A 50-year-old female patient was admitted to the hospital with complaints of breathlessness, coughing, bilateral pedal edema, anasarca, and constipation. She has a history of hypertension and congestive cardiac failure. Laboratory tests and imaging showed mild hepatomegaly, low hemoglobin, and grossly normal echocardiogram. She was diagnosed with congestive cardiac failure secondary to hypertension. Her symptoms improved with diuretic and cardiac medication over her hospital stay.

1. CONGESTIVE CARDIAC
FAILURE IN A K/C/O
HYPERTENSION
• AJITA SADHUKHAN
• PHARM D 4TH YEAR
• ROLL No. – 1
• ENROLLMENT No. - 150821207001
26-03-2020
1

2. SUBJECTIVE EVIDENCE :-
Patient IPD No. 18017062
Department Female Medicine Ward II
Gender Female
Age 50 years
Weight 88 Kg
Date of Admission 18.9.18
Date of Discharge 25.9.18
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3. Reason for admission :
C/O:
- constipation (today)
- breathlessness
- coughing
- b/l pedal edema since 7 days
- anasarca
Past Medical History :
- k/c/o HTN and CCF
Past Medication History: NAD
Family and Social History: NAD
Previous Allergies: NKA
Pregnancy Status: NAD
Bowel habits: Regular
Bladder habits: Decreased
Built: Obese
Appetite: Decreased
Sleep: Disturbed
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Temperature: 98.6 F
Pulse: 84 bpm
Respiration: increased
B.P.: 140/90 mm Hg
CNS: conscious and oriented
SpO2: 97% with RA
CVS: Basal crepts
RS: b/l crepts +
PA: Distended

4. Complete Blood Count (18.09.2018)
LABORATORY
PARAMETERS
OBSERVED VALUE NORMAL RANGE UNIT
Hb 8.9 12.5-16 g/dL
WBC 13150 4000-10500 /mcgL
Neutrophils 81 50-70 %
Eosinophils 02 0-7 %
Lymphocytes 15 20-40 %
Monocytes 02 <10 %
Basophils 00 <1 %
RBC 3.75 4.20-5.40 Millions/mcgL
MCH 23.7 27-31 pg
Platelets 304000 1.5-4.5*10^5 /mcgL
MCV 80 78-100 fL
Hematocrit (PCV) 30 37-47 %
MCHC 29.7 32-36 g/dL
RDW-CV 13.6 11-14.6 %
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5. SERUM ELECTROLYTES: (18.09.2018)
LABORATORY
PARAMETERS
OBSERVED VALUE NORMAL RANGE UNIT
Na+ 137 130-145 mEq/L
K+ 4.6 3-5 mEq/L
Cl- 98 98-106 mEq/L
Ser. Creatinine 1.1 up to 1.5 mg/dL
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SERUM ELECTROLYTES: (22.09.2018)
LABORATORY
PARAMETERS
OBSERVED VALUE NORMAL RANGE UNIT
Na+ 135 130-145 mEq/L
K+ 4.4 3-5 mEq/L

6. • 18.09.2018
1. Troponin 1 Detection: Negative
2. ECG Report: Sinus Rhythm, Low T wave
(V2)
3. Urine Analysis:
a. Physical Examination:
i. Appearance: Hazy
b. Chemical Examination:
i. Blood: 3+
c. Microscopic Examination:
i. Pus cells: 10-12/HPF (0-10)
ii. RBCs: 10-12/HPF (0-10)
4. USG (Abd. & Pelvis): Mild
Hepatomegaly
• 19.09.2018
Thyroid Function Test: TSH (2nd generation):
0.24 uIU/mL (0.3-5.0)
• 20.09.2018
1. Thyroid Function Test: TSH (2nd generation): 2.3
uIU/mL (0.3-5.0)
2. Lipid Profile:
i. Se. Cholesterol: 113 mg/dL (desirable)
ii. Se. Triglyceride: 121 mg/dL (desirable)
iii. Se. HDL Cholesterol Direct: 14.5 mg/dL (low)
iv. Se. LDL Direct: 48.3 mg/dL (optimal)
v. Se. VLDL Cholesterol/HDL Ratio: 2.7901 (0-4.9)
vi. Se. LDL/HDL Cholesterol: 1.1926 (upto 3.5)
3. 2D Echo: Grossly normal 2D
echocardiography
• 21.09.2018
USG (Renal Doppler): Normal
• 23.09.2018
Thyroid Function Test:
i. Free T3: 3.83 pg/mL (2.0-4.4)
ii. Free T4: 1.41 ng/mL (0.8-2.0)
iii. TSH (2nd generation): 2.10 uIU/mL (0.3-5.0)26-03-2020 6

