pneumonia-case study

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1 I.C.C.U Case Presentation Acute coronary syndromes (unstable angina) Done By :- Mustafa Adnan Malki

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2 Name :- S. M Gender :- Male . Age :- 37 years . Height :- 175 cm . Weight :- 70 kg . Admission Date :- 29/12/1432 Nationality :- Saudi. Unit :- I.C.C.U IBW = 69 -75kg (ideal weight)

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3 Objective :- Family history

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4 Objective :- Time/ Date Temp. HR/min (60 -100 ) BP ( mmgh ) (120/80) R.R /min (15-20) O2 saturation % 29.12.32 37.4 C 53 101/60 18 95% 30.12.32 37.3 c 64 100/64 20 93% The patients is conscious , oriented with spontaneous breathing.

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5 Test – result – normal range Na 139 (136-145mmol/l) Albumin 4.7 (3.4-4.8g/dl ) Urea 17 (10-50) Creatinin 0.84 (0.5 – 1.2 mg/dl) SGPT (ALT ) 18 (0-50) SGOT (AST) 10 (10-50) Fasting glucose 104(65-115 mg/dl) Phosphorus 1.2 (0.87-1.45 mg/dl) Calcium 9.4 ( 8.9 – 10.2 mg/dl ) Cholesterol 120 (120-200 mg/dl ) Potassium 3.6 (3.5-5.3 mmol /l) Mg 0.99 (0.66-1.07 mmol /l) A ) Biochemistry Normal liver function normal Kidney function Cardiac Enzymes CPK 49 (39-308 U/L ) CK-MB 12 (7-25 U/L ) Troponin 0 ( 0-0.090 ng /m ) .

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6 Test – result – normal range WBC 5.9 (4-10) HGB 14.6 (13 – 18 ) HCT 41.3 (42-52) Hematocrit platelet count 263 (140-400) MCV 88 (83-101) mean corpuscular volume Coagulation profile PT 11.5(10-15) Prothrombin time (plasma clot) PTT 39.9 (26-40) Partial thromboplastin time (blood clot) INR 0.96 (0.90 – 1.20) (for monitoring of anticoagulant action) . B ) Hematology

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7 Lungs :- normal . heart :- normal . abdomen :- normal . - nervous system :- normal . ECG :- No ST Segment elevation . Echo :- * no wall motion abnormality , * mild mitral valve prolapse , * E.F : 57 % (55-70) . Acute coronary syndrome with unstable angina

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8 ECG (electrocardiogram ) Electrical leads from the ECG machine are taped to the chest, legs and arms and a recording is made of the electrical activity of the heart . Echocardiogram The probe sends ultrasound beams into your body and their reflections are detected and used to generate images of the heart.

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9 Current Medications :- 4 ) Treatments prior to admission:- No previous treatments were taken . Time Medications 29/12/32 - Acetyl salicylic acid 81 mg P.O daily. Clopidogril 75 mg orally once daily . Simvastatin 40 mg P.O daily. Isosorbide dinitrate 20 mg P.O /12 h. Amlodipine 2.5 mg P.O once daily. Ranitidine 150 mg orally / 12 h . Enoxaparin 60 mg S.C /12 h . Morphine sulphate 2mg i.v (Stat. dose)

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10 1) Smoking . 2) Having family history of coronary artery disease ( CAD) .

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13 Therapy Indication Comments Acetyl salicylic acid 81 mg P.O daily. unstable angina (anticoagulant agents) - contaminant use of these 2 anticoagulant agents is class 1 recommendation for Angina patients (3) .. AHA . - Right recommended dose for both (4) . Enoxaparin 60 mg S.C /12 h . Clopidogril 75 mg orally once daily . Although it is recommended as alternative of ASA in patients having ASA allergy (3) , it also recommended to reduce CVE’S with angina patients (5) . Simvastatin 40 mg P.O daily. Cardiovascular events , prophylaxis Right recommended dose (4). but the dose should reduced in this situation . .

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14 Therapy Indication Comments Amlodipine 2.5 mg P.O once daily. ( ca channel blocker .. Relaxation of coronary artery > blood flow . unstable angina . 5 mg p.o daily is the recommended dose for unstable angina (4) Isosorbide dinitrate 20 mg P.O /12 h. ( dilatation of peripheral arteries and veins) unstable angina (Long-term Prophylactic Management) Right recommended dose (4). Ranitidine 150 mg orally / 12 h Stress ulcer , prophylaxis Right recommended dose (4) . Morphine sulphate 2mg i.v (Stat. dose) pain management given to control chest pain as state dose .

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Plan 15 Drug-drug interaction Severity the resultant effect monitoring Simvastatin 40mg + amlodipine Major Amlodipine increase Sr Con. Of simvastatin. Avoid use simvastatin with dose more than 20 mg . If indicated , use lower simvastatin dose with closely monitoring for simvastatin toxicity. amlodipine + isosorbide dinitrate Moderate Synergistic hypotensive effects Monitor B.P regularly. - Advise the patients about the symptoms hypotension. ASA + clopidogril + enoxaparin Moderate Increase risk of bleeding . - monitor for reduced platelet function and . - Monitor signs and symptoms of bleeding . 1 ) Drug interactions (4) dailymed.nlm.nih.gov/ dailymed / drugInfo.cfm

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Normal liver and kidney function >> No Need for dose adjustment . Dose Adjustment - Continue current therapy and change amlodipine dose into 5 mg P.O once daily instead of 2.5 mg. P.O once daily. - Use lower simvastatin dose(20 mg once daily).

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17 3) Early restoration of blood flow to the heart and to prevent complete occlusion and MI (in unstable angina )

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18 Drug monitoring test or ADR requiring monitoring ASA , clopidogril and enoxaparin CBC Liver function test . Bleeding time . Isosorbide dinitrate Liver function test . Hypotension . Simvastatin Liver function test . Amlodipine - Fatigue , palpitation ,hypotension . Ranitidine CBC Constipation .

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21 1) Smoking cessation with an individualized plan, which may include nicotine replacement therapy. 2) Regular physical exercise such as brisk walking, swimming for at least 30 minutes on at least three days per week. 3) A diet low in saturated fat and dietary cholesterol is recommended .

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22 Surgery ( BACE ( Basal Annuloplasty of the Cardia Externally ) may be done to treat underling cause (MVP) Future plan :-

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Thank you

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1) 2011 ACCF/AHA Focused Update of the Guidelines for the Management of Patients With Unstable Angina/ Non–ST-Elevation Myocardial Infarction (Updating the 2007 Guideline ) 2) Micromedex software , android .

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