptoms began about 3 months ago, and over that time, they have worsened
to the point where they have become very bothersome. She states that her mother was
prescribed a pill for this, but she is hesitant to take the same thing because she heard on
the news and from friends that the medication may not be safe. She also does not want
to “get her period back,” if possible. Successfully treated for depression in the past, she
is currently controlled on paroxetine therapy. She currently exercises three times a week
and tries to follow a low-cholesterol diet.
PMH
Depression
GERD
HTN
Hypothyroidism
FH
Mother died of stroke at age 67; father died of lung cancer at age 62.
Patient has one brother, 52, and one sister, 48, who are alive and well, but both with HTN.
SH
Married, mother of two healthy daughters. She walks on her treadmill three times a week
and is trying to follow a dietitian-designed low cholesterol diet. She does not smoke.
Meds
Hydrochlorothiazide 25 mg po once daily
Omeprazole 20 mg po once daily
Paroxetine 20 mg po once daily
Synthroid 75 mcg po once daily
All NKDA
ROS
(+) hot flashes, occasional night sweats and insomnia, vaginal dryness. (–) for weight
gain, constipation. LMP 12 months ago
VS BP 128/86, P 78, RR 15, T 36.4°C; Wt 76.2 kg, Ht 5'6''
Skin Warm, dry, no lesions
HEENT WNL
Neck/Lymph Nodes Supple, no bruits, no adenopathy, no thyromegaly
Lungs/Thorax CTA bilaterally
Breasts no masses
20
CV RRR, normal S1 and S2; no MRG
Abd Soft, NT/ND, (+) BS; no masses
Genit/Rect Pelvic exam normal except (+) mucosal atrophy; stool guaiac (–)
Ext (–) CCE; pulses intact
Neuro Normal sensory and motor levels
Labs
Na 136 mEq/L Hgb 12.7 g/dL Ca 9.3 mg/dL Fasting Lipid Profile:
K 3.9 mEq/L Hct 39.3% AST 32 IU/L T. chol 190 mg/dL
Cl 104 mEq/L 3
WBC 6.5 × 10 /mm 3 ALT 30 IU/L LDL 132 mg/dL
CO2 25 mEq/L Plt 208 × 103/mm3 TSH 2.46 mIU/L HDL 50 mg/dL
BUN 10 mg/dL FSH 87.8 mIU/mL Trig 180 mg/dL
SCr 0.7 mg/dL UPT (–)
Random Glu 98 mg/dL
Other PAP smear and mammogram: Normal

