Case Studies

Dr. Schlesselman is an assistant clinical professor at the University of Connecticut (UConn) School of Pharmacy. Ms. Grgas is a PharmD candidate at the UConn School of Pharmacy

CASE ONE

While working in theambulatory care clinic, PJ, apharmacy student completingan experiential rotation,is handed a patient chart bythe attending physician. Thephysician asks PJ to reviewthe chart and make a recommendationto him onhow to treat the patient.

As PJ reviews the chart, he sees that the patient, a 40-year-old woman, has a history of perennial rhinitis symptomswith paroxysmal episodes, including sneezing, watery rhinorrhea,and nasal pruritus. The onset of these symptoms didnot occur until after age 35. The patient reports increasedsymptoms following exposure to strong odors, temperaturechanges, and smoke. The patient also experiences a loss ofthe sense of smell. According to the laboratory work, thepatient lacks a clinically significant positive skin test orserum immunoglobulin E antibodies to a specific allergen.The patient has previously used antihistamines with poorresponse.

At the end of the visit note, PJ sees that the physicianscribbled a note that he diagnosed the patient as havingrhinitis, but he is unable to read the word before ?rhinitis.? Hecannot determine if it says ?allergic? or ?nonallergic.?

From the description of the symptoms, is the patient morelikely to have allergic or nonallergic rhinitis?

CASE TWO

RH, a 32-year-old woman,calls her local pharmacy?sautomated system to refillher Risperdal Consta. Beforerefilling the prescription, thepharmacist checks RH?s profile.The pharmacist noticesthat RH has not filled thisprescription in over 2months. Luckily, the pharmacist is precepting a 6th-year pharmacystudent on rotation. She asks the student to call RH andask her how often she is using her Risperdal Consta.

After speaking with the patient, the student informs thepharmacist that RH stopped taking the medication more than2 months ago, as the profile shows. RH told the student thatshe "was feeling better; the voices went away" and that shewas feeling "normal" again. RH informed the student that shewas requesting a refill because she is not "feeling right," andshe is ?seeing people in the room even though they are notreally there.?

Having heard this information from the student, the pharmacistdecides that it is best to not fill the medication untilshe speaks with the physician who prescribed the medication.The student is confused by this decision, since RH isobviously in need of therapy.

Even though RH is having symptoms, what is the pharmacist?srationale for not filling the medication and calling thephysician instead?

ANSWERS

CASE ONE:

The symptoms described in the patient?s chart are consistent with nonallergic rhinitis. Nonallergic rhinitis often has an onsetafter age 35 with persistent symptoms and exacerbations during winter months. Patients with nonallergic rhinitis exhibit a hyperreactivity to nonspecificstimuli, including odors, temperature change, smoke, or spicy foods. In these patients, response to antihistamines is poor. In contrast, allergic rhinitis usuallyhas childhood onset with a family history of allergic rhinitis, eczema, or atopy. Allergic rhinitis typically has seasonal exacerbations to indoor or outdoorallergens and will respond well to antihistamine therapy.

CASE TWO:

Risperdal Consta contains extended-release microspheres, providing effects thatlast 4 to 6 weeks. Due to a delayed onset of activity (3 weeks), oral antipsychotic therapy is necessary to provide therapeutic levels of antipsychotic therapyand control symptoms during that time. Because RH is already experiencing symptoms, she needs oral antipsychotic therapy to control her symptomsuntil a dose of Risperdal Consta takes effect.

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