CASE STUDY ONE Mrs. G is an 87-year-old retired English teacher of 41 years and semi-professional piano player, who started playing early in her childhood. Unfortunately, after the death of her beloved husband

LEARNING OUTCOMES

On successful completion of this unit, you should be able to:

LO1 - Describe basic principles of pharmacology with respect to Quality Use of Medicines (QUM) (GA4, GA5)

LO2 - Describe the pathophysiology of selected National Health Priority areas to explain their respective clinical manifestations, prevention, and pharmacological management (GA4, GA9)

LO3 - Explain how physiological changes that occur across the lifespan impact on disease processes and drug administration (GA4, GA9)

LO4 - Relate microbiological principles to infection control practices (GA4, GA5)

CASE STUDY ONE

Mrs. G is an 87-year-old retired English teacher of 41 years and semi-professional piano player, who started playing early in her childhood. Unfortunately, after the death of her beloved husband, it became increasingly difficult to care for herself, and therefore Mrs. G’s children made the difficult decision to move her into a retirement home to ensure that she was well-supported and adequately cared for.

Over the last month, the nursing staff at her retirement home have noticed a significant decline in Mrs. G’s cognitive function involving short-term memory deficits, confusion, paranoia, and recurrent irritability. Her long-term memory, on the other hand, has not become an issue. Further to this, Mrs. G has also expressed that she had been experiencing difficulties when playing the piano. She reports feeling as though her hands are not able to move like they used to, making it challenging to play intricate songs. Mrs. G also demonstrates a loss of balance when walking around the retirement home, which makes it very difficult for her to participate in daily walks and fitness classes. Mrs. G’s family doctor referred her to an MRI brain scan, which provided the results demonstrated in Figure 1 (see the image on the right). For comparison, Mrs. G’s earlier scan is also provided (on the left), which was taken 15 years ago after she suffered a nasty head trauma.

Question 1 Name the disease that is most likely responsible for Mrs. G’s clinical picture and articulate your rationale. In your answer, you are expected to make meaningful references to Mrs. G’s MRI image and describe changes there that support your opinion about the nature of her pathology.

Question 2 In your own words and writing no more than five (5) short dot points, describe the pathogenesis of the disease you identified above.

Question 3 One of the medications Mrs. G has been prescribed is an acetylcholine esterase inhibitor. In your own words, explain how the pharmacodynamics properties of this medication help manage her condition.

Question 4 It is known that the bioavailability of the drug she has been prescribed with is 36%. She takes a tablet that contains 1.5 mg of the active ingredient twice a day. Determine the daily amount (mg) of active ingredient that reaches her systemic circulation. (Show your calculations.)

Question 5 Considering that 95% of the active ingredient is absorbed from her gastrointestinal system, determine the daily amount (mg) of the drug that undergoes first pass metabolism. (Show your calculations.)

CASE STUDY continued

One sunny day, Mrs. G decides to go for a walk in the gardens of the retirement home, when she stumbles over a branch and falls. She feels excruciating pain in her hip. A fellow resident calls out to the nursing staff, and Mrs. G is taken to the emergency department at the Royal Melbourne Hospital. An X-ray reveals that she had hip fracture and must have surgery to repair it. Mrs. G wonders whether this is linked to the pain she had been experiencing in her left knee the last few years. The specialist explains to Mrs G that the pain in her left knee is due to loss of cartilage between bones at the knee joint and that the fracture might have been due to weakened bones. A blood test shows negative for rheumatoid factor. He tells her he would like her to have a bone mineral density test to measure her bone density. The DEXA scan gave a T-score of −3.0. Mrs. G is now given bisphosphonates and told to increase her daily intake of calcium and take vitamin D supplements.

Question 6 Name the most likely condition Mrs. G had on her left knee and list two clinical signs/ symptoms of the condition that support your claim. Describe the pathogenesis of your diagnosed condition.

Question 7 Considering Mrs. G’s T-score, identify the disease she suffers from, briefly describe the pathogenesis of this disease, describe the mechanism of action of bisphosphonate, and explain the benefits of this treatment in her present condition.

Question 8 Based on its aetiology and considering Mrs. G’s DEXA scan as well as the condition you identified under Question 6, identify the type of fracture she most likely suffered from as the result of her recent accident.

Name and discuss changes in TWO physiological factors associated with aging that make bone fracture healing in elderly more difficult and slower than in younger individuals.

CASE STUDY 2

Hilda Wilde is a 45-year-old woman, who was diagnosed with asthma as a child. She recalls her first asthma attack being horrendous; chest tightness, breathing difficulty, wheezing, feeling anxious, and sweating profusely. She was rushed to and spent many days in hospital as a child until she managed to identify the triggers for her asthma attacks and control them early. The triggers she identified were cold temperature, pollen, smoky environment, and respiratory infection/cold, which continue to be the triggers throughout her adult life. She also developed hay fever and an allergy to penicillin in her 20’s, which didn’t surprise her as her mum also had these conditions.

One spring day, Hilda is traveling with her husband as she is finding herself stressed by her work. However, in the afternoon, a thunderstorm approaches and she quickly develops the wheeze and tightness she dreads. Her husband notices Hilda is struggling and helps her with her bronchodilator inhaler. However, Hilda’s wheezing and shortness of breath does not ease off, even with her inhaler. She finds it hard to talk or get up and walk. Her lips start to turn blue. Hilda’s husband rushes her to hospital where she is given corticosteroids. She is told she must stay in hospital a few days so that her condition can be monitored.

A few days later, Hilda’s asthma is under control, and she is now discharged from hospital. She is told to take her preventer medication every day, even if she is feeling well.

Question 1 Hilda has been told to take her ‘preventer’ medication every day.

