Case Based Learning Pharmacology

1. Case Based Learning Pharmacology HSS 3101

2. Learning Objectives To understand the anatomical, physiological, and pathological processes involved in cardiac emergencies. To understand the pharmacological and alternative treatment options available for cardiac emergencies. To become familiar with the first aid approach involved in cardiac emergencies. To understand the social factors involved in the pathogenesis of various cardiac disorders that consequently result in cardiac emergencies. Ask two students to write the important clinical information from each slide At the end of the session they will present the case independently It should start with 23 year old male who presents with etc Alternative therapy for MI is coronary artery bypass graft Generate discussion by asking students to formulate learning objectives 2 minutes, thinking and discussion

3. Case Introduction A 53 year old man, Mr. John Smith, suddenly started having chest pain. His wife called the ambulance, and paramedics responded within 15 minutes of the onset of his chest pain. He was taken to the Ottawa Heart Institute at 2:12 am. Ask a student to read the introduction Make sure there are two students writing the important information down Ask is the timing important, why? Focus on onset

4. Pre-hospital care Discuss how paramedics differentiate between serious and benign chest pain. Discuss the various first aid measures that paramedics use if they suspect cardiac emergencies. What other important questions should paramedics ask Mr. Smith or his wife? Discuss “if you were the paramedics what would you do, what would you ask? Mention CPR (30:2) Mention Defibrillation Mention oxygen administration Mention emergency cardiac medications (nitro) Mention OPQRST Mention ABC’s Mention the primary vs secondary survey (other important questions) Mention semi fowler position

5. Differential Diagnosis Thinking and Discussion Formulate hypothesis individually 2 minutes Formulate hypothesis in pairs 3 minutes

6. Paramedic Report 53 year old Caucasian male presented with acute onset, sharp sub-sternal chest pain that radiates to his neck. He describes the pain as “a ton of bricks” sitting on his chest. He describes the pain as 9/10 and has positive Levine’s sign. The pain is not responsive to 2 aspirin 325 mg PO and nitroglycerine 2.2mg sublingual. ECG shows hyper-acute T waves. Define terms Define ECG (ask someone to draw NSR on the whiteboard) Identify different waves and their width Describe the methods that nitro is given (sublingual------drains right to the heart, pill and patch and the dangers with defi)

7. Paramedic Report Referred Pain What is referred pain?

8. Paramedic Report Normal ECG Discuss the Wigger diagram Identify the heart sounds Discuss the pressure changes at various times Identify S3, S4 Play normal heart sounds at this point

9. Paramedic Report Patient’s ECG Significance of ST Elevation Narrow your differential

10. Paramedic Report • The patient is diaphoretic, pale, and anxious on exam. • Blood pressure is 145/90 • HR is 120, RR is 21 with dyspnea • Temperature is 38oC. • The patient is started on high flow oxygen and given 2 mg morphine sulfate. • Narrow your differential diagnosis and discuss the results paying attention to vitals and ECG results. • Discuss the vital sign finding • Discuss why there is an increase in T, HR, RR, • Discuss blood pressure (do not know patients baseline) • Discuss signs and symptoms of shock • Discuss the psychological symptoms the patient experiences and how they can be reduced

11. Emergency room CC: Acute substernal chest pain HPI: Mr. Smith suddenly woke up and realized he was having severe chest pain 9/10, his wife called 911, the patient denies severe exercise or sexual activity prior to onset. Discuss chief complaint HPI Why do you ask about physical activity or sexual activity? What is the next step Continue expanding or reducing your differential Ask students to formulate more questions for Mr. Smith

12. History Medical Hx Mr. Smith has a of 2-y history of hypertension for which he has been taking HCTZ 25 mg/d (compliance?), Mr. Smith denies any history of hypercholesterolemia or diabetes. The patient’s father died of an MI (myocardial infarction) at age 54, and his brother underwent coronary artery bypass graft surgery 3 years ago at age 46. Not taking any medications other than HCTZ No known drug allergies Discuss compliance (why is it low for BP meds) Discuss the importance of health maintenance education Discuss family history and the genetic basis for hypertension, lipid abnormalities and atherosclerosis and other cardiac risk factors Discuss the importance of checking Mr. smith for diabetes and hypercholesterolemia even when no hx Next step?

