This is a case on Diastolic heart failure with Type 2 Diabetes mellitus. Here we have discussed the pharmaceutical care plan (SOAP) about the treatment and non pharmacological approaches to treat the specified conditions

1. HEART FAILURE, HYPERTENSION with TYPE
2 DIABETES MELLITUS

2. Heart Failure

5. • Age: 55 years
• Sex: Female
• Weight: 67 Kg
• Unit: Med 4
• IP No: 283747

6. • Reasons for admission:
C/O breathlessness and wheezing since 2 days
H/O excessive breathlessness more during
activity since 2 days and is progressive in
nature from grade 2 to grade 4.
H/O cough since 1 week.
• PMHx:
k/c/o HTN and T2DM since 20 years and on
regular treatment Enalapril 2.5 mg 1-0-0
and insulin

7. This patient belongs to Stage C (lllb) of Heart
Failure

8. No Hx of TB/ Thyroid/ Cardiac disease
• Allergies:
NKA
• SHx:
NS

9. General examination
• NO Pallor/ Icterus/ Clubbing/ Edema/
Cyanosis
• BP: 160/90 mmHg
• Pulse: 80 BPM
• CVS: S1S2 +, Tachycardia +, No murmurs
• RS: B/L NVBS +, Tachypnoea +
• CNS: NFND
• SpO2: 95%

10. PROVISIONAL DIAGNOSIS
T2DM with HTN with CCF to R/O IHD
? Dilated Cardiomyopathy

11. CARDIOMYOPATHY
Signs of Heart Failure
• Pul. Edema
• S3 gallops
• Cool extremities
• Pleural effusion
• Cheynes stoke respiration
• Tachycardia
• Cardiomegaly
• Increased JVP
• Peripheral edema

12. DAY1
• BP: 160/90 mmHg Pulse: 80 BPM
• CVS: S1S2 +, Tachycardia +, No murmurs
• RS: B/L NVBS +, Tachypnoea +
• CNS: NFND
• SpO2: 95%

13. DAY 1 cont…
• ADV: HCT, RBS, FBS, PPBS, HbA1C, Urea,
Serum Creatinine, Serum electrolytes, Urine
routine, ECG, 2D-ECHO, CXR- PA view,
Fundoscopy.

14. LAB REPORTS
Hematology
Hb:
WBC:
DLC:
•N
•E
•B
•L
•M
Plt:
ESR:
10 g%
7400 cells/ cumm
68%
01%
00%
30%
01%
3.85 lakhs cells/ cumm
120 mm/hr
RBS
UREA
S.Cr
177 mg/dl
90 mg/dl
1.5 mg/dl
Electrolytes
Sodium
Potassium
Chlorides
139 mmol/ L
4.4 mmol/ L
100 mmol /L

15. TREATMENT CHART
Drug Dose R Freq. D
1
Inj. Furosemide 40 mg IV 1-1-0 +
Inj. Insugen – R 4-4-4 SC 1-1-1 +
Tab. Pantoprazole 40 mg PO 1-0-0 +
Syp. Viscofast (Bromohexine + Terbutaline
+ Guanephensin)
5 ml PO Q8H +
Inh. Levosalbutamol + Ipratropium Br 100
mcg +
20 mcg
INH Q8H +
Tab. Telmesartan 40 mg PO 1-0-0 +
Inj. Piperacillin Tazobactum 4.5 g IV 1-1-1 +

16. DAY 2
• BP: 130/70 mmHg Pulse: 80 BPM
• O/E patient was symptomatically better
• C/O Numbness B/L feet (DPN)
• HbA1C: 8.6 FCBG: 141 mg/dl
• SpO2: 96%
• CVS: S1S2 +, no Murmurs
• RS: B/L NVBS +

17. DIABETIC PERIPHERAL NEUROPATHY

18. DAY 2 cont…
• ADV: 2D- ECHO, Thyroid Profile,
Ophthalmologist, Treatment as per chart
• Ophthalmologist opinion:
Moderate DR+ (NPDR)

19. CXR - PA view showing NORMAL and CARDIAC
HYPERTROPHY

21. Fundoscopic differences Between Hypertensive & Diabetic Retinopathy
Hypertensive Retinopathy Diabetic Retinopathy
Retina Dry Wet
Hemorrhages Few Multiple
Edema Rare Extensive
Exudates Rare Multiple
Cotton wool spots Multiple Few
Flame shaped
Hemorrhages
Common Rare
Visually abnormal blood
vessels in retina
Arteries Veins
21

