A 86-year-old male presented with chest discomfort and was diagnosed with acute coronary syndrome. Exams found hypertension, coronary artery disease, chronic kidney disease on dialysis. ECG showed ischemia. Troponin was elevated. He was started on medications including losartan, metoprolol, clonidine, thyroxine, torsemide, esomeprazole, fluconazole, clopidogrel, nifedipine, atorvastatin. Counseling addressed medication adherence, lifestyle modifications like smoking cessation, diet, exercise and regular checkups to prevent recurrence.

1. Case Study On Acute
Coronary Syndrome
REGISTER NUMBER:381510717
PHARM.D INTERN

2. A 86 years old male patient was admitted in
the hospital with chief complaints of chest
discomfort from today morning.

3. PAST MEDICAL HISTORY:
K/C/O,
 Hypertension
 Coronary Artery Disease
 Chronic Kidney Disease (on dialysis)
S/P,
 Pacemaker Insertion

4. PAST MEDICATION HISTORY:
TRADE NAME GENERIC
NAME
DOSE FREQUENCY
T.Repace Losartan 50mg 1-0-1
T.Arkamin Clonidine 100mcg 1-1-1
T.Thyronorm Thyroxine 50mcg 1-0-0
T.Aztor Atorvastatin 5mg 0-0-1
T.Shelcal 500mg 1-0-1

5. ON PHYSICAL EXAMINATION:
 Temperature: 98.6°F
 Respiratory rate: 22/ min
 Pulse rate: 83 beats/ min
 Blood pressure: 130/80 mmHg
 SPO2 : 100%

6. ON SYSTEMIC EXAMINATION:
On systemic examination revealed minimal crepitations bilaterally
on auscultation over the chest
 CVS: S1 and S2 audible, normal
 RS: NVBS
 CNS: NFND
 GU & GI ( Abdomen) : P/A Soft

7. LAB INVESTIGATIONS:
ECG:
ECG was done which showed Sinus rhythm; First degree AV
block; Incomplete right bundle branch block; Moderate ST
depression; T wave abnormalities; possible lateral ischemia.
Troponin-I:
Troponin-I was elevated 20.34 pg/ml

8. S- SUBJECTIVE
O- OBJECTIVE
A- ASSESMENT
P- PLAN

9. SUBJECTIVE:
A 86 years old male patient was
admitted in the hospital with chief
complaints of chest discomfort from
today morning.

10. OBJECTIVE:
The patient was a known case of hypertension, coronary
artery disease on medication and has chronic kidney disease
and on Haemodialysis. On general examination, he was
conscious and oriented. He is uneducated and lives a
sedentary lifestyle with normal socio-economic status. He
takes mixed diet and his bowel and bladder habits are
normal and has loss of appetite and lack of sleep.

11. ASSESSMENT:
Acute coronary syndrome:
 Acute coronary syndrome describes a group of clinical symptoms
representing acute myocardial ischemia.
 The clinical symptoms include acute myocardial infarction, which
includes either ST-segment elevation (STEMI), or non-ST- segment
elevation (NSTEMI), and unstable angina.

12. PLAN:
S.NO TRADE NAME GENERIC NAME DOSE ROA FREQUENCY
1. T.Repace Losartan 50mg PO 1-0-1
2. T.Aztor Atorvastatin 5mg PO 0-0-1
3. T.Promolet-XL Metoprolol succinate 500mg PO 1-0-1
4. T.Thyronorm Thyroxine 50mcg PO 1-0-0
5. T.Dytor Torsemide 10mg PO 0-1-0
6. T.Shelcal 500mg PO 1-0-1
7. T.Calcigard Nifedipine 20mg PO BD
8. T.Sompraz Esomeprazole 20mg PO 1-0-1
9. Inj.Fragmin Dalteparin 2500units S/C -
10. T.Syscan Fluconazole 100mg PO 1-0-0
11. T.Sizodon Risperidone 0.5mg PO -

13. Critical Analysis:
S.NO TRADE NAME GENERIC NAME DOSE STANDARD DOSE INFERENCE
1. T.Repace Losartan 50mg 50mg Compliance with standard dose
2. T.Aztor Atorvastatin 5mg 5mg Compliance with standard dose
3. T.Promolet-XL Metoprolol succinate 50mg 50mg Compliance with standard dose
4. T.Thyronorm Thyroxine 50mcg 50mcg Compliance with standard dose
5. T.Dytor Torsemide 10mg 10mg Compliance with standard dose
6. T.Shelcal 500mg 500mg Compliance with standard dose
7. T.Calcigard Nifedipine 20mg 20mg Compliance with standard dose
8. T.Sompraz Esomeprazole 20mg 20mg Compliance with standard dose
9. Inj.Fragmin Dalteparin 2500units 2500units Compliance with standard dose
10. T.Syscan Fluconazole 100mg 100mg Compliance with standard dose
11. T.Sizodon Risperidone 0.5mg 0.5mg Compliance with standard dose
Critical analysis:

