Transcript Case Studies For B.Pharm. Sem V students

L.M.COLLEGE OF PHARMACY
AHMEDABAD-380009
CASE STUDIES
Courtesy:
• Dr. Parloop Bhatt
• Shreya Gupta
• Khevna Maniar
Corresponding E-mail:[email protected]
Case Study of Asthma
Efforts of:
•Kinjal Gamit (132280290012)
•Surbhi Pandor (132280290024)
•Mauli Patel (132280290030)
•Nidhi Prajapati (132280290033)
•Sangada Bhargav (132280290042)
B- Pharm Sem- 5, 2015 (132280290012, 132280290024, 132280290030, 132280290033 and 132280290042)
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Case Presentation I
• A 34 years old, female who was an office manager by
profession visited her physician complaining of dyspnea,
cough and occasional wheezing symptoms upon increased
“stressful” situations.
• Onset was determined to be three years ago insidiously as a
result of grief over losing a beloved pet.
• It was provoked by exercise, emotional/physical stress,
cigarette smoke, mold, and also worse with seasonal
respiratory allergies.
• She was diagnosed with asthma caused due to stress.
• She was prescribed with bronchial non- steroidal inhaler
medication.
B- Pharm Sem- 5, 2015 (132280290012, 132280290024, 132280290030, 132280290033 and 132280290042)
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Case Presentation II
• A 12 year old girl was brought in the hospital who had
experienced nasal congestion, difficulty in breathing and chest
tightness while playing with the pet cat.
• On further inquiry it was revealed that the central heating
furnace filters had not been cleaned in the last year and both
the parents were frequent smokers.
• The patient was diagnosed with mild persistent asthma.
• She was treated with corticosteroid metered-dose inhaler
(MDI) for daily use and a short- acting β2-agonist.
• Her parents were also advised to:
 Reduce their smoking and to not smoke inside the house.
 Clean the furnace filters.
 Not keep the pet cat in the house.
B- Pharm Sem- 5, 2015 (132280290012, 132280290024, 132280290030, 132280290033 and 132280290042)
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Case Presentation III
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Mr. GT is 54 years old and has been diagnosed with asthma
for 4 years now. He is 180 cm tall and weighs 95 kg.
He has recently been admitted to hospital with acute
exacerbation of his asthma, due to lower respiratory tract
infection.
During his admission, his steroid medication was altered
from Qvar Easi- Breathe 100 µcg twice daily to Symbicort
400/12 Turbo- inhaler 1 puff twice a day.
He also takes Salbutamol Easi-breathe inhaler 200 µcg when
required.
Q.1 What are the symptoms of Asthma?
Q.2 What is the line of treatment depending on severity of the
cases?
B- Pharm Sem- 5, 2015 (132280290012, 132280290024, 132280290030, 132280290033 and 132280290042)
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Symptoms
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Common symptoms of ASTHMA are as follows:
Frequent cough, especially at night.
Losing your breath easily or shortness of breath.
Feeling very tired or weak when exercising.
Wheezing or coughing after exercise.
Getting easily upset, being grouchy or moody.
Signs of a cold or allergies are seen: like sneezing, runny
nose, cough, nasal congestion, sore throat and headache.
 Trouble sleeping due to difficulty in breathing while laying
down.
B- Pharm Sem- 5, 2015 (132280290012, 132280290024, 132280290030, 132280290033 and 132280290042)
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Causes
• Family history of asthma:
Genetic.
• Allergic reactions.
• Environmental factors.
• Smoking: If one is a smoker or
mother is smoking during
pregnancy.
• Obesity.
• Micro- organisms.
• Stress.
• Physical exertion.
• Chemicals.
B- Pharm Sem- 5, 2015 (132280290012, 132280290024, 132280290030, 132280290033 and 132280290042)
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Diagnosis
Diagnosis of Asthma done by:
• Spirometry or Lung Function Test: Single-breath diffusing
capacity can help differentiate Asthma from COPD.
• Bronchoprovocation tests.
• Chest X-ray test.
• Allergy testing.
• Family history is checked for cases of asthma.
B- Pharm Sem- 5, 2015 (132280290012, 132280290024, 132280290030, 132280290033 and 132280290042)
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Treatment
• Asthma cannot be cured. But appropriate management can
control the disease and enable people to enjoy healthy life.
• Management involves four component:
1. Assessment and Monitoring.
2. Education/ Awareness.
3. Controlled Environmental Factors.
4. Medications: Rescue Inhalers, Inhaled Corticosteroids, β2
Sympathomimetics, Anticholinergics, Anti- Leukotriene Drug
and Mast cell stabilizers.
B- Pharm Sem- 5, 2015 (132280290012, 132280290024, 132280290030, 132280290033 and 132280290042)
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Definition
• Asthma is a common chronic disorder of the air way which is
due to inflammation of the air passages in the lungs affects
the sensitivity of the nerve endings in the airways so they
become easily irritated and has recurring symptoms:
 Air flow obstruction.
 Bronchial hyper responsiveness.
 Underlying inflammation.
• In an attack:
 The lining of the passages swell causing the airways to narrow.
 Reducing the flow of air in and out of the lungs.
B- Pharm Sem- 5, 2015 (132280290012, 132280290024, 132280290030, 132280290033 and 132280290042)
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Drugs used in Asthma
1. Bronchodilators:
• β- adrenergic: Salbutanol, Terbutaline, Formoterol,
Salmeterol.
• Methylxanthines: Theophylline, Aminophylline, Choline
theophyllinate, Dyphylline, Hydroxyethyl Theophylline.
• Anticholinergics: Ipratropium bromide, Tiotropium bromide.
2. Anti- Inflammatory:
• Leukotriene antagonists: Montelukast, Zafirlukast.
• Mast cell stabilizers: Sodium Cromoglylate, Ketotifen.
• Corticosteroids: Prednisolone, Fluticasone, Budesonide,
Beclomathasone.
• Immunoglobin- E Antibody: Omalizumab.
B- Pharm Sem- 5, 2015 (132280290012, 132280290024, 132280290030, 132280290033 and 132280290042)
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Advice as a Pharmacist
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Stop smoking.
Do regular mild breathing exercises.
Be in control.
Take special care in cold weather.
Eat healthily.
Avoid exposure to known allergens.
Take the medication properly and on time.