Assessment
50-year-old, symptomatic postmenopausal woman considering HRT versus other
treatment options
CLINICAL COURSE
The patient returns to her physician after taking HRT for 1 year. She reports that her hot
flashes, night sweats, and occasional insomnia have significantly decreased and would
like to know if she should continue taking the HRT regimen and if so, for how long.
21
‫‪B. Pharm.‬‬ ‫‪Level Four‬‬ ‫)‪Therapeutics (PH 429‬‬
‫)‪(Credit Hours‬‬ ‫‪Practical‬‬
‫‪Section 9‬‬
‫)‪Polycystic ovarian syndrome (PCOs‬‬
‫‪22‬‬
CASE
A 22 y/o woman presents to her gynecologist because of irregular widely spaced menses.
Menarche was at age of 14 but she has rarely had regular cycles. For the past years, she
has had only 3 complete menses once going 6 months between periods. Upon physical
examination she has a temperature of 37, heart rate 80 bpm, blood pressure 140/85
mm/Hg. She is 165 cm tall and weighs 83 kg and not welling to be pregnant. She is
overweight with acne and a few dark hairs on her face. Examination reveals normal
genitalia without tenderness or masses.
23
Section 10
CASE
Chief Complaint
“My left leg and arm are numb, and I’m having trouble walking.”
HPI
Cathy Olson is a 24-year-old woman who was in excellent health until 10 months ago,
when she developed progressive sensory loss on her right face, distorted hearing in the
right ear, and intense vertigo. These symptoms intensified over 10 days; at which time
she was hospitalized. A brain MRI showed an enhancing lesion in her right pons and a
total of six other lesions, three of which are periventricular. CSF evaluation revealed
elevated IgG index and oligoclonal bands. During that time, she chose to start glatiramer
acetate 20 mg SC daily. She presents to clinic today indicating that she has had
progressive left-sided sensory loss, resulting in a left footdrop, left arm weakness, and
difficulty ambulating that began approximately 10 days ago, when she had a mild URI
and was experiencing increased stress at work.
PMH
Frequent migraine headaches since adolescence that have been difficult to control
despite therapy with acetaminophen, aspirin, and caffeine (Excedrin) and sumatriptan
Mild recurrent bouts of depression that have not been treated pharmacologically
FH
The patient is of Norwegian descent. She was born in Arizona and moved at the age of
12 to Ohio. She has no siblings, and both parents are alive and well. There is no family
history of neurologic disease.
SH
The patient is married and is employed as an accountant. She has not smoked for 3
years; before that she smoked 1 ppd. Her use of alcohol is limited to an occasional glass
of wine or beer on weekends.
Medications
Acetaminophen, aspirin, and caffeine (Excedrin) 2 tablets po PRN
Sumatriptan 50 mg po PRN
Glatiramer acetate (Copaxone) 20 mg SC daily
Allergy NKDA
ROS
Unremarkable except that she reports feeling run down and tired. Also reports past
difficulty with urinary control (incontinence) and a subjective feeling of weakness in hot
weather. No previous history of visual disturbance (e.g., pain, blurred or double vision) or
motor disturbance.
Gen: The patient is a white woman who appears to be slightly anxious but is otherwise
in NAD.
VS: BP 120/72, P 88 and regular, RR 20, T 36.6°C; Wt 55 kg, Ht 5'5''
Skin: Normal turgor; no obvious lesions, tumors, or moles
24
HEENT: NC/AT, TMs clear
Neck/Lymph Nodes: Supple, without lymphadenopathy or thyromegaly
CV: RRR; S1, S2 normal; no MRG
Lungs: Clear to A and P
Abd: NTND
Neuro:
- The patient is alert, oriented, and cooperative. CNs II–XII: Mild subjective sense of
auditory distortion and tinnitus in right ear despite intact auditory acuity.
- PERRLA; visual acuity is 20/20 both eyes. Funduscopic examination is normal. EOMs
are full in extent. Slight nystagmus present.
- Motor tone and strength are 5/5 on the right upper and lower extremities and 4/5 on the
left upper and lower extremities. DTRs are hyperactive throughout.
- Sensory examination reveals moderate diminution in the subjective intensity of light
touch and pinprick on the left, with maximal deficits noted in the left foot.
- Coordination testing is normal except for modest unsteadiness on performing tandem
walking and casual gate. Romberg maneuver is positive.
Brain MRI
Multiple areas of increased periventricular white matter signal (plaque)
CLINICAL COURSE
The patient was treated with the regimen you recommended, with gradual resolution of
her symptoms. Two years after the initial presentation, she returns to clinic with
complaints of increased difficulty walking and some blurring of her vision. Her muscle
strength is intact in the upper extremities, but there is marked weakness in the lower
extremities, especially the left side. DTRs are hyperactive in the lower extremities, and
tone is slightly spastic. The patient’s gait is slow, but she is able to walk without
assistance. Her affect is sad, and she is tearful during the examination. She states that
she is concerned about the progression of her disease.
25

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Mansoura University

Fluid Intake/Output and Daily Weights

• Lisinopril/hydrochlorothiazide 20/12.5 mg PO once daily. stopped approximately 6

The patient is a middle-aged Hispanic woman appearing to be in moderate distress

BP 240/130 mm Hg right arm, 232/128 mm Hg left arm (manual readings performed in

P 74, RR 24, T 36.8°C; Wt. 80 kg, Ht. 5′5″

Normal tone and temperature, good turgor

Neck supple, no JVD, no bruits, no thyromegaly, or lymphadenopathy

Normal female genitalia, heme-negative stool

A & O × 3, CN II–XII intact, motor/sensory normal, DTRs 2+

Enlarged heart, no infiltrates

although there does

A 63-year-old woman with a long-standing history of HTN and gastroesophageal reflux

Meds (Per Patient History; She Did Not Bring Records)

No gross motor-sensory deficits present

Deep vein thrombosis

Mary is a 38-y-old female who presents to the emergency department with a

daily Omeprazole 20mg PO as

needed Combined oral

Ibuprofen 200mg PO as needed for headache or

pain Multivitamins PO daily

Past medical History

Occasional aches and pains

T 37 C, Weight 97 Kg, Height 170 cm.

Neck and Lymph nodes: no abnormality

MS is a 38-y-old woman with symptoms and imaging consistent with LIE

Other PAP smear and mammogram: Normal

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