14. DISCHARGE SUMMARY:
S.NO GENERIC NAME DOSE ROA FREQUENCY
1. Losartan 50mg PO 1-0-1
2. Metoprolol succinate 50mg PO 1-0-1
3. Clonidine 100mcg PO 1-1-1
4. Thyroxine 50mcg PO 1-0-0
5. Torsemide 10mg PO 0-1-0
6. Shelcal 500mg PO 1-0-1
7. Fluconazole 150mg PO 1-0-0(until 25/1/2021)
8. Esomeprazole 20mg PO 1-0-1
9. Clopidogrel 75mg PO 1-0-0
10. Nifedipine 20mg PO 1-0-1
11. Atorvastatin 20mg PO 0-0-1

15. DRUG INTERACTION:
1.Atorvastatin and Fluconazole:
 Interaction effect: Concurrent use of Atorvastatin and Fluconazole may result in an increased risk of
myopathy (rhabdomyolysis).
 Clinical management: Closely monitor patient for signs and symptoms of muscle pain, tenderness and
weakness.
2.Fluconazole and Torsemide:
 Interaction effect: Concurrent use of Fluconazole and Torsemide may result in increased Torsemide
exposure and risk of toxicity.
 Clinical management: Fluconazole enzyme inhibitory effects may persist for 4-5 days after
discontinuation because of long-half life. Caution is advised and carefully monitor for Torsemide
toxicity.

16. 3.Fluconazole and Risperidone:
Interaction effect: Concurrent use of Fluconazole and
Risperidone(Antipsychotics)may result in an increased risk
of cardiotoxicity( QT prolongation)
Clinical management: Caution is advised on
concombinant use of both drugs.

17. Discussion:
A 86 years old male patient was admitted in the hospital with chief complaints of chest discomfort from
today morning. The patient was a known case of hypertension, coronary artery disease on medication and
has chronic kidney disease and on Haemodialysis. On general examination, he was conscious and oriented.
On systemic examination, minimal crepitations bilaterally on auscultation over the chest was revealed.
ECG was done which showed Sinus rhythm; First degree AV block; Incomplete right bundle branch block;
Moderate ST depression; T wave abnormalities; possible lateral ischemia. Repeat ECG showed persisting
ischemic changes Troponin-I was elevated 20.34 pg/ml. He is uneducated and lives a sedentary lifestyle
with normal socio-economic status. He takes mixed diet and his bowel and bladder habits are normal and
has loss of appetite and lack of sleep.

18. GOALS OF THERAPY:
 To decrease mortality and complications.
 To reduce the severity or eliminate episodes of ischemia.
 To prevent further myocardial injury.

19. PATIENT COUNSELING:
REGARDING DISEASE:
Acute coronary syndrome: It is the condition where sudden reduction or blockage of
blood flow to the heart
Symptoms:
Pain areas- in the chest, arm, or jaw
Pain circumstances- can occur in the chest at rest or with exertion
Respiratory- shortness of breath
Others – Chest discomfort, sweating.
 If you experience any of these symptoms immediately consult your physician.

20. REGARDING MEDICATION:
 T. Losartan is an anti-hypertensive drug for Hypertension given 50mg orally for
twice a day
 T. Metoprolol succinate is an anti-hypertensive drug given 50 mg orally for twice
a day.
 T. Clonidine is an anti-hypertensive drug is advised to administered orally twice a
day.
 T.Thyronorm 50 mcg for treatment of hypothyroidism was given once daily.
 T.Torsemide is a diuretic agent drug is advised to administered orally once a day.
 T.Esomeprazole is an antacid is advised to administered orally twice a day.

21. T.Shelcal 500mg is a vitamin D supplement is advised to administered orally
twice a day.
Cap.Fluconazole an antifungal agent for oral thrush is advised to administered
orally once a day.
T..Clopidogrel 75mg an antiplatelet medication used to prevent heart attack
and was given once daily.
T.Nifedipine 20mg is given for chest pain, and advised to take orally twice
daily.
T.Atorvastatin 20mg was prescribed once daily.
Take medication as prescribed by the physician.
Medication adherence helps to improve and prevent recurrence.
Do not skip the dose , if you miss the dose do not double the dose ; follow the
dose as per scheduled.

22. REGARDING LIFESTYLE
MODIFICATION:
Self-care prevents recurrence of ACS that includes;
 Adherence to prescribed medication helps to improve the quality of life.
 Smoking cessation is adviced.
 Limitation of alcohol consumption is adviced.
 Health check ups for BP, Cholesterol levels should to be done regularly.
 Healthy diet including- Diet high in fruits, vegetables, whole grains.
 Limit salt and sugar intake.
 Maintain healthy Body Mass Index.
 Avoid sedentary lifestyle. Mild aerobic activity like 15 minutes of walking is
recommended.