A case presentation on Coronary artery disease followed by S.O.A.P analysis.

1. A CASE PRESENTATION ON
CORONARY ARTERY DISEASE
PRESENTED TO:
DR.
Swathi(Asst.Professor))
PRESENTED BY:
Mahesh Gomasa
Roll. No. 18CE1T0010
Bharat School of Pharmacy

2. INTRODUCTION :
 Coronary artery disease is the narrowing or blockage of the coronary arteries,
usually caused by atherosclerosis.
 The plaques can restrict blood flow to the heart muscle by physically clogging
the artery or by causing abnormal artery tone and function.
 Without an adequate blood supply, the heart becomes starved of oxygen and
the vital nutrients it needs to work properly. This can cause chest pain called
angina, a heart attack (injury to the heart muscle) may occur.
CAUSES :
 Smoking
 High blood pressure
 High cholesterol
 Diabetes or insulin resistance
 Sedentary lifestyle...

3. PATIENT PROFILE :
Patient name: XXX
Age:43yrs
Wt: patient unable to stand
Gender: Male
IP.NO: 9169
Dt.of Admn: 26/08/19
Dept: Cardiology, ward(ICCU)
Chief Dr. :S.K.Sahu.
CHIEF COMPLAINTS :
C/O of SOB grade II –IV associated with fever and cough.
Severe chest pain from 4days.

4. VITALS:
Day 1
Temperature 99°F
Pulse rate 69 beats/min
Blood pressure 130/70mmHg
Heart rate 67
Sp02 94
GRBS 276mg/dL

5. PROVISIONAL DIAGNOSIS :
*CAD- ARDS
*ACS- moderate LV dysfunction
*AKI(Acute kidney injury)
*Dyselectrolemia- Hypokalemia

6. :LAB INVESTIGATION
FINAL DIAGNOSIS:
CAD. (Coronary artery disease)
PARAMETERS NORMAL RANGE REPORTED VALUE
Haemoglobin 13.5-17.5g/dL 17.0gdL
Neutrophills 40-70% 55%
Wbc's 40-55% 47%
Lymphocytes 20-40% 31%
Eosinophils 1-6% 3%
Monocytes 2-10% 7%

7. TREATMENT CHART:
S.
No
01
02
03
04
05
06
07
08
BRAND NAME GENERIC NAME CATEGORY
Tab. Renosave Acetylene+Taurine Mucolytic
Inj.Lasix Furosemide Diuretics
Tab. Aldactone Spiranolactone K+.sparing
diuretic.
Tab. Ecospirin Aspirin Antiplatelet agent
Tab. Clavix Clopidogril Antiplatelet agent
Tab. Razel Rosuvastatin Statins
Tab. Concor Bisoprolol Crd. Selected.
But. Blockers
Tab. Ivabid Ivabradine C. Vs. Agent
DOSE Route Freq.
1.tab Po Bd
20mg Iv Tid
25mg Po Od
150mg Po Od
75mg Po Bd
20mg Po Od
2.5mg Po Od
5mg Po Bd
1 2
√ √
√ √
√ √
√ √
√ √
√ √
√ √
√ √

8. 09
10
11
12
13
14
15
16
Inj. Pan Pantoprazole P. P. Inhibitor
Tab. Rivotril Clonazepam Benzodiazepin
e
anticonvulsant
Syp. Lactihep Lactilol Laxative
Inj. EpimeTz Cefepime+tazo
bactum
Cefalosporins
Inj. HAI Heparin Anti -diabetic
agent
Inj. Doxy Doxycycline Tetracycline
Tab. Montek Monlelukast+A
cebrophylline
LeukotrieneRe
ceptorblocker
Tab. Stalopam
+
Esitalopram+Cl
onazepam
Selec.serotoni
nReuptakeInhi
bitor
40mg iv Od
0.5mg Po Od
15ml Po Hs
1.125mg Iv Bd
Acc-grbs S/c Tid
100mg Iv Bd
1tab Oral Bd
10/0.5
mg
Oral Od
√ √
√
√
√ √
√ √
√ √
√ √
√ √

9. SOAP ANALYSIS

10. SUBJECTIVE EVIDENCE:
A 43yr.old male was admitted with chief complaints of SOB grade -
II-IV associated with fever and cough. These symptoms are since
4days
OBJECTIVE EVIDENCE:
On examining the lab details it is noted that there is slight change
ASSESSMENT:
Based on the subjective and objective evidence it is diagnosed as
CAD -Coronary artery disease.

