A 60-year-old male patient with a history of coronary artery disease and hypertension presented with breathing difficulties, dizziness, and chest pain. Diagnostic tests indicated systemic hypertension and pulmonary edema, leading to a treatment plan that includes medications like furosemide and enalapril, along with lifestyle changes such as avoiding smoking and consuming low sodium foods. Patient counseling highlighted the importance of monitoring health conditions, medication adherence, and regular blood tests to assess kidney function.

2. SUBJECTIVE
NAME Mr.X
AGE 60Yrs
SEX MALE
WEIGHT 56Kg
HEIGHT 161cm
BMI 21.6Kg/m2 (Normal)

3. CURRENT PROBLEM : C/O Breathing Difficulty 3 Days, Dizziness 2 days
MEDICAL HISRTORY : Coranary Artery Disease (CAD)
Sustained Hypertension
MEDICATION HISTORY :K/H/O Irregular Medication CAD & SHT – Tab Lasix-
20mg,Tab.Enapril-2.5mg,Tab.Tenolol-50mg,Tab,Atorva-40mg,Tab.Isodril-5mg
FAMILY HISTORY : Nil
DRUG FOOD ALLERGY : Nil

4. OBJECTIVE
VITALS
SIGNS
Normal
Values
DAY 1
10.12.2023
DAY 2
11.12.2023
DAY 3
12.12.2023
DAY 4
13.12.2023
TEMP (F) 97.8 F 98.4 98.6 98.4 98.5
BP (mm/Hg) 120/80mmHg 230/140 200/110 130/90 130/80
PR (/mm) 60-100(min) 96 92 78 76
RR (/mm) 12-16(min) 22 20 18 20

5. LABARTARORY INVESTIGATION
LABORATARY
PARAMETERS
OBSERVED
VALUES
NORMAL
VALUES
Hb 14.5g/dl Men : 14 to 18 g/dl
Women: 12 to 16g/dl
Tlc 6000 cells/Cu.mm 4000 to 11000/ml
Plt 150000/mcL 150,000 to 450,000/ml
Rbc 4.4M/mcL Men :4.35 to 5.65M
Women: 3.92 to 5.13M

6. LIVER AND RENAL FUNCTION TEST
TESTS OBSERVED VALUE NORMAL VALUE
Bilirubin 0.8 mg/dl 0.2 to 1.3 mg/d
Protein 6.8g/dl 6.0 to 8.3g /dl
Urea 42mg/dl  5 to 20mg /dl
Creatinine 1.3mg/dl 0.74 to 1.35 mg/dl
RBG 102mg/dl Less than 140 mg/dl

7. ECG (ELECTROCARDIOGRAM):
Abnormal
CHEST X RAY :
Pulmonary Edema

8. A 60 year old male patient was admitted with breathing difficulty 3 days
,chest pain , with dizziness and he is a married , non vegetarian and
smoker and family history nil . And the person physical examination
shows the temperature is normal and the blood is increased day by day
and the Hb ,Tlc, Rbg values or normal and the urea level is high and
because The plasma urea was significantly related to both age and
diastolic systolic blood pressure. And the ECG was abnormal and the
X – ray results shows pulmonary edema.

9. • The patient results shows the patient blood pressure was high
and the ECG is abnormal it shows the patient was diagnosed
as a Systemic Hypertension and the urea level is high
because of systemic hypertension.
• And the x- ray results shows diagnosed as a Pulmonary
Edema

10. PLAN
Drug Treatment Chart
S.
NO
BRAND
NAME
GENERIC
NAME
DOSE ROA FREQ Day
1
Day
2
Day
3
Day
4
1 Inj.Lasix Furosemide 20mg/2
ml
IV 1-0-1
   
2 Inj.Deriphyll
in
Theophylline 100mg/
2ml
IV 1-0-1
   
3 Inj.Ampilin Ampicillin 500mg/
2ml
IV 0-1-0
   
4 Tab.Lasix Furosemide 20mg Oral 1-1-0
   
5 Tab.Enapril Enalpril 2.5mg Oral 1-0-0
   

11. S.N
O
BRAND
NAME
GENERIC
NAME
DOSE ROA FREQ DAY
1
DAY
2
DAY
3
DAY
4
6 Tab.Tenolol Atenolol 50mg Oral 1-0-0
   
7 Tab.Ecosprin Aspirin 75mg Oral 0-1-0
   
8 Tab.Plavix Clopidogrel 75mg Oral 0-1-0
   
9 Tab.Atrova Atorvastin 40mg Oral 0-0-1
   
10 Tab.Aldactone Spironolacton
e
25mg Oral 1-0-0
   
11 Tab.Isodril Isorbide Di
Nitrate
5mg Oral 1-1-1
   

12. • Furosemide and enalapril drug also having internal bleeding .
• Small wound self have a heavy blood so it is the reason for alternating aspirin
Etofylline product labelling states that use with sympathetic blockers (i.e, beta-blockers)
should be avoided.
• I will advice to avoid smoking

13. PATIENT COUNSELLING
DISEASE BASED:
• High blood pressure is a common condition that affects the body's arteries. It's
also called hypertension. If you have high blood pressure, the force of the blood
pushing against the artery walls is consistently too high. The heart has to work
harder to pump blood.
• Pulmonary edema is a condition caused by too much fluid in the
lungs. This fluid collects in the many air sacs in the lungs, making it
difficult to breathe.

14. LASIX (Furousemide):
Take potassium supplements or potassium-rich diet (banana,
spinach, coconut water, etc.) as Lasix Tablet can decrease
your potassium levels and lead to dehydration.
You may be asked to get regular blood tests done to monitor
your kidney function.

15. ENALAPRIL:
Take this medicine in the dose and duration as advised by your doctor. Swallow it as a whole.
Do not chew, crush or break it. Enalapril 2.5 Tablet may be taken with or without food, but it is
better to take it at a fixed time.
ATENOLOL:
It may cause dizziness. If this happens to you, get up slowly when rising from a sitting or lying
position.
It can hide symptoms of low blood sugar if you are diabetic. Monitor your blood sugar levels
regularly.
Do not stop taking Aten 50 Tablet suddenly as it can cause your blood pressure to rise
suddenly, thereby increasing the risk of heart attack and stroke.

16. PLAVIX
For best results, take it at the same time every day.
Plavix Tablet increases your risk of bleeding. Be careful while shaving,
using sharp objects, or cutting fingernails or toenails.
Do not discontinue using the medicine without consulting your doctor as
this may increase your chances of having another heart attack or stroke.
If you are scheduled to undergo a surgery or dental treatment, you may
be asked to stop taking Plavix Tablet temporarily.

17. ATROVA
• It may cause diarrhea, gas or an upset stomach. If any of these happen to you,
take it with food.
• Inform your doctor if you experience fatigue, muscle weakness or muscle pain.
• Your doctor may check your liver function before starting the treatment and
regularly thereafter. Inform your doctor if you notice signs of liver problems such
as stomach pains, unusually dark urine or yellowing of skin or eyes.

18. DIET BASED PATIENT COUNSELING
FOOD:
• Consume low sodium and trans free foods and eat rich nutrients and fresh fruits and
berries avoid alcohol consuming.
LIFE STYLE CHANGES:
• Do normal exercise and workout.
• Strictly avoid alcohol ,smoking and other drugs.
• Don’t be a emotion do medication.