22. TREATMENT CHART
Drug Dose R Freq. D
1
D
2
Inj. Furosemide 40 mg IV 1-1-0 + +
Inj. Insugen – R 4-4-4 SC 1-1-1 + +
Tab. Pantoprazole 40 mg PO 1-0-0 + +
Syp. Viscofast (Bromohexine + Terbutaline
+ Guanephensin)
5 ml PO Q8H + +
Inh. Levosalbutamol + Ipratropium Br 100
mcg +
20 mcg
INH Q8H + +
Tab. Telmesartan 40 mg PO 1-0-0 + +
Inj. Piperacillin Tazobactum 4.5 g IV 1-1-1 + +

23. DAY 3
• BP: 130/80mmHg Pulse: 84 BPM
• CVS: S1S2 +, no Murmurs
• RS: B/L NVBS +
• ADV: Treatment as per chart

24. TREATMENT CHART
Drug Dose R Freq. D
1
D
2
D
3
Inj. Furosemide 40 mg IV 1-1-0 + + +
Inj. Insugen – R 6-6-6 SC 1-1-1 + + +
Tab. Pantoprazole 40 mg PO 1-0-0 + + +
Syp. Viscofast (Bromohexine + Terbutaline
+ Guanephensin)
5 ml PO Q8H + + +
Inh. Levosalbutamol + Ipratropium Br 100
mcg +
20 mcg
INH Q8H + + +
Tab. Telmesartan 40 mg PO 1-0-0 + + +
Inj. Piperacillin Tazobactum 4.5 g IV 1-1-1 + + +

25. DAY 4
• BP: 130/90mmHg Pulse: 82 BPM
• CVS: S1S2 +, no Murmurs
• RS: B/L NVBS +, crepts +
• CBG: 217 mg/dl FCBG: 194 mg/dl
• Urea: 90 mg/dl S.Cr: 1.5 mg/dl
• ECG imp: Left ventricular hypertrophy
• ADV: Repeat urea, Creatinine, ECHO, Urine
Routine

26. TREATMENT CHART
Drug Dose R Freq. D
1
D
2
D
3
D
4
Inj. Furosemide 40 mg IV 1-1-0 + + + +
Inj. Insugen – R 6-6-6 SC 1-1-1 + + + +
Tab. Pantoprazole 40 mg PO 1-0-0 + + + +
Syp. Viscofast (Bromohexine + Terbutaline
+ Guanephensin)
5 ml PO Q8H + + + +
Inh. Levosalbutamol + Ipratropium Br 100
mcg +
20 mcg
INH Q8H + + + +
Tab. Telmesartan 40 mg PO 1-0-0 + + + +
Inj. Piperacillin Tazobactum 4.5 g IV 1-1-1 + + + +

27. DAY 5
• BP: 136/80 mmHg Pulse: 76 BPM
• Urea: 96 mg/dl S.Cr: 1.8 mg/dl
• FCBG: 198 mg/dl PPBS: 232 mg/dl
• O/E Patient symptomatically better
• Thyroid Profile: WNL
• ADV: CST, Nephrologists opinion

28. TREATMENT CHART
Drug Dose R Freq. D
1
D
2
D
3
D
4
D
5
Inj. Furosemide 40 mg IV 1-1-0 + + + + +
Inj. Insugen – R 10-10-10 SC 1-1-1 + + + + +
Tab. Pantoprazole 40 mg PO 1-0-0 + + + + +
Syp. Viscofast (Bromohexine +
Terbutaline + Guanephensin)
5 ml PO Q8H + + + + +
Inh. Levosalbutamol + Ipratropium Br 100 mcg
+ 20 mcg
INH Q8H + + + + +
Tab. Telmesartan 40 mg PO 1-0-0 + + + + +
Inj. Piperacillin Tazobactum 4.5 g IV 1-1-1 + + + + +
Inj. H. Mixtard 0-0-16 SC 0-0-1 +

29. DAY 6
• BP: 174/76 mmHg Pulse: 85 BPM
• CVS: S1S2 +, no Murmurs
• RS: B/L NVBS +
• Patient discharged at request, will be followed
in Nephrology OPD
ECHO: Concentric LVH
LV Diastolic Dysfunction
EF: 74%

30. TREATMENT CHART
Drug Dose R Freq. D
1
D
2
D
3
D
4
D
5
D
6
Inj. Furosemide 40 mg IV 1-1-0 + + + + + +
Inj. Insugen – R 10-10-10 SC 1-1-1 + + + + + +
Tab. Pantoprazole 40 mg PO 1-0-0 + + + + + +
Syp. Viscofast (Bromohexine +
Terbutaline + Guanephensin)
5 ml PO Q8H + + + + + +
Inh. Levosalbutamol + Ipratropium Br 100 mcg +
20 mcg
INH Q8H + + + + + +
Tab. Telmesartan 40 mg PO 1-0-0 + + + + + +
Inj. Piperacillin Tazobactum 4.5 g IV 1-1-1 + + + + + +
Inj. H. Mixtard 0-0-16 SC 0-0-1 + +

