CASE STUDIES

Case ONE: When the patient brought this prescription into the pharmacy,Don Lavasseur, RPh, of Publix Pharmacy in Jupiter, Fla, studiedit for a few minutes. Unable to understand the prescriptionorder, Lavasseur asked the patient if she knew what medicationthe physician was giving her. The patient gave Lavasseur thename of the drug. Can you figure out this prescription?RM, a 35-year-old mother of 2 children, presents to her localpharmacy with a prescription for propranolol 20 mg 4 timesdaily. She immediately asks to speak with the pharmacist,before having the prescription filled. She expresses concernthat the physician must have given her the wrong prescription.She explains that she has read about propranolol because herhusband takes it for migraines, although she knows it is usuallyprescribed for high blood pressure. RM did not go to the physicianfor high blood pressure, or even migraines, so she does notunderstand why she would be taking this medication.

When the pharmacist asks RM why she went to the doctorand what he told her, RM says she remembers him explainingthat something was wrong with her thyroid. She admits that shedoes not remember much of what the doctor said.

Because RM's diagnosis is unclear, the pharmacist asks RMto describe the symptoms she has been experiencing. RMexplains that she has been fatigued and unable to lift her childrenfor the past few months. She also has noticed that sheoften feels short of breath and nervous. She even notices thather hands shake. RM has been concerned that she might beapproaching menopause since she sweats a lot, is intolerant toheat, and has intermittent rapid heartbeats, but she does notthink that it is likely since she just had a baby 6 months ago.Although she is happy to lose extra pounds after pregnancy,she also thinks that she is losing weight too fast.

From RM's symptoms and her statement about her thyroid,the pharmacist suspects that RM has postpartum thyroid dysfunction.The pharmacist explains that postpartum thyroid dysfunctionis a transient hyperthyroidism, lasting 1 to 4 months, andoccurring in the first 8 months postpartum. He assures RM thatpropranolol is sometimes used in patients with hyperthyroidism.

RM does not understand how a blood pressure medicationwill cure her hyperthyroidism. What should the pharmacist tellRM about the use of propranolol in hyperthyroidism?

Case TWO: While en route to a nearby pharmaceutical company, a tractor-trailer truck carrying potassium cyanide crashes into abridge. The driver opens the trailer to inspect the cargo.Unfortunately, one of the boxes has been severely crushed,breaking the bottles inside.

When the police and paramedics arrive at the scene, the drivercomplains of shortness of breath, rapid heartbeats, and confusion.As the paramedic examines the driver, he notices thatthe driver's mental status is rapidly becoming depressed.

The paramedic rushes the driver to the local hospital. On theway to the hospital, the paramedic contacts the EmergencyDepartment (ED). He gives a list of medications that will beneeded to treat the driver to the ED staff.

Unfortunately, no one writes down the list of necessary medications.When an ED staff member calls the pharmacy to havethe medications delivered, the staff member simply tells the pharmacistto bring whatever is needed to treat cyanide poisoning.

What medications should the pharmacist bring to the ED?

Dr. Schlesselman is a clinical pharmacist based in Niantic, Conn.

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CASE 1: The pharmacist should explain to RM that propranololwill not "cure" her hyperthyroidism, but rather it will controlthe symptoms while inflammation of the thyroid resolves. Betablockerswill blunt some of the somatic symptoms, such as palpitations,tremor, and anxiety, thus providing symptomatic relief.

CASE 2: The focus of treating cyanide poisoning is the conversion of hemoglobinto methemoglobin, binding the cyanide ion. The pharmacist should bringamyl nitrite, sodium nitrite, and sodium thiosulfate. The amyl nitrite and sodiumnitrite are necessary to increase methemoglobin levels, whereas the sodium thiosulfateconverts the cyanide to thiocyanate, which can be excreted in the urine.

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