Home' Australian Pharmacist : Australian Pharmacist December 2014 Contents Australian Pharmacist December 2014 I ©Pharmaceutical Society of Australia Ltd.
CONTINUING PROFESSIONAL DEVELOPMENT
“IT IS ALSO IMPORTANT TO IDENTIFY ANY ALARM SYMPTOMS THAT
MAY INDICATE A MORE SERIOUS UNDERLYING CONDITION.”
• Are you taking any medicines at the
moment (including over-the-counter
and herbal medicines)?
• Do you have any medical conditions?
• Do you currently smoke?
Mr Rogers has his prescriptions
dispensed regularly at your pharmacy.
His most recent prescriptions, filled last
week, were for atorvastatin 10 mg daily,
lisinopril 2.5 mg daily and metformin
500 mg twice daily. Mr Rogers is noticeably
overweight; you remember calculating his
body mass index (BMI) several months ago
and being shocked to find that it was around
30 kg/m2. He mentions that his doctor is
always telling him he needs to be ‘healthier’.
Mr Roger’s tells you he doesn’t smoke.
In addition to the information you have
already gathered, you ask Mr Rogers to
describe the frequency and severity of
his symptoms, and whether there are any
aggravating or relieving factors. Given
his age, it is also important to identify
any alarm symptoms that may indicate
a more serious underlying condition.
Based on your discussion with Mr Rogers,
there are several possible causes of his
Angina pectoris – the clinical
manifestation of myocardial ischaemia,
which occurs when coronary blood flow
is inadequate to meet myocardial oxygen
Restriction of myocardial
blood supply is generally caused by
atherosclerotic obstruction of the coronary
arteries or severe anaemia (which reduces
the oxygen-carrying capacity of blood).
Angina is a common presenting symptom
among people with coronary artery
disease. Typically, it is characterised by
chest discomfort behind the breastbone
(retrosternal), which may be described as
pressure, heaviness, squeezing, burning,
or a choking sensation.
The chest pain
can feel constricting and radiate to the
neck, jaw or arm.
However, not all patients
experience chest pain. Some people
develop shortness of breath or light-
headedness, or atypical pain localised in
the neck, jaw, or shoulders.
Hiatus hernias are encountered
frequently in people with reflux
disease. However, only a minority of
people with hiatus hernias have
Based on the
discussion you have had with Mr Rogers, it
is possible that he is experiencing
symptoms of reflux associated with an
underlying hiatus hernia. In particular,
obesity predisposes to hiatus hernia due
to increased abdominal pressure.
for further investigation may be necessary,
particularly if symptomatic reflux is poorly
Gallstones (cholelithiasis) – small,
hard deposits in the biliary tract,
usually in the gallbladder. The majority
of gallstones contain cholesterol as
their major component, but some are
composed of calcium bilirubinate.
Cholesterol gallstones form when bile in
the gallbladder becomes supersaturated
with cholesterol, which precipitates
from solution as solid crystals that
eventually aggregate into macroscopic
Gallstones develop insidiously
and can remain asymptomatic for
years. When a gallstone migrates into
the opening of the cystic duct, it can
obstruct the outflow of bile during
gallbladder contraction. The increase in
gallbladder wall tension produces biliary
colic, a characteristic type of severe
upper abdominal pain. Risk factors for
gallstone formation include female
gender, increasing age and obesity.
Based on the information you have
gathered, it is evident that Mr Rogers
has multiple risk factors for coronary
artery disease, including dyslipidaemia.
However, based on the nature and onset
of the symptoms he has described, it is
unlikely that his symptoms are associated
with recurrent episodes of angina. Angina
can be precipitated by exertion, eating,
cold exposure, or emotional stress.
intensity of angina pain or discomfort is
not affected by cough or a change in
In contrast, Mr Rogers has
described his symptoms as being worse at
night when lying down and says his
symptoms are not relieved by rest.
Hiatus hernia – occurs when a portion
of the stomach protrudes through the
diaphragmatic oesophageal hiatus
(small opening in the diaphragm
through which the oesophagus
Predisposing factors include
advanced age (due to age-related
muscle weakening and loss of tissue
elasticity), pregnancy and obesity.3,5,6
Hiatus hernias are particularly common
in Western countries. This may be
related to the high prevalence of
low-fibre diets, which can result in
chronic constipation and straining
during bowel movements, leading to an
increase in intra-abdominal pressure.
Although hiatus hernias are generally
asymptomatic, some people experience
new or worsening symptoms of gastro-
This results from
a loss of lower oesophageal sphincter
pressure, causing reflux of gastric
contents into the oesophagus and
prolonged oesophageal mucosa acid
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