7. ASSESSMENT
• Provisional Diagnosis: CCF with HTN
• Justification:
• A 50 year old female patient was admitted to female
medicine ward unit 3 with complaints of breathlessness,
coughing, bilateral pedal oedema, anasarca since 7 days
and constipation today. The patient was obese and is a
k/c/o HTN.
• Based on subjective evidence, past medical history and
blood pressure, the patient was diagnosed with
congestive cardiac failure in a K/C/O hypertension.
26-03-2020 7
Final Diagnosis:
Congestive cardiac
failure in a K/C/O
hypertension

8. GOALS OF TREATMENT
• Hypertension:
• The overall goal is to reduce morbidity and mortality by at least intrusive
means possible.
• JNC 7 guidelines recommend goal B.P. less than 140/90 mm Hg for most
patients, less than 140/80 mm Hg for patients with Diabetes Mellitus, and
less than 140/80 mm Hg for patients with CKD who have persistent
albuminuria (>30 mg urine albumin excretion per 24 hours)
• Congestive Cardiac Failure:
• Improve quality of life, relieve or reduce symptoms, prevent or minimize
hospitalizations, slow disease progression and prolong survival.
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9. TREATMENT OPTIONS
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• Hypertension:

10. • Congestive Cardiac Failure:

11. Day 1: 18.9.18
• Temp. normal
• Pulse: 102 bpm
• BP: 150/90 mm Hg
• SPO2: 97% @ RA
• RS: B/L crepts +
• Pedal oedema +
• CNS: conscious and oriented
• UOP = 2450 cc
• GC: poor
• P/A: soft
26-03-2020 11

12. Day 1 Medication Chart
26-03-2020 12
DRUG DOSE ROUTE FREQUENCY INDICATIONS
Tab. Bisacodyl 2 tab (5 mg each) P.O. HS Contipation
Inj. Furosemide 40 mg
20 mg
I.V. Stat
6 hrly
Pedal oedema
Tab. Spironolactone 20 mg P.O. 1-1-0 CCF
Inj. Ranitidine 1 amp. P.O. 8 hrly Acidity
Inj. Ondansetron 1 amp. P.O. 8 hrly Emesis
Tab. Atorvastatin +
Aspirin
10 mg + 75 mg P.O. 0-0-1 Hyperlipidemia

13. Day 2: 19.9.18
• Temp. normal
• Pulse: 89 bpm
• BP: 140/90 mm Hg
• SPO2: 97% with RA
• RS: clear, B/L crepts +
• CNS: conscious and oriented
• PA: soft
• UOP: 1940 cc
• Pedal oedema decreased
• Ix: cardio ref. today, shift to ward,
Renal Doppler, USG (KUB), Lipid
profile, LFT
26-03-2020 13

14. Day 2 Medication Chart
26-03-2020 14
DRUG DOSE ROUTE FREQUENCY INDICATIONS
Tab. Bisacodyl 2 tab (5 mg each) P.O. HS Contipation
Inj. Furosemide 40 mg
20 mg
I.V. Stat
6 hrly
Pedal oedema
Tab. Spironolactone 20 mg P.O. 1-1-0 CCF
Inj. Ranitidine 1 amp. P.O. 8 hrly Acidity
Inj. Ondansetron 1 amp. P.O. 8 hrly Emesis
Tab. Atorvastatin +
Aspirin
10 mg + 75 mg P.O. 0-0-1 Hyperlipidemia