11. PLANNING:
ABOUT DRUGS:
1)Renosave:
Class:Mucolytic, Antidote
MOA:It acts as a hepatoprotective agent by restoring hepatic
glutathione by opening disulphide bonds in mucoproteins and
lowers mucus viscosity
2) LASIX:
Class:Diuretics
MOA:It blocks the absorption of sodium &chloride in the kidney
tubules
3)ALDACTONE:
Class:Potassium sparing diuretics

12. MOA:These increases urination without loss of potassium.
4)ECOSPIRIN:
Class:Antiplatelet agent
MOA:It is a inhibitor of both prostaglandins synthesis and platelets
aggregation which irreversibly inactivates Cox via Acetylation.
5) CLAVIX:
Class:Antiplatelet agent
MOA:It is a inhibitor of platelet activation and agression through the
irreversible binding of its active metabolitrs to the P2Y12 class of ADP
receptors on platelets
6) RAZEL:
Class:Statins
MOA:It is a competitive inhibitor of HMG-CoA reductase rate limiting
enzyme;this limits the conversation of 3-hydroxy 3-methylhlutaryl-co
enzymeA to Mevalonate, a precursor of sterols, including cholesterol
7) CONCOR
Class:Cardioselective beta blocker
MOA:It competitively blocks the beta1 receptors with little or no

13. 8) IVABID:
Class:Miscellaneous cardiovascular agent's
MOA:It blocks hyperpolarisation activated cycliccyclic nucleotide
gated channel responsible for the cardiac pacemaker if current
9) RIVOTRIL:
Class:Benzodiazepine anti convulsants
MOA:It binds to the Benzodiazepine site of GABA receptors and
produces sedative, anxiolytic, muscle, relaxing
10) LACTIHEP(syp)
Class:Laxative
MOA:Lactihep makes the stool soft and promotes easy bowel
movement
11) EPIME-Tz

14. Class:4th generation cephalosporins, beta lactamase inhibitors
12) DOXY:
Class:Tetracycline
MOA:It inhibits potassium synthesis
13) Montek-Ab
Class:Leukotriene receptor antagonist
14) STALOPAM-PLUS
Class:Selective serotonin Reuptake inhibitor, Benzodiazepine anti-
convulsants.

15. PATIENT COUNSELLING:
ABOUT DISEASE:
 Coronary artery disease is the narrowing or blockage of the coronary arteries, usually
caused by atherosclerosis.
 The plaques can restrict blood flow to the heart muscle by physically clogging the
artery or by causing abnormal artery tone and function.
 Without an adequate blood supply, the heart becomes starved of oxygen and the vital
nutrients it needs to work properly. This can cause chest pain called angina, a heart
attack (injury to the heart muscle) may occur.
ABOUT DRUGS:
 LASIX: Drink enough water while talking LasixLasix
 ALDACTONE:Best to take in morning hours to avoid sleep disturbences for
urination
 ECOSPIRIN:Take along with food to avoid gastric problems

16.  LACTIHEP: 15-30ml/day ;once a day at meals
 CLAVIX: Taken with or without food at around same timing every day.
 IVABID:Usually 2times a day at around Same timing every day.
 DOXY:2times a day with full galss of water for each dose.
 MONTEK: Unless necessary a pregnant women should not be taken as it excrete through
milk.
LIFE STYLE MODIFICATIONS:
 Control blood glucose levels
 Maintain normal blood pressure
 Take healthy diet
 Control body weight
 Smoking cessation
 Avoid alcohol drinking

17. THANK YOU...