Kelas B

PPOK

K.K., a 57-year-old woman with a long history of COPD, presents to establish care. She is
concerned about her recurring hospitalizations because of lung problems. She has been to the
emergency department five times in the last year and was admitted twice because of episodes of
worsening cough, sputum production, and dyspnea. Her most recent FEV1/FVC ratio was 0.46,
and her absolute FEV1 was 45% of predicted. She is currently taking tiotropium one puff (18
mcg) as well as albuterol inhaler as needed for shortness of breath. She uses oxygen at 2
L/minute when sleeping (∼ 8 hours/night). She is a former smoker, 50 pack-years, but quit 2
years ago.
1. What change in treatment would you recommend?
2. What non pharmacology therapeutic should be recommended at this point?
3. When she has to stop the therapy?

Ulkus Peptikum

A.D. is a 70-year-old woman who retired from teaching 5 years ago. A few days ago, she noticed
black “tarry” stools and was hospitalized for an upper GI bleed most likely secondary to NSAID
use. She complains of “feeling tired” and occasionally dizzy for about 1 week. A.D. presents
with a 5-year history of osteoarthritis for which she takes naproxen 250 mg in the morning and
500 mg in the evening. When questioned, she denies the use of corticosteroids, bisphosphonates,
anticoagulants, clopidogrel, or a selective serotonin reuptake inhibitor (SSRI). She did not have a
history of a previous ulcer or related complication. Other medications include
hydrochlorothiazide 25 mg daily and lisinopril 20 mg daily for hypertension, selfdirected
treatment with enteric-coated aspirin 81 mg daily, calcium carbonate, and a multivitamin. A.D.
does not use tobacco or drink caffeinated beverages but does have an occasional glass of wine.
She denies epigastric pain, nausea, vomiting, anorexia, and weight loss but notes a recent change
in stool color. A review of other body systems are noncontributory other than previously
indicated. There are no known food or drug allergies. Physical examination reveals a well-
developed weak woman in no acute distress. The abdomen was normal with no pain on
palpation. Bowel sounds were normal with no guarding, masses, hepatomegaly, or
splenomegaly. The rectum was normal but with guaiac-positive stool. Vital signs include a
temperature of 98.9◦F, blood pressure of 100/65 mm Hg, and a heart rate of 90 beats/minute.
Pertinent laboratory values include:
Hgb,11.0 g/dL
Hct, 35%
Blood urea nitrogen (BUN), 40
Serum creatinine (SCr), 1.5 mg/dL
All other laboratory values are within normal limits.
1. What factors placed A.D. at increased risk for experiencing an NSAID-induced ulcer and
related upper GI bleeding?
2. Which ulcer-healing regimen would be recommended if A.D. were reported to be H. pylori–
positive?
3. What is the concern regarding the use of COX-2 inhibitors and the risk for cardiovascular
toxicity?
4. How does a COX-2 inhibitor compare with a PPI and a non- or partially-selective NSAID
when used to decrease ulcer risk and related complications? Have any studies evaluated GI
safety in patients taking a COX-2 inhibitor plus a PPI?
5. What parameters should be monitored to determine A.D.’s response to treatment?

Mual -Muntah

M.C., a 54-year-old woman with breast cancer, is in the clinic today to receive her first cycle of
chemotherapy. Her chemotherapy will consist of intravenous (IV) docetaxel 75 mg/m2,
carboplatin dosed to achieve an area under the curve (AUC) of 6 mg/mL/minute. This will be
repeated every 21 days. In addition, she will receive trastuzumab 4 mg/kg IV for one dose, then 2
mg/ kg/week for 17 weeks. M.C. does not drink alcohol or smoke. Her only other medical
condition is adult onset diabetes, which is controlled with metformin and diet. She has had four
children, now all grown, and had substantial morning sickness with each of her pregnancies.
M.C.’s neighbor has told her that all chemotherapy causes severe nausea and vomiting.
1. How likely is M.C. to experience nausea and vomiting?
2. M.C. is at moderate risk for acute CINV. Her personal risk factors include female sex, history
of morning sickness with pregnancy, and being a nondrinker. The docetaxel has a low risk of
acute CINV, the carboplatin has a moderate risk of acute CINV with a high risk of delayed
CINV, and the trastuzumab has a minimal risk of acute CINV. What antiemetics are available
for M.C.?
3. M.C. is at moderate risk for acute nausea and vomiting and at high risk for delayed CINV
symptoms, as a result of her chemotherapy regimen of docetaxel, carboplatin, and
trastuzumab. What would be the most appropriate antiemetic regimen for M.C.?

Hipertensi

D.C. is a 44-year-old black man who presents to his primary care provider concerned about high
BP. At an employee health screening last month he was told he had stage 1 hypertension. His
medical history is significant for allergic rhinitis. His BP was 144/84 and 146/86 mm Hg last
year during an employee health screening at work. D.C.’s father had hypertension and died of an
MI at age 54. His mother had diabetes and hypertension and died of a stroke at age 68. D.C.
smokes one pack per day of cigarettes and thinks his BP is high because of job-related stress. He
does not believe that he really has hypertension. D.C. does not engage in any regular exercise
and does not restrict his diet in any way, although he knows he should lose weight. Physical
examination shows he is 175 cm tall, weighs 108 kg (body mass index [BMI], 35.2 kg/m2), BP
is 148/88mmHg (left arm) and 146/86 mm Hg (right arm) while sitting, heart rate is 80
beats/minute. Six months ago, his BP values were 152/88 mm Hg and 150/84 mm Hg when he
was seen by his primary-care provider for allergic rhinitis. Funduscopic examination reveals
mild arterial narrowing and arteriovenous nicking, with no exudates or hemorrhages. The other
physical examination findings are essentially normal. D.C.’s fasting laboratory serum values are
as follows:
Blood urea nitrogen (BUN), 24 mg/dL
Creatinine, 1.0 mg/dL
Glucose, 105 mg/dL
Potassium, 4.4 mEq/L
Uric acid, 6.5 mg/dL
Total cholesterol, 196 mg/dL
Low-density lipoprotein cholesterol (LDL-C), 141 mg/dL
High-density lipoprotein cholesterol (HDL-C), 32 mg/dL
Triglycerides, 170 mg/dL
An electrocardiogram (ECG) is normal except for left ventricular
hypertrophy (LVH).
1. What is the proper assessment of D.C.’s BP?
2. Why does D.C. have hypertension?
3. What is D.C.’s BP goal and how can Framingham risk scoring influence BP goal
determination?
4. How can antihypertensive drug therapy reduce D.C.’s risk of hypertension-associated
complications?
5. How should D.C.’s race influence the selection of an antihypertensive regimen?
Kelas A