15. Day 3: 20.9.18
• Temp. normal
• Weight: 88 Kg
• Pulse: 107 bpm
• BP: 130/80 mm Hg
• SPO2: 97%
• RS: NAD
• CVS: NAD
• CNS: NAD
• PA: soft
• No fresh complaints, GC stable, stool not passed
• Adv: FD/SRD, daily weight monitoring
26-03-2020 15

16. Day 3 Medication Chart
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DRUG DOSE ROUTE FREQUENCY INDICATIONS
Tab. Bisacodyl 2 tab (5 mg each) P.O. HS Contipation
Inj. Furosemide 40 mg
20 mg
I.V. Stat
6 hrly
Pedal oedema
Tab. Spironolactone 20 mg P.O. 1-1-0 CCF
Inj. Ranitidine 1 amp. P.O. 8 hrly Acidity
Inj. Ondansetron 1 amp. P.O. 8 hrly Emesis
Tab. Atorvastatin +
Aspirin
10 mg + 75 mg P.O. 0-0-1 Hyperlipidemia

17. Day 4: 21.9.18
26-03-2020 17
• Temp. normal
• Weight: 85 Kg
• RBS: 132 mg/dL
• Pulse: normal
• BP: 140/90 mm Hg
• SPO2: 97%
• RS: NAD
• CVS: NAD
• CNS: NAD
• c/o b/l and lateral pedal oedema, stool not passed (since 3 days), breathlessness,
giddiness
• Adv: FD/SRD, daily weight monitoring; Ix: ECG, Send F (free) T3, F T4, TSH
• 2 tab. Dulcolax stat, inj. Lasix (20) IV TDS, Tab. Aldactone (25) 1-1-0, Tab. Dan P stat

18. Day 4 Medication Chart
26-03-2020 18
DRUG DOSE ROUTE FREQUENCY INDICATIONS
Tab. Bisacodyl 2 tab (5 mg each) P.O. HS Contipation
Inj. Furosemide 40 mg
20 mg
I.V. Stat
6 hrly
Pedal oedema
Tab. Spironolactone 20 mg P.O. 1-1-0 CCF
Inj. Ranitidine 1 amp. P.O. 8 hrly Acidity
Inj. Ondansetron 1 amp. P.O. 8 hrly Emesis
Tab. Atorvastatin +
Aspirin
10 mg + 75 mg P.O. 0-0-1 Hyperlipidemia

19. Day 5: 22.9.18
• Temp. normal
• Weight: 86 Kg
• Pulse: 112 bpm
• Respiration: normal
• c/o bodyache, anorexia, muscle pain, stool not passed
• BP: 140/90 mm Hg
• SPO2: 95% with RA
• RS: NAD
• CVS: NAD
• CNS: NAD
• Ix: F T3, F T4, TSH, Na+, K+, ECG
• Adv: FD/SRD, daily weight monitoring, plan CAG, Pulmonary CT, angio to rule out
chronic pulmonary thromboembolism
• 2 tab. Dulcolax stat, Discoline 100 mL syringe 10 mL 1226-03-2020 19

20. Day 5 Medication Chart
26-03-2020 20
DRUG DOSE ROUTE FREQUENCY INDICATIONS
Tab. Bisacodyl 2 tab (5 mg each) P.O. HS Contipation
Tab. Diclofenac +
Paracetamol
50 mg +500 mg P.O. Stat Analgesic
Tab. Spironolactone +
Torsemide
25 mg + 10 mg P.O. 1-1-0 CCF
Inj. Ranitidine 1 amp. P.O. 8 hrly Acidity
Inj. Ondansetron 1 amp. P.O. 8 hrly Emesis
Tab. Atorvastatin +
Aspirin
10 mg + 75 mg P.O. 0-0-1 Hyperlipidemia

21. Day 6: 23.9.18
• Temp. normal
• Weight: 88 Kg
• Stool not passed
• Pulse: 110 bpm
• BP: 166/96 mm Hg
• SPO2: 96%
• RS: NAD
• CVS: NAD
• CNS: NAD
• Adv: FD/SRD, daily weight monitoring, NBM today morning, plan pulmonary
CT, angio
26-03-2020 21

