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University of Alabama at Birmingham
School of Medicine
Pharmacology Case #2
MR N.
October 4, 2002
MEDICAL RECORD # 0000001
9/25/02
Mr. N, the 80 y.o. husband of Ms. N, has the following medical problems:
1. Angina pectoris.
2. Hypercholesterolemia.
3. Hypertension.
4. COPD.
5. Tobacco abuse.
6. Peripheral vascular disease.
7. Degenerative joint disease.
8. Status post left herniorraphy.
9. Status post bilateral cataract extractions.
10. Insomnia.
Current Medications
1. Nitroglycerin 0.4 mg sl prn chest pain.
2. Isosorbide mononitrate mg po q 8 am and 2 pm.
3. Ipratropium bromide metered-dose inhaler 2 puffs qid.
4. Metoprolol 25 mg po bid
5. Enteric-coated aspirin 81 mg qd.
6. Benazapril 20 mg po bid.
7. Multiple vitamins one tablet po qd.
8. Docusate calcium 100 mg po bid prn constipation.
9. Amitriptyline 25 mg po hs prn sleep.
Interval History
Mr. N comes in with his wife, Mrs. N (Case #1), for a routine visit. He continues to
smoke 1 pack of cigarettes daily and notes no change in his typical 1 block dypsnea
on exertion. Weekly bouts of moderately severe substernal chest tightness radiate
into the left upper extremity and are associated with nausea and diaphoresis. These
symptoms are precipitated by exertion and emotional upset and are relieved by rest
and sublingual nitroglycerin. He describes no change in the frequency, severity or
associated symptoms and denies palpitations, orthopnea, paroxysmal nocturnal
dypsnea, ankle edema or easy fatiguibility. Mr. N is independent in his self-care
Activities of Daily Living (ADL’s), but requires assistance from his wife for banking,
shopping and transportation (i.e., Instrumental ADL’s). The patient reports tolerating
a low fat, low cholesterol diet since the last appointment on 7/7/02. Memory
impairment, falls, urinary incontinence and difficulty walking are denied, but Mr. N
complains of urinary hesitancy, diminished stream and constipation.
Physical Examination
The patient is robust, obese older man in no acute distress.
BP 165/60, P 72, sitting; T 97o, Wt 200 lbs (no change since 7/7/02)
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University of Alabama at Birmingham
School of Medicine
Skin: Good skin turgor w/ moist mucus membranes.
Neck: Supple with a right carotid bruit and no jugular venous distention.
Chest: Increased AP diameter with hyperresonant lung fields and diminished breath
sounds throughout. (+) Bibasilar rales.
Heart: Point of maximum impulse not palpable with a soft S1 and a physiologically
split S2. (+) S4G, a 2/6 systolic ejection murmur is best appreciated at the apex and
base.
Abdomen: Benign.
Rectum: Good sphincter tone, a 2(+) smoothly enlarged prostate, brown hemoccult (-)
stool.
Extremities: Bony hypertrophy of the right greater than left knees without effusions
or signs of acute synovitis. Dependent rubor and absent pedal pulses in the feet.
Laboratory
 Electrocardiogram: normal sinus rhythm, normal electrical axis, left atrial
enlargement and Q waves consistent with an old inferior wall myocardial
infarction.
 Urinalysis and serum electrolytes, glucose and BUN/creatinine are within
normal limits.
 PSA 4.5.
 Fasting lipid panel: Cholesterol 300, HDL cholesterol 32, LDL cholesterol
153, triglycerides 165.
Note:
Mrs. N also comes today. Review her medical history from Case #1.
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University of Alabama at Birmingham
School of Medicine
Questions
1. Comment on each medicine Mr. N is taking. (Be familiar with the class of drug,
route of administration, duration of action, side-effect profile).
2. Comment on his history, physical examination and laboratory values. Note any
abnormalities and consider if any are drug-induced.
3. What approach to his lipid/cardiovascular status would be reasonable? (do not
worry about details here yet, since we will cover antianginal, antihypertensive and
hypolipidemic drugs in the next section of the course)
4. If his COPD worsened, what drug could be used to improve his symptoms?
5. Mrs. N complains of pain in her right knee. What would you suggest to relieve
her pain?