Ulkus Peptikum

R.L. is an otherwise healthy 45-year-old man who works in a high-stress job as an air traffic
controller at a major airport. He complains of a 2-week history of “burning stomach pain”
sometimes accompanied by “indigestion and bloating.” The pain initially occurred several times
a day, usually between meals, and sometimes awakened him at night, but it has increased in
frequency during the last week. Initially, the pain was temporarily reduced by food or antacids.
Last week, R.L. tried an OTC H2 receptor antagonist that “lasted longer” but did not provide
adequate symptom relief. R.L. states that he experienced a similar type of pain about 12 years
ago when he was treated with omeprazole for a suspected peptic ulcer. He has smoked one pack
of cigarettes daily for the past 20 years, has an occasional glass of red wine with dinner, and
usually drinks 4 to 6 cups of caffeinated coffee throughout the day. R.L. takes acetaminophen
when needed for occasional headaches and a daily multivitamin but denies the use of any other
OTC or prescription medications, including NSAIDs and the previous use of clarithromycin or
metronidazole. He denies nausea, vomiting, anorexia, weight loss, and changes in stool
consistency or color. A review of other body systems is noncontributory. He has no known food
or drug allergies.

Physical examination is normal except for epigastric tenderness on palpation of the upper
abdomen. Vital signs include a temperature of 98.8◦F, blood pressure of 132/80 mm Hg, and a
heart rate of 78 beats/minute. Pertinent laboratory values include the following:
Hgb, 14.0 g/dL
Hct, 44%
Stool guaiac test, negative

1. All other laboratory values are within normal limits. What signs and symptoms are suggestive
of a recurrent peptic ulcer?
2. What factors should be taken into consideration when selecting a first-line eradication
regimen? What are the therapeutic options for first-line H. pylori eradication in the United
States? Which is the preferred H. pylori eradication regimen for R.L.?
3. R.L. is prescribed a 14-day PPI based three-drug eradication regimen containing amoxicillin
and clarithromycin. What instructions would you provide R.L. regarding his medications?
4. What would have been the preferred initial H. pylori eradication regimen if R.L. had a
documented allergy to penicillin?
5. What parameters should be monitored to determine R.L.’s response to treatment?

Kasus PPOK

T.A., a 51-year-old white male smoker, presents with daily cough and mild dyspnea on exertion
with strenuous activity. He has noticed that walking up two flights of steps bothers him, when
previously it did not. He has had a slight amount of wheezing, but no chest pain. He has no
known chronic medical problems. He has smoked 1.5 packs/day for 34 years and he continues to
smoke that amount. His physical examination is unremarkable. Chronic obstructive pulmonary
disease is suspected.

1. What diagnostic test should be ordered?

2. Office spirometry demonstratesman FEV1/FVC of 0.69 and an absolute FEV1 of 81% of
predicted. Using GOLD criteria, what is T.A.’s stage of COPD and what other diagnostic tests
would be necessary before initiating therapy?
3. What therapeutic interventions should be recommended for T.A. at this point?

Kasus Mual Muntah

E.G. is a 54-year-old man with newly diagnosed head and neck cancer who will receive radiation
therapy concurrently with chemotherapy containing cisplatin and fluorouracil. His daily
(Monday through Friday) radiation treatments will last for 6 weeks. He has a heavy smoking
history (35 pack-years) and “quit” last week, although it is not going well. After E.G.’s nausea
and vomiting from the chemotherapy subsides, is he at risk for experiencing radiation-induced
nausea and vomiting?
1. What antiemetic prophylaxis is appropriate?
2. what non-pharmacology therapy you could suggestion to?

Hipertensi

B.A. is a 62-year-old woman who is postmenopausal, does not smoke, and never drinks alcohol.
Since being diagnosed with hypertension, she has modified her diet, begun routine aerobic
exercise, and has lost 10 kg in the past 18 months. She now weighs 72 kg and is 165 cm tall. Her
BP is now 150/94 mm Hg (150/92 mm Hg when repeated) and has consistently remained near
this value for the past year. Her BP when first diagnosed was 156/96 mm Hg. Physical
examination shows no LVH and no retinopathy. Urinalysis is negative for protein. Other
laboratory tests are normal, except for dyslipidemia. B.A. has no health insurance and is
concerned about the cost of therapy. Her Framingham risk score is 22%. She takes over-the-
counter calcium with vitamin D, and her provider wants to start HCTZ 25 mg/day.
1. Is HCTZ an appropriate agent for B.A.?
2. How should a thiazide diuretic be started in B.A.?
3. B.A. is prescribed HCTZ 25 mg daily. How should she be counseled regarding this therapy?
4. When is potassium correction needed to manage diuretic-induced hypokalemia?
5. How should the increase in B.A.’s uric acid be managed?