case studies

1. Case Presentation
on
Unstable Angina
Presented by
SAGAR DAS

2. Patient details:
 Age : 60 years
 Sex: Female
 Weight: 65 kg
 Date of admission: 20/01/11.
 Date of discharge: 24/01/11.
 Family history : No previous family history

3. Complaints on admission
 C/o Chest pain, giddiness, and 3 episodes of vomiting since today
morning.

4. Subjective evidence:
 C/o Chest pain, giddiness and 3 episodes of vomiting since
today morning.
Objective evidence:
ECG:T-wave inversion.

5. Assessment
From the subjective and objective evidence it is
diagnosed as the patient was suffering from Unstable
Angina.

6. Goals:
Patient Specific:
To relieve the symptoms – chest pain, giddiness and
vomiting.
Disease specific:
To improve the disease condition and to prevent further
complications of Angina.

7. Assessment of Current Therapy
Drugs Dose Rout
e
Freque
-ncy
Day of
Adm.
2 3 4 5
O2 Inhalation 3L/min I N SOS + + + + +
Inj. Rabeprazole 20mg I V 1- 0- 0 + + + + +
Inj. Ondansetron 4 mg I V SOS + + + - -
Tab. Aspirin 325mg Oral Stat + - - - -
Inj. Heparin 5000 U S C 1- 0- 1 + + + + +
Tab. Isosorbide
dinitrate
5mg S L SOS + + + + +
Tab. Atorvastatin 20mg Oral 1- 0-0 + + + + +
Tab. Clopidogrel 75mg Oral Stat + - - - -
Tab. Metoprolol 25mg Oral ½ - 0- 0 + + + + +
Tab. Aspirin+
Clopidogrel
75mg+
75mg
Oral 1- 0- 0 - + + + +

8. Progress chart
Day of
admission
PR 80 bpm
BP 114/70 mm Hg
3 episodes of vomiting.
Day 2 PR 80 bpm
BP 110/80 mm Hg
Vomiting 1 episode.
Day 3 Chest pain reduced
PR 76 bpm
BP 110/60 mm Hg
No complaints of vomiting.
Day 4 Chest pain reduced
PR 70 bpm
BP 120/70 mm Hg
Day 5 Patient feels better

9. Planning :
Discharge Medications:
• Tab. Metoprolol 25mg ½ -0-0
• Tab. Clopidogrel + Aspirin 75 mg +75mg 0-1-0
• Tab. Isosorbide dinitrate 5mg SOS
• Tab. Atorvastatin 20mg 0-0-1
• Tab. Rabeprazole 40mg 1-0-0

10. Monitoring Parameters
 Metoprolol: Bradycardia, heart failure, bronchospasm, hypotension, rash,
depression.
 Clopidogrel: Hemorrhage, abdominal pain, constipation, dyspepsia,
gastritis, UTI, bronchitis, rash, edema, hypertension.
 Aspirin: GI bleeding, leukopenia, thrombocytopenia, angioedema, hearing
loss,rash, urticaria.
 Isosorbide dinitrate :Headache, tachycardia, flushing, palpitations, rash,
hypersensitivity reactions.
 Atorvastatin: Allergic reaction, abdominal pain, dyspepsia, flatulence,
myalgia, increased liver function test results.
 Rabeprazole: Headache.
 Ondansetron: Hypoxia, anaphylaxis, headache, hypotension, abdominal
pain, urine retention,rash.
 Heparin: Hemorrhage, thrombocytopenia, prolonged clotting time,
ulceration.

11. Advise to the Prescriber:
 Clopidogrel: Advise the clinician for prompt treatment if the patient shows
the signs and symptoms of thrombocytopenia.
 Aspirin: Advise clinician to monitor prothrombin time, BUN, serum creatinine
and liver function test results periodically during salicylate therapy to detect
abnormalities.
 Atorvastatin: Advise clinician to check liver function tests and lipid levels
periodically before and after the therapy.
 Heparin: Advise clinician to monitor platelet count and assess patient
regularly for signs and symptoms of abnormal bleeding.

12. Clinical Pharmacist Intervention:
 Drug – Drug interactions:
Clopidogrel + Aspirin - May increase the risk for GI bleeding.
Isosorbide dinitrate + antihypertensives- Additive hypotensive effects.
Heparin + Oral anticoagulants – Increased anticoagulant effect.

13. Patient counselling
 Metoprolol: Advise patient to take exact dose with meals as absorption is
increased.
 Clopidogrel: Instruct patient to report unusual bleeding.
Inform patient that it may take longer time than usual to stop bleeding, so
advise him to stop the activities in which trauma and bleeding may occur.
 Aspirin: Advise patient to take drug with food or after food to avoid GI
upset.
Advise patient receiving high dose, long term aspirin therapy to watch for
bleeding gums and signs of GI bleeding.
 Isosorbide dinitrate: Advise patient to take tablet on empty stomach .
Instruct patient to wet the sub-lingual tablet with saliva, place it under
tongue until it is completely absorbed.
Advise patient to avoid alcohol while taking drug because severe
hypotension, CV collapse may occur.

14.  Advise patient to quit smoking, strenuous exercise and
emotional upset.
 Patient should be advised to take food containing
polyunsaturated fattyacids which help to decrease the levels
of triglycerides, LDL cholesterol in the blood(deep sea fatty
fish, vegetable oils).
 Advise patient to take high fiber diet-Oat meal, beans, peas,
rice bran, barley, citrus fruits, straw berries, apple pulp.
 Advise patient to take lots of fruits, vegetables and grains
which are naturally low in fat and contain no cholesterol.

15. Thank you