On observing increase in severity, consult the doctor
immediately and seek guidance.
• Do not self medicate.
• Avoid multiple medications.
B- Pharm Sem- 5, 2015 (132280290012, 132280290024, 132280290030, 132280290033 and 132280290042)
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Case study of Constipation
Efforts of:
•Uttam Prajapati (132280290034)
•Himanshu Suthar (132280290046)
B-Pharm Sem-5, 2015 (132280290034 and 132280290046)
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Case Presentation
• 76 year old female with Past Medical History of Hypertension,
Diabetes Mellitus II and Hyperlipidemia, goes to a clinic.
• She complained of having stools only twice a week and of feeling
“full.” Her last colonoscopy one year ago was clean.
• She has been eating ample vegetables, drinks sufficient water and
recently included Metamucil (a bulk producing fiber supplement) to
her diet.
• She was diagnosed as a case of constipation.
• Q.1 What are the causes of constipation?
• Q.2 What should be the line of treatment for such patients?
B-Pharm Sem-5, 2015 (132280290034 and 132280290046)
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Symptoms & Causes
• Possible symptoms:
• Passing fewer than 3 stools
per week.
 Causes:
 Insufficient dietary fiber or
fluid.
• Straining ineffectively. Passing  Inadequate physical activity.
smaller than normal stools.
Functional impairment.
• Passing hard, dry stools.
 Change in routine (e.g., travel,
hospitalization).
• Staining undergarments with
watery seepage that passes
around hardened faeces.
• Feeling that evacuation is
incomplete.
• Feeling bloated.
 Psychological distress (e.g.,
abuse, depression, anxiety).
 Colonic, anorectal, endocrine
or metabolic disorders.
 Side effects from multiple
medications.
B-Pharm Sem-5, 2015 (132280290034 and 132280290046)
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Risk Factors
• The following factors can increase a person’s likelihood of
becoming constipated; however, these do not need to be present
for constipation to occur:
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Age group of 65 and above.
Eating less food.
Using multiple medications, in high amount.
Sedentary lifestyle (lack of exercise).
Ignoring the urge to defecate.
Lack of adequate fluid intake.
Less intake of fibrous food.
B-Pharm Sem-5, 2015 (132280290034 and 132280290046)
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Diagnosis
The diagnosis of constipation mainly includes the following:
• Blood tests.
• Stool examination.
• Colonoscopy.
B-Pharm Sem-5, 2015 (132280290034 and 132280290046)
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Treatment
• Depending on the cause it may be medicated as
follows:
A. Idiopathic constipation: Bisacodyl, Co- danthramer, Codanthrusate (High dosage stimulant laxatives).
B. Opioid- induced constipation: Methylaltrexone.
C. Hepatic encephalopathy: Lactulose.
D. Neurological constipation: Faecal softeners.
E. Constipation during pregnancy: Senna, magnesium
salts, and docusate.
B-Pharm Sem-5, 2015 (132280290034 and 132280290046)
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Drugs used in Constipation
•Bulk Laxatives:
Hydrophilic Colloids.
Bran.
Methylcellulose.
 Psyllium.
Ispaghula.
•Osmotic laxative:
Saline purgatives.
Magnesium sulphate salts
(Epsom salts).
Magnesium hydroxide (Milk of
Magnesia).
Lactulose.
•Faecal Softeners:
Dioctyl sodium sulfosuccinate
(DOSS).
Mineral oils.
Glycerin suppositories.
•Stimulant/ Irritant Purgative:
Senna.
Cascara.
Castor oil.
Bisacodyl.
Phenolphthalein.
B-Pharm Sem-5, 2015 (132280290034 and 132280290046)
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Advice as a Pharmacist
•Eat more fiber.
•Drink at least 1.2 liters (six to eight glasses) of fluids a day.
•Avoid alcohol and soft drinks.
•Do mild exercise everyday.
•Never ignore the urge to go to the toilet.
•Patient in want or need of immediate relief may take:
1. Enemas like mineral oil, water, saline, etc.
2. Suppositories.
3. Other Over the Counter laxatives.
B-Pharm Sem-5, 2015 (132280290034 and 132280290046)
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Case Study of
Chronic Obstructive Pulmonary Disease
(COPD)
Efforts of:
•Tarang Jadav (32280290015)
B- Pharm Sem- 5, 2015 (132280290015)
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Case Presentation
• 51-year old female patient presented to the health
center’s emergency department with severe dyspnoea on
excretion and progressive edema of the lower extremities.
• She is a 40 pack-year smoker and currently still smokes
cigarettes.
• She found yellowish sputum produced in cough, lack of
energy, shortness of breath.
• She could not stand or walk for more than 1 minute to 2
minutes without becoming fatigued.
Q.1 What are the causes of COPD?
Q.2 What is the line of treatment for such patients?
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B- Pharm Sem- 5, 2015 (132280290015)
Signs and Symptoms
Symptoms of COPD usually don’t appear untill significant lung
damage.
Symptoms of COPD include:
• Shortness of breath
• A chronic cough that produces yellowish sputum
• Frequent respiratory infections
• Having to clear throat in the morning
• Chest tightness
• Wheezing
• Lack of energy
• Blueness of the lips
• Unintended weight loss
B- Pharm Sem- 5, 2015 (132280290015)
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Diagnosis
• Pulmonary function test : This machine measures how much
air your lungs can hold and how fast you can blow the air out
of your lungs.
• Chest X-ray: A chest X-ray can show emphysema, one of the
main causes of COPD. An X-ray can also rule out other lung
problems or heart failure.
• CT scan: A CT scan of your lungs can help detect emphysema
and help determine if you might benefit from surgery for
COPD. CT scans can also be used to screen for lung cancer
produced from COPD
• Arterial blood gas analysis: This blood test measures how
well your lungs are bringing oxygen into your blood and
removing carbon dioxide.
B- Pharm Sem- 5, 2015 (132280290015)
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Treatment
• Bronchodilators: These medications — which usually come in an inhaler —
relax the muscles around your airways.
ß2 agonist
• It includes albuterol (ProAir HFA, Ventolin HFA, others), levalbuterol
(Xopenex), Fenoterol.
Anticholinergics: Ipratropium bromide, tiotropium bromide, Oxitropium
bromide .