• Name the broad drug category preventer medications belong to, describe their mechanism of action, and explain their benefits in Hilda’s case.
• Describe the benefit of topically administered preventers in Hilda’s case.

Question 2 Hilda has been advised about the possibility of oral thrush. Explain how Hilda can prevent oral thrush from occurring by discussing therapy options.

Question 3 Describe how the thunderstorm could have contributed to Hilda’s asthma. In your answer you must discuss the link between allergen exposure and an asthma attack.

CASE STUDY 3

Bruce is a 47-year-old journalist, who decides to visit his doctor due to some gastrointestinal symptoms. At first, he experienced some minor abdominal pain and cramping, which was then followed by diarrhea, and therefore Bruce convinced himself that it was just a minor stomach bug. However, he had also been noticing that he’d been getting sick more often recently. Weeks went by, and the diarrhea just increased in frequency, and he also experienced periods of constipation in between the diarrhea periods, which he found rather odd. In addition, instead of feeling better, he started to feel really fatigued. This had been going on for 8 months before his wife finally convinced him to make an appointment with his family doctor, who then referred him to a gastroenterologist. A couple of months later, when he finally goes to his specialist appointment, Bruce admits after questioning that he has had blood in his stool, but he didn’t want to tell the doctor as he was embarrassed and didn’t want to get checked for hemorrhoids. The gastroenterologist also asks many questions about Bruce’s diet and his weight and discovers that Bruce has lost 15 kg in the past year despite eating a lot of hot chips and mashed potatoes – the only thing Bruce feels doesn’t make his diarrhea worse. The gastroenterologist then tells Bruce he will need to perform a colonoscopy to investigate further.

After the colonoscopy, the surgeon tells Bruce that they found several polyps in his bowel, which is not necessarily a cause for concern as many polyps are benign, but they will have to wait on the results of the biopsies to make sure none of them were malignant. A week later the surgeon calls Bruce – the biopsy shows evidence that the growth is malignant and anaplastic, and that they can’t rule out metastatic growths. Bruce is called back in for follow-up tests, and they find that there is an abnormal growth in his liver.

Bruce is now sent to an oncologist, who recommends that he has surgery to remove any remaining polyps, a portion of his bowel, and the abnormal growth from his liver. Based on the advice from his oncologist, Bruce also decides to undergo chemotherapy treatment. Whilst doing some routine checks after his treatment, Bruce is informed he has neutropenia.

Question 1 Define and describe the terms malignant and anaplastic and discuss what this means for Bruce’s prognosis

Question 2 Explain why Bruce has an increased risk of immunosuppression due to his condition and its treatment.

Question 3 Explain the rationale for Bruce’s oncologist recommending chemotherapy in this instance and describe the mechanism of action of chemotherapeutic agents.

Question 4 Name the gene family p53 belongs to and describe possible consequences of p53 gene mutation(s).

CASE STUDY continued

Bruce’s friend Greg has been trying to support him throughout his journey. Greg is a 42-year-old ITspecialist, who suffers from Type II diabetes mellitus, which has been under control using an oral anti-hyperglycaemic medication and a reasonably healthy diet. Rather disturbingly, however, Greg has been experiencing numbness and some awkward tingling in his left foot recently.

Question 5 Assuming that Greg’s present symptoms are associated with his Type II diabetes mellitus, explain the link between:

• Type II diabetes mellitus and Greg’s peripheral neuropathy, and
• peripheral neuropathy and the potential for formation of leg ulcers

Question 6 Although Greg takes an oral anti-hyperglycaemic medication, in the later stages of his condition, he may need to take insulin as well. Explain why insulin administration would be recommended in his case.

CASE STUDY 4

Maria is a 67-year-old retired, obese woman, who lives with her husband Max. She enjoys sitting down to a movie every night with a bottle of Shiraz and a large packet of salt and vinegar chips or tub of cookies and cream ice cream. Maria doesn’t like to exercise, particularly since she gets chest pain upon exertion. Maria’s father passed away from a heart attack at the age of 60. Maria’s mother has type II diabetes and hypertension, which she controls with medications.

Maria has noticed that her chest pain has become more frequent and is lasting for a longer period of time. More recently, it has been occurring while she is watching television in the evening or whilst reading her book in bed. She decides to make an appointment with her GP for later in the week.

At the medical clinic, the GP looks at Maria’s medical history. She was diagnosed with hypertension four years ago, for which she was put on an ACE inhibitor. The GP worries about Maria’s latest symptoms so writes a referral for her to see a cardiovascular specialist for an ECG and a coronary angiogram to determine why Maria has been short of breath and unwell.

One day, whilst waiting for her results, Maria starts to feel more nauseous and dizzier than usual. She starts to feel clammy and sweaty, and her face seems grey in colour. The chest pain returns, but now feels like a crushing pain, and she can’t breathe. Her husband, Max, dials 000, and she is rushed to hospital. An ECG shows that Maria has ST elevation, and a blood test indicates that she has high levels of myocardium-specific troponin in her blood. Maria is given heparin intravenously as well as aspirin and tissue plasminogen activator. She is taken into surgery, where a coronary angioplasty is performed.

Question 1 Before her current problems, Maria was prescribed with an ACE inhibitor for her hypertension. Explain the benefits of ACE inhibitor administration in the treatment of hypertension with specific emphasis on how this treatment reduces blood pressure.

Question 2 Maria noticed that ‘her chest pain has become more frequent and is lasting for a longer period of time…’ Name the condition Maria was most likely experiencing and explain its pathogenesis.

Question 3 Considering her clinical symptoms and laboratory findings, name the condition Maria is suffering from when admitted to the hospital and explain the benefits of tissue plasminogen activator administration in her present state.