13. History continued Social Hx • Mr. Smith smokes two packs of cigarettes per day for 35 years, drinks alcohol moderately. • He’s married for 25 years and has three children. • He graduated from High School. • He attends church regularly. • Hobbies include woodworking and gardening. • He drinks one to two cups of coffee per day. • He denies exposure to environmental toxins. • He denies any financial problems but is concerned about how his illness will affect his income. • Mr. Smith is not physically active and is obese (BMI>30). • His sources of support are his wife, minister, and a sister who lives near the patient. • Components of social history and significance • Framingham study • Marriage protection? • Discuss cardiac risk factors • Discuss environmental components of history with clinical relevance to cardiology • Discuss exercise • Discuss obesity and BMI • Discuss social support

14. History discussion Construct a pedigree with the information given, how would you obtain more information. (I think this is going to be too much for 2101 students and with the time restriction) What will you be looking for in the physical examination? Pedigree is not necessary Focus on the physical examination What systems are you going to check What to you expect to find Discuss your findings in the history Discuss ROS

15. Physical Examination • General: • Mr. Smith is a pleasant male lying comfortably supine in bed. He appears to be the stated age with a BMI of 32. • Vital Signs: • Temp 38.1°C orally • Respiration 23 • Heart rate (HR) 121 and regular • Blood pressure (BP) 142/93 left arm supine • Skin: • Tattoo left arm, otherwise no lesions • Discuss vital signs and if you want to pharmacologically intervene at this point • Is the patient stable? • Discuss auscultation, percussion, inspection and palpation • Discuss what tool you need in order to do this

16. Physical examination • Eyes: • External structures normal, without lesions, PERRLA. • EOM intact. • Visual fields intact. • Benign fundoscopic exam. • Mouth: • Several dental fillings, otherwise normal dentition. • No lesions • Chest: • Symmetrical expansion. • Lung fields clear to percussion. • Breath sounds normal except end-inspiratory crackles heard at both bases that do not clear with coughing. • Define new terms • Discuss visual changes and clinical suspicion of stroke • Dental fillings significance? • Discuss abnormal findings in percussion and significance • Discuss crackles and play sound if you wish

17. Physical examination • Heart: • No cardiac impulse visible. • Apical impulse palpable at the sixth intercostal space 2 cm lateral to the midclavicular line. • Normal S1, physiologically split S2. S4 heard at apex. • No murmurs, rub, or S3. • Abdomen: • Flat, no scars. Positive bowel sounds. • No bruits, no CVA tenderness. • No hepatomegaly or splenomegaly by palpation. • No tenderness or guarding. • No inguinal lymphadenopathy • Discuss and define new terms • Discuss PMI • Discuss S4 play sound (mandatory) • Discuss abdominal findings and clinical significance • http://solutions.3m.com/wps/portal/3M/en_US/Littmann/stethoscope/education/heart-lung-sounds/

18. Physical examination • Peripheral Vascular: • Radial, ulnar, brachial, femoral, dorsalispedis, and posterior tibial pulses +2/4 bilaterally. Popliteal pulses nonpalpable. No femoral bruits • Neurologic: • Cranial nerves: I through XII intact. Motor: +5/5 upper and lower extremity, proximally and distally. Sensory intact to pinprick upper and lower extremities proximally and distally. • Respiratory: • Notes cough every morning and has produced 1 teaspoon of gray sputum for years. Denies hemoptysis or pleuritic chest pain. Last chest x-ray prior to today was 3 years ago. • Discuss and define terms • Go through the neurological exam • Discuss the respiratory examination and findings • What is the next step • What to do you want to order • What do you expect to find

19. Lab tests Which tests would you consider, why and what would you expect to see? What are the cost of these tests? How invasive are these test (prioritize) How is the sensitivity and specificity of these tests (compromised?) Are they affected by any other factors eg. diet, time of the day, muscle mass etc.