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University of Alabama at Birmingham
School of Medicine
Answers.
1. Current Medications
Nitroglycerin 0.4 mg sl prn chest pain. – anti-anginal vasodilating nitrate, fast-acting,
sublingual route of administration to avoid first-pass metabolism and give rapid onset of
action, used during an acute attack of angina.
Isosorbide mononitrate 10 mg po q 8 am and 2 pm.—anti-anginal vasodilating nitrate,
long-acting, taken orally, used prophylactically every day, but with a drug-free interval at
night to diminish the development of tolerance; often causes severe headaches when
taken initially, but tolerance develops to this side-effect, also causes orthostatic hypo
tension and reflex tachycardia if not taken with a beta blocker.
Ipratropium bromide metered-dose inhaler 2 puffs qid. -- muscarinic antagonist, unable
to enter bloodstream or CNS because of quarternary ammonium ion,, inhaled to block
ACh receptors on pulmonary smooth muscle cells and bronchi; decreases
bronchoconstriction and bronchial secretions.
Metoprolol 25 mg po bid – beta-1 adrenergic receptor antagonist, taken orally, relieves
anginal pain, lowers heart rate, lowers myocardial O2 demand, improves survival postMI, side-effects include bronchospasm at high doses due to blockade of pulmonary beta2 adrenergic receptors, bradycardia, hypotension, fatigue, depression, impotence.
Enteric-coated aspirin 81 mg qd. – taken orally at this low dose prophylactically to
diminish platelet activity, reduce risk of cardiovascular accident; inhibits irreversibly
COX-1 and COX-2; side-effects at this dose minimal, gastric irritation.
Benazapril 20 mg po bid. -- ACE inhibitor, taken orally, reduces production of
Angiotensin II, which is a vasoconstrictor, and reduces breakdown of bradykinin, which
is a vasodilator; Used as a vasodilator and natriuretic agent to reduce hypertension,
improve survival after MI, reduce symptoms of congestive heart failure; side-effects
include cough, hypotension, angioedema, renal insufficiency, hyperkalemia, sodium loss.
Multiple vitamins one tablet po qd. – everybody should take a Flintstone multivitamin
once a day; my favorite is Barney.
Docusate calcium 100 mg po bid prn constipation – stool softener, helps eliminate pain at
excretion, taken orally as needed, detergent action allows water to enter stool.
Amitriptyline 25 mg po hs prn sleep – inhibits reuptake of serotonin and norepinephrine,
thus increasing actions of serotonin and norepinephrine, takes several weeks to become
effective in treating depression; causes sedation, inhibition of muscarinic receptors,
histamine 1 receptors, alpha1and alpha 2 adrenergic receptors; side-effects: antimuscarinic effects (blurred vision, dry mouth, urinary retention, constipation,
tachycardia, sweating, agitation), postural hypotension.
2. Mr. N has chronic obstructive pulmonary disease (presumably due to his chronic
smoking), stable angina, peripheral vascular disease, untreated pure
hypercholesterolemia, poorly controlled hypertension, symptoms of urinary
obstruction & constipation (aggravated by his use of the highly anticholinergic
amytriptyline as a sedative). His risk factors for coronary heart disease need
considerable work in order to reduce his risk of having another MI. The use of
amitriptyline in this patient is probably contraindicated because of its less wellknown propensity to depress cardiac contractility, to increase the QT interval on
his EKG, and to increase blood pressure and heart rate. These tendencies probably
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University of Alabama at Birmingham
School of Medicine
underlie reports in the medical literature of new cardiovascular events in coronary
artery disease patients taking tricyclic antidepressants.
3. He needs to stop smoking and probably add a statin to lower is cholesterol.
Additional antihypertensive therapy is warranted. Diet and exercise modification
would help.
4. Poor pulmonary function probably requires addition of albuterol (switch him to
CombiVent that contains albuterol plus ipratropium) and possibly low-dose
theophylline.
5. Mrs. N is at risk for gastric distress already as a result of prednisone therapy.
NSAIDs are likely to aggravate that problem. She may need to try rest and ice on
her knee. Alternatively, COX-2 selective drugs (expensive) or acetaminophen are
options.
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University of Alabama at Birmingham
School of Medicine
Some additional tidbits for faculty moderator consideration only:
left herniorraphy: PRIOR SURGICAL REPAIR OF A LEFT INGUINAL
HERNIA.
right carotid bruit: THE SOUND MADE BY TURBULENT BLOOD FLOW
THROUGH A PARTIALLY OBSTRUCTED CAROTID ARTERY; A
MANIFESTATION OF PT'S
PERIPHERAL VASCULAR DISEASE & ATHEROSCLEROSIS.
1 block dypsnea: A FANCY TERM FOR SHORTNESS-OF-BREATH AFTER
WALKING 1 BLOCK ON A LEVEL SURFACE, A ROUGH MEASURE OF THE
SEVERITY OF HISLUNG DISEASE.
Increased AP diameter with hyperresonant lung fields: THESE
ARE THE PHYSICAL FINDINGS IN SOMEONE W/ EMPHYSEMA (I.E.,
OVEREXPANDED POORLY VENTILATED LUNGS). PROBABLY, HE NEEDS
COMBIVENT (IPATROPRIUM + ALBUTEROL) & LOW-DOSE THEOPHYLLINE &
MUST STOP SMOKING.
Point of maximum impulse not palpable with a soft S1 and a physiologically split S2. (+)
S4G, a 2/6 systolic ejection murmur is best appreciated at the apex and base: THE
POINT OF MAXIMUM IMPULSE LOCALIZES THE APEX OF THE HEART & IS A
ROUGH MEASURE OF VENTRICULAR SIZE. IN PERSONS W/ EMPHYSEMA,
YOU DON'T OFTEN FEEL IT BECAUSE OF THE OVERINFLATED LUNGS.
ALSO BECAUSE OF THE OVERINFLATION, THE FIRST HEART SOUND (S1) IS
SOFTER THAN NORMAL. THE S4G (S4 GALLOP) IS A NONSPECIFIC
PRESYSTOLIC SOUND OF UNKNOWN SIGNIFICANCE IN AN OLDER ADULT.
THE MURMUR IS ONE RELATED TO AORTIC VALVE
STENOSIS, PROBABLY MILD. HE WILL NEED ANTIBIOTICS PRIOR TO ANY
INVASIVE PROCEDURE (E.G., COLONOSCOPY, TOOTH EXTRACTIONS, ETC).
Dependent rubor and absent pedal pulses in the feet: THESE ARE SIGNS OF THE
PATIENT'S OVERALL TENDENCY TO ATHEROSCLEROSIS. THE FIRST
TERM APPLIES TO THE FLUSHING OF THE LOWER EXTREMITIES OFTEN
SEEN IN PATIENTS W/ADVANCED PERIPHERAL VASCULAR DISEASE WHEN
THE FEET ARE IN A DEPENDENT (I.E., BELOW THE LEVEL OF THE HEART)
POSITION. TREATMENT W/ PENTOXIPHLLIN? STOP SMOKING!
Cholesterol 300, HDL cholesterol 32, LDL cholesterol 153, triglycerides 165. (All
abnormal? What is normal?): THIS PATIENT HAS AN ELEVATED TOTAL
CHOLESTEROL, A LOW HIGH DENSITY LIPOPROTEIN CHOLESTEROL (HDL)
AND A HIGH LOW DENSITY LIPOPROTEIN CHOLESTEROL (LDL), WHICH IS
VERY UNFAVORABLE FOR FUTURE HEART ATTACKS, STROKE AND OTHER
VASCULAR EVENTS. HE PROBABLY NEEDS TO BE TREATED W/ A STATIN,
AS WELL AS THE DIET HE'S ON.
Supported by a grant from the Association of American Medical Colleges and the John
A. Hartford Foundation.
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