Case Studies in Hypertension, Angina, and Diabetes: Management and Treatment

Mrs. Freeman is a 50 year old nurse who presents to you with complaints of feeling unwell. She has no significant past medical history. However, she smokes one pack of cigarettes per day and drinks socially. She states she feels she has a healthy diet but does appear to be overweight.

 

On examination, all of Mrs. Freeman’s vital signs are within normal limits except for her blood pressure which is 158/98. The second assessment BP is 160/94 and your final assessment BP is 156/98. She is 160 cm tall and weighs 85 kg.

 

Mrs. Freeman is diagnosed with hypertension and will be placed on anti-hypertensive medications.

 

1. In addition to prescribing anti-hypertensive medications for Mrs. Freeman, what non-pharmacological approaches could be used to address her high blood pressure? (1 mark for each non-pharmacological approach given to a maximum of 5 marks)

2. Identify five (5) classifications of drugs that are commonly used to manage hypertension. (5 marks)

3. Choose three (3) of the drug classifications that you identified in question 2 (two) and explain in-depth how each classification reduces blood pressure. (4 marks per classification for a total of 12 marks)

(a) In addition, name one (1) drug from each drug classification. (3 marks)

Mr. Fortuna is a 62 year old male complaining of chest pain on and off for the last six months. He states he had an episode of chest pain at the office this afternoon and at that time he became very short of breath, and diaphoretic. He states that in addition to chest pain, the pain also radiated down his left arm but that it went away after a few minutes. States he is pain free at this time. He admits to smoking about 10 cigarettes per day and states he has 2 – 3 alcoholic drinks per night.

 

On examination, Mr. Fortuna is a short, moderately obese man who appears in no distress. All vital signs are within normal limits. Mr. Fortuna is diagnosed with stable angina and is ordered nitroglycerine and an antiplatelet medication. 

 

1. The main aim in the pharmacological treatment of angina is to reduce the workload of the heart and in doing so, the amount of oxygen it demands. Discuss in detail how nitrates would achieve this aim. (5 marks)

2. Nitroglycerine spray, two puffs sublingually, was prescribed for Mr. Fortuna.

(a) Why has nitroglycerine been prescribed to be given sublingually? (3 marks)

(b) Identify two other routes of administration for nitroglycerine. (2 marks)

3. Anti-platelets, such as aspirin, are essential in the management of stable and unstable angina. Explain how aspirin produces its effects. (5 marks)

4. The opioid, Morphine, is often used to manage severe chest pain in patients; however, doses must be carefully titrated to obtain the optimal effect. But even with careful titration, patients may exhibit overdose symptoms. 

(a) Identify 4 (four) patient symptoms you may see in a patient who has had an overdose of morphine? (4 marks)

(b) What drug is used to reverse the effects of Morphine in patients who are experiencing overdose symptoms? (1 mark)

Mr. Kyle Rogers is a 50 year old male who arrived in the emergency room with a three week history of polyuria and polydipsia accompanied by an unexplained 10 kg weight loss and blurred vision.

 

On examination his vital signs are within normal limits but his blood glucose level is elevated. The emergency physician diagnosed Mr. Rogers with Type 2 Diabetes and he was treated appropriately.

 

Upon discharge from the hospital, Mr. Rogers was instructed to perform blood glucose measurements 4 times a day. He was also ordered: 

10 units of Humalog (insulin lispro) subcutaneous before breakfast 

15 units of Humulin R (regular insulin) subcutaneous before dinner

  
20 units of Humulin N (intermediate acting insulin) subcutaneous at bedtime

 

1. Differentiate between the three types of insulin that have been ordered for Kyle by completing the following chart. (12 marks – 1 mark for each square)
            

Five months after his initial diagnosis, Mr. Rogers’s family physician decided to start weaning Mr. Rogers off of his insulin and at the same time he was started on an oral antihyperglycemic agent. Mr. Rogers was ordered: Metformin (Glucophage) 500 mg po BID

 

2. Which pharmacologic class of anti-hyperglycemic agents does Metformin belong to? (1 mark)

(a) Explain the mechanism of action of the drug Metformin. (3 marks)

 

3. Studies are being conducted to determine whether or not oral anti-hyperglycemic agents would be beneficial for Type 1 Diabetics as an adjunct medication. Discuss why oral anti-hyperglycemic agents cannot be the first line of treatment for Type 1 Diabetes. (4 marks)