Case Studies

Lauren S. Schlesselman, PharmD
Published Online: Saturday, May 1, 2004
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Case ONE: RS, a 60-year-old woman, comes to the local pharmacy to obtain a refill on her prednisone prescription and to buy an OTC sleep aid. After paying for her purchases, RS asks to speak with the pharmacist about some health problems she is experiencing.

RS complains to the pharmacist that her mouth and eyes are very dry. She often is awakened during the night by this mouth dryness and needs to drink water to relieve it. She even finds it difficult to speak and eat. She also has experienced blurred vision, although she is not sure whether the dry eyes are causing it. At first, RS thought that her mouth and eyes were dry because she was not drinking enough water, but she has increased her fluid intake and has found no relief from the dryness.

When the pharmacist inquires about RS' use of prednisone, RS explains that it is for her rheumatoid arthritis. Because RS already has an autoimmune disorder, the pharmacist suspects that RS may have Sj?gren's syndrome, the second most common rheumatic disorder after rheumatoid arthritis. He recommends that RS schedule an appointment to see her physician for further evaluation.

RS is thankful for the advice, but she would like to know whether there is anything she can do to relieve her dry mouth and dry eyes until she is seen by her physician.

Case TWO: CR, a 29-year-old female, is brought by her boyfriend to the Emergency Department of the local hospital. CR is in a somnolent state and is unable to answer questions or follow commands. Her boyfriend is able to tell the physician that CR is an insulin-dependent diabetic. She had been complaining about a headache and feeling fatigued since the night before.

On physical examination, her vital signs are as follows: heart rate 120 beats/min, blood pressure 85/45 mm Hg, respiratory rate 28 breaths/min, and temperature 99.5̊F. Her mucous membranes are dry. Tenting of the skin is present. Her deep tendon reflexes are mildly hyporeactive. Exams of the lung, heart, and abdomen are within normal limits.

Laboratory findings include these numbers: sodium 130 mEq/L, potassium 4.0 mEq/L, chloride 100 mEq/L, carbon dioxide 10 mEq/L, serum creatinine 1.5 mg/dL, and glucose 650 mg/dL. Her arterial blood gas results on room air are the following: pH 7.2, Paco2 22 mm Hg, Pao2 100 mm Hg, and serum bicarbonate 8 mEq/L.

What acid?base disorder does CR exhibit?

Case THREE: UC, an emaciated 35-year-old alcoholic, is admitted to the local hospital. The diagnosis on admission is pneumonia. From the admission laboratory work, his complete blood count was reported as follows: red blood cell count (RBC) 3.1 x 106 cells/mm3, white blood cell count (WBC) 4.6 x 103 cells/mm3, hemoglobin (Hgb) 12.5 g/dL, hematocrit (HCT) 34%, mean corpuscular volume (MCV) 110 fL, mean corpuscular hemoglobin (MCH) 40 pg/cell, mean corpuscular hemoglobin concentration (MCHC) 36 g/dL, and platelets 174,000/mL.

What type of anemia does UC have?

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Case ONE: To relieve RS' dry mouth, the pharmacist can recommend artificial saliva and mouth-moisturizing gels. If she uses mouthwash, she should be reminded to use a product that does not contain alcohol. To relieve dry mouth at night, she can use a humidifier. For dry eyes, RS should use an artificial-tears product.

Case TWO: With a pH of 7.2, CR is clearly acidemic. She also has an extremely low serum bicarbonate level, suggesting metabolic acidosis. This result is consistent with the low Paco2 value due to respiratory compensation. These findings suggest that CR has metabolic acidosis. Due to her history of diabetes, it is most likely due to diabetic ketoacidosis.

Case THREE: UC's laboratory findings are consistent with macrocytic anemia (low RBC, Hgb, and HCT, along with increased MCV and MCH). These findings are typical with folic acid deficiency, as is common in alcoholics.



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