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1. Presenting by A.J.VISHALI

2. PATIENT DEMOGRAPHIC DETAILS
 NAME: xxx
 AGE:47 yrs
 DEPARTMENT:CARDIOLOGY
 IP NO:IPC1600000894
 BLOOD GROUP: “B”+ve

3. SOAP ANALYSIS
S-SUBJECTIVE EVIDENCE
C/O profused sweating, discomfort, weakness, can’t
able to stand
social history: nothing significant
past medical history : known hypertension, non
diabetic presented with right sided chest pain
associated with profuse sweating –CAD- acute inferior
wall MI , taken up primary PTCA/STENT.

4. Final diagnosis: CAD – acute IWMI , SR mild LV
dysfunction , CAG – two vessel disease, primary
PTCA/STENT to RCA

5. O-OBJECTIVE EVIDENCE
S.NO TEST ABNORMAL
VALUE
NORMAL
VALUE
1. RANDOM
BLOOD
SUGAR
189mg/dl 70-150mg/dl
2. APTT 56sec 30-40sec
3. PCV 38% 40-54%
4. WBC COUNT 10,300
num/ul
4000-10,000
num/ul

6. A-ASSESSMENT
from subjective and objective evidence patient is
suffering from
Coronary artery disease

7. P-PLANING
S.NO DRUG NAME GENERIC
NAME
DOSE FREQ/ROUT
E
1. Tab ecosprine Aspirin 150mg BD/oral
2. Tab clopitab Clopidogrel 75mg BD/oral
3. Tab pletoz Cilostazol 100mg BD/oral
4. Tab tonact Atorvastatin 40mg OD/oral
5. Tab restyl Alprazolam 0.5mg OD/oral
6. Tab metolar Metoprolol 25mg BD/oral
7. Tab pantocid pantoprazole 40mg OD/oral

8. MECHANISM OF ACTION
1.Tab Ecosprine (aspirin):
MOA: chemicals like prostaglandins are released when
there is injury, infection or inflammation and this
causes pain and fever. Aspirin decreases the amount of
this chemical in the body by blocking the enzyme that
makes prostaglandins.inhibition of prostaglandin also
reducesthe function of platelets and the ability of
blood to clot.
ADRS: severe allergic reaction

9. 2.Tab clopitab (clopidogrel):
MOA: slowing the platelet from sticking to blood vessels
ADR: tingling sensation, numbness, indigestion
3. Tab pletoz (cilostazol):
MOA: it works by improving blood flow to the legs by
keeping platelet in the blood from sticking
togetherand clotting.

10. ADRS: headache, diarrhea, dizziness, runny nose,
nausea, stomach pain
4. Tab tonact (atorvastatin):
MOA: tonact blocks an enzyme HMG-COA-reductase
that is required in the body to make cholesterol. It
thus lowers the level of cholesterol in the body.
ADRS: joint pain, headache, allergic reaction

11. 5. Tab restyl (alprazolam):
MOA:Benzodiazepines bind nonspecifically to
benzodiazepine receptors BNZ1, which mediates sleep, and
BNZ2, which affects muscle relaxation, anticonvulsant
activity, motor coordination, and memory. As
benzodiazepine receptors are thought to be coupled to
gamma-aminobutyric acid-A (GABAA) receptors, this
enhances the effects of GABA by increasing GABA affinity
for the GABA receptor. Binding of the inhibitory
neurotransmitter GABA to the site opens the chloride
channel, resulting in a hyperpolarized cell membrane that
prevents further excitation of the cell.
ADRS: nausea , drowsiness , fatigue

12. 6. Tab metolar (metoprolol):
MOA: Metolar XR (Metoprolol) is a type of beta-blocker
which is primarily prescribed to treat angina and
hypertension. It works by affecting your heart and
blood circulation, improving your blood flow by
affecting certain substances in your body. It may also
be used by patients recovering from a heart attack.
ADRS: Headache, Upset stomach, Diarrhea,
Constipation
, Vomiting,Tiredness or drowsiness

13. 7. Tab pantocid (pantoprozole):
MOA: Pantoprazole is a selective “proton pump
inhibitor”, a medicine which reduces the amount of
acid produced in your stomach
ADRS: GI disturbances

14. PATIENT COUNSELLING
 Rest
 Light salt limited diet
 Fish and fish oil is good
 Loss weight if over weight
 Reduce stress
 Exercise regularly