Pt pharm cases april08

Cases - Pharmacology for Physical Therapists
Please answer the Pre-Case Questions prior to the course
Case 1 - Pre-Case Questions:
1. What are some of the common adverse effects from traditional chemotherapy
(antineoplastic) medications?

2. What are the potential issues and strategies for the physical therapist while managing

a patient who might be immunocompromised?
RJ is a 57 year old woman with metastatic breast cancer diagnosed 1 year ago, at which time she
underwent a modified radical mastectomy followed by antineoplastic drugs. The cancer, however,
has evidently metastasized to other tissues, including bone. She recently developed pain in the
lumbosacral region that was attributed to metastatic skeletal lesions in the lower lumbar vertebrae.
RJ was admitted to the hospital to pursue a course of radiation treatment to control pain and
minimize bony destruction at the site of the skeletal lesion. Her current pharmacologic regimen
consists of an antineoplastic regimen (including doxorubicin, cyclophosphamide, and taxol) and an
antiestrogen (tamoxifen). She was also given a combination of narcotic and nonnarcotic analgesics
(codeine/APAP) to help control pain. Physical therapy was consulted to help control pain and
maintain function in this patient.
RJ began to experience an increase in GI side effects including nausea, vomiting and epigastric
pain. She was reluctant to try any other analgesic drugs because she was experiencing adequate
pain relief from the codeine / acetaminophen combination by taking approximately 12 tablets per
day. The persistent nausea and anorexia had a general debilitating effect on the patient and the
physical therapist was having difficulty engaging the patient in an active general conditioning
Current Meds:
Chemotherapy every 3 weeks (doxorubicin / cyclophosphamide / paclitaxel)
Tamoxifen 20mg po qd
Codeine/APAP (Tylenol #3) 30/325 1-2 tabs every 3-4 hours prn pain
Zoloft 50mg po qd
Group Discussion Questions:
1. What are the common adverse effects from codeine / acetaminophen? 2. What are other alternative medications that RJ could try for pain management? What are the potential adverse effects from these alternatives? 3. How might you expect RJ’s chemotherapy regimen to contribute to her problems? 4. Describe any potential nonpharmacologic alternatives for pain management for RJ?
Case 2 – Pre-Case Questions:
1. What are the most common adverse effects from non-steroidal anti-inflammatory drugs

2. What are the signs and symptoms of gastrointestinal bleeding?

LL is a 41 year old female medical research liaison states that she has been having left (dominant)
lateral shoulder pain for 15 years (MOI was a skiing incident which she called a “backwards spread
eagle”). The pain is located anteriorly and radiates down the lateral shoulder to about the insertion
of the left deltoid. Her PMH includes a first metatarsal debridement/resection/fusion x2 and a
bunionectomy, a gastric ulcer in college and presently intermittent nocturnal gastric reflux. LL has
some residual arthritis in her feet post op. She also has Von Willebrand’s disease (an inherited
clotting problem) which she manages (when bleeding) with nasal desmopressin spray as needed.
She had a hysterectomy and 3 c-sections previously.
LL has managed the shoulder pain with over the counter NSAID (she has been taking Ibuprofen
800mg po tid). The pain, which now is continuous, is exacerbated with overhead activities, and
pulling a rolling suitcase. The pain is also pronounced while sleeping and with the arm at her side.
She can get relief with positioning the arm passively in slight abduction. It is of note that she is
reporting an increase in gastric pain as well.
Current Meds:
Ibuprofen 800mg po tid
Maalox as needed for gi upset
Desmopressin nasal spray as needed for bleeding
Group Discussion Questions:
1. How can the gi side effects of ibuprofen be minimized in this patient? 2. Is ibuprofen the best choice for LL? What are the alternatives? 3. What are the nonpharmacologic alternatives for pain control in this patient?
Case 3 – Pre-Case Questions:
1. What are the signs and symptoms of hypoglycemia (low blood sugar)?
2. List the best sugar choices for treating a low blood sugar in a diabetic patient quickly:

SJ is an 18-year-old female began experiencing problems with glucose metabolism following a viral
infection when she was 12. She was subsequently diagnosed as having type I diabetes mellitus.
Since that time, her condition has been successfully managed by intensive insulin therapy with
frequent (up to 8 times per day) blood sugar checks. Once-daily administration of long acting
insulin with short acting insulin at meal time and bedtime based on blood sugars usually provides
optimal blood sugar control although SJ has frequent episodes of hypoglycemia. She is also very
active athletically and was a member of her high school soccer team. Currently she is entering her
first year of college and is beginning preseason practice with the college’s soccer team.

Current Meds:
Lantus 30 units sc q hs
Humalog coverage for carbohydrates eaten and blood sugar results
Glucagon – she carries a syringe in her soccer bag at all times
Levothyroxine 0.05mg po qd (for thyroid replacement)
Group Discussion Questions:
1. As the physical therapist who serves as the team’s sports medicine practitioner, what problems / concerns / and influences should you be concerned with regarding her activities and medications? 2. What specific advice would you give SJ regarding pre training blood sugar checks, snacks 3. What advice would you give to the coach regarding how to recognize and treat a low blood

Case 4 – Pre-Case Questions:

1. What is the neurochemical basis of lorazepam’s effects (its mechanism of action)?
2. How does baclofen affect muscle excitability (what is its mechanism of action)?