22. Day 6 Medication Chart
26-03-2020 22
DRUG DOSE ROUTE FREQUENCY INDICATIONS
Inj. Multivitamins +
Normal Saline
1 amp. + 100 mL I.V. OD @ 40 mL/hr Multivitamin Supplement +
electrolyte balance
Tab. Spironolactone +
Torsemide
25 mg + 10 mg P.O. 1-1-0 CCF
Inj. Ranitidine 1 amp. P.O. 8 hrly Acidity
Inj. Ondansetron 1 amp. P.O. 8 hrly Emesis
Tab. Atorvastatin +
Aspirin
10 mg + 75 mg P.O. 0-0-1 Hyperlipidemia

23. Day 7: 24.9.18
• Temp. normal
• Stool not passed since 2 days
• Weight: 85 Kg
• Pulse: 80 bpm
• BP: 120/80 mm Hg
• SPO2: 98%
• RS: NAD
• CVS: NAD
• CNS: NAD
• PA: soft
• No fresh complaints, GC stable
• Adv: FD/SRD, daily weight monitoring, plan CAG, NBM today, CT pulmonary
angio, PFT, F/U reporting
• Neb. With Duolin 1-1-1-1, Neb. With Budocort 1-0-126-03-2020 23

24. Day 7 Medication Chart
26-03-2020 24
DRUG DOSE ROUTE FREQUENCY INDICATIONS
Inj. Multivitamins +
Normal Saline
1 amp. + 100 mL I.V. OD @ 40 mL/hr Multivitamin Supplement +
electrolyte balance
Tab. Spironolactone +
Torsemide
25 mg + 10 mg P.O. 1-1-0 CCF
Inj. Ranitidine 1 amp. P.O. 8 hrly Acidity
Inj. Ondansetron 1 amp. P.O. 8 hrly Emesis
Tab. Atorvastatin +
Aspirin
10 mg + 75 mg P.O. 0-0-1 Hyperlipidemia
Neb. Levosalbutamol +
Ipratropium Bromide
50 mcg + 20 mcg Nasal 1-1-1-1 B/L crepts
Neb. Budesonide 200 mcg Nasal 1-0-1 B/L crepts

25. Day 8: 25.9.18
• Temp. normal
• Stool not passed since 4-5 days
• Pulse: 84 bpm
• BP: 120/80 mm Hg
• SPO2: 99%
• RS: NAD
• CVS: NAD
• CNS: NAD
• PA: NAD
• GC stable
• Adv: FD/SRD, daily weight monitoring, F/U with reports to physician, PFT,
Discharge patient26-03-2020 25

26. Day 8 Medication Chart
26-03-2020 26
DRUG DOSE ROUTE FREQUENCY INDICATIONS
Inj. Multivitamins +
Normal Saline
1 amp. + 100 mL I.V. OD @ 40 mL/hr Multivitamin Supplement +
electrolyte balance
Tab. Spironolactone +
Torsemide
25 mg + 10 mg P.O. 1-1-0 CCF
Inj. Ranitidine 1 amp. P.O. 8 hrly Acidity
Inj. Ondansetron 1 amp. P.O. 8 hrly Emesis
Tab. Atorvastatin +
Aspirin
10 mg + 75 mg P.O. 0-0-1 Hyperlipidemia
Neb. Levosalbutamol +
Ipratropium Bromide
50 mcg + 20 mcg Nasal 1-1-1-1 B/L crepts
Neb. Budesonide 200 mcg Nasal 1-0-1 B/L crepts

27. Discharge Medication Chart
26-03-2020 27
Adv.:
(i) Take the above medications for 7 days
(ii) come for follow up on next Monday or Thursday at OPD No- 11
DRUG DOSE ROUTE FREQUENCY
Tab. Ecospirin AV (75 +10) mg PO 0-0-1
Tab. Rbson D (20 + 30) mg PO 1-0-1
Tab. Dytor Plus (25 + 10) mg PO 1-1-0

28. GOALS ACHIEVED
• No fresh complaints
• Pedal oedema decreased.
• General condition stable.
• Blood pressure controlled.
26-03-2020 28

