临床药学肾病专业临床案例试题.doc

CaseNum96PtNameDon WhiteAddress939 Field DriveAge33Height5 8Weight140 lbSexMRaceWhiteAllergiesNKDASectionNameRenal DisordersCaseNameRenal Failure (Chronic)ChiefComplaintDW, a 33-yo male, presents to the diabetes clinic for a follow-up outpatient appointment.HxPresIllnessEight weeks ago, DW was discharged from the hospital with diagnoses of silent MI, pulmonary edema (resolved), severe HTN, and renal insufficiency. Before this hospitalization, DW had not seen a physician in a year. A cardiac catheterization was postponed until renal function stabilized.PastMedicalHxDW has had type 1 DM for 20 years and has been hospitalized approximately ten times for DKA. Diabetic complications include diabetic retinopathy, nephropathy, gastroparesis, and mildperipheral neuropathy. DW states that he does have a blood glucose meter, but that it has been broken for awhile. Also, DW has been hypertensive for approximately 5 years. DWs past surgical history is significant for retinal laser photocoagulation 2 weeks ago.SocialHxRemote smoking history 1 ppd x 2 years, but has not smoked in 10 years. DW is a salesman. He drinks alcohol socially. He denies any illicit drug use.FamilyHxFather with MI at age 49, (+) hypercholesterolemia, (-) diabetesReviewOfSystemsDW has noted some lower extremity edema. He denies orthopnea, palpitations, syncope, angina, or dyspnea on exertion.PhysicalExamGEN: Pleasant white man in NAD who is A & O x 3.VS: BP 155/95 mmHg, HR 70 bpm, RR 12 rpm, T 98.8F, Wt 64 kgHEENT: NC/AT, moist oral mucosa with poor dentition, thyroid WNL, no carotid bruits detectedCHEST: Clear to auscultationCV: RRR, no m/r/gABD: Positive BS, no hepatosplenomegalyEXT: 2+ pretibial edema on lower extremities, calluses on bottom of both feet, decreased sensation bilaterally to 5.07 monofilamentLabsAndDxTestsSodium 133 mEq/LPotassium 5.4 mEq/LChloride 105 mEq/LCO2 content 22 mEq/LBUN 58 mg/dLSerum creatinine 3.7 mg/dLGlucose 456 mg/dLCalcium 8.5 mg/dLPhosphorus 4.7 mg/dLAlbumin 2.2 g/dLHgbA1c 12.0TSH 3.05Hgb 12.2 g/dLHct 36.1%Platelets 223,000/mm3WBC 6900/mm3Urine analysis:Color yellowSpecific gravity 1.015Blood 3+Protein 3+pH 5.0Glucose traceUrine collection 24 hours:Urine creatinine clearance 25 mL/minUrine total protein 17.7 g/24 hLipid panel (fasting):TChol 336HDL 30LDL 221VLDL 85TG 348Renal ultrasound:Bilateral kidneys consistent with renal disease, no mass or hydronephrosisEchocardiogram:EF 44%DiagnosisPrimary:1) Type 1 diabetes mellitus (history of nonadherence)2) Chronic renal failureSecondary:1) Hyperlipidemia2) Hypertension3) Coronary artery disease s/p myocardial infarctionRxRecord(on discharge from hospital) DateRx NoPhysicianSergeantSergeantSergeantSergeantVincentVincentVincentDrug and StrengthFurosemide80 mgZestril20 mgNorvasc5 mgDiovan80 mgLescol20 mgToprol XL100 mgAspirin EC325 mgQuantity603030303030100Sig1 po bid1 po daily2 po daily2 po daily1 po hs1 po daily1 po dailyRefills333322RPhNotes10/01 Case manager gave DW a voucher for a blood glucose meter. DW was given a log book to record blood glucose. Patient to bring log book to each clinic visit. Reviewed importance of adherence to diet and insulin therapy to help postpone further complications. Patient is aware that he could soon be a candidate for dialysis. HgbA1c ordered.CaseNum96QuestNum951QuestionWhich of the