CLINICAL PHARMACOLOGY CASES
ARTERIAL HYPERTENSION CASES
1. A pregnant woman with blood pressure values up to 155/100 after repeated measurements. The
patient has no subjective complaints. Laboratory investigations do not show any deviations from the
reference values. Consider the need for medical treatment and prescribe a rational therapy
Dx: Arterial Hypertension 1st Degree, Pregnancy
Treatment:
 ACEI and ARBs contraindicated during pregnancy due to risk of birth defects and
foetal/neonatal renal failure
 Hydralazine (peripheral vasodilator), Nifedipine (long-acting form, CCB), Labetolol (combined
 and  blocker), Methyldopa (central acting  agonist) – indicated for hypertension during
pregnancy
o Methyldopa = considered 1st line treatment for hypertension during pregnancy
 non-tocomimetic = doesn’t cause uterine contraction
o Hydralazine = IV used for preeclampsia and eclampsia (hypertensive emergencies)

 Diuretics – only indicated for highly resistant hypertension
o assess with gynaecologist foetus/placental unit  if foetal cardiac tone is low –
diuretics contraindicated
 -blockers – tocomimetic  be careful to administer during 3rd trimester as may cause
premature birth
 150/95 is borderline hypertension in pregnancy 
Prescriptions:
Rp./ Methyldopi 250mg
D. scat. No. 1 in tab.
S. take 1 tab. every 8 hours (3 times per day)
2. A 40-year-old man complains of a morning headache, tightness in the neck and heart palpitations.
His complaints date back to about 2 months. Upon medical examination has been found repeatedly
elevated blood pressure up to 170/105. Laboratory investigations do not show any deviations from
the reference values. The patient has bronchial asthma which is treated with inhaled corticosteroids
(Becotid). Prescribe a rational therapy.
Dx: Arterial Hypertension 2nd Degree, Asthma
Treatment:
 atopic asthma - -blockers contraindicated
 ACEI – SE: dry cough in some patients  replace ACEI with ARB (Valsartan)
Prescriptions:
Rp./ Enalaprili 10mg
D. scat. No. 1 in tab.
S. take 1 tab. every 12 hours before meal
#
Rp./ Amlodipini 5mg
D. scat. No. 1 in tab.
S. take 1 tab. once per day
3. A 70-year-old man is being treated for two years irregularly with Reserpine. Upon medical
examination has been found elevated BP up to 180/100. Laboratory investigations have found
elevated levels of blood sugar (up to 7.5 mmol/L) and high values of serum cholesterol. Prescribe a
rational therapy.
Dx: Arterial Hypertension 2nd Degree, Diabetes Mellitus
Treatment:
 reserpine not working  STOP
 ACEI and ARB indicated for diabetes patients as they are nephroprotective
o contraindicated to be given together
 statins indicated to reduce serum cholesterol to reduce  CVD
Prescriptions:
Rp./ Enalaprili 5mg
D. scat. No. 1 in tab.
S. take 1 tab. every 12 hours before meal
#
Rp./ Amlodipini 5mg
D. scat. No. 1 in tab.
S. take 1 tab. once per day
#
Rp./ Metformini 250mg
D. scat. No. 1 in tab.
S. take 1 tab. every 12 hours
#
Rp./ Atorvastatini 10mg
D. scat. No. 1 in tab.
S. take 1 tab. once per day in the evening
CORONARY HEART DISEASE (STABLE ANGINA)
1. A 45-year-old man complains of severe chest pain which usually radiates to the left arm and appears
when he performs heavy physical work. The pain results within 2-3 minutes on resting. His ECG is
normal and upon exercise testing, the patient experiences pain and ST-elevation appear at 90 Watt.
Diagnosis is coronary heart disease (stable angina). Prescribe a rational therapy for treatment and
prophylaxis of pain attacks.