PL was a vibrant 73 year old lady. She lived alone, drove in the community and was very active in
her church senior group. She also participated in the “Old Ladies Bowling League” every Saturday.
PL woke up one morning unable to speak or move her right side. When she did not show up at her
afternoon social, her friends came to check on her. They found her on the floor unable to
communicate but bruised and disheveled from trying to get to the next room.
PL was taken to the hospital and started immediately on anticoagulants. She was found to have an
occlusion in the left middle carotid artery resulting in an ischemic stroke. Physical therapy,
occupational therapy, and speech therapy were ordered and evaluations completed on the first day.
After a week of therapy, reflex activity (spasticity) had increased in the patient’s right arm and leg
despite neuromuscular techniques and positioning. The patient also appeared more despondent and
had begun to refuse some therapy sessions. PL frequently closed her eyes and began crying
whenever friends visited. The physician agreed to start the patient on oral baclofen (Lioresal) to
treat the spasticity and clorazepate (Tranxene) an antianxiety drug.
Current Meds:
Ciprofloxacin 250mg po bid x 7 days for urinary tract infection (started 5 days ago)
Lexapro 10mg po qd for depression (started 1 week ago)
Baclofen 10mg po tid
Lorazepam 0.25mg po tid prn anxiety

Group Discussion Questions:

1. What are the potential positive and negative effects of baclofen on PL’s progress in physical 2. What is the primary drawback to oral baclofen therapy and what alternative method of administration might be used to deal with this drawback? 3. What are the possible negative side effects of lorazepam that could affect PL’s rehabilitation 4. If PL’s Coumadin dose were too high and her blood was overly anticoagulated, what signs or symptoms of this might you expect to see or hear about from her? 5. How might PL’s other medications affect her rehabilitation progress?

Case 5 – Pre-Case Questions:

1. What are the indications for donezepil and other cholinesterase inhibitors for
Alzheimer’s Disease?
2. What are the main adverse effects of donezepil?

3. What are the main adverse effects from chronic systemic corticosteroid use such as
RM is a 75 year old man who has been living with his daughter for the last 5 years. After his wife died 5 years ago, he began to show signs of increasing withdrawal, frequent crying spells, and difficulty taking care of himself. He was started on an antidepressant but within 2 years, he had declined to the point where he could no longer live independently. He needed reminders to eat meals, drink adequate fluids, take his medications (he also too an anti-hypertensive) and often forgot who family members were. He moved to his daughter and son-in-law’s home where he stayed in a room downstairs that had been converted to an apartment. He ate meals with the rest of the family and attended church. The family physician prescribed donepezil (Aricept) for his symptoms of dementia. RM has a history of rheumatoid arthritis and hypertension. One afternoon, after eating lunch, he fell on his way back downstairs to his room. Unable to get up, he called for his daughter, and an ambulance took him to the hospital. X-rays showed an intertrochanteric fracture, which was repaired surgically with the patient under general anesthesia. After surgery, he was referred to physical therapy with touch down weight bearing orders. Current Meds:
Hydrochlorothiazide 25mg po qd
Hydrocodone and acetaminophen (Lortab) for post-op pain 1-2 tabs po q3-4h prn pain
Lorazepam (Ativan) 0.25mg po tid prn agitation
Prednisone 10mg po qd for rheumatoid flare (he has been taking this dose for 3 months)
Aricept 5mg po qd
Cephalexin 500mg po qid (started 2 days ago for redness and swelling of incision)
It is of note that RM’s incision is not healing well.
On the first day, the physical therapist found him to be very lethargic and difficult to evaluate. He
was not following commands for ROM and manual muscle testing. Sit to stand transfers took
maximal assist of two people and RML became very hypotensive every time attempts to stand were
made. On the second day, he was somewhat combative and resisted any movement of his operated
leg. Nursing reported that he had tried to get out of bed the night before.
Discussion Questions:
1. What medications might be responsible for the hypotensive episodes and how can the physical therapist deal with this orthostatic hypotension? 2. Could any of the medications used during or after surgery contribute to the sudden decline in RM’s cognition and intellectual function? 3. Would continued use of donepezil (Aricept) be helpful in this patient? Why or why not? 4. How might RM’s prednisone contribute to his problems? 5. What alternative pharmacological and nonpharmacological interventions might be helpful if the agitation and combativeness does not improve?
Case 6 - Pre-Case Questions:
1. Describe how asthma differs from COPD in terms of pathophysiology
2. Describe how asthma differs from COPD in terms of treatment

AG is a 55 year old man who smoked heavily for 25 years. After having a lobectomy 3 years ago,
he gave up smoking but not before he developed COPD requiring brochodilators – ipratropium
(Atrovent), salmeterol (Serevent). He lives with his wife in a small four room house. Since going
on disability, his primary activity is walking to and from the mailbox each day.
His wife finally convinced him to see the doctor after listening to him complain about feeling
poorly and having increasing shortness of breath for several weeks. He was diagnosed with
moderate heart failure and Type II diabetes. His physician put him on digoxin (Lanoxin), labetolol,
furosemide (Lasix), and metformin (Glucophage). He ordered home health services for diabetic
monitoring and teaching as well as physical therapy for strengthening exercises and aerobic

Current Meds:
Atrovent inhaler 2 puffs qid
Serevent inhaler 2 puffs bid
Digoxin 0.25mg po qd
Lasix 20mg po qam
Labetalol 200mg po bid
Glucophage 500mg po bid
Methylprednisolone dose pak for COPD flare (on day 4 of 7 day course)
Discussion Questions:
1. How does digoxin affect the heart and how might this medication affect exercise responses? 2. Is AG taking any other medications that could affect his response to exercise? 3. Is AG at risk of having a hypoglycemic episode when exercising? Why or why not? How might his methylprednisolone affect his blood sugar? Why or why not? 4. Given these medications, what precautions should be taken when starting or modifying an



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