following may be contributing to the progression of renal disease for DW?I. diabetes.II. hypertension.III. hyperlipidemia.AnswerChoiceAI onlyAnswerChoiceBIII onlyAnswerChoiceCI and II onlyAnswerChoiceDII and III onlyAnswerChoiceEI, II, and IIICorrectAnswerEExplanationThe most common causes of chronic renal failure (CRF) are diabetes and HTN. Hyperlipidemia is a major risk factor for CRF. All three play a role in the progression of renal disease.CompetencyStmt1.1.1K-TypeKCaseNum96prnMooreAccucheck test strips100achs3MooreRegular insulin sliding scale SQac QuestNum952hs3MooreHumulin N10 units SQq AM3 MooreHumulin N12 units SQq HS3Vaccinations: Received QuestionWhich medication(s) may be responsible for DWs increase in potassium?I. FurosemideII. LisinoprilIII. ValsartanAnswerChoiceAI onlyAnswerChoiceBIII onlyAnswerChoiceCI and II onlyAnswerChoiceDII and III onlyAnswerChoiceEI, II, and IIICorrectAnswerDExplanationZestril (lisinopril) is an ACE inhibitor. Diovan (valsartan) is an ARB. Both can lead to increased serum potassium, especially with worsening renal function. Furosemide is a loop diuretic that is often used in combination with an ACE inhibitor or an ARB to help decrease serum potassium in chronic renal failure patients.CompetencyStmt1.3.3K-TypeKCaseNum96QuestNum953QuestionIf the patients potassium increases, it might be necessary to give him oral/rectal Kayexalate. Which phrase best describes Kayexalate?AnswerChoiceAExtended release productAnswerChoiceBTransdermal delivery systemAnswerChoiceCOil in water emulsionAnswerChoiceDOral mucosal delivery systemAnswerChoiceECation exchange resinCorrectAnswerEExplanationKayexalate (generic name: sodium polystyrene sulfonate) is an example of a cation exchange resin. Sodium polystyrene sulfonate removes potassium by exchanging sodium ions for potassium ions in the GI tract before the resin is excreted from the body. An example of a transdermal drug delivery system is a nitroglycerin patch. An example of an oil in water emulsion is propofol. An example of an oral mucosal delivery system is nicotine gum. An example of an extended release formulation is Procardia XL.CompetencyStmt1.2.7K-TypeCaseNum96pneumovax and hepatitis B vaccine before discharge.QuestNum954QuestionSince DW travels for his job, he often carries his insulin vials on the road with him. He is not sure how long a vial is good for once it has been opened. How long is Humulin-N insulin stable once opened?AnswerChoiceA7daysAnswerChoiceB28 daysAnswerChoiceC3 monthsAnswerChoiceD6 monthsAnswerChoiceE1 yearCorrectAnswerBExplanationLilly recommends that opened insulin vials be discarded after 28 days. Insulin can be stored in the refrigerator (do not freeze) or at room temperature (not to exceed 86F). The expiration date for in-use insulin pens varies from 10-28 days, depending on the type of insulin.CompetencyStmt2.2.5K-TypeCaseNum96QuestNum955QuestionDWs nurse finds a pale red, almond shaped, bevel-edged tablet in DWs bed. She cannot read the markings. Concerned that a dose may have been missed, the nurse wants you to identify the tablet. You tell the nurse that the name of the medication is:AnswerChoiceAZestril 20 mgAnswerChoiceBToprol XL 100 mgAnswerChoiceCNorvasc 5 mgAnswerChoiceDDiovan 80 mgAnswerChoiceEEnteric-coated aspirin 325 mgCorrectAnswerDExplanationDiovan 80 mg