Dx: Coronary Heart Disease (Stable Angina)
Treatment:
 Glyceral Trinitrate = for chest pain but short acting (nitrate = vasodilator)
 Isosorbid Dinitrate = depot-tab. (20mg, 2.day, ½ tab.) (nitrate = vasodilator)
 -blocker = they reduce HR  less energy  demand for blood is reduced   risk of MI
Prescriptions:
Rp./ Glyceryli trinitratis (Nitroglycerine ®) 0.5 mg
D. scat. No. 1 in subling. tab.
S. put under tongue in case of chest pain – if no effect after 10minutes apply another, up to 3
#
Rp./ Isosorbidi dinitratis 20mg
D. scat. No. 1 in tab.
S. take 1 tab. every 12 hours
#
Rp./ Bisoprololi 10mg
D. scat. No. 1 in tab.
S. take 1 tab. once per day
#
Rp./ Acidum Acetylsalicylicum 100mg
D. scat. No. 1 in tab.
S. take 1 tab. once per day
#
Rp./ Atorvastatini 10mg
D. scat. No. 1 in tab.
S. take 1 tab. once per day in the evening
2. A 58-year-old man complains of severe chest pain and breathlessness when he climbs steep stairs.
The patient has night episodes of shortness of breath or when he performs light physical work. Upon
medical examination has been found that he has COPD. His ECG is normal and upon exercise testing,
the patient experiences pain and ST-elevation appears at 75 Watt. Diagnosis is coronary heart
disease (stable angina) with COPD. Prescribe a rational therapy for treatment and prophylaxis of pain
attacks.
Dx: Coronary Heart Disease (Stable Angina) with COPD
Treatment:
 aspirin – caution in patients with asthma
 selective muscarinic anticholinergic (bronchodilator) – ipratropium, tiotropium
 corticosteroid for COPD – prednisolone
Prescriptions:
Rp./ Glyceryli trinitratis (Nitroglycerine ®) 0.5 mg
D. scat. No. 1 in subling. tab.
S. put under tongue in case of chest pain – if no effect after 10minutes apply another, up to 3
#
Rp./ Bisoprololi 10mg
Rp./ Verapamili 80mg
D. scat. No. 1 in tab.
D. scat. No. 1 in tab.
S. take 1 tab. once per day
S. take 1 tab. once per day
#
Rp./ Tiotropiumi 18mcg
! if dyspnoea gets worse – replace -blocker with CCB
D. flac. No. 1
S. take 1 puff once per day
#
Rp./ Prednisoloni 30mg
D. scat. No. 1 in tab.
S. take 1 tab. once per day
3. A 68-year-old man presents to his primary healthcare doctor complaining of chest pain when he
performs light physical work 2-3 times per week. The patient takes Mananil, because he has
comorbidity of diabetes mellitus. Based on the laboratory investigations blood has been found to be
in normal ranges with the current therapy. His ECG is normal and upon exercise testing, the patient
experiences pain and ST elevation appears at 65 Watt. Diagnosis is coronary heart disease (stable
angina) with diabetes mellitus. Prescribe a rational therapy for treatment and prophylaxis of pain
attacks.
Dx: Coronary Heart Disease (Stable Angina) with Diabetes Mellitus
Treatment:
 ACEI indicated in patients with diabetes mellitus ∵ they are nephroprotective
 Metformin to replace Mananil to help treat DM
 statins indicated in patients with angina to  risk of further cardiac complications
Prescriptions:
Rp./ Glyceryli trinitratis (Nitroglycerine ®) 0.5 mg
D. scat. No. 1 in subling. tab.
S. put under tongue in case of chest pain – if no effect after 10minutes apply another, up to 3
#
Rp./ Bisoprololi 10mg
D. scat. No. 1 in tab.
S. take 1 tab. once per day
#
Rp./ Metformini 250mg
D. scat. No. 1 in tab.
S. take 1 tab. every 12 hours
#
Rp./ Atorvastatini 10mg
D. scat. No. 1 in tab.
S. take 1 tab. once per day
CHRONIC HEART FAILURE
1. A 59-year old man from 3 months complains of breathlessness when he performs light physical work.
His chest x-ray examination shows light pulmonary oedema. The ECG shows sinus rhythm – 72 bpm
with left ventricular enlargement. He suffered a MI 4 years ago. He also has a history of arterial
hypertension for 18 years with BP up to 190/120. His current therapy is Nifedipine (3 x 10mg),
Propranolol (2 x 80mg) and Hydrochlorothiazide (1 x 25mg). Dx is Chronic heart failure (NYHA II),
Arterial Hypertension 3rd Degree and Status post MI. Prescribe a rational therapy.
Dx: Chronic Heart Failure (NYHA II), Arterial Hypertension 3rd Degree, Status Post MI
Treatment:
 STOP taking Nifedipine, it’s contraindicated post MI.