20. Variations of cardiac proteins in serum Hours of onset of problem

21. Lab results • Chemistry Profile: • Normal, except elevated CPK and Troponin • CBC: 6700 • WBC: 49 • Hct; HBG 16; 40 S, 5 B, 44 L, 5 M, 6 E • PT, PTT: Normal • What do these results indicate, what is your next step? Discuss chemistry profile Discuss CBC Discuss coagulation studies Narrow DDx down

22. ECG ECG. HR 123, ST elevationV1 through V5.

23. Imaging studies R L Discuss imaging options? Discuss how to read the chest x-ray Discuss how to diagnose Cardiomegaly Discuss the significance Ask the two students to present Have a third student write down the case on the whiteboard What is the Diagnosis? Can you diagnose at this point Chest X-Ray: Cardiomegaly, otherwise clear

24. Diagnosis Myocardial Infarction

25. Assessment and Plan • Mr. Smith presented with a classic history for MI. The CPK, troponin and electrocardiogram support the diagnosis. Since he was taken to the hospital within 3 hrs of symptom onset he is a candidate for Thrombolytic therapy • Treatment regimen • ASA • Beta Blocker • Ace inhibitor • tPA • Statin • Categorize • Indications and contraindications • Mechanism of action • Side effects, adverse effects • Discuss why tPA was given • Discuss what must be done before tPA • Discuss compliance • Discuss monitoring parameters and set one up for Mr. Smith

26. Pharmacological therapy Discuss the indication and contraindication for the various medications paying close attention to all aspects of Mr. smiths history. Discuss the pharmacokinetics and pharmocodynamics of the selected medications. Discuss the toxicity and the adverse effects of the medications and the potential for drug interaction.

27. Follow-up While in observation, Mr. Smith started having shortness of breath which was slightly improved when his bed was elevated to 45 degrees (orthopnea), he also had an episode of sudden night time attack of severe breathlessness. On examination, Mr. Smith had crackles heard initially in both lung bases and a displaced apex beat. ROS reveals no pitting peripheral edema, ascites, and hepatomegaly. Discuss and define new words Formulate DDx (first independently and then in pairs) From this point on ask 2 different people to write the information down to present at the end Choose people who are not participating

28. Lab Tests Formulate a new DDx list Explore the various ways to test your hypothesis. What laboratory tests would you consider and what would you expect What imaging studies would you consider

29. Lab results Troponin and CK was within normal limits Mr. Smith had elevated B-type natriuretic peptide EKG identifies left ventricular hypertrophy Other laboratory results were within normal limits Echocardiography revealed reduced ejection fraction. Narrow the DDx Discuss BNP Discuss the anatomy, and pathophysiology of ventricular hypertrophy with specific focus on Mr. Smith Discuss the next step

30. Results Discuss what the imaging studies and laboratory values indicate. Why is this patient having this problem?

31. Treatment Pharmacological therapy Beta Blocker Ace inhibitor Angiotensin receptor blocker Cardiac glycosides Calcium channel blocker Antiplatelets Diuretics Categorize Indications and contraindications Mechanism of action Side effects, adverse effects Discuss compliance Discuss monitoring parameters and set one up for Mr. Smith

32. Pharmacotherapy Name two medications within each class and how it can be used in heart failure Discuss the mechanism of action and pharmacokinetics of these medications Discuss the adverse effects, toxicity, side effects and potential for drug interactions Discuss the other methods that can be used in treating heart failure.

33. Follow up Mr. Smith’s condition continued to deteriorate at home for the next few days. He suffered a pulmonary embolism which led to cardiac arrest. He was rushed to hospital, but he was pronounced D.O.A. Say Ahhhhhhhhhh