31. Discharge medications
Drug Dose R Freq.
Tab. Furosemide 40 mg PO 1-1-0
Inj. Insugen – R 10-10-10 SC 1-1-1
Inh. Levosalbutamol + Ipratropium Br INH Q8H
Tab. Telmesartan 40 mg PO 1-0-0
Inj. H. Mixtard 0-0-16 SC 0-0-1
Tab. Atorvastatin 10 mg PO 0-0-1
Tab. Amlodipine 5 mg PO 1-0-0

32. Pharmaceutical
Care Plan

33. Subjective Evidence Objective Evidence
• Breathlessness
• Wheezing
• Orthopnoea
• Cough
•ECG
•ECHO
•Blood Pressure
•Elevated blood glucose
•S.Cr levels
•Urea levels

34. Final Diagnosis
Based on subjective and objective evidence the
patient was diagnosed with T2- DIABETES
MELLITUS with HYPERTENSION with HEART
FAILURE (Hypertrophic Cardiomyopathy –
Preserved Ejection Fraction) with CHRONIC
KIDNEY DISEASE

35. Goals of Treatment
For Heart Failure:
• Relieve symptoms of central and
peripheral circulatory congestion
• Improve quality of life
• Reduce neurohormonal activation
• Minimize or prevent acute CHF
exacerbations
• Slow progression of CHF
• Increase survival
• Maintain appropriate blood pressure
and lipid values.
• Reduce mortality
For Diabetes mellitus:
• focus on controlling blood sugar
levels in the normal or near-normal
range
• Prevent symptoms of hyperglycemia
• Promote SMBG
• Administer medical and nutritional
therapy that balances food intake
with physical activity and
pharmacologic therapies
• Prevent long-term complications
(micro vascular and macro vascular
disease)
• Maintain appropriate blood pressure
and lipid values.
• Treat other physiologic derangements
when present.
• Maintain a flexible and normal
lifestyle

36. Treatment Options
For Heart Failure
• ACE inhibitors / ARB’s
• Diuretics
• Beta blockers
• Spironolactone
• Digoxin / Dopamine

37. For Diabetes:
• Insulin
• OHA
1. Sulfonylurea's
2. Biguanides
3. Thiazolidinediones
4. Alfa glucosidase
Inhibitors
5. DPP- 4 inhibitors

38. Goals achieved
• Patient was symptomatically better by day 2
• Blood pressure was brought to near normal by
day 3

39. Problems identified
• Cardiac enzymes were not done (CKMB)

40. Monitoring Parameters
Disease Related
• ECG
• ECHO
• Chest X-ray
• Blood pressure
• Weight
• Fluid intake
• Electrolytes
• Vital signs
• Renal function test
• Blood Glucose levels
• Glycosylated Hb
• Lipid Levels
• Fundoscopy
Drugs Related
• Blood Pressure
• Blood Glucose levels
• Weight
• Electrolytes
• Renal function test

41. Patient Counseling

42. About Disease

44. About Medication
– Name and purpose
– Dose and frequency
– Medication adherence
– Possible adverse effects
– Missed dose

45. DASH Diet
• Cut the Salt
• Get Your Grains
• Load Your Plate With
Vegetables
• Don't Forget Fruit
• Have Some Yogurt
• Go for Lean Meats and Fish
• Add Nuts and Legumes
• Cut Back on Fats and Oils
• Watch the Sweets
• Get Enough Potassium

46. • Healthy life style with daily
exercise
(the ADA recommends 150
min/week (distributed over at
least 3 days) of aerobic
physical activity)
• Self-Monitoring of Blood
Glucose
• Nutritional recommendations
Food/amount Serving/exchange The size of
1 cup cooked rice or pasta 2 starch tennis ball
1 slice bread 1 starch compact disc case
1 cup raw vegetables or fruit 1 fruit or vegetable baseball
1/2 cup cooked vegetables or fruit 1 fruit or vegetable cupcake wrapper full or size of ice cream
scoop
1 ounce cheese 1 high-fat protein pair of dice
1 teaspoon olive oil 1 fat** half dollar
3 ounces cooked meat 1 protein deck of cards
3 ounces tofu 1 protein deck of cards
** Remember to count fat servings that may be added to food while cooking (oil for sautéing, butter, or shortening for baking)

47. THANK YOU