 The Px is post MI, therefore immediately change Propranolol (non-selective) with High doses
of Bisoprolol/Metoprolol (cardioselective -blockers)
 ACEI – can reverse left ventricular hypertrophy
 Aspirin
 Statins
 Spironolactone (K-sparing diuretic). Initially 100mg daily, alternatively initially 25-200mg
daily. Dose may be taken as a single dose or divided dose.
Prescriptions:
Rp./ Bisoprololi 10mg
D. scat. No. 1 in tab.
S. take 1 tab. once per day
#
Rp./ Furosemidi 40mg
D. scat. No. 1 in tab.
S. take 1 tab. every 12 hours
#
Rp./ Enalaprili 5mg
D. scat. No. 1 in tab.
S. take ½ tab. every 12 hours before meal
#
Rp./ Spironolactoni 25mg
D. scat. No. 1 in tab.
S. take 1 tab. once per day
#
Rp./ Acidum Acetylsalicylicum 100mg
D. scat. No. 1 in tab.
S. take 1 tab. once per day
#
Rp./ Atorvastatini 10mg
D. scat. No. 1 in tab.
S. take 1 tab. once per day
2. A 65- year-old man from 3 months complains of breathlessness and fatigue with ordinary physical
activity. Upon medical examination has been found that he has pulmonary and ankle oedema. The
ECG shows atrial fibrillation. Dx is Chronic heart failure and Atrial fibrillation. Prescribe rational
therapy.
Dx: Chronic Heart Failure and Atrial Fibrillation
Treatment:
 Hospital Tx – due to degree of decompensation and new atrial fibrillation finding
 Decrease cardiac frequency by giving IV Digoxin/IV Amiodarone (if Px has
hypertension/hypertonia)
 IV Furosemide for the Oedema. 3/4 ampules per day for 3/4 days. Then tablets.
 Anticoagulants:
o Initially, (Direct therapy) - IV High molecular Heparin for atrial fibrillation
o 3/4 days later (Indirect therapy) - Dabigatran, Rivaroxaban (antithrombin)
 After all this, the Px solely begins to recover. You begin with low dose ACEI along with Beta
blockers.
Prescriptions:
Rp./ Amiodaroni 1000mg
Rp./ Digoxini 0.5mg
OR
D. flac. No. 1
D.t.d. No. 1 in amp.
S. 15mg/min for first 10minutes (150mg), then
S. administer 1 amp. IV every
S. 1mg/min for the next 6 hours (360mg)
S. 8 hours
#
Rp./ Furosemidi 20mg (or 40mg)
D.t.d. No. 1 in amp.
S. slow IV infusion over 1-2 minutes (or IM once)
#
Rp./ Heparin 5000IU
D. flac. No. 1
S. give IV infusion
#
Rp./ Dabigatran 150mg
D. scat. No. 1 in tab.
S. 3-4 days after heparin infusion, take 1 tab. every 12 hours PO
#
Rp./ Bisoprololi 10mg
D. scat. No. 1 in tab.
S. take 1 tab. once per day
#
Rp./ Enalaprili 5mg
D. scat. No. 1 in tab.
S. take ½ tab. every 12 hours before meal
PNEUMONIA CASES
1. A 77-year-old woman; an acute onset of disease with dry cough, dyspnoea, pain in the right lung,
hectic fever, adynamia. The Px has DM type 2 diagnosed 16 years ago & takes Maninil 5mg in the
morning and the evening. She doesn’t state any drug allergy.
Dx: Acute (Bacterial) Pneumonia with Concomitant Diabetes Mellitus Type 2
Treatment:
 CURB65 criteria – treat in hospital
 assume Streptococcus pneumoniae
 stop Maninil  start Metformin
Prescriptions:
Rp./ Ceftriaxoni 1000mg
D. flac. No. 6
S. 2000mg IV in solution after scarification probe –
S. 2000mg once per day for 3 days
#
Rp./ Metformini 250mg
D. scat. No. 1 in tab.
S. take 1 tab. every 12 hours
2. A 30-year-old man for 4 days has been complaining of catarrhal symptoms, muscle aches, subfebrile
temperature. The day before the visit- the temperature was elevated to 40°C, complete adynamia.
Auscultatory findings: diffuse dry crepitations in both lungs. The Px says he is a long-time smoker.
The previous year he took antibiotics (he can’t remember the name) but had to interrupt the Tx
because of a rash accompanied by itching. Px has Acute (viral) pneumonia. Drug-induced allergy.