tablets are pale red, almond shaped, and bevel-edged. Zestril 20 mg tabs are red, round, and biconvex. Toprol XL 100-mg tablets are white, round, biconvex, and scored. Norvasc 5 mg is a white oblong, octagon-shaped tablet with a flat face and a beveled edge. Most 325 mg enteric-coated aspirin are orange, round tablets.CompetencyStmt2.2.3K-TypeCaseNum96QuestNum956QuestionWhich of the following sources can help identify medications?I. IdentidexII. Goodman and Gillmans The Pharmacological Basis of TherapeuticsIII. Applied TherapeuticsAnswerChoiceAI onlyAnswerChoiceBIII onlyAnswerChoiceCI and II onlyAnswerChoiceDII and III onlyAnswerChoiceEI, II, and IIICorrectAnswerAExplanationIdentidex, Physicians Desk Reference (PDR), Drug Facts & Comparisons, Mosbys GenRx, and Ident-A-Drug Reference can be used to help identify medications. Goodman and Gillmans contains basic pharmacologic and therapeutic information, but nothing to help identify medications. Applied Therapeutics is a good source for drug treatment information but is not helpful in identifying medications.CompetencyStmt3.1.1K-TypeKCaseNum96QuestNum957QuestionWhich of the following is NOT a typical, common complication of chronic renal disease?AnswerChoiceARenal osteodystrophyAnswerChoiceBHyperparathyroidism secondary to hyperphosphatemiaAnswerChoiceCAnemiaAnswerChoiceDHypokalemiaAnswerChoiceEHypertensionCorrectAnswerDExplanationRenal osteodystrophy (bone disease) is a common manifestation of chronic renal failure (CRF). It is a complex disorder initiated by decreased elimination of phosphorus by the kidneys. This results in the inhibition of renal activation of vitamin D, which in turn decreases gut absorption of calcium. Low blood calcium concentration stimulates parathyroid hormone (PTH) secretion. As renal function declines, chronic PTH stimulation results in increased mobilization of calcium from bone. The anemia of CRF is characteristically normochromic and normocytic. It is attributable mainly to decreased erythropoietin secretion from damaged kidneys. As renal failure progresses, HTN usually develops from salt and water retention. Hyperkalemia, not hypokalemia, is more likelyin patients with CRF.CompetencyStmt1.1.3K-TypeCaseNum96QuestNum958QuestionThe attending physician has suggested using both an ACEI and an ARB in this patient. You are not familiar with any advantage of using both together. Which of the following would be the best source to explore the value of this combination.AnswerChoiceADrug Interaction FactsAnswerChoiceBHandbook of Nonprescription DrugsAnswerChoiceCBruces guide to combination therapiesAnswerChoiceDUpToDateAnswerChoiceELexi-Comp Drug Information on your hand-held deviceCorrectAnswerDExplanationUpToDate is likely to have information about recent studies and trends in drug therapy. The Handbook of Nonprescription Drugs has only OTC information. Lexi-Comp drug information provides much information about drugs but not necessarily about combinations of drugs. There is no such publication as Bruces guide.CompetencyStmt3.1.1K-TypeCaseNum96QuestNum959QuestionThe patient presents a prescription for furosemide, but mentions to you that in the hospital they had to use two water pills to keep the edema at bay. What diuretic would be used in combination with furosemide?AnswerChoiceAHCTZ 25 mg poAnswerChoiceBDiamox 