• Inhaled steroids
• Inhaled corticosteroid medications can reduce airway inflammation and help
prevent exacerbations. Fluticasone (Flovent) and budesonide (Pulmicort) are
examples of inhaled steroids.
• Phosphodiesterase-4 inhibitors
• A new type of medication approved for people with severe COPD and
symptoms of chronic bronchitis is roflumilast (Daliresp), a
phosphodiesterase-4 inhibitor.
• Oral Corticosteroid: Prednisone
• For people who have a moderate or severe acute exacerbation, short courses
of oral corticosteroids prevent further worsening of COPD.
• Methylexanthines: Theophylline
B- Pharm Sem- 5, 2015 (132280290015)
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Definition
• Chronic obstructive pulmonary disease (COPD) is a chronic
inflammatory lung disease that causes obstructed airflow
from the lungs.
• Symptoms include:
 Breathing difficulty
 Cough
 Sputum production
 Wheezing.
• It is caused by long-term exposure to irritating gases or
particulate matter, most often from cigarette smoke.
• Emphysema and chronic bronchitis are the two most common
conditions that contribute to COPD.
B- Pharm Sem- 5, 2015 (132280290015)
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Advice As A Pharmacist
• Adherence to medication.
• Be regular for doctor’s
appointment
• Avoid smoking.
•Avoiding inhalation of lung
irritants :
•Taking regular exercise
•Eating healthily
•Vaccinations
B- Pharm Sem- 5, 2015 (132280290015)
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Case Study of Cough
Efforts of:
•Gandhi Pratik (132280290058)
• Shreya Gupta (132280290059)
• Malaviya Vikas (132280290060)
• Kriyanshi Maniar (132280290061)
B- Pharm Sem- 5, 2015 (132280290058, 132280290059, 132280290060 and 132280290061)
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Clinical Case I
Geeta, 17 years of age, has been brought to her doctor for wet
cough. She has throat pain and cough since 7 days, and fever
since 3 days. She has been on home remedies for 7 days and
has not take any medication.
Symptoms:
• Cough, accompanied by
chest pain
• Low Fever since 3 days.
• Sore throat
• No other abnormalities.
Physical Examination :
•Weight : 47.704 kg
•Blood pressure: 116/84
•Pulse : 80 per minute
•Temperature:99.8 F
•Wheezing
•Examination of lungs showed
no abnormalities
B- Pharm Sem- 5, 2015 (132280290058, 132280290059, 132280290060 and 132280290061)
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Clinical Case II
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Mrs. Robinson was a 57-year-old woman who presented with
an irritating paroxysmal dry cough. It appeared to have
persisted following a chest infection three months earlier.
• She had symptoms with a sore throat and purulent sputum.
She smoked regularly and speaking at presentations was an
important part of her job.
• Now the cough was dry and paroxysmal and was being
noticed at work. There was no associated wheezing or
nocturnal symptoms and her chest was clear.
Q.1 What are the causes of cough?
Q.2 What is the line of treatment for such patients?
B- Pharm Sem- 5, 2015 (132280290058, 132280290059, 132280290060 and 132280290061)
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Signs And Symptoms
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Sore throat
Purulent sputum.
No wheezing
No nocturnal symptoms
B- Pharm Sem- 5, 2015 (132280290058, 132280290059, 132280290060 and 132280290061)
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Diagnosis
•
Physical Exam: To check for signs of problems related to
cough, your doctor will use a stethoscope to listen to your
lungs. He or she will listen for wheezing (a whistling or
squeaky sound when you breathe) or other abnormal sounds.
• Lung function tests can help diagnose asthma and other
conditions.
• An X-ray of the sinuses. This test can help diagnose a sinus
infection.
B- Pharm Sem- 5, 2015 (132280290058, 132280290059, 132280290060 and 132280290061)
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Treatment
• Antitussives depress the medullary cough center or
anesthetize stretch receptors of vagal afferent fibers in
bronchi and alveoli . Eg: Dextromethorphan, Codeine
• Expectorants decrease viscosity and facilitate expectoration.
Eg.Guafenesin, bromohexine, ipecac and saturated solution of
potassium iodide (SSKI)
• Demulcents are cough syrups (or cough linctuses) that may
suppress coughing by forming a protective layer over the
throat (pharynx). These can be given to children Eg. Sucrose,
glycerol
• Mucolytics are cough medicines that make it easier to cough
up mucus.
B- Pharm Sem- 5, 2015 (132280290058, 132280290059, 132280290060 and 132280290061)
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Definition
• Cough is an explosive expiratory maneuver that is reflexively
or deliberately intended to clear the airways. It is one of the
most common symptoms prompting physician visits.
• It is a sudden and often repetitively occurring reflex which
helps to clear the large breathing passages from secretions ,
irritants, foreign particles and microbes.
• The cough reflex consist of 3 phases: inhalation , a forced
exhalation, against a closed glottis, and a violent release of air
from the lungs following opening of the glottis, usually
accompanied by a distinctive sound
B- Pharm Sem- 5, 2015 (132280290058, 132280290059, 132280290060 and 132280290061)
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Drugs Used in Cough
1. Pharyngeal
demulcents
 Lozenges, cough drops
2. Expectorants
 Bronchial secretion
enhancers Sodium or
Potassium
 Citrate, Potassium
iodide
 Mucolytics Bromhexine,
Ambroxol
3. Antitussives (Cough centre
suppressents)
Opioids Codeine,
Pholcodeine.
 Nonopioids Noscapine,
Dextromethorphan,
Antihistamines
Chlorpheniramine
4. Adjuvant antitussives
 Bronchodilators
Salbutamol, Terbutalin.
B- Pharm Sem- 5, 2015 (132280290058, 132280290059, 132280290060 and 132280290061)
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Advice As A Pharmacist
• Ensure adequate fluid intake
• Ensure the completion of the course.
• Most short term coughs are caused by viruses so antibiotics will not
help.
• Parecetamol or ibuprofen can cease aches and fevers. Wash your
hands frequently during the cold and flu season.
• Avoid people who have a cold or influenza if possible.
• Avoid exposure to secondhand smoke, both at home and in the
workplace.
• Increase your fluid intake. This helps keep the mucus thin and helps you
cough it up. It also helps prevent dehydration.
• Make sure your immunizations are current, such as pertussis to reduce
your risk of getting whooping cough.