29. POINTS TO BE INTERVENED WITH THE
DOCTOR
26-03-2020 29
• Drug Interactions:
• Major:
i. Aspirin + Furosemide: Concurrent use of loop diuretics and NSAIDs may result in
reduced diuretic effectiveness and possible nephrotoxicity. During concomitant use of
NSAIDs and diuretics, monitor signs of worsening renal function and assure diuretic
efficacy, including appropriate effects on blood pressure.
ii. Aspirin + Spironolactone: Concurrent use of NSAIDs and potassium sparing diuretics
may result in reduced diuretic effectiveness, hyperkalaemia or possible nephrotoxicity.
When concurrent use is necessary, monitor for signs of worsening renal function and
assure diuretic efficacy, including appropriate effects on blood pressure.
iii. Aspirin + Torsemide: Concurrent use of loop diuretics and NSAIDs may result in reduced
diuretic effectiveness and possible nephrotoxicity. During concomitant use of NSAIDs
and diuretics, monitor signs of worsening renal function and assure diuretic efficacy,
including appropriate effects on blood pressure.

30. PATIENT COUNSELING
26-03-2020 30
• ABOUT DISEASE:
i. HTN: Hypertension is a persistent increase in blood pressure above 120/80 mm Hg. It is one of
the most common worldwide diseases afflicting humans and is a major risk factor for stroke,
myocardial infarction, vascular disease, chronic kidney disease. It is a highly manageable disease
and easily treatable with correct medication and adherence to therapy.
ii. CCF: Congestive Cardiac Failure is a clinical syndrome in which the heart fails to pump blood at
the rate required by the metabolizing tissues or in which the heart can do so only with an
elevation in filling pressure. It is a treatable disease that can be easily managed with medications
and proper diet.
• ABOUT DRUGS:
➢Educate patients about the medications.
i. Tab. Ecospirin AV: it is a combination of Atorvastatin (10 mg) and Aspirin (75 mg) that is used to prevent
heart attack and stroke. Take one tablet at night with food to help avoiding stomach upset. Swallow it as a
whole. Do not chew, crush or break it. Common side effects include indigestion, diarrhoea, headache, etc.
notify your doctor if you are tired than usual, do nott feel hungry, or if you have yellow eyes, skin, muscle
symptoms (pain or weakness), particularly if you have fever, a sick feeling or dark urine.
ii. Rbson D: It is a combination of Domperidone (30 mg) and Rabeprazole (20 mg) given for acidity and
heartburn. Take is medicine in the dose and duration as advised by your doctor. Swallow it as a whole. Do
not chew, crush or break it. It is to be taken on empty stomach preferably 30 minutes before food. Inform

31. your doctor if you get watery diarrhoea, fever or stomach that does not go away. Long
term use can cause weak bones and deficiency of minerals such as magnesium.
iii. Dytor Plus: It is a combination of Spironolactone (25 mg) and Torsemide (10 mg) given
to treat pedal oedema. Swallow the tablet as a whole. Do not chew, crush or break it. Take
this medicine in the dose and duration as advised by your doctor. It may be taken with or
without food, but it is better to take it at a fixed time. Common side effects include
electrolyte imbalance, hypomagnesemia, hyponatremia, hypouricaemia, hypocalcaemia.
• LIFESTYLE MODIFICATIONS:
i. Reduce sodium intake to no more than 2.4 g or 6 g sodium chloride.
ii. Maintain adequate intake of dietary potassium (tender coconut, banana, spinach)
iii. Maintain adequate intake of dietary calcium and magnesium for general health (dairy
products, spinach, legumes, sprouts).
iv. Reduce intake of dietary saturated fat and cholesterol for overall cardiovascular health.
v. Engage in aerobic activities for at least 30 minutes daily (mild walking)
vi. Reduce your fluid intake.
vii. Reduce stress (meditation).
viii. Follow DASH diet.26-03-2020 31

32. Diet Plan

33. REFERENCES :
• A textbook of Pharmacotherapy : By Joseph P. Dipiro and Robert L.
Talbert, 7th Edition, Mc-Graw Hill Publications
• Medscape
• Cims
• Micromedex
• Mayoclinic.com

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