Dx: Acute (Viral) Pneumonia. Drug Induced Allergy
Treatment:
 assume Beta-Lactam allergy and cross allergy to macrolides  quinolones indicated?
Prescriptions:
Rp./ Levofloxacini 500mg
D. scat. No. 1 in tab.
S. take 1 tab. once per day for 7 days
3. A 27-year-old woman, 3 months pregnant, for 5 days has been with dry cough, subfebrile
temperature without any particular change in the general appearance. Auscultatory findings: diffuse
dry crepitations in both lungs. The Px had smoked for a few years but stopped once the pregnancy
was diagnosed. Px has acute bronchitis and is pregnant.
Dx: Acute Bronchitis. Pregnancy
Treatment:
 assume viral pneumonia – wait 3 days and then start Tx (after 3 days may have become
bacterial)
 aminopenicillins safe during pregnancy (CI = Tetracyclines, Quinolones, Aminoglycosides)
Prescriptions:
Rp./ Amoxicillini 500mg
D. scat. No. 1 in tab.
S. take 1 tab. every 8 hours for 5-7 days
OR
Rp./ Cefuroxime 500mg
D. scat. No. 1 in tab.
S. take 1 tab. every 12 hours for 5-7 days
UTI/URINARY BLADDER/URETHRA CASES
1. A 23-year-old woman complains of a sudden onset of frequent urination and urinary urgency
accompanied by pain and burning sensation. She feels very nice in the urinary bladder region. The
complaint started after vacationing at a mountain cabin which lacked proper sanitation. Urine
sediment: a large number of leucocytes, simple epithelial cells and individual erythrocytes.
Dx: Cystitis/Urethritis
Treatment:
 Fosfomycin + Tromethamol = Monurol ®
Prescriptions:
Rp./ Monurol® 3.0g
D. flac. No. 1 in sachets.
S. dissolve sachet in 200ml of water and take once
2. A 24-year-old woman, 7 lunar months pregnant, with a substantial increase in the body weight,
started to urinate more than her usual frequency. The urination is accompanied by pain, burning
sensation, and incomplete bladder emptying sensation. Her temperature was elevated up to 37.3°C,
which along with the summer heat, exacerbates the patient’s discomfort. Urine sediment: a large
number of leucocytes, simple epithelial cells, individual erythrocytes.
The patient never had kidney complaints. During the course of the pregnancy, she has maintained
normal arterial blood pressure values. About a year ago, she had similar complaints in the winter,
and she was treated with Biseptol for acute cystitis.
Dx: Recurring Cystitis (Recidivans Cystitis)? OR Acute Cystitis
Treatment:
 Biseptol contraindicated during pregnancy  Amoxicillin or Cefuroxime
Prescriptions:
Rp./ Amoxipenicillini 500mg
D. scat. No. 1 in tab.
S. take 1 tab. every 8 hours for 3 days
OR
Rp./ Cefuroximi 250mg
D. scat. No. 1 in tab.
S. take 1 tab. every 12 hours for 3 days
3. An 18-year-old man after spending his summer vacation camping at the beach, started to feel
discomfort such as burning in the penile canal, a foreign body sensation, and a sense of incomplete
voiding. He feels weak heaviness in the pelvic floor. The complaints are constant, but moderately
increase during urination, erection and ejaculation. There is no urethral discharge, but seldom weak
moisture appears. The urethral test for Chlamydia trachomatis is positive.
Dx: Chlamydia
Treatment:
Prescriptions:
Rp./ Doxycyclini 100mg
D. scat. No. 1 in tab.
S. take 1 tab. every 12 hours for 7 days
DIABETES CASES
1. A 56-year-old man, driver, complains of fatigue, genital irritation, thirst, excessive urination for
several months. BMI 27kg/sqm, waist circumference 98cm. FPG 8.5 mmol/L, cholesterol 6.2 mmol/L,
LDL-cholesterol 4.3 mmol/L, HDL-cholesterol 0.8 mmol/L, triglycerides 3.5 mmol/L, BP 150/100
mmHg. Prescribe a rational therapy
Dx: Diabetes Mellitus Type 2
Treatment:
 change lifestyle to help reduce weight (BMI – borderline overweight)
 combination drug = Cholib = 10mg Simvarstatin/145mg Fenofibrate
Prescriptions:
Rp./ Metformini 250mg
D. scat. No. 1 in tab.
S. take 1 tab. 1-2 times per day before (during) meal
#
Rp./ Cholib®
D. scat. No. 1 in tab.
S. take 1 tab. once per day
2. A 50-year-old man with DM-2 for 5 years, on current therapy with Metformin 2x1000mg/daily and
Glimepiride 4mg/daily. Complains of hypoglycaemia. BMI 35.5 kg/sqm. Lab findings: HbA1c 8.5%,
FPG 7.2 mmol/L, PPG 10.5 mmol/L, cholesterol 5.1 mmol/L, LDL-cholesterol 3.4 mmol/L, HDLcholesterol 1.0 mmol/L, triglycerides 2.1 mmol/L, BP 130/80 mmHg. Prescribe rational therapy.
Dx: Diabetes Mellitus Type 2
Treatment:
 hypoglycaemia may be due to Glimepiride  STOP
 GLP-1 receptor agonists – also indicated to help against obesity
Prescriptions:
Rp./ Liraglutidi 1.2mg
D.t.d. No. 1 in amp.
S. subcutaneous injection once per day
#
Rp./ Simvarstatini 10mg
D. scat. No. 1 in tab.
S. take 1 tab. once per day
3. A 78-year-old woman with DM-2 for 38 years on current therapy with Metformin 3x1000mg/daily,
Glimepiride 6mg/daily, Pioglitazone 30mg/daily. Complains of hypoglycaemia. Concomitant diseases:
Arterial Hypertension, Coronary Artery Disease, Acute MI 3 years ago. BMI 32 kg/sqm. Lab findings:
HbA1c 8.8%, FPG 10.5 mmol/L, PPG 13.4 mmol/L, cholesterol 5.1 mmol/L, LDL-cholesterol 3.6
mmol/L, HDL-cholesterol 1.2 mmol/L, triglycerides 2.1 mmol/L, BP 130/80 mmHg. Does she need a
change in the therapy? Prescribe rational therapy.
Dx: Diabetes Mellitus Type 2
Treatment:
 admit to Hospital for observation for at least 2 days
 hypoglycaemia may be due to Glimepiride  STOP
 Pioglitazone CI in 3rd and 4th stage cardiac insufficiency
Prescriptions:
Rp./ Liraglutidi 1.2mg
D.t.d. No. 1 in amp.
S. subcutaneous injection once per day
#
Rp./ Insulatard® 1.0IU
D.t.d. No. 1 in amp.
S. subcutaneous injection once per day in the evening
#
Rp./ Simvarstatini 10mg
D. scat. No. 1 in tab.
S. take 1 tab. once per day
BRONCHIAL ASTHMA CASES
1. A 26-year-old man, a non-smoker, complains of attacks, in the past 2-3 weeks, usually short episodes
of breathlessness, occurring intermittently, not more than 1-2 times weekly, often associated with
exertion. The patient has no complaints between attacks. According to the functional tests, the
values of PEF (FEV1) are over 80% of the reference range for this age. Prescribe rational therapy.
Dx: Bronchial Asthma – Mild Intermittent Type
Treatment:
Prescriptions:
2. A 31-year-old woman complains of attacks of severe breathlessness, cough with sputum, chest
tightness and palpitations. These symptoms date back over 5 years. She was treated with
Salbutamolum, an inhaler as needed, and Disodium Cromoglycate. Lately, the attacks have become
as frequently as 4-5 times weekly, sometimes at night, as a result of which the patient has increased
the Salbutamol inhalation up to several times daily. According to the functional tests, PEF (FEV 1) is
between 60%-80% of the reference range for this age. Prescribe rational therapy.
Dx: Bronchial Asthma – Moderate Persistent Type
Treatment:
Prescriptions:
3. A 38-year-old man, a non-smoker, with an 11-year history of bronchial asthma, complains of
insomnia, headache, palpitations, hand tremor. For 8 weeks he has been treated with Teotard
300mg 2 x 1 tabl. every 12 hours daily, and inhaled glucocorticosteroid (Beclomethasone
Dipropionate) 2 x 1 inhalation daily. A month ago, because of diagnosed peptic ulcer disease, he was
prescribed Cimetidinum-tabl. with a daily dose of 2 x 400mg. Improve the therapy
Dx: Bronchial Asthma – Moderate Persistent Type. Peptic Ulcer Disease in the Duodenum.
Theophylline Intoxication (?)
Treatment:
Prescriptions: