Case Study 2 – Janine and Sandy
Janine (26yrs, 170cms tall and weighs 60kgs) and her partner Robert (26yrs) share a house and live next door to Janine’s Mum Sandy (55yrs), whom she cares for. All three are of aboriginal descent and live in the remote Northern Territory. Janine has visited the nearest health clinic with complaints of high-grade fever and pain in her lower-limb joints for the past week.
The fever started with pain in her throat and was associated with rigors. Her temperature was 39°C. Her ESR on examination was 36 mm/hr and her CRP was 53 mg/L. Janine is diagnosed with acute rheumatic fever (ARF).
1.Discuss the key strategies associated with therapeutic management of ARF. In your answer, focus your discussion on antibiotic treatments, taking into account demographic factors. (5 marks) (100 words)
2. Outline the pharmacotherapy management recommended to prevent the recurrence of acute rheumatic fever and the development or progression of rheumatic heart disease. (5 marks)(100 words)
Janine presents 2 years later with shortness of breath and syncope. Upon examination by the local doctor she is deemed to have loud ejection systolic murmur. Her doctor orders an echocardiogram and she is found to have an ejection fraction of 50% and thickening of the aortic valve. She is diagnosed with severe aortic stenosis and it was determined that she should undergo a valve replacement. She decides to have a mechanical valve and undergoes open heart surgery to get the valve replaced. She is commenced on Warfarin (Marevan) and stabilised on an INR between 2.5-3. Her usual dose is 5mg daily for the warfarin. Later she contemplates pregnancy and discusses her anticoagulation strategy during pregnancy with an obstetrician, given the teratogenic risks associated with the use of Warfarin.
3.Discuss potential management options with respect to anticoagulation during pregnancy, supported by evidence from clinical studies using a risk benefit approach (20 marks). (400 words)
After a successful pregnancy Janine was restarted on Warfarin (Marevan). She presents 3 years later with shortness of breath. Upon examination she has a heart rate of 130 bpm, and she is in atrial fibrillation. She was also noted to be hypertensive 160/95 with high blood sugar levels. At this stage she weighed 62kgs and her blood tests revealed the following.
Na-135mmol/L, K+-3.8mmol/L, Cl—101mmol/L, Scr: 90micromol/L
Fasting BSL was 9.2. Hba1c: 7.5%.
4.Janine is commenced on metoprolol 25 mg po bd for management of atrial fibrillation, Metformin 1g po bd – Type 2 Diabetes and Perindopril -5mg po daily for BP. Discuss the key long-term risk associated with AF in Janine and the medication management regime you would recommend, using a risk benefit approach supported by references (10marks) (200 words).
Janine continues to assist her mom Sandy (now 58yrs) and notices a slight decline. Sandy has a medical history that includes glaucoma and hypertension for which she uses the following
Latanoprost eye drops 0.005% 1 drop each eye at nocte
Olmesartan 20mg po mane
Sandy has not had a regular menstrual periods for 5 years, but still experiences irregular menstrual bleeding once every three or four months. She experiences symptoms of hot flushes, mainly at night. Sandy smokes 20 cigarettes per day and does not drink alcohol.
5.Discuss the role of hormone replacement therapy (HRT) in the management of post-menopausal osteoporosis, using a risk benefit approach supported by information sourced from relevant trials (20marks) (400 words).
Sandy is commenced on HRT and continues to take it for 3 years. During a routine breast exam, the GP notices a breast lump. Further investigations reveal that she has developed localised breast cancer in the left breast, with no evidence of metastatic spread to other areas of the body. She is offered mastectomy and undergoes the removal of her breast with good outcome. She has been advised to stop the HRT. Sandy continues with her regular medications including Olmesartan and Xalatan eye drops for the following 2 years. One morning, when getting out of bed, she experiences dizziness, light-headedness and visual disturbance (blurred and double vision). She falls to the ground. Her phone is nearby and she calls for an ambulance.
Sandy is transferred to Alice Springs base hospital and is stabilised by the ED team. Following a series of x-rays, it is determined that Sandy has a fractured neck of femur and a fractured wrist.
6. Sandy has a DXA scan and her results reveal a T-score of -2.7 and a Z-score of -1.2. Interpret Sandy’s results in relation to normal population average. Discuss the management of osteoporosis using bisphosphonates, taking a risk benefit approach (supported by clinical trials). (400 words) (20 marks)