250 mg IVAnswerChoiceCBumex 2 mg poAnswerChoiceDZaroxolyn 5 mg poAnswerChoiceEDemadex 20 mg poCorrectAnswerDExplanationDiuretics with a different mechanism of action can be given with furosemide to help overcome diuretic resistance. Most thiazide diuretics including hydrochlorothiazide (HCTZ) are not effective with a low GFR. Zaroxolyn (metolazone) is an exception to this rule. Combining metolazone with furosemide is effective in patients with decreased GFRs. Diamox (acetazolamide), a carbonic anhydrase inhibitor, is ineffective in patients with a low GFR and may worsen acidosis associated with CRF. Bumex (bumetanide) and Demadex (torsemide) are both loop diuretics like furosemide.CompetencyStmt1.2.2K-Type KCaseNum96QuestNum960QuestionWhich medication(s) can improve outcomes in patients post-MI and is/are also optimal for use in a patient with DM?I. ACE inhibitorsII. Calcium channel blockersIII. Beta blockersAnswerChoiceAI onlyAnswerChoiceBIII onlyAnswerChoiceCI and II onlyAnswerChoiceDII and III onlyAnswerChoiceEI, II, and IIICorrectAnswerAExplanationACE inhibitors and beta blockers have been shown to improve outcomes post-MI, but beta-blockers may mask signs and symptoms of hypoglycemia. Calcium channel blockers have not been show to improve outcomes.CompetencyStmt1.2.1K-TypeK96 肾脏疾病病人姓名：唐怀特地址：田野路 939号年龄：33 身高：177cm性别：男性 种族：白人体重：63.5Kg过敏史：无主诉唐怀特，男，33岁，糖尿病诊所门诊。现病史八周前，怀特被诊断静息性心急梗塞，肺水肿，严重高血压和肾功能不全。在这次入院前，怀特已经有1年时间没有看过医生。待肾功能稳定后再进行心导管插入手术。既往史患者怀特患有1型糖尿病20年，并且由于糖尿病酮症酸中毒入院约10次。患者有多种糖尿病综合症，包括视网膜病变，肾病，胃轻瘫和神经病变。怀特曾有血糖计，但是他说一会就会坏掉。怀特大约有5年的高血压史。两周前，怀特经历过视网膜激光凝固治疗。社会史患者在多年前有一天一包的吸烟史，但是近10年未吸烟。患者职业是一名售货员。在社交活动中会饮酒。否认使用过任何违禁药品。家族史患者父亲在49岁时患有心急梗塞，高胆固醇血症，糖尿病。整体评价患者阐述下肢水肿，否认端坐呼吸，心悸，昏厥，心绞痛，和运动性呼吸困难。体格检查一般情况：男性，白人，无明显疼痛，亲切，言语正常生命体征：血压：155/95 mmHg，心率：70bmp，呼吸频率：12rmp，体温：37.1，体重64Kg头、眼、耳、鼻、喉：头部正常无创伤；口腔粘膜湿润，牙列不齐；甲状腺正常；未检测到静脉血管杂音。肺：两侧听诊呼吸音清心脏：心率和心律规则整齐腹部：肠鸣音正常，无肝脾肿大。四肢：下肢胫骨前水肿2+，双足底皮肤硬结，双侧感知下降到5.07单纤丝。实验室和诊断检查钠 133 mEq/L 钾 5.4 mEq/L氯 105 mEq/L CO2 22 mEq/L血尿素氮 58 mg/dL 血清肌酸酐 3.7 mg/dL葡萄糖 456 mg/dL 钙 8.5 mg/dL磷 4.7 mg/dL 白蛋白 2.2 g/dLHgbA1c 12.0 促甲状腺激素刺激激素 3.05血红蛋白 12.2 g/dL血细胞比容 36.1% 血小板 223,000/mm3白细胞 6,900/mm3，尿检：黄色，比重1.015，血3+，蛋白3+，PH5.0，葡萄糖微量24小时尿液收集：尿肌酐清除率 25 mL/min，尿总蛋白 17.7 g/24 h脂质： 靶细胞 336 高密度脂蛋白 30低密度脂蛋白 221 极低密度脂蛋白 85甘油三酯 348肾脏超声：双侧肾脏疾病，无肾脏积水超声心电图：EF 44% 诊断最主要的：1 1型糖尿病2 慢性肾衰竭其次：1高血脂2高血压3冠状动脉疾病/心肌梗塞用药记录（出院带药）日期处方号医师SergeantSergeantSergeantSergeantVincentVincentVincent药物和剂量呋塞米 80 mg捷赐瑞20 mg络活喜 5 mg代文80 mg来适可20 mg琥珀酸美托洛尔控释片剂100 mg阿司匹林325 mg数量603030303030100用法1 po bid1 po daily2 po daily2 po daily1 po hs1 po daily1 po dailyRefills333322药师记录和其他病人信息10/01 病案管理发放患者怀特一个血糖计，怀特需要记录血糖值。患者去诊所时需要携带该记录本。回顾饮食与胰岛素治疗的重要性，希望能暂缓并发症。告知患者他很有可能将来接受透析治疗。问题1对于患者怀特来说，下列哪种促进了肾脏疾病的形成？：糖尿病 ：高血压 ：高血脂A：，B：，C：I and II，D：II and III，E：I, II, and III正确答案：E解释：造成慢性肾衰竭的最主要原因是糖尿病和高血压。高脂血症是另一个重要的因素。所以这三项都促进肾病的恶化。2下列哪种药造成患者怀特体内钾升高？：呋塞米 ：赖诺普利 ：缬沙坦A：，B：，C：I and II，D：II and III，E：I, II, and III正确答案：D解释：赖诺普利是一种乙酰胆碱酯酶抑制剂。颉沙坦是一种肾上腺素受体结合剂。这两种药物都能够升高血钾，尤其是在肾功能受损的情况下。呋塞米是一种利尿剂，常与乙酰胆碱酯酶抑制剂或者肾上腺素受体结合剂合用来降低肾病患者的血钾浓度。3如果患者血钾升高，那么需要给药聚苯乙烯磺酸钠，下列哪些描述符合聚苯乙烯磺酸钠？A：缓释药B：透皮给药C：水包油乳剂D：口腔粘膜给药E：阳离子交换树脂正确答案：E解释：聚苯乙烯磺酸钠是一种阳离子交换树脂，在树脂排出人体前，聚苯乙烯磺酸钠在胃肠道中将钠离子与钾离子互换。透皮吸收的制剂的例子是硝酸甘油片是。水包油乳剂的例子是异丙酚。口腔粘膜给药的例子是烟碱胶剂。缓释药的例子是心痛定。4患者怀特由于工作原因需要出差，他经常需要携带胰岛素。他不太确定当他开启后还能保存多久。优泌林N胰岛素开启后多久是稳定的？A：7天B：28天C：3个月D：6个月E：1年正确答案:B解释：礼来介绍开启后的胰岛素能够保存28天，胰岛素应该保存在冷藏条件（不结冰