CASESTUDIES

CASE 1: MS, a 21-year-old college student, is required to have a completephysical examination prior to participating in tryouts for the school's baseballteam. Since he has no significant medical history and is in excellent physicalshape, MS considers the examination a waste of his time.

On examination, the physician notes that MS appears to be a well-developed,well-nourished man in no apparent distress. His vital signs are within normallimits. During physical assessment, no abnormal findings are noted.

Before completing the paperwork to permit MS to try out for the team, thephysician explains to MS that he still needs some blood work done. He informsMS that the lab results will be back the following day, so MS can return for thepaperwork then.

When the lab results are returned, the physician is surprised to read thatMS has elevated aminotransferases. All other results are within normal limits.The physician calls MS with the results. He explains that MS will need furtherlab work, including evaluation for possible hepatitis.

Upon further workup, it is determined that MS has hepatitis C, genotype 2a.Since MS feels healthy, he urges the physician to sign the health forms andnot to worry about the diagnosis. The physician instead sits MS down for a discussionon how to avoid spreading the disease and implications for his futurelife. After the enlightening discussion, MS agrees to initiate therapy.

With MS'genotype, what is the anticipated duration of therapy with pegylatedinterferon and ribavirin?

CASE 2: PT, a 55-year-old obese woman, presents to her local pharmacy.Along with filling her prescription for atenolol, PT wishes to purchase atube of miconazole vaginal cream and a case of bottled water. She explainsto the pharmacist that this is the third tube of antifungal cream that she haspurchased in the last month. PT states that she is very frustrated by herinability to eliminate her vaginal yeast infection. She considers it almost asannoying as the unquenchable thirst that she has been experiencing.

The pharmacist asks PT to describe how and when she is administeringthe miconazole cream. PT confirms that she administers the cream immediatelyprior to retiring for the evening. Administering the cream is the last thingshe does at night so gravity does not cause some of the cream to "leak out."

Convinced that PT is using the vaginal cream properly, the pharmacistwonders why PT is unable to cure the infection after 2 courses of antifungaltreatment. She is also concerned about PT's unquenchable thirst. The pharmacistreviews PT's medication profile for possible causes. The only medicationon her profile is the atenolol prescription she is refilling.

The pharmacist then asks PT if her physician has ever evaluated her foror diagnosed her with diabetes mellitus. PT appears surprised. "Yes, as amatter of fact, during my last appointment my doctor told me that I have diabetes.I was supposed to see a dietitian, but I do not need anyone telling mehow to eat. I am going to eat whatever I want,"she says.

The pharmacist recommends that PT make an appointment to see herphysician as soon as possible. She explains that she is concerned that PT's diabetesmellitus is not controlled, particularly if PT is not following dietary changes.

Why does the pharmacist suspect that PT's diabetes mellitus is not controlled?

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

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CASE ONE: Genotype 1, the most common type in the United States, is usually treated for 12months. Studies show that patients with genotypes 2 or 3 can be offered 6 months ofpegylated interferon and ribavirin therapy.

CASE TWO: Recurrent genital yeast infections and unquenchable thirst are both symptoms ofincreased glucose levels associated with diabetes. Since no medications were prescribed,PT's physician must have been attempting to control her diabetes withdietary changes. Unfortunately, PT was unwilling to make such changes. The pharmacistshould refer PT back to the physician for initiation of medications (and counselingon lifestyle modifications and risks associated with diabetes).

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