Question

1-A 70 years old person arrived in the ER complaining about chest pain. What medication will the patient get? Why

2-A patient suffering from severe, constant dull knee pain is diagnosed with knee osteoarthritis. Which group of pharmaceutical agents would you consider adequate to relieve this kind of pain?

Answer 1

A 70 years old person arrived in the ER complaining about chest pain. What medication will the patient get? Why

Chest pain is pain or discomfort in the chest, typically the front of the chest. It may be described as sharp, dull, pressure, heaviness or squeezing, associated with symptoms like pain in the shoulder, arm, upper abdomen or jaw or nausea, sweating or shortness of breath. It can be of cardiac send non cardiac reasons for it. Chest pain is common in older adults and causes people to worry because of potential association with the heart. It is sometimes difficult to tell cardiac pain from other types of chest pain.

Cardiac Chest Pain

• Lack of oxygen to heart (i.e. angina, heart attack)
  • Often described as heaviness, pressure, squeezing or pain in left arm
  • More common in men over 60
  • Improved or relieved with additional oxygen or nitro-glycerine medication
• Inflammation of the pericardium (the membrane around the heart)
  • Often sharp intense pain starting abdomen/back; radiate to thigh/scrotum
  • May/may not have fever; heart rate typically higher; NOT relived by oxygen
  • Medication typically needed; need to determine cause-viral or bacterial
• Painful heart beat(i.e. disorder of heart value; abnormal heart rate)
  • Occasionally have chest pain but usually not symptoms; medication to treat

Non Cardiac Chest Pain

• Pulmonary (related to lungs- i.e. pleurisy, pneumonia, pulmonary embolism, etc.)
  • Often described as sharp, intermittent pain, can be worse with breathing
  • May have shortness of breath and rapid heartbeat
  • Treatment: Oxygen may help; NSAID/Tylenol or other pain meds if ordered
• Gastrointestinal (i.e. reflux, esophagitis, peptic ulcer, pancreatitis, cholecystitis)
  • Often cause sharp intense pain NOT relived by oxygen
  • May or may not also have a fever; heartrate typically elevated
  • Treatment: Medication typically needed
• Musculoskeletal (i.e. costochondritis, muscle strain, rib fracture, fibromyalgia)
  • Pain is usually sudden and localized; could be associated with muscle trauma; severe cough
  • Pain worse with deep breath
  • Treatment: Ice or heat may help; NASAIDs may also help
• Chest wall pain (i.e. muscle strain, rib fracture)
  • Pain is usually sudden and localized; could be associated with a trauma to a muscle, severe cough
  • Pain is worse with deep breath
  • Treatment: Ice or heat; NSAIDs may also help
• Psychogenic (i.e. anxiety)
  • Symptoms do not fit with physical signs
  • Treatment: relaxation, oxygen, massage

Medication of Chest pain.
The treatment protocol of chest pain is completely depended on the differential diagnosis of to find out the underlying cause. It is done by

History taking- find out the any previous episodes of angina, hypertension, diabetes, high lipid levels in blood, family history of heart attacks, habits like smoking and alcoholism

Physical Examination- Vital Signs, Observe heart sounds, check for tachycardia, bradycardia, and heart murmurs.

Medical Examination- An electrocardiogram (ECG), Chest radiograph, Echocardiography, CT scanning is used in the diagnosis of aortic dissection

Blood test- Blood tests: Troponin I or T (to indicate myocardial damage), Complete blood count, Lipid profile, Electrolytes and renal function (creatinine), Liver enzymes, Creatinine kinase (and CK-MB fraction in many hospitals)

Treatment-   In case of a cardiac cause- Medication include

• Aspirin. Aspirin and other anti-platelet medications reduce the ability of your blood to clot, making it easier for blood to flow through narrowed heart arteries.
• Nitrates. Often used to treat angina, nitrates relax and widen your blood vessels, allowing more blood to flow to your heart muscle.
• Beta blockers. These block the effects of the hormone epinephrine, also known as adrenaline. They help your heart beat more slowly and with less force, decreasing the effort your heart makes and easing the heart pain.
• Statins. Statins lower blood cholesterol by blocking a substance your body needs to make cholesterol. They might also help your body reabsorb cholesterol that has accumulated in the build-up of fats (plaques) in your artery walls, helping prevent further blockage in your blood vessels.
• Calcium channel blockers. Also called calcium antagonists, these drugs relax and widen blood vessels by affecting the muscle cells in the arterial walls. This increases blood flow in your heart, reducing or preventing angina.
• Ranolazine. This anti-angina medication might be prescribed with other angina medications, such as beta blockers. It can also be used as a substitute if your symptoms don't improve with the other medications.

2-A patient suffering from severe, constant dull knee pain is diagnosed with knee osteoarthritis. Which group of pharmaceutical agents would you consider adequate to relieve this kind of pain?

Osteoarthritis is degenerative bone and joint daises’ characterized by progressive degenerative changes in the cartilage of one or more joints (as of the knees, hips, and hands) accompanied by thickening and overgrowth of adjacent bone and that is marked symptomatically chiefly by stiffness, swelling, pain, deformation of joints, and loss of range of motion

In knee osteoarthritis, the cartilage in the knee joint gradually wears away. As the cartilage wears away, it becomes frayed and rough, and the protective space between the bones decreases. This can result in bone rubbing on bone, and produce painful bone spurs.

Osteoarthritis symptoms often develop slowly and worsen over time. Signs and symptoms of osteoarthritis include:

• Pain. Affected joints might hurt during or after movement.
• Stiffness. Joint stiffness might be most noticeable upon awakening or after being inactive.
• Tenderness. Your joint might feel tender when you apply light pressure to or near it.
• Loss of flexibility. You might not be able to move your joint through its full range of motion.
• Grating sensation. You might feel a grating sensation when you use the joint, and you might hear popping or crackling.
• Bone spurs. These extra bits of bone, which feel like hard lumps, can form around the affected joint.
• Swelling. This might be caused by soft tissue inflammation around the joint.

Pharmacology Management of Osteoarthritis pain

Acetaminophen -Acetaminophen (Tylenol, Paracetamol and Panadol) has both analgesic and anti-pyretic actions. Acetaminophen, up to 4 g per day, is the first medication recommended EULAR (European League against Rheumatism) guidelines for treatment of mild to moderate OA.

NSAIDS- Non-steroidal anti-inflammatory drugs treat inflammatory pain, and also reduce swelling and joint stiffness. Conventional NSAIDs like ibuprofen, Naprosyn, diclofenac and commonly used. But long term use of them are associated with higher GI toxicity including ulceration, perforation and bleeding.

Duloxetine-In November 2010 the FDA approved duloxetine hydrochloride, a serotonin and norepinephrine reuptake inhibitor (SNRI), for the treatment of chronic musculoskeletal pain conditions including OA and chronic low back pain.

Topical/transdermal agents- Topical and transdermal agents used as adjunctive therapy theoretically reduce the incidence of systemic side effects, making them attractive in geriatric populations. Capsaicin- Topical Capsaicin is available over-the-counter in two different strengths (0.025% and 0.075%). Topical NSAID and Transdermal lidocaine patches are used extensively to reduce pain.

In Later stages of severe pain injections of intra-articular agents, portico-steroid and Hyaluronic Acid seems to provide relief to the patients.