• Steam or menthol inhalation can help.
• Stop smoking
• Cough should resolve but can last upto four weeks.
• Try lozenges .
B- Pharm Sem- 5, 2015 (132280290058, 132280290059, 132280290060 and 132280290061)
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Case Study Of Diarrhea
Efforts of:
Drishti Dave (132280290009)
Mrunalini Deshpande (132280290010)
B- Pharm Sem- 5, 2015 (132280290009 and 132280290010)
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Case Presentation
Q.1 What are the causes of diarrhoea?
Q.2 What is the line of treatment for such patients?
B- Pharm Sem- 5, 2015 (132280290009 and 132280290010)
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Signs And Symptoms
• Daily severe abdominal pain
• Fever
• Urgency of fecal defecation
• 8-10 times/day small volume stools
•Headache
•Uneasiness
•Bleeding
•Lightheadedness or dizziness from dehydration
•Loss of appetite
•Nausea and vomiting
•Abdominal cramps
B- Pharm Sem- 5, 2015 (132280290009 and 132280290010)
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Diagnosis
• From the stool culture test it was found to be a
retroviral infection.
• Father of the patient is an HIV positive.
• Hence, there is a possibility that she might be
suffering from AIDS.
B- Pharm Sem- 5, 2015 (132280290009 and 132280290010)
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Treatment
Drugs prescribed• Pediatric anti retroviral drug:
 Nitazoxamide
• To treat chronic diarrhea:
 Racecadotril
B- Pharm Sem- 5, 2015 (132280290009 and 132280290010)
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Definition
DIARRHEA
• Diarrhea is an increase in the volume, wateriness, or
frequency of bowel movements.
• It is generally a change in bowel habit that results in
substantially more frequent and looser stools than
usual.
• Diarrhea is also found to be occurring as a symptom
in some of the infectious diseases such as AIDS.
B- Pharm Sem- 5, 2015 (132280290009 and
132280290010)
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Drugs used in Diarrhea
• Anti cholinergic
 Bellandona, Atropine, Hyoscyamine
• Opiates
 Loperamide, Diphenoxylate, Paregoric
• Adsorbents
 Kaolin, Bismuth subsalicylate
• Oral rehydration solution is also given sometimes as
a supplement so as to prevent dehydration due to
fluid loss.
B- Pharm Sem- 5, 2015 (132280290009 and 132280290010)
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Advice as a Pharmacist
• Drink plenty of clear fluids such as water and fruit
squash.
• Avoid drinks that contain high amount of sugar.
• Avoid milk and milky drinks.
• Eat light and easily digestible food.
• Maintain personal hygiene.
• Consume drugs as prescribed by the doctor.
B- Pharm Sem- 5, 2015 (132280290009 and 132280290010)
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Case Study of Emesis
Efforts of:
•Darji Lalit (132280290008)
•Sushama Sinha (132280290051)
•Susmita Rajbongshi (132280290052)
•Pathik Parekh (132280290064)
B- Pharm Sem- 5, 2015 (132280290008, 132280290051, 132280290052 and 132280290064)
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Case Presentation I
• A 3-year-old boy was taken to a hospital for evaluation of
head trauma and persistent nausea, abdominal pain and
vomiting.
• He had run down a hill in the afternoon and fell headfirst onto
the cement. He had not lost consciousness, but that evening
after dinner he began vomiting, which continued for 9 days.
• The head, eyes, ears, nose, and throat exam revealed a healed
abrasion and small laceration on his right forehead, with slight
swelling. The head CT (Computed Tomography) and the Cell
Blood Count was normal. He was treated with
Dexamethasone, Lorazepam and Ondansetron.
• The urine has 500 mg/dL glucose and 80 mg/dL or more of
ketones (i.e. very high level). Thus, it was concluded that
persistent emesis was due to Diabetes mellitus Type- 1 and he
was treated accordingly.
B- Pharm Sem- 5, 2015 (132280290008, 132280290051, 132280290052 and 132280290064)
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Case Presentation II
• A 55 years old woman was diagnosed with stage 1 breast
cancer at age of 46 years.
• She had undergone routine mammography since age 40.
• After she underwent lumpectomy and axillary node
dissection, the patient experienced post-operative emesis.
• She was administered Dexamethasone, but vomitting
remained poorly controlled.
• The patient was then prescribed a combination of antiemetics: Ondansetron, Dexamethasone, Lorazepam.
• Despite these combination of anti emetics she experienced
several episodes of chemotherapy induced nausea and
vomiting(CINV).
Q. 1 What are the risk factors and symptoms of emesis?
Q. 2 What should be the line of treatment for emesis?
B- Pharm Sem- 5, 2015 (132280290008, 132280290051, 132280290052 and 132280290064)
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Symptoms
The symptoms following emesis may include:
• Nausea, Motion sickness.
• Loss of appetite.
• Abdominal pain.
• Dizziness.
• Cardiac pain.
• Decreased fluid intake.
• Intermittent vomiting and regurgitation.
• Belching.
• Progressive retrosternal pain while eating (i.e. pain behind
the breastbone).
• Weight loss.
B- Pharm Sem- 5, 2015 (132280290008, 132280290051, 132280290052 and 132280290064)
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Diagnosis
Emesis is mainly a symptom of a disease. It may suggest:
• In the Digestive Tract: Gastritis, Gastroenteritis,
Gastroesophageal Reflux Disease, Pyloric stenosis, Bowel
obstruction, Food allergies (E.g.: Milk allergy or lactose
intolerance), Food poisoning, etc.
• In the Sensory System: Motion sickness, Ménière's disease.
• In the Brain: Concussion, Cerebral hemorrhage, Migraine,
Brain tumors, Benign intracranial hypertension and
Hydrocephalus.
• Due to Metabolic Disturbances: Hypocalcaemia, Uremia,
Adrenal insufficiency, Hypoglycemia, Hyperglycemia.
• In Pregnancy: Hyper- emesis, Morning sickness.
• Due to Drug Interaction: Alcohol, Opioids, many
chemotherapy drugs, some Entheogens.
• Due to Infection by Microbes: E.g.: Norovirus, Swine
influenza, etc.
B- Pharm Sem- 5, 2015 (132280290008, 132280290051, 132280290052 and 132280290064)
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Treatment
• Treat complications such as dehydration, hypocalaemia,
metabolic alkalosis in acute situation.
• Implement therapeutic strategies to supress or eliminate
symptoms.
• Antiemetic drugs: Only when the cause of nausea is known.
• Gastric emptying study: In patients with suspected
gatroparesis.
• 5-HT3 receptor antagonist with long half- life and greater
binding affinity: Enhanced effect.
B- Pharm Sem- 5, 2015 (132280290008, 132280290051, 132280290052 and 132280290064)
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Definition
• Vomiting is the involuntary, forceful expulsion of the contents
of one's stomach through the mouth.
• Nausea is the sensation of impending emesis and is frequently
accompanied by autonomic changes, such as increased heart
rate and salivation.
• Vomiting is uncomfortable and can cause dehydration
because fluid is lost and because the ability to rehydrate by
drinking is limited.
B- Pharm Sem- 5, 2015 (132280290008, 132280290051, 132280290052 and 132280290064)
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Drugs used in Emesis
1.
2.
3.
4.
Anticholinergics: Hyoscine, Dicyclomine.
Neuroleptics: Chlorpromazine.
Prokinetic drugs: Metoclopramide, Cisapride, Mosapride.
Adjuvant anti- emetics: Benzodiazepines, Dexamethasone,
Nabilone.
5. H-1 Antihistamines: Promethazine, Diphenhydramine.
6. 5-HT3 Antagonists: Ondansetron, Granisetron.
B- Pharm Sem- 5, 2015 (132280290008, 132280290051, 132280290052 and 132280290064)
52
Advice as a Pharmacist
• Avoid foods that are hard to digest.
• If the smell of hot food makes you feel ill, try eating cool or
cold meals.
• Eat six small meals each day instead of three large ones.
• Do not lay down after eating. Rest with your head higher than
your feet.
• If you feel nauseated when you wake up in the morning, eat
some lean meat or cheese before going to bed or keep plain
crackers by the side of your bed and eat a few before
awakening.
• Drink at least six glasses of water a day.
B- Pharm Sem- 5, 2015 (132280290008, 132280290051, 132280290052 and 132280290064)
53
Case Study of Glaucoma
Efforts of:
•Maria Bandookwala (132280290053)
•Mittal Bhayani (132280290054)
B- Pharm Sem- 5, 2015 (132280290053 and 132280290054)
54
Case Presentation
•Mrs.BA, a 49 years old female, presented in private practice for a
routine examination. Her main presenting symptoms was
presbyopia; having difficulty with reading fine print.
•She had been prescribed spectacles in her early twenties for
reading work.
•No reported history of glaucoma, cataracts, unusual eye
conditions, blindness, heart or blood pressure problems, or
diabetes is seen.
Q.1 What are the causes of glaucoma?
Q.2 What is the line of treatment for such patients?
B- Pharm Sem- 5, 2015 (132280290053 and 132280290054)
55
Signs And Symptoms
•
•

•








The main symptoms of glaucoma is gradual loss of vision.
Chronic open angle glaucoma:Loss of peripheral field vision happens first.
Acute-angle closure glaucoma:Sudden occular pain
Seeing halos around light
Red eye
Very high IOP (> 30 mmHg )
Nausea and vomiting
Suddenly decreased vision
Fixed, mid-dilated pupil
Oval pupil in some cases.
B- Pharm Sem- 5, 2015 (132280290053 and 132280290054)
56
Diagnosis
To be safe and accurate, five factors should be checked
before making a glaucoma diagnosis:
• The inner eye pressure (intraocular pressure or IOP)
[tonometry]
• The shape and color of the optic nerve
(ophthalmoscopy or dilated eye exam)
• The complete field of vision (perimetry test)
• The angle in the eye where the iris meets the cornea
(gonioscopy)
• Thickness of the cornea (pachymetry).
B- Pharm Sem- 5, 2015 (132280290053 and 132280290054)
57
Treatment
• Treatment of glaucoma can be either medical or surgical. In
normotensive glaucoma a reduction of 30 percent would be
considered a reasonable initial target pressure after treatment.
• The drugs can be broadly broken into two groups:
• Drugs that lower IOP: Betaxolol
 Brimonidine
 Dorzolamide
 Latanaprost
• Drugs that offer the additional benefit of neuroprotection: Oral calcium channel inhibitors
 Mementine
B- Pharm Sem- 5, 2015 (132280290053 and 132280290054)
58
Definition
• Glaucoma is a group of eye conditions resulting in optic nerve
damage, which may cause loss of vision. Abnormally high
pressure inside your eye (intraocular pressure) usually, but
not always, causes this damage.
• Glaucoma is an eye disease that gradually steals your vision.
• Often, glaucoma has no symptoms and can suddenly result in
vision loss.
• Without proper treatment, glaucoma can lead to blindness.
B- Pharm Sem- 5, 2015 (132280290053 and 132280290054)
59
Drugs used in Glaucoma
• Based upon mechanism of action:
Alphaadrenergic
agonist
Beta
blockers
Carbonic
anhydrase
inhibitor
Epinephrine Prostagland- Miotics
compounds ine
analogs
Reduce
amount of
aqueous
produced,
some also
increase
removal
of fluid
from the
eye.
Reduce
the
amount
of
aqueous
produced
Reduce
production of
aqueous
humor.
Increase
Increase
removal of secondary
fluid.
route for
aqueous
humor to
drain.
B- Pharm Sem- 5, 2015 (132280290053 and 132280290054)
Increase
the
removal
of
aqueous
humor
from the
eye.
60
Advice As A Pharmacist
• Dorzolamide eye drops are used to control
increased pressure within the eye (glaucoma)
• Remember to use the drops regularly – try
not to miss any doses.
• If you normally wear soft contact lenses,
please make sure your doctor knows about
this.
• Regular eye examinations are recommended.
• Eating vitamin-rich fruits and vegetables.
• Taking a vitamin supplement, protecting eyes
from injury, and getting medical treatment
for systemic illness promote good eye
health..
B- Pharm Sem- 5, 2015 (132280290053 and 132280290054)
61
Case Study of Hepatitis B
Efforts of:
• Komal Bangroo (132280290002)
• Bhagat Divya V. (132280290004)
• Panchal Hetal S. (132280290023)
• Neha Raina (1322802900036)
B- Pharm Sem- 5, 2015 (132280290002, 132280290004, 132280290023 and 132280290036)
62
Case Presentation I
• A 27 year old African female was presented to the emergency
room with a five days history of malaise, fatigue, low grade
fever and nausea.
• Yesterday, she noted that her urine was very dark and her
stools were light in color.
• She also complained of joint pain.
• Physical examinations were run on her and it was found that
her liver was enlarged.
• She had a history of three sex partners in the past few months
and denied illegal drug use.
• Otherwise she was in good health.
• She was diagnosed for Hepatitis B following the tests.
B- Pharm Sem- 5, 2015 (132280290002, 132280290004, 132280290023 and 132280290036)
63
Case Presentation II
• Shilpa immigrated to America from Vietnam as an eleven
year old girl. After twelve years of living in Kansas, she
married her college boyfriend. She became pregnant in the
first month of marriage. Included in her first trimester
prenatal screening was a serologic test for HBsAg (a surface
antigen test for hepatitis B). She was shocked to learn that she
was HBsAg positive.
• Her obstetrician informed her that she was probably
chronically infected with HBV and most likely had been
infected since birth. Neither Shilpa nor her mother recalled
any signs or symptoms of viral hepatitis at any point in the last
20+ years.
Q.1 What are the symptoms a Hepatitis patient usually
experiences?
Q. 2 What is the treatment for Hepatitis B?
B- Pharm Sem- 5, 2015 (132280290002, 132280290004, 132280290023 and 132280290036)
64
Symptoms
The symptoms seen are as follows:
• Malaise.
• Abdominal pain.
• Dark urine.
• Fever.
• Joint pain.
• Loss of appetite.
• Nausea and vomiting.
• Weakness and fatigue.
• Peripheral oedema.
• Pain in the left side of the stomach.
B- Pharm Sem- 5, 2015 (132280290002, 132280290004, 132280290023 and 132280290036)
65
Definition and Types
• Hepatitis is a medical condition defined by the inflammation
of liver cells.
• They are of the following types:
1. Hepatitis A : Caused by Hepatitis A virus, transmitted from
contaminated food or water or from close contact with
someone who's infected.
2. Hepatitis B: Caused by the Hepatitis B virus, transmitted by
infected blood.
3. Hepatitis C: Transmitted by contaminated blood- most
commonly through needles shared during illegal drug use,
not easily detected.
4. Hepatitis D: Caused by a small circular enveloped RNA virus,
only after infection of Hepatitis B.
5. Hepatitis E: Caused by Hepatitis E virus, transmitted mainly
by water.
B- Pharm Sem- 5, 2015 (132280290002, 132280290004, 132280290023 and 132280290036)
66
Diagnosis
Hepatitis B is most common in occurrence.
• By assessing an individual's symptoms: Physical exam, medical
history, liver biopsy, and imaging.
• Blood testing: Blood chemistry, serology , liver enzymes and
nucleic acid testing.
• Hybridization and Polymerase Chain Reaction (PCR) assays.
• Immunohistochemical staining: In liver tissues, by the core
antigen of Hepatitis.
• Hepatitis B surface antigen: Only for Hepatitis B.
B- Pharm Sem- 5, 2015 (132280290002, 132280290004, 132280290023 and 132280290036)
67
Treatment
• Treatment based on different types are as follows:
1. Hepatitis A: Rest, eat in parts rather than having whole meals
and avoid consumption of alcohol.
2. Hepatitis B: Take prescribed antiviral medications (E.g.:
Lamivudine, Adefovir, Telbivudine, Entecavir, etc), Interferon
Alfa-2b (Intron A), Liver transplant, anti- viral injection.
3. Hepatitis C: Interferons combined with Ribavirin plus a
protease inhibitor such as Boceprevir or Telaprevir (very
expensive).
4. Hepatitis D: Liver transplantation may be considered for
cases of acute Hepatitis D, anti- viral injection of Hepatitis B
(75% success).
5. Hepatitis E: Immunosuppressive Therapy, no proper
treatment available.
68
B- Pharm Sem- 5, 2015 (132280290002, 132280290004, 132280290023 and 132280290036)
Guidelines For Hepatitis B
As per WHO, the following simple guideline has been proposed
for diagnosis and treatment of WHO:
• The use of a few simple non-invasive tests to assess the stage
of liver disease to help identify who needs treatment.
• Prioritizing treatment for those with cirrhosis- the most
advanced stage of liver disease.
• The use of two safe and highly effective medicines, Tenofovir
or Entecavir, for the treatment of chronic hepatitis B.
• Regular monitoring of inflammation using simple tests for
early detection of liver cancer, to assess whether treatment is
working or not and if treatment can be stopped.
B- Pharm Sem- 5, 2015 (132280290002, 132280290004, 132280290023 and 132280290036)
69
Advice as a Pharmacist
• Immunization for children and vaccination for 15-20 years of
age is necessary.
• Take care of hygiene factors like:
 Washing hands.
 Using latex condoms.
 Not sharing drug needles and personal items.
• Avoid contact with or living with a patient of Hepatitis
infection.
• Blood screening guidelines and laboratory testing guidelines
must be followed.
• Follow physician’s order, if infected. Take proper medications.
• Reduce the consumption of alcohol.
B- Pharm Sem- 5, 2015 (132280290002, 132280290004, 132280290023 and 132280290036)
70
Case Study of Myasthenia Gravis
Efforts of: Nikhil Suthar
Enrollment No.: 132280290047
B- Pharm Sem- 5, 2015 (132280290047)
71
Case Presentation
• A 67 year old man complaining of double vision was found to
have bilateral ptosis covering most of the pupil on the right
side and partially obscuring that on the left. The ptosis was
worse in the evening but almost absent in the morning.
• He admitted to tiredness in the arm and legs on exercising
which recovered with resting.
• A clinical diagnosis of the ocular myasthenia gravis was made.
• Q.1:What are the symptoms of myasthenia gravis?
• Q.2:What should be the line of treatment of these kind of
patients?
B- Pharm Sem- 5, 2015 (132280290047)
72
Symptoms
• Eyes, eyelids and face :- In myasthenia gravis (MG), one or
both eyelids may droop. There may also be blurred or double
vision, often at the end of the day or when a person is tired.
Around 90% of people with the condition have problems with
their eye muscles at some point.
• Limbs and movement :- Myasthenia gravis can sometimes
affect the muscles of the arms, legs and neck. This can cause
mobility problems, such as a waddling gait, head drop and
difficulty performing physical tasks such as lifting.
B- Pharm Sem- 5, 2015 (132280290047)
73
Diagnosis
• The diagnosis of MG relies mostly on the patient's history and
physical findings with particular attention to neurologic, eye
motility and eyelid examination.
• Edrophonium chloride test may be done, which temporarily
blocks the breakdown of acetylcholine, and briefly relieves
weakness. 2 mg is given first and if no improvement is seen in
30s, more 8 mg is injected.
• The diagnosis is also done with blood that measures the
amount of blocking antibody present in the system.
B- Pharm Sem- 5, 2015 (132280290047)
74
Treatment
• Treatment is done with Neostigmine 15 mg is given orally
and frequency is then adjusted according to response.
• Medicines such as Pyridostigmine/Physostigmine
prevents the breakdown of acetylcholine, an important
chemical that helps the muscle to contract. These
medicines work best in mild myasthenia gravis. They
improve muscle strength and in contraction.
• Immunosuppressive therapy is started by Prednisone/
Prednisolone at 30-60 mg/day which induces remission
in about 80% of the advanced cases. 10 mg/day or on
alternate days is used for maintenance therapy.
B- Pharm Sem- 5, 2015 (132280290047)
75
Definition
• A rare chronic autoimmune disease marked by muscular
weakness without atrophy, and caused by a defect in the
action of acetylcholine at neuromuscular junctions. It is where
anomalous antibodies are produced against the naturally
occurring acetylcholine receptors in voluntary or skeletal
muscles.
• This condition causes abnormal weakness of muscles.
B- Pharm Sem- 5, 2015 (132280290047)
76
Pathogenesis
• The clinical features of myasthenia gravis are caused by
specific auto-antibodies acting on the nicotinic
acetylcholine receptor. These antibodies accelerate
receptor turnover, shortening their typical lifetime in the
skeletal muscle membrane from around 7 days to 1 day.
This process results in marked depletion of receptors
from myasthenic skeletal muscle (about 90%) explaining
its fatigability.
• The frequent finding of a specific concurrent hyperplasia
or tumors of the thymus supports the autoimmune basis
for the disease.
B- Pharm Sem- 5, 2015 (132280290047)
77
Advice as a Pharmacist
• Myasthenia Gravis does not occur due to any external factor.
• The antibodies are generated within the body of patient.
• As a pharmacist, patient should advise to improve life style
and do light exercise or undergo physiotherapy.
• Food which gives stress to muscles in swallowing such as meat
should be avoided.
• If affected, then nursing facility is recommended to maintain
hygiene and take proper patient care.
B- Pharm Sem- 5, 2015 (132280290047)
78
Case Study of
Organophosphate Poisoning
Efforts of:
•Khevna Maniar (132280290017)
•Ayushi Kothari (132280290018)
B- Pharm Sem- 5 2015 (132280290017, 132280290018)
79
Case Presentation
• Patient was a 25 years old male with no past medical history. He
was found unconscious by his brother at 6 pm on the day of
hospitalization. The patient showed no symptoms preceding this
event. He was an active farmer who had a family farm in Kenya.
• He was not on any medications and had no known drug
allergies. His family history was also clear.
• Patient had a history of alcohol abuse. He drank 8-10 beers a day
and a couple of cups of the local brew, changaa.
• A half-empty bottle of “COWDIP” (malathion) was found next to
the patient’s unconscious body. It was suspected that the
patient had mistaken it for some sort of ethanol and consumed
it.
B- Pharm Sem- 5 2015 (132280290017,
132280290018)
80
Case Details
• Patient was admitted to medicine ward, obtunded, breathing
4-6 times a minute and bradycardic.. He is treated with
atropine at night.
• Patient goes into cardiac arrest in the morning and CPR was
commenced immediately.
• Vital signs (after pulse recovered): BP 90/50 HR 34. Patient
was then ventilated with a bag mask and he soon regained his
normal pulse.
• Patient had mothball odoured emesis throughout
resuscitation effort. Manual ventilation was stopped, when
patient had 4-6 spontaneous breaths a minute.
• He received 2mg of atropine, 1 amp of D50 for hypoglycemia
and multiple doses of bicarbonate to reverse acidosis.
Q.1 What are the causes of organophosphate poisoning?
B- Pharm Sem2015 (132280290017,
132280290018)
81
Q.2 What is the line of treatment
for5 such
patients?
Signs and Symptoms
•
•
•
•
•
•
•
•
•
•
•
•
Salivation .
Lacrimation.
Urination.
Defecation.
Emesis.
Gastrointestinal motility.
Bronchorrhea .
Bronchospasm.
Bradycardia.
Neck weakness.
Proximal muscle weakness.
Cranial nerve abnormalities.
•Tightness in chest.
•Convulsions.
•Muscle weakness and cramps.
•Paralysis.
•Headache.
•Ataxia.
•Miosis.
•Hypertension and hypoglycemia.
•Anxiety.
•Depression in respiration and
circulation.
•Diarrhea.
•Sweating.
•Unconsciousness.
B- Pharm Sem- 5 2015 (132280290017, 132280290018)
82
Diagnosis
• HEENT:
 Pupils were constricted and
sluggishly reactive to light.
 Buccal mucosa was moist.
 Cranial Nerve could not be
assessed.
 No evidence of trauma on
the head was found.
 Poor dentition.
• Lungs:
 Few spontaneous breaths.
 Rhonchi heard.
 No wheezes heard.
• Skin:
 No suspicious skin lesions.
 Grooming was poor.
•Heart:
Heart Rate of 40s after CPR.
Regular rhythm.
No murmurs auscultated.
•Abdomen:
Soft, non tender, nondistended.
No organomegaly.
Normal
active
bowel
sounds.
•Extremities:
Cool to touch but not
cyanotic.
Weak femoral pulse.
No edema.
B- Pharm Sem- 5 2015 (132280290017, 132280290018)
83
Treatment
• Atropine is given in amount of 2mg then double dose is
given every 5 minutes until tachycardia or pupillary
dilation, used as an antidote as it is a muscurinic
antagonist.
• Pralidoxime (2-PAM) is given in amount of 30mg/kg over 30
minutes then it is reduced to 8mg/kg for every hour
infusion, used for muscle recovery.
• Benzodiazepine is given from day 2 to 5 during recovery.
E.g.: Diazepam.
• Obidoxime, Aprophen, N- methylatropine nitrate are
potential candidates for treatment of OPs.
B- Pharm Sem- 5 2015 (132280290017, 132280290018)
84
Definition
• Organophosphates are organic molecules containing one or
more phosphate ester groups, usually found in insecticides,
pesticides or nerve agents.
• They inhibit cholinesterase activity, causing acute
muscarinic manifestations (e.g.: salivation, lacrimation,
urination, etc) and some nicotinic symptoms, including
muscle fatigue and weakness. Neuropathy can develop
days to weeks after exposure.
• Diagnosis is clinical and sometimes with a trial of atropine,
measurement of RBC acetyl cholinesterase level or both.
Neuromuscular toxicity is treated with IV Pralidoxime.
B- Pharm Sem- 5 2015 (132280290017, 132280290018)
85
Drugs used in Organophosphate Poisoning
• Atropine: Atropine is a competitive antagonist for
the muscarinic acetylcholine receptor types M1, M2, M3,
M4 and M5. It is classified as an anticholinergic
drug (parasympatholytic).
• Pralidoxime: In organophosphate poisoning, an
organophosphate binds to just one end of the
acetylcholinesterase enzyme (the esteric site), blocking its
activity.
 Pralidoxime is able to attach to the other half (the
unblocked, anionic site) of the acetylcholinesterase
enzyme. The antidote then unbinds from the site, and thus
regenerates the enzyme, which is now able to function
again.
B- Pharm Sem- 5 2015 (132280290017, 132280290018)
86
Advice As A Pharmacist
• Possible Allergic Reactions: They are very rare. Dermatitis
over the eyelids, with erythema, itching, anaphylaxis and local
edema.
 Atropine has many possible drug interactions in our body. It
can interact with about 641 drugs, our certain food items and
alcohol (ethanol).
• Following occupational exposure, patient should not be
allowed to return to work with organophosphates until serum
cholinesterase activity returns to 75% of the known normal
level.
• Moreover, precautions should be taken while handling
organophosphates.
• Proper hand and face masks should be worn.
• And PLEASE DON’T TAKE ORGANOPHOSPHATE CHEMICALS AS
SUGAR SYRUPS OR ALCOHOL.
B- Pharm Sem- 5 2015 (132280290017, 132280290018)
87
Case Study of Ulcer
Efforts of:
•Gauri Deshmukh (132280290055)
•Labdhi Doshi (132280290057)
B- Pharm Sem- 5, 2015 (132280290055 ans 132280290057)
88
Case Presentation
• A 32 old working women, who describes her life stressful has
noticed significant Epigastric pain and backache for the past 5
weeks.
• She smokes one pack of cigarettes per day and frequently
takes Naproxen for headaches. This morning she went to the
emergency department complaining of hematemesis (i.e.
blood while vomiting).
• She was admitted and the gastroenterologist performed an
upper endoscopy that revealed 1 cm ulcer.
Q.1 What are the causes of ulcer?
Q.2 What is the line of treatment for such patients?
B- Pharm Sem- 5, 2015 (132280290055 ans 132280290057)
89
Signs and Symptoms
•
•
•
•
•
•
•
•
•
Epigastric pain.
Pain: Gnawing, Burning Or Annoying.
Significant backache.
Relived by intake of fried or other acid producing food.
Pain occurs even when stomach is empty.
Dyspepsia.
Bloating.
Blenching.
Hematemesis or melena.
B- Pharm Sem- 5, 2015 (132280290055 ans 132280290057)
90
Diagnosis
• Based on the clinical characteristic symptoms. Ulcer is an open sore on an
external or internal surface of the body, caused by a break in the skin or
mucous membrane which fails to heal. Ulcers range from small, painful
sores in the mouth to bedsores and serious lesions of the stomach or
intestine
• Endoscopies or barium contrast x-rays.
• Blood tests for an infection: Serology Test (Immunoglobulins).
• An oesophagogastroduodenoscopy (EGD), a form of endoscopy (also
known as a gastroscopy).
• By direct visual identification- For the location and severity of an ulcer.
1. Peptic Ulcer: Stomach
2. Gastric Ulcer: Stomach and duodenum.
3. Bleeding Peptic Ulcer.
4. Stress Ulcer.
5. Gastro- oesophageal Reflux Disease (GERD).
6. Zollinger- Ellison Syndrome.
B- Pharm Sem- 5, 2015 (132280290055 ans 132280290057)
91
Treatment
•
•
•
•
Antibiotics: For H. pylori infection.
Proton pump inhibitors for 8 weeks to heal the ulcers.
A repetitive endoscopy to check progress.
H2 Antagonists: Provide relief from peptic ulcers, heartburn
and indigestion.
• Antacids.
B- Pharm Sem- 5, 2015 (132280290055 ans 132280290057)
92
Drugs used in Ulcers
1. H2 Receptors Antagonists:
E.g.: Ranitidine, Cimetidine, Famotidine.
2. Proton Pump Inhibitors:
E.g.: Omeprazol, Iansoprasole.
3. Drugs that Neutralise gastric acid (Antacids):
E.g.: Milk of magnesia, Gelusil, Magnesium trisilicate,
Aluminium hydroxide, Alginates.
4. Ulcer Protective's:
E.g.: Sucralfate, Bismuth chelate, Misoprostol.
5. Anti Helicobacter Pylori Drugs:
E.g.: Amoxicillin, Clarithromycine, Metronidazole.
B- Pharm Sem- 5, 2015 (132280290055 ans 132280290057)
93
Advice as a Pharmacist
• Abstain from smoking and alcohol consumption.
• Awareness about appropriate use of NSAIDs.
• Awareness of Over the Counter medications and herbal
products containing NSAIDs.
• Consult a physician prior to taking these medications.
• Avoid intake of less spicy and oily food.
• Maintain proper sleep, diet, exercise and mental tranquility.
• Maintain proper hygiene.
B- Pharm Sem- 5, 2015 (132280290055 ans 132280290057)
94