Please use Australian Medicine Handbook and Australian Guide lines for referencing. Read the instructions carefully and please make sure you answer the questions correctly.

Please answer the questions accompanying each clinical scenario, and reference the answers well.

In no more than 1000 words, you are required to answer the specific questions associated with the following cases.  Please consider each aspect and address the issues in terms of providing the best available pharmaceutical care.  Support your responses through appropriate research, using various sources (i.e. not just text books, but also journal articles.  Your responses are to show that you understand the issues and that you are able to apply your knowledge to optimise patient care. You are to pay particular attention to proper referencing, both in text, as well as at the end of your assignment. Please use the referencing system specified in your student manuals……..make sure that all your references are consistent i.e. all are formatted identically.

Part A

Mrs Angela Smith, a 49-year-old female presents to your pharmacy with a prescription for a reducing dose of prednisolone and Symbicort 200/6 from the local hospital. She tells you that over the weekend during a thunderstorm she needed to go to the emergency department with severe shortness of breath, coughing and wheezing, and was feeling very distressed due to her symptoms. She was diagnosed as having an asthma attack and was stabilised and discharged with 2 days’ supply of prednisolone.  She was also given a prescription for eformoterol plus budesonide, a combination inhaler, and prednisolone 25mg tablets to be taken as a reducing dose.

Your records show she has not had her preventer inhaler dispensed for several years, and on discussion with Angela, she tells you that she hasn’t used a preventer for a long while, and that her asthma has been a little uncontrolled over the past couple of weeks particularly in the mornings but was relieved with salbutamol.  She also discusses how she gets short of breath now even without doing much strenuous work during shifts at the factory.  Mrs Smith admits to being a smoker for over 30 years, but doesn’t think there would be much point to giving up now, and doesn’t think she could. Her spouse is also a smoker.

Prescription is as follows:

Rx

Prednisolone 25mg take 2 daily and reduce dose as directed.  (mitte 30 tablets)

Symbicort 200/6 Inhale 2 puffs twice a day and 1 inhalation when needed; repeat after a few minutes up to a max of 6 inhalations.

She is unsure of how long to continue the combination inhaler and wants to know how she should reduce the prednisolone dose.

Q1.      Is Mrs Smith’s asthma well-controlled?  Give an explanation for your findings. Explain how she should reduce the prednisolone dose, the rationale for this type of dosing schedule including the Symbicort schedule, and how long she should use the Symbicort inhaler.

Q2.      Explain what has contributed to Mrs Smith’s current asthma presentation.

Q3.      Write an asthma management plan for Mrs Smith.

Over the next few years, Mrs Smith’s health further deteriorates and she undergoes a number of respiratory tests:

Spirometry results:

• Forced expiratory volume (FEV₁) 0.94L
• Predicted FEV₁7 L
• FEV₁ % predicted 35%
• Forced vital capacity (FVC) 1.53 L
• FEV₁/FVC 62 (62%)
• FEV₁ Post salbutamol 0.99L

Q4.      Explain what these spirometry results for Mrs Smith indicate.

Q5.      List all the factors that could have contributed to Mrs Smith’s condition now.

Part B

Miss BM is a 42 yr. old female who presented to the emergency department complaining of vomiting, palpitations and abdominal pain.  On examination she also had peripheral oedema and an eczema-type rash and dry skin on her legs.   She had a past history of cardiovascular problems resulting in a mitral valve repair when she was 32 years old.  It was identified that she had biventricular heart failure.

Medications on admission:

Aspirin 100mg daily

Digoxin 250mcg daily

Enalapril 10mg daily

Ferrous sulphate 350mg daily

As an inpatient she developed a pulmonary embolism and was commenced on enoxaparin then warfarin 5mg a day was added to her therapy on day 3.  As the pharmacist you investigated the pathology results and in particular the full blood count where you noticed that her platelet count had decreased from 247 x10⁹/L to 83 x 10⁹/L.

Q1.      Briefly explain why warfarin was commenced together with enoxaparin and what is the clinical significance of the pathology results with this patient and what other therapeutic options would now be appropriate in the management of this patient?

Q2.      Miss BM was also commenced on frusemide 40mg daily, and bisoprolol 2.5mg daily.

Explain fully the potential rationale for commencement of these new medications.

Q3.      Explain what monitoring is required with this therapy and what counselling you would include for her regarding the warfarin treatment and her new drug therapy.

Q4.      Would any alternative therapy be considered to reduce her risk of having a stroke?  Explain fully your consideration.

Six months later she presented to her cardiologist complaining of episodes of more palpitations and following an ECG her digoxin was ceased and she was commenced on amiodarone in addition to her other medications.

Q5.      What is the usual commencement dosing with this drug and explain why this schedule is necessary?  In addition, what else needs to be considered with this patient along with the cautionary advice that should be given to the patient about this medication?